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This is to certify that the
THE EFFECT OF FORMAT ON EDWéAJ’ffiSWtW THE ACUTE CARE
SETTING FOR PATIENTS DIAGNOSED WITH CHRONIC OBSTRUCTIVE
PULMONARY DISEASE .
presented by
ROSEMARY CLARE ZIVIC
has been accepted towards fulfillment
of the requirements for
_MASIER_degree in JURSINL.
8/0/5572 Kinda
Major professor
Date AUGUST 7, 1990
0-7639 MS U is an Affirmative Action/Equal Opportunity Institution
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THE EFFECT OF FORMAT ON EDUCATION IN THE ACUTE CARE
SETTING FOR PATIENTS DIAGNOSED WITH CHRONIC
OBSTRUCTIVE PULMONARY DISEASE
BY
ROSEMARY CLARE ZIVIC
A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTERS OF SCIENCE IN NURSING
COLLEGE OF NURSING
1990
ABSTRACT
THE EFFECTS OF FORMAT ON EDUCATION IN THE ACUTE CARE
SETTING FOR PATIENTS DIAGNOSED WITH CHRONIC
OBSTRUCTIVE PULMONARY DISEASE
BY
Rosemary Clare Zivic
An experimental design utilizing pre-intervention,
post-intervention format was conducted to test differences
in patient learning resulting from two teaching methods.
The sample population were patients diagnosed with Chronic
Obstructive Pulmonary Disease (n=20). Changes in knowledge
were measured using The Pulmonary Rehabilitation Health
Knowledge Test (Hopp, Lee & Hills, 1989). King's (1981)
conceptual framework was used as theoretical basis for this
study.
Data were analyzed using Pearson Product Moment
Correlation, Analysis of Variance and Covariance, T-Test and
descriptive statistics. There was no statistical
significance found between teaching interventions once
covariates number of places taught and teaching within the
past twelve months were controlled. A Paired-T Test
indicated improvement for both groups on post-intervention
scores is of clinical significance to advanced nursing
practice.
To my husband, Peter Zivic,
with all of my love.
ii
ACKNOWLEDGEMENTS
This research would not have been completed without the
valuable assistance of many people. I am grateful to Sharon
King, R.N., Ph.D for serving as chairperson for this
committee.
In addition, I would like to thank the committee members,
Barbara Given, RJN. Ph.D., Dorothea Milbrandt R.N. MAS.N.,
Patty Peek, R.N. M.S.N. for their support and guidance. I
also appreciate the patience and guidance of Manfred Stommel
for his assistance in the data analysis and interpretation of
the data.
A special thank you to Imogene King for critiquing the
conceptual framework chapter and for her words of
encouragement.
I wOuld also like to express my deeply felt appreciation
to my family for without their love, guidance assistance and
understanding, this thesis would not have been completed.
iii
Table of Contents
Page
LIST OF FIGURES................................ vi
LIST OF TABLES ............................... vii
CHAPTER
I. THE PROBLEM...................................... 1
Introduction..................................... 1
Purpose.......................................... 133
Statement of the Question........................ I6
Hypothesis....................................... 17 ~
Definition of Terms.............................. qzkua
Limitations of the Study......................... .Ibww
Assumptions of the Study.......................... aswvw
Overview of the Chapters.......................... 26/””
II. THE CONCEPTUAL FRAMEWORK.......................... 22
Introduction...................................... 22
King's Theory of Goal Attainment.................. 22
The Social System................................. 22
Interpersonal System.............................. 26
Personal System................................... 32
Schematic Representation of the Conceptual Model
Pertaining to the Hypothesis...................... 37
III. REVIEW OF LITERATURE.............................. 40
Introduction...................................... 40
Patient Learning.................................. 41
Difficulties in Educating the Patient with COPD... 43
Content of Patient Education Programs
In Relation to Learning........................... 45
Presentation of Pulmonary Education Programs...... 55
Conclusion.................... ..... ............... 61
IV. METHODOLOGY....................... ............ .... 64
Overview....................... ......... .......... 64
Two Group Pre-Intervention,
Post-Intervention Design.......................... 65
Sample............................................ 67
Data Collection Site.............................. 68
iv
QEQEEQI BQQQ
Data Collection Procedure......................... 68
Operational Definitions........................... 73
Instrument........................................ 76
Operationalization of Study Variables.............. 79
Reliability and Validity........................... 81
Hypothesis......................................... 85
Statistical Analysis of Data....................... 86
Protection of Human Rights......................... 87
Summary............................................ 89
V. DATA ANALYSIS...................................... 90
Introduction....................................... 90
Results............................................ 90
Clinical Characteristics........................... 92
Summary........................................... 102
Reliability of Questionnaire...................... 103
Data Presentation of Research..................... 103
Questions and Hypothesis.......................... 108
Tests for Hypothesis.............................. 109
Discussion................................ ....... . 111
Findings Concerning Sociodemographic
Characteristics................................... 112
Findings Concerning Clinical Characteristics...... 112
Findings Pertaining To Hypothesis................. 113
Summary........................................... 114
VI. SUMMARY AND IMPLICATIONS.. .................. ...... 115
Overview.......................................... 115
Summary of Findings............................... 115
Descriptors of the Study Sample................... 117
Sociodemographic Characteristics.................. 117
Clinical Characteristics.......................... 120
Past Education ...... ..... ...... . ..... . .......... .. 122
Physiological Parameters.......................... 123
Teaching Post Discharge........................... 123
Instrument........................................ 124
Serendipitous Findings Related to Instrument...... 124
Statement of the Research Question................ 126
Research Hypothesis............................... 127
Summary of Hypothesis............................. 130
Limitations of the Study.......................... 131
Recommendations and Conclusion.................... 132
Implications for Advanced Nursing Practice........ 133
Implications for Nursing Education................ 140
Implications for Nursing Research................. 142
Summary............................. ............ .. 145
REFERENCESCOOOOOOOOOOOOOOO000......OOOOOOOOOOOOOOOOOOOOO 146
LIST OF FIGURES
Elms __gePa
I Schematic Representation of Conceptual Model
Pertaining to Hypothesis......................... 38
II Data Collection Flow Chart ..... .. ................ 70
vi
10
11
12
13
LIST OF TABLES
Frequency and Percentage of Age Range
Distribution of Subjects........................ 91
Length, Number and Percentage of Time Since
Diagnosed with COPD in Years.................... 93
Frequency and Percentage of Hospital Visits Past
welve months.OOOOOOOOOOOOOOOOOOO 00000000000000 O 93
Frequency and Percentage of Physician Visits Past
TwelvenonthSOOOOOOOOOOOOOOOOOOOOOOOOOOOOO0...... 94
Frequency and Percentage of Emergency Room Visits
PaSt Twelve HonthSOOOOOOOOOOOOOOOOOOO ..... 0.0.0... 94
Number and Percentage of Visits to the Emergency
Room Post InterventionOOOOOOOOOOOOOOOOOOOOOOOOOOO 95
Frequency and Percentage of Length of Hospital
Of StaYOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 96
Frequency and Percentage of COPD Education Past
TwelveMonthso.OOOOOOOOOOOOOOO0.00000000000000000 97
Frequency and Percentage of Educational Settings
Utilized Past Twelve Months Before Admission..... 98
Description, Mean, and Standard Deviation of
Subpopulation For Physiological Parameters....... 99
Frequency and Percentage of Physiological Inclusion
CriteriaOIOOOOOOOOOOOO00......OOOOOOOOOOOOIOOOOOO 100
Description of Subpopulation for Pre- and
Post-Intervention Scores For Mean and Standard
DeViation0.0000000000000000000IO..0. ..... 00...... 102
Pearson Product Moment Correlation of Sample for
Length Diagnosed with COPD and Oxygen Saturation
by Intervention and Knowledge Difference.......... 104
vii
14
15
16
17
BESS
Correlation for Hospital and Clinic by Pre- and Post
Intervention...................................... 105
One-Way Analysis of Variance for Difference Between
Mean Scores for Pre- and Post-Intervention and
Knowledge Difference.............................. 106
Analysis of Variance for Pre- and Post-Intervention
Means for Number of Places Taught Within Past
TwelveMonthSOOOOOOOOOO0......OOOOOOOOOOOOOOOOOOOO 107
Paired-T Test for Comparison of Grand Means Pre-
and Post-Intervention Knowledge Scores.............108
viii
Appendix
00 mt»
LIST OF APPENDICES
Page
Screening Cheekl ist O O O O O O O O O O O O O O O O O O O O O O O O O 0 C1 ix
Letter of Explanation........................ clxii
consent...0....00....OOOOOOOOOOOOOOOOOOOOOOO. CIXiv
Pre-intervention Questionnaire Without
Instrument...0.0I0.000000IOOOOOOOOOOOOOOOOOOOCIXVii
Post-Intervention Questionnaire Without
InstrumentOOOO0.0000IOOOOOOOOOOOOOIOOOOOOOOOO ClXXi
Instrument: Raw Data, Frequencies, Means
and Standard Deviation.......................clxxiv
Community Resources........................clxxxvii
Discharge Instructions........................cxcii
UCRIHS Approval Letter........................cxciv
Ingham Medical Center Approval Letter......... cxcv
ix
CHAPTER 1
THE PROBLEM
Introduction
Chronic Obstructive Pulmonary Disease (COPD) is a major
cause of mortality and morbidity in the United States,
affecting nearly ten million persons. Since 1979, COPD and
related conditions have been rising most rapidly among the
leading causes of death and accounted for 69,100 deaths in
1984 (American Lung Association, 1988). The total number of
deaths attributed to COPD and asthma has increased 332%
since 1960. Data from the National Health Interview Survey
which is based on a probability sample of United States
households, have been used to estimate that 21.5 million
Americans suffer from COPD (chronic bronchitis and
emphysema) and asthma (American Lung Association, 1988).
Respiratory diseases are often insidious in onset and
become progressively more debilitating. This progression of
the disease, characterized by frequent exacerbations and
repeated hospitalizations, explains the chronicity of the
disease (Miracle, 1984). While the hospitalized patient may
receive optimal care from a variety of disciplines, all too
often the patient is discharged without an adequate
understanding of the disease process or methods to help in
self-care at home.
2
Patients diagnosed with COPD, whether it is the first
time or on subsequent occasions into the acute care setting,
are often discharged without an adequate understanding of
the disease (Miracle, 1984). Consequently, patients may
suffer from a lack of knowledge. Patients who lack knowledge
of appropriate self-care may have behavior patterns which
function to exacerbate the disease and therefore experience
subsequent readmissions into the acute care setting. In
today's economy, frequent admissions mean increasing costs
for the patient, the hospital, and the third party payer
(Miracle, 1984).
The prospective pricing system for the hospitalized
Medicare patient, established in 1983, preset a payment rate
for each patient admission. Chronic Obstructive Pulmonary
Disease (#88), under the Diagnostic Related Group (DRG)
system, is located under Diseases and Disorders of the
Respiratory System (Bartlett, 1988). Respiratory diseases
are considered low reimbursement DRG. In other words,
hospitals are reimbursed less money than some other
diagnoses in the DRG categories.
Whether the hospitalized patient with the diagnosis of
COPD stays three or ten days, the hospital will receive the
same amount of money. As hospitals incur increased
expenses, the goal becomes treating the acute exacerbation
of the disease. Rising costs tend to decrease the length of
in-patient stays, forcing patients and their families to
3
become increasingly responsible for their own care after
discharge (McPhee et a1. 1983).
The chief goal for the chronically ill is to live as
normally as possible despite their symptoms and disease
(Stockdale-Wooley, 1984). Education can help promote
self-management of the chronically ill. With self-care as
the goal of the chronically ill, self-management of the
illness can facilitate appropriate modifications of their
life-styles (Stockdale-Wooley, 1984).
Researchers have confirmed the importance of education
for the chronically ill patient, specifically the COPD
patient (Gilmartin, 1986; MacDonnell, 1981; Miracle, 1984).
Mazzuca (1982) reviewed twenty-seven experimental studies
regarding the effects of patient education on chronic
diseases published between 1970 and 1981. Mazzuca stated
that education did improve patient compliance in behavioral
oriented programs, often with special attention in changing
the environment in which patients care for themselves. He
further stated that behavioral programs were consistently
more successful at improving the clinical course of the
disease.
Mazzuca indicated that the patient should be taught
less about pathophysiology and more about integrating new
demands into daily routines. According to Mazzuca, patient
education teaches the patient about the disease and its
treatment. The patient who receives instruction is presumed
4
to be in a better position to participate in his or her own
health care and maximize therapeutic benefit.
The purposes of education for the patient with chronic
illness such as COPD can be very complex such as helping the
patient to regain some measure of control over life and
understanding the effects of chronic disease. Two very
important outcomes may occur if the patient can retain the
information that is taught. First, the patient may assume
more responsibility for self-care. Second, patients may be
more able to adapt life-style changes in functional status
without losing sight of themselves as an individual
(Gilmartin, 1986).
The patient who is diagnosed with a chronic disease may
lead a full life adapted to the life-style changes that are
inherent in the disease and treatment. A higher level of
information or skills may also help the patient with COPD
stay in the community longer and be more independent at
home. Education benefits patients both psychologically, by
minimizing acute care readmissions, and physiologically due
to fewer exacerbations of the disease.
Cohen (1981) reviewed research and non-research based
literature relative to their value in patient education.
Areas examined included principles of education,
methodology, content, and barriers to education. Cohen
concluded that the need for patient education was
demonstrated in exploratory studies on patient knowledge.
5
There are some indications that variables such as, stress,
age and educational level may influence patient learning.
According to Cohen (1981), the most common goals of
patient education programs are changes in knowledge as shown
by paper and pencil tests and behavioral changes (Hartley &
Brandt, 1967; Allendort 8 Keegan, 1975; Pratt, 1957).
Videotape versus lecture teaching methodologies were also
critiqued. Of the three studies cited, videotape instruction
produced a greater increase in knowledge and was cited as
more efficient (Brachen et a1. 1977; Fisher 1977; Lindeman &
Van Aernam, 1971).
McPhee and associates (1983) studied patient knowledge
levels after hospitalization. The purpose of the study was
to design effective standardized materials, methods, and
procedures which could be produced and implemented on a
large scale. McPhee gave instructions on the day of
discharge and interviewed each patient one month latter.
McPhee and colleagues were unable to demonstrate that the
use of a one-time discharge instruction improved patient
knowledge, compliance, or functional status after
hospitalization. He concluded that effective in-patient
education requires more than a simple one-time verbal or
written instruction.
Howard et al. (1987) evaluated the effectiveness of a
structured respiratory teaching program based upon the
American Lung Association booklet," Help Patients to Better
6
Breathing (1985)." Patients diagnosed with COPD
hospitalized over a thirteen month period were compared on
several parameters to assess changes in their ability to
manage their disabilities. The researchers determined that
those who participated in numerous teaching sessions had
fewer hospitalizations, shorter length of stay, and longer
stays in the community. Clients who were taught to manage
their disease more effectively appear to spend between 15
and 25% fewer days in the hospital. Decreased hospital days
represents a major savings for both patients and the health
care system. However, the sample did not have a sufficient
number of persons to be statistically significant.
Hopp et a1. (1989) developed and validated a knowledge
test for pulmonary rehabilitation covering the content areas
defined in areas identified as common to programs
nationwide. The researchers identified that the benefits of
knowledge testing are immediate feedback and correction of
misperceptions. Drawbacks to knowledge testing included
resistance of participants to taking written tests due to
inability to read well. Also, some people take tests well
and memorize information easily but still be unable to put
the information to use. The researchers concluded that
knowledge change may not be translated into behavior change,
but knowledge is the basis upon which behavior change is
built.
7
Researchers concluded that there is'a need for patient
education to help the patient adapt his or her life-style
and lead a full life even with a chronic disease. Education
on the day of discharge, according to the study by McPhee
and colleagues (1983) was not effective. Howard and
colleagues (1987), on the other hand, showed that patients
followed in the out-patient clinic after their
hospitalization were rated as being knowledgeable about
their medication and more interested in their program
(Howard et al. 1987). Hopp et al. (1989) recognized that
knowledge change may not be translated into behavior change,
but knowledge may be the basis which behavior is built.
In 1971, The President's Committee on Health Education
stated that there was a great deal of health information
given to the patients, but very little of that information
was utilized (Stockdale-Wooley, 1984). An English
psychologist, Philip Ley, has done extensive research of
factors affecting the recall of medical information. The
main findings of Ley's (1979) research includes:
1) patients fail to recall much of what
they are told,
2) the number of statements not recalled is a
function of the number presented,
3) age is not consistently related to recall,
4) medical knowledge is related to recall,
8
5) anxiety is related to recall in a curvilinear
fashion,
6) content of recall can be influenced by
manipulating serial position of content and
perceived importance,
7) intelligence is not related to recall,
8) recall can be influenced by
shorter words and sentences
explicit categorization
repetition and
use of concrete-specific rather than
abstract-general advice statements.
Ley (1979) demonstrated that neither age nor
intelligence showed any consistent relationship to recall.
However, one exception was a study with patients over
sixty-five years of age. Diagnostic statements were most
clearly recalled and those concerning instructions and
advice were most poorly recalled. Ley concluded that the
largest gains in recall were obtained by the use of
specific-concrete, rather than general-abstract advice
statements.
Gilmartin (1986) cited a number of factors important to
effective learning. These factors included the following:
a) readiness to learn, b) denial, c) emotional stability,
d) psychosocial assets, e) acceptance of disease,
9
f) motivation, g) health beliefs, h) locus of control,
1) fatigue, j) reduced strength and endurance,
k) changes in cognition, and l) hypoxemia and hypercapnia.
The patient who is afflicted with COPD experiences
metabolic alterations associated with hypoxia and
hypercapnia. These alterations effect the individual's
personality and functioning. Specifically, people may be
more forgetful or unable to reason correctly because of an
organic brain syndrome caused by the cerebral anoxia. The
limited respiratory reserve that is characteristic of COPD
affects all facets of the person's life (Sexton, 1983).
Due to forgetfulness and fatigue associated with COPD,
the time of day and the length of the session should be
taken into consideration in the establishing of the
educational program. The education process needs to be
scheduled when the patient is not receiving respiratory
treatments or percussion or not doing activities of daily
living (Sexton, 1983).
In addition, the patient emotional status may adversely
affect their own ability to learn. Denial of the severity
of the disease may adversely affect the patient's readiness
to learn. The physical effects of the illness itself may
affect the ability to learn. The patients' past behavior in
dealing with illness may have engendered habits contrary to
any new suggestions for change (Gilmartin, 1986).
10
Both a person's background and beliefs about health and
disease influence the ability to learn. Gilmartin (1986)
utilized The Health Belief Model and stated five perceptual
areas of belief that may interfere with or enhance learning.
These areas include: a) seriousness or severity,
b) susceptibility, c) a threat of disease,
d) benefits, and e) barriers to taking action.
For example, a family member may have died from COPD,
so the patient may perceive that their illness is very
serious and feel that nothing will help them. The patient's
feeling of hopelessness can be a barrier in their ability to
learn or it can be a cue to action.
Acknowledging the given stresses of the patient with
COPD when admitted into an acute care setting, how much
information can the patient assimilate? Green (1977)
identified seven problems peculiar to health education
research in a theoretical paper. He noted that the benefits
of health education are "time dependent" and that motivation
for change is dependent upon the immediate stimulus.
The educational impact of a one time teaching
intervention such as discharge instructions may decay over
time. This decay is particularly relevant to behavioral
changes, such as smoking cessation, dietary restrictions,
and complicated drug regimens where "back sliding" is
common. Green also noted that "what works for one patient
does not work for all". The educational strategy that
11
improves patient knowledge, compliance, and function in some
patients may yield very different results in others (McPhee
et al. 1983).
Nursing educators as well as nursing theorists concur
that education is fundamental to the care of the patients.
The Joint Commission on Accreditation of Hospitals (JACH),
in its Standard of Nursing Service (April, 1979), states
that:
"A brief and pertinent written nursing care plan should
be developed for each patient...It may include patient
and family teaching programs and the
social-psychological needs of the patient (Billie,
1981)".
The question is, at what point in time is patient
education the most appropriate and optimally retained by the
patient with chronic COPD? Should the in-patient education
be given at a more optimal time during hospitalization?
Should education deal mainly with the most pertinent issue
in the acute care setting and upon discharge further
education be initiated by the outpatient clinical nurse
specialist?
A search of the literature has revealed a wealth of
information on pulmonary education for the patient with COPD
with the emphasis on rehabilitation programs (Gilmartin,
1986: MacDonnell, 1981: Davide, 1981: Miracle, 1984: Make &
Paine, 1986). Gilmartin (1986) utilized the Health Belief
12
Model and incorporated this model in patient education.
Gilmartin noted that education is essential in all settings
and that the goal of education is to change health beliefs
of patients and their families. MacDonnell (1981) stated
that the cornerstone of pulmonary rehabilitation is
education and Davide (1981) recognized that through
pulmonary education the patient with COPD can maximize their
health potential and minimize the effects of the lung
disease on their daily living. Miracle (1984) concluded
that in order to achieve maximum benefits of pulmonary
education patients with COPD must be afforded the
opportunity to learn about both the disease process and
about self-care behaviors necessary for coping with COPD.
Make and Paine (1986) cited documented improvement in
symptoms of COPD patients who participated in educational
programs and noted that failure to respond to educational
programs may be due to lack of patient motivation, conflicts
between patient and staff or a poor understanding of the
expectations of rehabilitation.
Authors concur that education is an important, if not
essential factor, for the patient with COPD. None
mentioned if learning which occurred in the acute care
setting, resulted in a higher level of knowledge after
discharge. Other researchers, such as Ley (1979), have
documented that the amount of information which is presented
in the acute care setting is only partially absorbed by the
13
patient. Redman (1975) considered the patient's motivation
and uses the term ”intelligent compliance", to refer to
behavioral changes based on understanding and not on ”blind
obedience” to a medical authority. Redman stated that
"intelligent compliance" is an area which needs further
investigation. The report of Joint Commission on Hospital
Accreditation stated in standards of nursing that education
of both patient and family is important.
Although the literature that was reviewed concurred on
the importance of education for the patient with COPD, very
little had been said on the retention of information once
the patient was discharged. McPhee and associates (1983)
study of patient education on the day of discharge was
unsuccessful in showing a significant improvement of patient
knowledge. Ley (1979) demonstrated that the length of time
elapsing between the patients being given the information,
and requesting to recall it, correlated with the amount
forgotten.
A closer look at Redman's "intelligent compliance"
concept when used in connection with retention of
information and recall of material is imperative for the
patient diagnosed with COPD. The importance of how and when
the educational material is presented to the patient with
COPD has been documented through research. However,
contemporary hospital practice makes it difficult to provide
appropriate educational opportunities. When a patient is
14
first hospitalized with acute symptoms, they are preoccupied
with those symptoms. Due to the current practice of earlier
discharge from the acute care settings, the patient may be
less receptive to educational exposure. This may be related
to insufficient time to make the emotional transition from
physical preoccupation of their symptoms to future
prevention.
BEIEQSE
The purpose of this experimental study is to determine
if information taught in two different formats in the acute
care setting to patients diagnosed with Chronic Obstructive
Pulmonary Disease results in differential retention of
content after discharge as determined by the pre and post
Pulmonary Rehabilitation Health Knowledge Test scores.
By the identification of the educational information
that the patient was able to learn while in the acute care
setting, nursing can help determine at what point
appropriate educational opportunities should be provided for
the patients diagnosed with COPD either in the acute care
setting or another health care arena.
Once the patient is discharged and in their home
environment the nurse in the primary care setting will work
to coordinate integration of inpatient and outpatient
education. The Visiting Nurse, clinic nurse or clinical
nurse specialist during the immediate post-discharge
interval needs to assess the amount of health information
15
that the patient remembers and then continue with the
educational process. In the immediate post-discharge
interval, the patient is generally visited for approximately
two weeks by Visiting Nurses if requested. Additionally,
the patient may visit the physician's office, clinical nurse
specialist or clinic within that two week interval.
To coordinate educational efforts successfully, the
clinical nurse specialist incorporates role characteristics
that include: assessor, educator, collaborator, advocate,
and clinician. The clinical nurse specialist will need to
utilize the data base from the pre-intervention and post-
intervention test scores to identify health learning needs.
In collaboration with acute care nurse and other members of
the interdisciplinary team, learning needs of the patient
with COPD may be identified. Through the application of
learning theories the clinical nurse specialist assists the
patient diagnosed with COPD to identify and meet their
health education needs in a climate of mutuality.
The patient diagnosed with COPD will benefit from the
communication and interaction which will occur with the
clinical nurse specialist as coordinator of the
collaborative team. Assessment for educational needs
through a combined effort among the collaborative team will
afford every opportunity for the patient to learn, retain
and hopefully begin to recognize the need for behavioral
changes and/or learning to adjust to their disease.
16
Pre and post intervention knowledge scores obtained
from the acute care setting can give the primary care nurse
important guidelines for follow-up teaching. The primary
care nurse can then provide immediate feedback and correct
misperceptions that were found in the knowledge test. If
the patient provided wrong answers on the post-test, the
topic can be discussed and the correct information
reinforced. It is recognized that knowledge change cannot be
translated into behavior change but knowledge can be the
basis upon which behavior change is built (Hopp et al.
1989).
tat t u stio
The goal of this experimental study employing a pre-and
post-intervention design is to identify the amount of
information recalled from the comparison of two educational
programs in an acute care setting to patients' diagnosed
with COPD. The results of this study will be analyzed to
answer the question:
w e on sta
3 1" 1! °_ '_ '. .llli a. . t 0 e
t' s'
of kngwlggge measured two weeks post-discharge?
17
Ernetnesis
Hypothesis: Pulmonary education taught in the acute care
setting employing three staged separate teaching
interventions will lead to a higher level of pulmonary
information than a single teaching intervention as measured
two weeks after discharge.
We
The following is a list of terms that are utilized in
this research study:
Patient with COPQ: A patient who is diagnosed with
emphysema, or chronic bronchitis or asthma and under medical
treatment for that condition.
Kgggtgggg: Knowledge is defined in this study as
information or input processed cognitively by the patient
that can be recalled accurately in future situations.
ngtning: Learning is a change in human disposition or
capability that persists over a period of time and that is
not simply attributed to processes of growth (Gagne, 1977).
thnge_1n_§ngg;ggge: A higher level of knowledge concerning
pulmonary information as indicated by an increase in the
post-intervention scores that is statistically significant
as compared to the pre-intervention scores prior to the
teaching intervention.
139 Weeks Pgst Qisgharge: A time frame of two weeks from
the discharge of a patient diagnosed with COPD, who
18
participated in this study, to the completion of the
post-test.
Pulmonary Information: Factual information taught from the
American Lung Association Video and Booklet entitled, "Help
Yourself to Better Breathing” for the experimental group.
Computerized discharge instructions for patients with a
respiratory disease from the protocol at the acute care
setting taught to the control group.
A. One Stage Intervention: Computerized Discharge
Instructions given to the patient as per protocol of the
acute care setting, lasting approximately twenty minutes.
B. Three Stage Intervention: Information taught over three
twenty minute teaching sessions.
Fit§t_§§§§1gn: Video is shown and printed booklet is given
to the patient.
Sgggng_§§§§ign: Printed booklet is discussed with the
patient.
Thizg_§g§§19n: Information is reviewed with the patient and
questions answered.
Stu
Limitations of the study include the following:
(1) The small number of patients participating in the
study due to local availability result in data
which are not generalizable to the larger
population.
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
19
The study sample is a convenience sample.
Pre-intervention may affect the post—
intervention scores and therefore affect the
internal validity.
The content taught in the teaching interventions
has not been tested in previous studies.
The physiological effects of hypoxemia and
hypercapnia on patients diagnosed with COPD may
interfere with cognition and responses on the pre
intervention and post intervention test.
Potential exists for investigator bias since the
investigator administered patient teaching. The
investigator was not present when consent was
requested, pre-intervention and post-intervention
tests administered, or random assignment made.
There is no control for other teaching that may
occur (i.e., respiratory therapists, doctors,
nurses).
No control for maturation across test time.
No control for post-test environment.
Assumptions pt the Study
For the purpose of this study the investigator makes
the following assumptions:
(1) Pulmonary education is an important component in
the acute care setting concerning their knowledge
level.
20
(2) Patient education is the first step for the
patient with a chronic disease, such as COPD,
to stay in the community longer and help the patient
regain some control of his life.
(3) The process of learning can be adequately
reflected by the comprehension of information that
was presented.
(4) Completion of the post-intervention two weeks post
hospitalization will adequately reflect recall of
information.
e w ers
This research study is organized into six chapters.
Included in Chapter I are an introduction, background of the
problem, statement of the problem, purpose of the study,
definition of terms, hypothesis, limitations and assumptions
for this study.
The conceptual framework and how the conceptual
framework relates to the problem under study is delineated
in Chapter II.
In chapter III a review of current literature that is
relevant to the research question, methodology,
instrumentation, and statistical analysis is incorporated.
Methodology and procedures are described in Chapter IV.
Included in this chapter are descriptions of the research
design, sample population, setting of the study,
21
instrumentation, data collection procedures, and scoring
procedures.
Research findings are presented in Chapter V. A
summary and interpretation of results of this study along
with implications for nursing practice, education and future
research are presented in Chapter VI.
Chapter II
CONCEPTUAL FRAMEWORK
Introduction
The conceptual framework upon which this study is based
is developed from Imogene King's theory of Goal Attainment
and the three interacting systems. The concept of a higher
level of information following preventive education for the
patient with COPD incorporates the perception and
interaction of both the nurse and the patient. Perception
and interaction are basic to King's theory of Goal
Attainment.
The following will address how King's conceptual
framework and the Theory of Goal Attainment interfaces with
pulmonary education for the patient diagnosed with COPD.
KING'S THEORY OF GOAL AIIAINMENI
Imogene King's nursing theory is comprised of three
systems: social, interpersonal, and personal (King, 1981).
According to King's theory, the nursing process involves the
development of a relationship between the patient and the
nurse that is goal directed toward health (Levine et al.
1988).
THE SOCIAL SYSTEM
The social system is considered central in that.
individuals' function in the social system is aimed toward
22
23
achievement of a common goal (Chinn & Jacobs, 1983). The
social system can be viewed as the suprasystem within which
other systems exist. King defined social systems as "...an
organized boundary system of social roles, behaviors, and
practices developed to maintain values and the mechanisms to
regulate the practices and rules.” Examples of social
systems given by King include families, religious groups,
educational systems, work systems and peer groups (King,
1981).
The acute care setting, for the purpose of this study,
will be viewed as social system. It is within this setting
that the nurse and the patient interact to achieve the
common goal of health education.
There are five concepts relevant to the social system as
defined by King, they are: 1) organization, 2) authority,
3) power, 4) status, and 5) decision making. Organization
is characterized by structure that orders positions and
activities. In addition, organization relates to formal and
informal arrangements of individuals and groups to achieve
personal and organizational goals (George, 1985). The
patient with COPD is admitted into an acute care setting
(the organization). The patient assumes a dependent role
and is dependent on the organization for his well-being.
The organization has a two-fold goal, to restore the patient
to optimal health and to educate the patient regarding his
disease.
24
Authority is characterized by observable provisions of
order, guidance and responsibility for actions, universal,
essential in formal organizations, reciprocal because it
requires cooperation, resides in the holder who must be
perceived as legitimate, situational, essential to goal
achievement, and associated with power (George, 1985).
According to King, authority is essential to the achievement
of goals. Authority functions to assure role expectations
and performance in a position.
Legitimate authority is essential for the registered
nurse to practice and is granted through the state in which
they practice. The authority given to the nurse by the
state's license allows that nurse to initiate the
educational process for the patient with COPD and follow
through with the process if there is mutual and reciprocal
cooperation between the nurse and the patient.
Power is closely related to authority. Power according
to King is seen in the role one enacts and in the position
one occupies. Power is defined as a process whereby one or
more persons influence other persons in a situation (King,
1981). Power is the capacity or the ability of a person or
a group to achieve health education through motivation and a
readiness to learn. The educational goal is the personal
power of the patient. The nurse also has the power to
educate and through education help in changing health
behaviors. The nurse and the patient form a dyad. The dyad
25
may incorporate either positive or negative power. Positive
power is mutual and goal setting: while negative power is
singular and negates the goal.
status according to King is defined as the position of
an individual in a group. Status is related to who you are
and what you do and how it is achieved (King, 1981). The
patient with COPD accepts the status of patient and learner.
The nurse accepts the status of health educator.
Decision-making is goal directed. There are at least
three components in every decision according to King, they
are: 1) the process, 2) the decision maker, and 3) the
decision is made.
Decision is defined as a process of choosing one
alternative from many based on facts and values,
implementation of the decision, and evaluation of the
achievement of goals. The nurse must make the initial
decision to evaluate the patient with COPD for educational
needs. Once the evaluation has been completed, the nurse
approaches the patient with the option for health education,
specifically, pulmonary education. Both the nurse and the
patient are involved in mutual goal setting and evaluation
of the goal.
In summary, the social system utilized for this study
is the acute care setting. The five concepts related to the
social system are partially incorporated within this study.
The organization (acute care setting) has a two fold goal to
26
restore the patient to optimal health and to educate.
Authority is granted to the registered nurse by the state's
licensing board to practice within the organization and to
initiate the educational process. Both the nurse and the
patient have power to accept or reject health education as
they form a dyad. The nurse accepts the status as nurse and
the patient accepts the status of learner. The nurse must
make the initial decision to evaluate the patient with COPD
for educational needs and approach the patient with this
option. The patient must decide to accept or reject health
education.
e o s
Interpersonal systems are formed by two people
interacting. Two interacting individuals form a dyad, three
a triad and four or more form a small group. As the number
of interacting individuals increase so does the complexity
of the interactions (George, 1985). There are five concepts
relevant to the interpersonal system, they are:
1) interactions, 2) communication, 3) transaction,
4) role, and 5) stress (King, 1981).
Interaction is characterized by values which influence
transactions and goal achievement (King, 1981). The process
of interactions between two or more individuals represents a
sequence of verbal and nonverbal behaviors that are goal
directed. Each individual in the situation brings their own
personal knowledge, needs, goals, expectations, perceptions,
27
and past experiences that influence the interactions (King,
1981).
Both the nurse and the patient with COPD bring into the
interaction their own set of needs, goals, expectations,
perceptions, and past experiences. How the nurse and the
patient interact will influence the outcome of the
educational process. The behavior of one individual will
affect the behavior of the other. For a positive
interpersonal relationship to occur participation is
required from both the nurse and the patient. Hopefully,
through a positive interaction, learning will occur and
increased level of information will be facilitated.
Communication is the informational component of
interaction. Communication is the interchange of thoughts
and opinions among individuals, and is influenced by a
person's goals, needs and expectations (King, 1981). A
human being is considered an open system that has continuous
communication with his environment and plays an integral
part in the process of information that is given and
received.
Communication is divided into intrapersonal and
interpersonal systems. Intrapersonal communication is the
information that is received through the sensory neurons,
processed, and the reactions occur through the motor
neurons. Any disturbance in this internal system may
interfere with the social system (King,1989).
28
Intrapersonal communication can also be defined as
nonverbal communication. The patient with COPD admitted
with acute exacerbation of the disease experiences a
disturbance in his internal communication. Hypoxia and
hypercapnia lead to fatigue, irritability, and defective
judgement.
Interpersonal communication is viewed as face to face
interaction of two or more individuals (King, 1981). This
communication can be verbal or nonverbal. Interpersonal
communication is the informational component of all human
interactions in the interpersonal system. Symbols for
verbal communication are provided by language and include
the spoken and written word (King, 1981).
Educational materials need to be evaluated for the
patient diagnosed with COPD. The information should be
printed without distortion of medical terminology and should
be clear with a distinct meaning. The spoken word may not
be remembered but the written word is a permanent record.
King noted that ninety percent (90%) of information
used in determining attitudes and feelings are derived from
nonverbal behavior. Touch is a very important aspect of
nonverbal behavior, along with distance, posture, facial
expression, physical appearance and body movement (George,
1985). The nurse needs to bring not only the knowledge and
skills for the educational process: but also needs to be
29
aware of nonverbal communication, such as the absence or
presence of touch, posture and facial expression.
"Learning takes place when communication is effective
(King, 1981).” In every interaction verbal and nonverbal
communication takes place between the patient and the nurse.
The perception of distance and disinterest by either the
patient or the nurse may lead to a non productive
relationship. On the other hand, the perception of
interest, openness and listening may lead to a therapeutic
environment. King states that "all behavior is
communication."
Transaction is defined by King as the process of
interactions in which human beings communicate with the
environment to achieve goals that are valued (King, 1981).
Communication is a component of transaction. A dyadic
interaction exists between the nurse and the patient when
there is an exchange of ideas and mutual goal setting.
King defines role as a set of behaviors expected when
occupying a position in a social system. Roles and
procedures define rights and obligations in a position and
in an organization. Roles are also interactions in specific
situations with one or more individuals interacting in a
specific situation or purpose (King, 1981).
Nursing assumes the role of educator for the patient
with COPD, while the patient assumes the role of learner.
Both the nurse and the patient through their mptpg1_gpp;§
30
expect a higher level of knowledge acquisition through
repeated educational exposure.
Stress is defined by King as a dynamic state whereby an
individual interacts with the environment to maintain
balance for growth, development, and performance, which
involves an exchange of energy and information between the
person and the environment for regulation and control of
stresses. The nurse can help the patient reduce stress in
the educational format by the following:
1) mutual planning with the patient:
2) determination of patients motivation to learn:
3) personalization of educational outcomes in terms of each
patients environment and goals: .
4) observation of behavioral clues from the patient
during the teaching session and follow through with
those clues:
5) helping the patient to ask questions about the
information that is discussed:
6) anticipation of the patient's concerns and help the
patient to deal with them:
7) planning for realistic achievement of mutual goals.
In summary, portions of the interpersonal system are
incorporated into this study. The interpersonal system is
defined as a dyad (two people) interacting that represents
verbal and non-verbal behavior. The concepts of the
interpersonal system which are interaction, communication,
31
transaction role and stress are adapted into the framework
for this study.
WW1
.Communication as defined by King is the informational
component where there is interchange of thoughts and
opinion. Since a human being is an open system there is
continuous communication with the environment.
Intrapersonal communication which is information
received through the motor neurons may affect the patient
diagnosed with COPD. Hypoxia and hypercapnia may lead to a
disturbance in the intrapersonal system. The patient may
exhibit behaviors such as fatigue, irritability and
defective judgement. Pertinent data such as: arterial blood
gases, ear and pulse oximetry are determined prior to a
teaching intervention. Alterations in the laboratory data
may effect the cognition of the patient.
Interpersonal communication is the face to face
interaction between two people. Communication may be verbal
or nonverbal. The symbols used in this study will
incorporate the use of a video, printed booklet, computer
sheet, and spoken word. According to King, "Learning takes
place when communication is effective".
Communication is a form of transaction. A dyadic
interaction exists between the nurse and the patient when
there is an exchange of ideas and mutual goal setting. The
process of mutual goal setting is npt being studied.
32
Roles of the nurse and the patient are defined. The
nurse assumes the role of educator, and the patient assumes
the role of learner. Stress according to King, is the
interaction of an individual with the environment to
maintain balance of growth, development and performance
which involves an exchange of energy and information between
the person and the environment for regulation and control of
stress. In this study, the nurse can help the patient
reduce stress in the educational format by the following:
1. observing for behavioral clues from the patient and
follow through with those clues, if feasible within the
confines of the study:
2. helping the patient to ask questions about the
information that is discussed:
3. helping the patient through communication for a new
frame of reference in learning about his or her disease.
Imp Egtsopal System
W The individual
is characterized by the following characteristics: a social
being, a rational being, and a sentient being (King, 1981).
There are six concepts relevant to the personal system, they
are: 1) perception, 2) self, 3) growth and development,
4) body image, 5) time, and 6) space (King, 1981).
Perception is each human being's perception of reality.
Perception is the major concept of the personal system.
Perception is that which influences all behaviors or to
33
which all other concepts are related. King defines the
elements of perception as the importing of energy from the
environment and organizing it by information. Perception
also transports energy and processes and stores information.
Overt behaviors are the exporting of information (George,
1985). King further defined perception as being related to
past experiences, to concept of self and to biological
inheritance (King, 1981).
The concept of perception is important to nursing as
well as the patient. The nurse must use the concept of
perception in the data gathering and interpretation of
patient data. In addition, nurses should avoid stereotyping
patients. Our perceptions may be influenced either
positively or negatively through stereotyping.
Additionally, the perception of the patient influences how
the transaction is interpreted. Relationships between a
nurse and a patient may be influenced by perceptions and
self-esteem of both members of the dyad.
The concept of self described as a dynamic individual,
an open system, and goal oriented (King, 1981). King
accepts the definition of self by Jersild, which is :
"The self is a composite of thoughts and feelings which
constitute a person's awareness of his individual
existence, his conception of who and what he is...
(King, 1981)”.
34
Every nurse and patient have their own concept of self.
Awareness of self helps one to become comfortable with who
and what we are (King, 1981). An understanding of how the
patient with COPD perceives himself and his current health
status, will assist the nurse in the educational process.
Growth and development includes the following
characteristics: cellular, molecular, and behavioral
changes in the individual (King, 1981). King further
defines growth and development as:
"the process that takes place in people's lives that
helps them move form potential capacity for achievement
to self-actualization".
Body image is a part of each stage in growth and
development. King defined body image as the person's
perception of his own body, along with how others react to
his appearance. As experiences and perception change so
does body image.
The patient with COPD undergoes changes in both the
areas of growth and development and body image. Hypoxia and
hypercapnia affect the patient at the cellular and molecular
level, causing changes in growth and development. The body
image also changes due to disease. The nurse must keep the
patient's response to disease in mind while in the educative
process, and help the patient become an active participant
in their self-care behavior.
35
Space is defined as existing in all directions and is
the same everywhere (King, 1981). Personal space differs
from territory in that the boundaries in the former are not
visible, whereas boundaries in the latter are fixed (King,
1981).
Characteristics of space are the following: universal,
personal, situational,dimensional, and transactional. These
characteristics are based on the individual's perception of
the situation. When a patient with COPD is admitted into
and acute care setting, he leaves his own personal space and
enter's into a strange environment. Diagnostic tests and
procedures invade his personal space. The patient needs to
feel a sense of personal space in the hospital before he can
begin to assimilate information that is given to him in an
educational mode.
Time is defined by King as the duration between one
event and the occurrence of another event. Characteristics
of time include the following: time is universal,
relational, unidirectional, measurable, and subjective.
Nurses need to help the patient's with COPD with time
orientation. This can be done through the use of clocks and
calendars. Another way to help with time orientation is to
set aside specific times of the day for the educational
process: this will help the patient with the time
perspective.
36
Perception is defined by King as how each person
perceives their reality and is influenced by all behaviors.
An element of perception that is incorporated in this study
involves the importing of energy from the environment, and
the storing and organizing the information. According to
King, communication is the first step toward learning.
Therefore, the comparison of the pre and post intervention
scores from the study, will help determine if the patients
perception of the educational sessions were stored and
organized.
Growth and development according to King, includes the
following characteristics: cellular, molecular and
behavioral changes in the individual. In this study. the
determination of the presence of hypoxia or hypercapnia for
the patient with COPD by mean of the pulse and ear oximetry
and arterial blood gases by medical record, along with the
presence of oxygen when the instructional sessions are
taught will be the only measurement of growth and
development.
Body image will not be accessed in this study,
although it is important for the nurse to be aware of the
changes that occur due to the chronic lung disease for the
patients body image. The concept of self will not be
studied, but accepted that the individual is dynamic and an
open system.
37
Space will not be defined in this study. Although the
instructional sessions will occur in the personal space of
the patients room in the acute care setting.
Time according to King is the duration between one
event and another event. The teaching sessions will be
initiated after a period of twenty-four hours from the
admission into the acute care setting. The experimental
group will receive three twenty minute instructional
sessions, the timing agreed upon with the patient. The
control group will receive a one-time twenty minute
instructional session close to the discharge date.
Therefore, the timing in this study represents the
repetition of educational exposure.
The schematic representation of the hypothesis is
represented in Figure I. The basic premise of the
hypothesis, visually represented, indicates that
communication between the nurse and the patient with health
education as its goal, specifically, pulmonary education,
will lead to internalization of knowledge and therefore, a
higher level of pulmonary information over an extended
period of time.
King's adapted conceptual framework is depicted by the
circles in the model. The circles are open, meaning that
the person is an open system with their environment. The
38
1'"; |l.'llll
\
\.
5332:6800
0.33058... 3:33:00 «.95. 6232
\ soizoguzx 4/
cozmoEaEEoo
a 2.6....
4w>m4 35.5.1
_mmm:z
ezmcai
9
A moomssozz
\ 2. .hzco
/
,, 0.53.. \
flzcohéaom/
:55:
ewmthmrz Oh @2.z..8). The coefficient alpha
did decrease in the post-test and follow-up.
Reliability coefficients normally range between 0.00
and +1.00, if all item total correlations are positive. The
higher the coefficient, the more stable the measure. For
the most purposes, 0.70 or above is considered a
82
satisfactory reliability coefficient (Polit and Hungler,
1987). However, high reliability of the instrument provides
no evidence of its validity for an intended purpose: low
reliability of a measure is evidence of low validity (Polit
& Hungler, 1987).
The alternative-form method has been used in education
to estimate the reliability of all types of interventions
(Carmines & Zeller,l979). The same test is not given on the
second test but an alternative form of the intervention is
administered. Two forms of the tests were intended to
measure the same thing. The correlation between the two
forms provides an estimate of reliability (Carmines &
Zeller, 1979). A limitation of the alternative—form method
of assessing reliability is the practical difficulty of
constructing alternative forms that are parallel. The
parallel form or alternative form was not utilized in this
study and is therefore considered a limitation.
Coefficient Alpha which encompasses Kuder-Richardson 20
was used to compute the multiple-item scale in the
questionnaires utilized in this study. According to
Carmines and Zeller (1979), Cronbach's alpha (coefficient
alpha) for a test having 2 N items is equal to the average
value of the split-half coefficients obtained for all
possible combinations of items into two half tests. Alpha
can be considered a unique estimate of the expected
83
correlation of one test with an alternative form containing
the same number of items.
Validity refers to the degree to which an instrument
measures what it is supposed to measure (Polit and Hungler,
1987). According to Polit and Hungler (1987) gpntgnt
1n1id1ty is of the most relevance to individuals designing a
intervention to measure knowledge in a specific content
area. The validity question being asked is: how
representative are the questions on this intervention of the
universe of all questions that might be asked on this
subject. Experts in the content area of pulmonary
rehabilitation were called upon to analyze the items in the
Pulmonary Rehabilitation Health Knowledge Test (Hopp et al.
1989).
gpngttntt_gnligity according to Polit & Hungler (1987)
is more concerned with the underlying attribute then with
the scores that the instrument produces. The scores are an
interest as they constitute a valid basis for inferring the
degree to which the subject possesses some characteristics.
The significance of construct validity is the linkage with
theory and theoretical conceptualization.
In summary, content validity will assess how
representative are the questions on this test of the
universe of all questions that might be tested. However,
construct validity is concerned with the underlying
attribute rather than the scores. Validation of an
84
instrument is a continual process according to Polit 8 .
Hungler (1987). The more evidence that can be gathered that
the an instrument is measuring what it is suppose to be
measuring, the more confidence researchers will have in its
validity. Ideal validity for the instrument would indicate
an overall increase in test scores with client compliance as
the final outcome.
In the Pulmonary Rehabilitation Health Knowledge Test
(Hopp et al. 1989) there was no significant difference
between forms D and E (F(1,57)=0.07,'p=0.792). The pattern
of change in test scores over time was not different between
forms D and E (Time by Form interaction: Pillai trace=0.02,
F(2,56)=0.53, p=0.591). The lack of difference between form
D and E would suggest that the forms are likely to be
equivalent. There was a change in the test scores across
time that approached significance. (Pillai trace=0.61,
F(2,56)=43.98, p=0.000). The means averaged across forms
were 20.27 for the pre-test, 26.54 for the immediate
post-test, and 28.25 for the three month follow-up. When
difference between the pre- and post-test scores were
computed, they were found to be significant (univariate
F(1,57)=58.44, p=0.000). The difference between the
post-test and the three-month follow-up was also significant
(univariate F(2,57)=9.99, p=0.003). The multivariate test
for these two contrasts was also significant (Pillai trace=
In
85
0.611, F(4,112) = 43.98, p=0.000), indicating a relationship
between the variables.
W
In this research study possible threats to internal
validity are:
1. Additional teaching which may take place in the acute
care setting, other than the intervention, may be a threat
related to history of the subject.
2. sicker patients in the hospital may have a greater
chance to be in the study even though randomly assigned and
may constitute a threat relating to selection.
3. Pre-testing may effect the post-test scores.
4. Extra personal time spent with the experimental group
during the teaching process may alter the post-intervention
scores.
5. There is the possibility that the personal time invested
by the nurse-investigator may have affected the
post-intervention scores and not the teaching intervention.
There was no threat to maturation nor loss to mortality
once the teaching intervention was initiated.
Hmotbsiio
Hypothesis : Pulmonary education, taught in the acute
setting employing three separate teaching sessions, will
lead to a higher level of pulmonary information, than a
86
single teaching intervention as measured two weeks after
discharge.
s c al 5 s o t
Analysis of Covariance (abbreviated ANCOVA) was employed
to analyze data from the experiment. ANCOVA is classified
as an inferential statistical tool, and is considered the
method of choice for an experimental design that includes a
pre-intervention. The ANCOVA allows the researcher to look
at the total variation of scores after treatment (02) and to
partial out pre-intervention differences before comparing
the experimental and control groups. By using the F
intervention, it allowed one overall comparison that tells
whether there was a significant difference between the means
of the groups. The analysis of covariance decomposed the
total variability of a set of data into the following three
components:
1. the variability resulting from the independent variable
(pulmonary education),
2. variability attributed to individual differences of the
pre-intervention, and
3. all other variability not explained by the factor and/or
covariant (Polit and Hungler, 1987).
Analysis of Covariance (ANCOVA) was used as a means of
providing statistical control for one or more extraneous
variables. ANCOVA can also be used to make further
adjustments for the slight differences between groups that
87
may remain even with randomization. An example of a
Covariance for this study was educational level and length
of illness.
WWW
All participants in this study received an explanation
of purpose and goals, approximate time involved in
participation, nature of the questions encountered. There
were no apparent risks in this study, and the benefit was
exposure to pulmonary education. Confidentiality and
anonymity were maintained by the use of number coded
questionnaires that were separated from the participants
name. All data was transcribed onto the computer as raw
numbers and were analyzed in aggregate form.
A letter of explanation and consent was given to each
participant detailing the above information by a unit
secretary. If the patient consented to participate in this
study, the unit coordinator would bring the patient a
pre-intervention. The participants were then randomly
assigned to the experimental and control group through
random number by the unit coordinator. All teaching
interventions were given by the nurse investigator. The
participants incurred no expense nor was there compensation
for participating in this study.
88
The follow-up telephone call after discharge was read
from a prepared script to the participant. The following
was the script:
"Hello, this is calling from the Michigan
State University College of Nursing. I am calling to see if
you would still like to participate in the study being
conducted to assist nurses in determining how effective
their teaching is for patients with lung disease.
Your identity will remain strictly confidential at all
times. You have the right to withdraw now and your medical
care will not be affected.
If you wish to continue to participate, you will be
sent within the next few days a final questionnaire that
will require approximately thirty minutes of your time. The
questionnaire will have a self-addressed stamped envelop.
Your prompt response would be appreciated.
Do you wish to continue with this study?
Yes No
(If Yes, the address will be verified at this time:
address: Thank
you for your time and assistance.
This study was approved by Michigan State University,
Human Subjects Committee (UCRIHS), and the Ingham Medical
Center Research Review Committee (Appendix H).
89
EBEEQEY
A discussion of methodology utilized in this study was
presented in Chapter IV. A detailed discussion of the
research design, sample, collection site, collection data,
questionnaire, statistical analysis and human rights was
delineated.
In Chapter V the sample will be described in relation
to findings reported with respect to the hypothesis. The
sample will further be related to the sociodemographic and
clinical characteristics. The reliability obtained for the
measurement instrument will be discussed in relation to the
instrument developed by Hopp et al. (1989), and the current
study. Additional findings will be reported concerned with
sociodemographic, characteristics of the subjects, and
patient education.
CHAPTER V
DATA ANALYSIS
IEEIQQQELIQR
In this chapter the sample will be described in
relation to socio-demographic and clinical characteristics.
The analysis of the data will be discussed in three
sections. The first section is entitled "Results". In this
section the data will be presented in a factual manner
without interpretation. The "Results" section will be
divided into descriptive and inferential statistics.
The second section is entitled "Discussion". The
interpretation of results of the statistical procedures and
the conclusions derived from them in relation to the
research problem will be presented. The final section is
entitled ”Summary". The hypothesis that was tested will be
addressed.
RESULTS
Sample gnaractgtistics
5° . 3 l'
The sample consisted of 20 persons who were admitted
into an acute care setting with the medical diagnosis of
Chronic Obstructive Pulmonary Disease (COPD). Eight of the
subjects (40 percent) were male and twelve (60 percent) were
female. Eighteen (94.5 percent) of the subjects were
Caucasian, one subject (5.3%) was Black, and one subject was
90
91
unspecified. Three of the twenty subjects that participated
in this study were readmitted into the acute care setting
within a two month period following the completion of the
post-intervention. One participant died three months after
participating in the study. Five subjects that initially
agreed to participate after beginning the pre-intervention
questionnaire withdrew from the study. The explanation for
withdrawing consisted of statements indicating that the
questionnaire was too difficult or they were too sick to
continue with the study. All subjects who received the
mailed post-intervention questionnaire completed and
returned them within the designated time limit for this
study.
The age range of the subjects was 40-83 years with a
sample mean of 59.2 (S.D.=12.3) years. Distribution of
subjects according to age is summarized in Table 1.
Table 1
Iroouono1_ono_Eotoootooo_of_boo_zonoo_
's 'b 'o ' s =
Numbor_of_§uoioot§
40-50 6 30.0
51-60 4 20.0
61-70 6 30.0
71+ 1 2949
Total 20 100.0
92
Marital status of the subjects of the subjects were
determined and analyzed. Ten (50 percent) of the subjects
were married, one (5 percent) was single, three (15 percent)
were divorced, and six (30 percent) were widowed.
Educational level of the subjects were varied. Four (20
percent) of the subjects had a less than high school
education. Six (30 percent) of the subjects graduated from
high school. Ten (50%) of the subjects had a greater than
high school education.
:1. . J :1 ! i !l
The following sample characteristics were analyzed to
determine the severity of disease for the subject
population. The following categories were included in the
pre and post intervention questionnaire: length of disease,
frequency of hospitalization within the past twelve months,
frequency of medical visits to the physician before
admission, emergency visits within the past twelve months
and after discharge, hours of oxygen use before and after
admission, oxygen flow rate before and after admission and
length of hospital stay.
Length of time the subject was diagnosed with COPD is
described in years. The range is from 0.25-17.5 years with
a sample mean of 4.39 (S.D.=1.82). Frequency and
percentages for length of disease is summarized in Table 2.
93
Frequency of hospital visits over the past twelve
months range from none to five with a sample mean of 2.3
(S.D.- 1.4). Summary of the data is presented in Table 3.
Table 2
MW
w =
Years Eroouonol Percentage
0.25 1 5.0
0.75 3 15.0
1.50 1 5.0
4.00 4 20.0
7.50 3 15.0
12.50 4 20.0
17.50 2 1219
Total 18* 90.0
*Two "no answer" responses.
Table 3
e o Hos V t
s v nt 8 n=20
Etoouonox New e s b'ec s W
None 0 0.0
1st 8 40.0
2nd 3 15.0
3rd 3 15.0
4th- 4 20.0
5th 1 EIQ
Total 19* 95.0
*One "no answer" response.
94
Visits to the physician over the past twelve month
period ranged from 1-7 visits with a sample mean of 5.1
(8.0.: 1.5). Summary of the data is presented in
Table 4.
Table 4
Iroooono2_ano_Eoroontaoo_of_£nxeioian_Yioits
_Root_TEolxo_Montho_lnszol
Etoouooox Number Eotoootooo
One 1 5.0
Three 2 10.0
Four 2 10.0
Five 6 30.0
Six 6 30.0
Seven 1 lttg
Total 20 100.0
Visits to the Emergency Room over the past twelve month
period ranged from 1-7 visits with a sample mean of 3.2
(8.0.82.6). Summary of the data is presented in Table 5.
Table 5
Etegnengy nnd 2gpc§ntage of ER Visits
3 =
Erosuonox Numoor_of_§ooioot§ Bertontooe
None 1 5.0
One 7 40.0
TWO 1 5.0
Three 3 15.0
Four 4 20.0
Six 1 5.0
Eight 3 1512
Total 20 100.0
95
Visits to the Emergency Room after discharge from the
acute care center post-intervention ranged from none to one.
Summary of the data is presented in Table 6.
Table 6
Reasons! moor Rotoontooo
None 17 85.0
One 1 5.0
Three 1 5.0
Five ; imp
Total 20 100.0
s o ' '5
Oxygen use at home prior to admission ranged from none
'to twenty-four hours. Fourteen subjects (70%) did not use
(oxygen prior to admission. The remaining 30% consisted of
«one (5%) subject used for twelve hours, one subject (5%)
used for twenty-two hours and four (20%) used for twenty-
four hours a day.
en sa a e ter 8
Oxygen use after discharge ranged from none to twenty-
fiour'hours. Twelve patients (60%) did not use oxygen. One
(5%) used for twenty hour a day while seven (35%) used
tWentynfour hours a day.
w ' 'ss'o
Oxygen flow rate prior to admission ranged from one to
‘three liters. One individual (5%) used a one liter flow
96
rate. Four individuals (20%) used a two liter flow rate and
one (5%) used a three liter flow rate.
Qz2son_Ilon_Eato_Aftor_niooharso
Oxygen flow rate after discharge ranged from one
subject (5%) used a one liter flow rate, five (25%) used a
two liter flow rate and two (10%) used a three liter flow
rate.
Length of stay was analyzed for the study sample. The
length of stay ranged from less than five days to thirty
days with a sample mean of 7.85 (S.D.= 5.89). The data are
presented in Table 7.
Table 7
‘QL‘IC 2 ,". ‘ 1" 0 1‘1. ! ' 17' . . -. I-..
.Ezoouonox Humoot_of_§uoioots Eoroontooo
<5 Days 8 40.0
6-7 Days 2 10.0
8-10 Days 2 10.0
11-15 Days 4 20.0
16-20 Days 1 5.0
21-30 Days _3_ ;§, 0
Total 20 100.0
e t ' i s e ast Education x osu s
The following sample characteristics were analyzed to
determine nistpry pt pnst gdncntipnn; exposures tetntgd t9
Ithug_gingnp§i§_pt_ggzp. The following categories were
iszluded in the pre and post intervention questionnaire:
97
1. education regarding the diagnosis of COPD over the past
twelve months,
2. sites where clients received education related to COPD,
3. was the past education was helpful.
The frequency of education concerning the diagnosis of
COPD over the past twelve months indicated that 10
individuals (50%) had npt received educational exposure.
The remaining 50% of the individuals had from one to more
than five educational sessions. The data are presented in
Table 8.
Table 8
Epggnengy and Egpggntngg pf COED Edugntion
s e ve o t n= 0
Eteouonor Maggots Woo
None 10 50.0
One 1 5.0
Two 3 15.0
Three 1 5.0
Six or more _1 aptp
Total 19* 95.0
* One "no answer" response.
Egpgntipngl Sitgg ngpttgg gs nglptnl
The respondents reported specific sites as most helpful
when learning about COPD. Ten patients (50%) reported that
taleey had n9 educational opportunities. Four patients (20%)
fcnand the physician's office as most helpful, two (10%)
anJnd the hospital most helpful, one (5%) reported the
98
clinic as most helpful, one (5%) reported the Breather's
Club as most helpful, and one (5%) reported "other" as most
helpful.
were not recorded as helpful.
Educational exposures ranged
indicating no exposure, to eleven
Visiting Nurses and the American Lung Association
from nine patients (45%)
(55%) of the subjects
engaging in one or more educational opportunities. The data
are presented in Table 9.
Table 9
‘eL" I. .. g e c e e .01: _‘ es 0
v s 'ss'o =
Site kimono}; Eeroontooo
None 9 45.0
Hospital 4 20.0
Doctor's Office 4 20.0
Clinic 2 10.0
Visiting Nurses 2 10.0
Breather's Club 3 15.0
American Lung Association 2 10.0
Other 2, 1pm
Total 28* 140.0
* Multiple educational sites.
'1' . '. .me -_s i s-ss-o 'or to eachino .1 -_ -1 'o:
The following clinical parameters were assessed while
in the acute care setting Wtoaohioo
Wign-
fol lowing data was determined:
1.
The patient's chart was reviewed and the
the use and flow rate of the oxygen,
99
2. room air oxygen level,
3. partial pressure of carbon dioxide in arterial blood,
4. oxygen saturation level either in arterial blood or
through pulse oximetry, and
5. the presence or absence of family during each teaching
intervention.
The physiological parameters measured for inclusion
criteria are differentiated between the subgroups are
presented in Table 10.
Table 10
WW
u ' s ' e =
Enable Emu neon __.Qe_.5t v oases
Room Air Oxygen Control 1.30 1.34 10
Experimental 1.20 1.32 10
Total 1.25 1.29 20
Oxygen Saturation Control 3 . 40 1 . 72 10
Measured In Experimental 4 . 90 2 . 33 10
Hospital Total 4 . 15 2 . 87 20
Partial Pressure Control 2 . 10 1 . 72 10
of Carbon Dioxide Experimental 2 . 50 1 . 58 10
Total 2.30 1.62 20
OXygen Use In Control 2 . 50 1 . 78 10
HOSpital Experimental 2 . 20 0 . 42 10
Total 2.35 1.26 20
\
\
100
The physiological parameters that were measured for
inclusion criteria for this study are presented in Table 11.
Table 11
WW
_InolooiomtritotiLmzzol
NEEDQI EQIQEBLQQE
No Data 9 45.0
40-49 1 5.0
50-59 7 35.0
60-69 2 10.0
70-79 1 .QLQ
Total 20 100.0
ommiatorotion
No Data 5 25.0
50-59 2 10.0
60-69 0 0.0
70-79 1 5.0
80-85 2 10.0
86-92 6 30.0
93-94 3 15.0
95 l 5,9
Total 20 100.0
W).
No Data 5 25.0
24-34 5 25.0
35-45 6 30.0
46-55 2 10.0
56-60 ; ;O.Q
Total 20 100.0
WM].
None 1 5.0
1 Liter 1 5.0
2 Liters 13 65.0
3 Liters 3 15.0
5 Liters 1 5.0
6 Liters 1 549
Total 20 100.0
101
Wagon
The presence of family during the teaching
interventions for control and the experimental group was
recorded after each teaching intervention. Two (10%) family
members were present during a portion of the teaching
interventions. Three (15%) family members were present
during the entire intervention and 15 (75%) had no family
members present during the teaching intervention.
't a u t'o P s 's
The following sample characteristics were determined to
assess additional teaching interventions after discharge
post-intervention: taught about COPD after discharge, and
Visiting Nurse access after discharge.
Eleven (55.0%) of the subjects did npt receive
Iadditional teaching about COPD after discharge from the
lmospital. Three patients (15%) received information from
Five individuals (25%) received
the Visiting Nurse .
One (5%) specified
iraformation from the physician's office.
"crther” as an additional source of information about COPD.
E ! H' 'l' H E ! E' 1
Access to Visiting Nurses after discharge post-
Thirteen (65%) subjects did not
111t:ervention was analyzed.
Three (15%) had a
hEVe a visiting nurse after discharge.
visiting nurse twice after discharge, and four (20%) had
four visits from a visiting nurse.
102
The differentiation of the control and experimental
group for the pre-and post intervention scores are presented
in Table 12. The data shows that both the control and
experimental groups increase their mean scores, however, the
experimental group had a slightly greater increase in the
mean score .
Table 12
pgsctiption of Subgtpnps to;
re- a d os - e ent'o s
lotioolo otouo Moan m. Ease
Scores for Pre- Control 23.4 6.32 10
Intervention Experimental 25.9 6.21 10
Total 24.6 6.23 20
Scores for Post- Control 28.0 4.54 10
Intervention Experimental 32.0 5.85 10
Total 30.0 5.50 20
Summary
The descriptive findings in the study population were
Presented in the previous section. The descriptions of the
sample were presented according to sociodemographic
'Vfllciables. Mean and standard deviations for physiological
and pre- and post-intervention scores were delineated.
103
BoliooiutLomiootionnaite
Cronbach's Alpha was utilized to determine the
reliability of the Pulmonary Rehabilitation Health Knowledge
Test (Hopp et al.1989). The final form of the Pulmonary
Rehabilitation Health Knowledge Test had a high internal
consistency (Cronbach's alpha - 0.86).
Thirty Nine of the forty items were tested. Item #21
was eliminated due to five no answer responses. The
reliability coefficient for the thirty-nine items was alpha
=0.82. Due to the low number of subjects (n=20) a factor
analysis could not be performed to explore the knowledge
questionnaire for dimensionality.
W
The research question and data will be presented in
‘this section along with associated data. The Pearson Product
Moment Correlation was the statistical technique utilized
for obtaining correlations among the study variables. The
CKDrrelation coefficient was utilized to calculate the degree
and direction of relationships between variables.
o u e e ion
The correlation (r) of the sample variables of age,
Past education, length of time since diagnoses of COPD,
Previous educational exposures within the past twelve months
Prior to admission, oxygen saturation and room air oxygen
104
levels during the admission in the acute care setting was
calculated.
In reference to the study variables listed above only
the length subject was diagnosed with COPD, and the oxygen
saturation correlated at a statistically significant level
of p-.05. Summary of correlational data are presented in
Table 13.
Table 13
Egnpspn Bppdngt Momgnt Cortelntion o: Snmplg to:
' nos w’ C D Satu
YatiLblo Qorrolation Siouifioonoe
lengtILoiaonosod
flitn QOPQ
Pre-Intervention -.05 p = .419
Post-Intervention -.28 p = .135
Knowledge Difference -.26 p = .145
W
Pre-Intervention -.31 p = .093
Post-Intervention -.06 p = .395
Knowledge Difference .38 p = .049
The Pearson Correlation Coefficient was
calculated to determine if there was a correlation between
the number of places the subject received previous
educational opportunities and which educational exposures
were significant. The data for a one-tailed significance
for the educational sites that were significant among the
study variables are presented in Table 14.
105
Table 14
g J !i E H .! J 3 :1. .
V' ' - - e =
VntiapLQ oorrolation signifioanoo
Hospital
Pre-Intervention .61 p = .002
Post-Intervention .56 p = .005
Clinic
Pre-Intervention .36 p = .061
Post-Intervention .42 p = .033
The data in Table 14 indicated that both the clinic and
hospital were highly correlated with the pre- and post-
intervention scores. The hospital teaching scores were most
significant.
The Pearson Product Moment Correlation Coefficient was
further calculated to determine if the relationship between
the number of educational exposures the subject received was
significant pre and post intervention. Pre and post-
intervention scores were significant. Pre-intervention was
.51 (p=.011): post-intervention was .51 (p=.012): while the
knowledge difference was not significant at -.10 (p=.340).
-W n s's V r'anc
A One-Way Analysis of Variance was computed to
determine the difference between the group means of pre-
intervention knowledge scores, post-intervention knowledge
scores and the knowledge difference between scores. The
106
difference between the mean scores of knowledge pre and post
intervention with the knowledge difference is presented in
Table 15. The data indicates that the within group
variation is greater than the between group variation.
Table 15
'1‘ W :1- ‘ .: 0 ‘- '- ce 0 D ‘ ‘1 ' 31‘ .“1
Moan_Sooroo_Eor_2ro:_ano.2oot_lntorxontion_and
MW
Sooroo m neoreoeof Moon I
_a__noeVr1a mores freedom Smog Ratio Prob
Wagon
Knowledge Scores
Between Groups 31.25 1 31.25 .795 .384
Within Groups 707.30 18 39.30
Total 738.55 19
Postlntonontion
Knonleggg stomps
Between Groups 80.00 1 80.00 2.92 .105
Within Groups 494.00 18 27.44
Total 574.00 19
Between Groups 11.25 1 11.25 .642 .433
Within Groups 315.30 18 17.52
Total 326.55 19
Analysis of Variance was further computed on the
-covariates. The number of places that a subject received
education prior to the intervention and if they had been
taught within the past twelve months were analyzed in
relation with the pre, post and knowledge level difference.
The data presented in Table 16 indicates that when the
107
covariates were statistically controlled the covariate
accounted for a significant amount of the variance. The mean
for the number of educational opportunities statistically
improved from pre- to post-intervention but were not
significant for the adjusted knowledge difference.
yarionoo Sonoroo Eroooom fioooro Ratio E
grog
Covariates 218.76 2 109.38 3.187 .070
# of Places 184.83 1 184.83 5.385 .035
Taught/12 mo 17.57 1 17.57 .512 .485
Main Effect 4.53 1 4.53 .132 .132
Group Effect 4.53 1 4.53 .132 .132
EQ§L_IDIEIEQDLLQB
Covariates 179.27
2 89.63 4.216 .035
# of Places 137.78 1 137.78 6.480 .022
Taught/12 mo 6.41 1 6.41 .302 .591
Main Effect 49.49 1 49.49 2.327 .148
Group Effect 49.49 1 49.49 2.327 .148
e
Covariates 3.83 2 1.92 .103 .903
# of Places 3.45 1 3.45 .186 .673
Taught/12 mo 2.75 1 2.75 .148 .706
Main Effect 24.06 1 24.06 1.295 .273
Group 24.06 1 24.06 1.295 .273
108
2312§§_I:I§§§
A Paired-T test was computed on the Grand Mean to test
the means of the knowledge score of the means for pre and
post intervention. The data are presented in Table 17 and
shows that the total post-intervention scores were higher
than the total pre-intervention scores with a two-tailed
level of significance at .000.
Table 17
Paired-T Test for Comparison of Grand Means
Pre- and Post-Intervention Knowledge Scores (n=20)
Earioolo noon 8:91.0o21 otoo_§rror
Knowledge
Post-
Intervention 30.00 5.496 1.229
Knooloooo
Pre-
Intervention 24.65 6.235 1.394
Difforonoo_luoonl fiool_2o_1 §LQl_Error
.35 4.146 .927
1218195 6 Doorooo_of_£roooom 2-tail Prob.
5.77 19 .000
s o d o
Beggargn_ggg§§iggz Is there a difference between one stage
and three stage educational format taught in the acute care
setting to patients diagnosed with Chronic Obstructive
109
Pulmonary Disease on patient's level of knowledge measured
two weeks post-discharge?
Hypothesis; Experimental group will have a higher test
score than the control group two weeks
after discharge.
null_flypotng§1§: There is no difference between the
experimental and control group in test
scores two weeks after discharge.
Wis
The Pearson Correlation Coefficient (r) was computed to
determine if the relationship between study variables were
statistically significant. The following study variables
were significantly related to knowledge scores. Oxygen
saturation (.38, p=.049) was significantly related to the
knowledge difference scores. The number and type of places
scores were significantly related to pre-intervention (.51,
p=.011) and post-intervention (.51, p=.012) knowledge
scores, however, the knowledge level difference was not
significant (-.098, p=.340). The types of educational
exposure that were significantly related to knowledge scores
included the hospital and clinic educational settings. The
hospital scores were significantly related to knowledge
scores pre-intervention (.61, p=.002) and post-intervention
(.56, p=.005). The clinic scores were significantly related
to knowledge scores only at post-intervention (.42, p=.033).
110
An Analysis of Variance was computed to detect existing
differences between the group means of pre- and post-
intervention knowledge scores and the knowledge difference.
The within group differences was greater than the between
group differences in the pre-intervention knowledge (between
group: 31.25, within group: 39.29) and knowledge difference
scores (between group: 11.25, within group 17.52). However,
for the post-intervention scores, the within group variance
was lower than the between group variance (between group:
80.00, within group: 27.44). Therefore, the between group
variation was greater than the within group variation for
the pre-intervention scores and knowledge difference scores,
indicating that the groups overlap to a large extent. The
between group variance was greater than the within group
variance in the post-intervention scores indicating that the
means of the groups must be different.
Analysis of Covariance was computed to determine if the
covariates (number of places and taught within past twelve
months) reduced the variability found in the post-
intervention scores. The mean scores on knowledge tests for
number of places (educational sites) (p=.035) were
significant pre-intervention with the Grand Mean 24.68. The
mean scores for number of places (educational sites)
(p=.022) improved statistically post-intervention with the
Grand Mean (30.26). However, the knowledge difference
adjusted between groups of number of places (p=.673) and
111
taught within the past twelve months (p=.706) were similar
with the main group effect (p=.273).
While the effect is in the expected direction, with the
experimental group increasing in knowledge scores, the
effect is not statistically significant. Therefore, it can
not be concluded with confidence that the experiment if
repeated would provide the same results.
Further, a paired T-test was computed to determine the
mean difference (5.35) between the control (24.65) and the
experimental (30.00) means. The t value was 5.77 with 19
degrees of freedom with the two tail probability is
significant at .000. However, the two-tailed test is a
nondirectional hypothesis test and is not as powerful as a
one-tailed (directional) test because it has a smaller
region of rejection (Porter & Hamm, 1986).
The increase in the knowledge scores from the pre-
intervention to post-intervention is highly significant for
the total sample. However, from the previous results, the
difference between the increase in knowledge scores for the
control and experimental group is net significant.
Therefore, h s s s cce ted an
eltezgetive hypotneeis is rejected.
DI§§Q§§lQE
The discussion section is categorized into four primary
areas: (1) findings concerning socio-demographic
112
characteristics of the study sample, (2) findings concerning
clinical characteristics of the study sample, and (3)
findings concerning the hypothesis.
1' -- 01c:.1i . ,. o-t‘uu: 1. ;._1 e.1s ' ~
The average sample population was Caucasian, female, 59
years of age, married, with a greater than high school
education.
E' ll ; i Eli . ] fl ! i !i
Severity of disease for the study sample included the
following data. The participants had been diagnosed with
COPD for an average of four years. Medical access over the
past twelve months prior to the present admission included
the following: subjects visited the emergency room an
average of three times, were admitted into an acute care
setting twice and saw the physician approximately five
times. Thirty percent of the study sample used home oxygen
prior to admission.
Half (n=10) of the study sample had not received past
educational opportunities over the past twelve months. The
remaining 50% (n=10) of the sample indicated educational
sites attended and which sites were the most helpful (Tables
8 and 9). sites ranked in descending order of most helpful
included: physician's office, hospital, clinic, Breather's
Club. Visiting Nurses and American Lung Association were
not indicated as helpful.
113
Physiological data of the study sample (Table 10),
while in the acute care setting, indicated that the average
room air oxygen level was between 50-59 mm Hg. Oxygen
saturation was between 86-92%, and the partial pressure of
carbon dioxide was between 35-35 mm Hg. Nineteen of the
twenty participants used oxygen while in the acute care
center.
Post-intervention teaching after discharge indicated
that eleven subjects (55%) did not receive additional
teaching. Nine individuals receiving additional teaching
from the following sites: physician's office (n=5),
visiting nurses (n=3), and one unspecified.
a o 8
Analysis of Variance computed on the mean scores pre-
and post-intervention indicated that the within group
variation was greater than the between group variation.
After the covariates (number of places and taught) were
statistically controlled there was not a significant
difference between the control and experimental group
(Tables 15 and 16).
A paired T-test indicated that the Grand Means for the
post-intervention (30.00) scores were greater than the pre-
intervention (24.65) scores, and statistically significant
at .000 (Table 17). However, from the previous results, the
114
difference between the increase in knowledge scores for the
experimental and control group was net significant.
EQMEABX
A description of the study sample in relation to socio-
demographics, clinical characteristics, and tests to
determine the validity of the hypothesis was presented.
The hypothesis to test if there was a difference
between the control and experimental group pre- and post-
intervention two weeks after discharge was rejected. The
null hypothesis was accepted.
A discussion of the study findings and the implications
of findings for nursing practice and future research will be
presented in Chapter VI.
CHAPTER VI
SUMMARY AND IMPLICATIONS
mien
In Chapter VI the study findings will be discussed and
summarized. The implications for nursing practice and
nursing eduction will be discussed and recommendations for
nursing research will be presented.
Windlass
An experimental design utilizing a pre- and post-
intervention format was employed to test for differences in
patient learning resulting from two teaching methods.
Change in learning was measured using the Pulmonary
Rehabilitation Knowledge Test (Hopp et al.1989). The test
was given to the participants before the interventions and
two weeks post-discharge. The 40-item self-administered
knowledge test measured knowledge in fifteen rehabilitation
topics. The final form of the instrument had a high
internal consistency (Cronbach's alpha = .86).
Thirty-nine of the forty items were utilized for
analysis. Item #21 was eliminated due to five no answer
responses. The reliability coefficient for the thirty-nine
items was alpha = 0.8166.
The mean scores for the pre-intervention control group
was 23.4 with a standard deviation of 6.32 (n=10). The mean
115
116
scores for the pre-intervention experimental group was 25.9
with a standard deviation of 6.21 (n=10). The mean scores
for the post-intervention control group was 28.0 with a
standard deviation of 4.54 (n=10). The mean scores for the
post-intervention experimental group was 32.0 with a
standard deviation of 5.85 (n=10).
Hopp et al. (1989) reported an approximate increase of
four and one-half points from the pre-test to the post-test
scores in prior research. This is consistent with this
study's data for the control group at 4.6 points. However,
the experimental group in this study increased their scores
by 6.1 points.
Data were collected from twenty patients admitted with
a diagnosis of Chronic Obstructive Pulmonary Disease, aged
40-83. Data were analyzed using Pearson Product Moment
Correlations, Analysis of Variance and Covariance, Paired T
test, and descriptive statistics. There was 39 significant
difference between the control and experimental group after
the covariates were statistically controlled.
The paired T-test indicated that the grand means for
the post-intervention scores were greater than the pre-
intervention scores and were statistically significant at
.000. However, from the previous results, the difference
between the knowledge scores was get significant.
The improved knowledge of the subjects may not be due
to any specific teaching module but through the interaction,
117
transaction of mutual goal setting, and the communication
that existed between the nurse and the patient. Nursing
interventions should be directed toward supporting patient
learning thus fostering patient compliance. Additionally,
the role of the Clinical Nurse Specialist offers an
opportunity for anticipatory guidance in assisting the
client to develop a new frame of reference for positive
growth in health maintenance and develop a knowledge base
for pre-existing disease states.
Deecziptete e; the Stedy gemple
c ' 'cs
A summary of the sociodemographic characteristics of
the study sample and comparison of these characteristics to
those of other research findings will be presented.
Age. The mean age of the study participants was 59.2
years with a range of 40 to 83 years (Table 1) with some
concentration of subjects in the 40-48 and 61-68 age groups.
Although a lower age limit of 40 years was specified in this
research study, no potential subjects were encountered.
Potential subjects were not included, however, because they
were older than 83 years. These findings were consistent
with the studies by Sahn et a1. (1980), Perry (1981), and
Heringa et al. (1987) whose mean age were reported between
60 to 61 years of age. Rubinfeld et a1. (1988) and Clough
et al. (1987) reported a younger age mean of 40.4 years and
53.4 years respectively. Howard et al. (1987) reported a
118
slightly older age mean of 63 years. Milazzo (1980)
reported a more narrow age range, however, no mean ages were
defined.
fiex. Female participants comprised the greater
proportion (n=12, 60%) of the sample in this study and is
net consistent with previous researchers who have studied
COPD populations. Sahn et a1. (1980), Milazzo, (1980), Perry
(1981), Heringa et al. (1987), and Howard & Davies, (1987)
had a male population of greater than 87%. Clough et al.
(1987) study population consisted of 52% male and 48%
female. Rubinfeld et a1. (1988) had a even distribution of
males and females.
Metitel fitet_e. Half of the participants were married
in the study sample, the remaining 50% comprised single
(5%), divorced (15%), and widowed (30%). Only one
investigator (Howard 8 Davies, 1987) reported marital
status, the data consisted of a slightly higher proportion
of married (57%) to widowed (13%), 6% were separated, and
11% divorced.
Bace 0; Ethnic Backgtound. The majority of the sample
population was Caucasian (94.5%), one subject was Black (5%)
and one subject was unspecified. No other specific racial
or ethnic background was specified. Two other studies
included race as a descriptor. Howard 5 Davies (1987)
studied 115 COPD patients, 96% were Caucasian, 4% Blacks and
one American Indian. Rubinfeld et a1. (1988) studied 263
119
Asthmatics, 95% of the subjects were Anglo-Australian and
the remaining 5% was not specified.
Egneetienel_fieekgzenng. Half of the study sample had a
greater than high school education. The remaining 50%
consisted of 30% with a high school education and 20% with
less than high school education. However, less than high
school was not further subdivided. Past studies included
education as an inclusion criteria Heringa et al.(1987)
minimum of a sixth grade education, and Milazzo (1980) with
a minimum of an eighth grade education. Rubinfeld et a1.
1988 described the study population with 19% receiving
tertiary education and 29% with a secondary education, the
remaining 52% was unspecified. Clough et al. 1987 stated
that the sample population was well educated with 42% high
school graduates and 15% college graduates.
In summary, subjects in this study were female and
ranged in age from 40-83 years with a mean age of 59. Half
of the subjects were married with a greater than high school
education and were predominately Caucasian.
Subjects in this study were similar in age to patients
in three other studies but averaged seven to nineteen years
older in two other studies and four years younger in one
study. The predominance of Caucasian subjects is consistent
with the two studies that used race as a descriptor. This
study sample contained more females than reported in
previous studies of COPD populations except for one study
120
where the results were evenly distributed. The marital
status of this study is slightly lower in the ratio of
married to widow than the study reported by Howard & Davies
(1897). Educational background was slightly lower than
Clough et al. 1987 where 57% of the sample had a greater
than high school education. Education was listed as
inclusion criteria and one study (Rubinfeld et al. (1988)
that described tertiary and secondary education in 48% of
the study sample. Sociodemographic characteristics except
for a slightly higher female population are comparable to
previous studies using COPD patients as a study sample. The
increase in the female population found in this study sample
may be related to the increase in exposure to respiratory
irritants such as smoking.
QliniQ§l_§h§I§Q£§I1§£iQ§
Severity of disease was determined for this study
sample by length of time diagnosed with disease, frequency
of hospitalization within the past twelve months, frequency
of visits to the physician, and emergency room within the
past twelve months and hours of oxygen usage prior to the
pre-intervention (Tables 2-7).
Previous research characterized severity of disease in
two studies each employing different criteria. Sahn et al.
(1980) and Perry (1980) categorized respiratory impairment
with pulmonary function tests. Rubinfeld et a1.(1988)
defined asthma severity as moderate severity if the subject
121
had six or more episodes per year and were healthy between
attacks. Chronic asthma was defined as an inability to
work.
Criteria for severity of disease employed in this
thesis was not found in previous literature. The study
sample was diagnosed with COPD ranged from 0.25 to 17.5
years with a sample mean of 4.39 (S.D.=1.82). Applying the
data from the mean statistics, the following data can be
interpreted regarding the severity of disease for the study
sample. The study sample visited the hospital twice a year,
however, for eight of the twenty subjects this was their
first admission. The physician was seen five times per year
and visited the emergency room three times prior to the pre-
intervention. Upon discharge from the hospital, 85% of the
subjects did not visit the emergency room within two weeks
but 15% of the subjects used the emergency room from one to
five times. Fourteen (70%) of the subjects did net use
oxygen pre-intervention while twelve (60%) subjects did net
use oxygen post-intervention upon discharge. The average
length of stay was 7.85 days in the acute care setting with
a standard deviation of 5.89. Of the sample population five
(20%) of the twenty patients were re-admitted into the acute
care setting within a two month period from discharge and
one subject died.
In summary, the study population on the average had
been diagnosed for four years, visited the physician five
122
times per year, the hospital twice, the emergency room three
times. Thirty percent of the subjects used oxygen prior to
admission and forty percent of the subjects used oxygen
after discharge. Fifteen percent of the subjects visited
the emergency room from one to five times within two weeks
post-discharge. Diagnostic Related Groups (DRG'S) impose
limitation in duration of hospitalization. Secondary to
these limitations one methodological difficulty which arose
in this study involved a greater likelihood that more
severely ill subjects would be hospitalized long enough to
be randomly assigned to the experimental group.
MM
Half of the study sample did net receive education
regarding COPD over the past twelve month period (Tables 8-
9) prior to the pre-intervention. The remaining 50% of the
participants engaged in one or more educational
opportunities and utilized the hospital and physician's
office as the most frequent setting for education regarding
their disease. Four (20%) of the subjects found the
physician's office as most helpful while two (10%) of the
subjects cited the hospital as most helpful. However, the
visiting nurses and the American Lung Association were not
included as helpful by the participants.
Previous studies (Perry, 1980: Stockdale-Wooley,
1984,; Clough, et a1. 1987; Howard, & Davies, 1987:
Rubinfeld, et al. 1988) included past education as a
123
descriptor of the study. However, Rubinfeld, et al. 1988
equated past educational material on asthma with higher
scores than those subjects who had not such exposure. The
findings of Rubinfeld is consistent with the findings of
this thesis, however, when past educational exposure was
used as a covariate, there was no statistical significance
between the control and experimental group scores (Tables
15-17).
W
The study sample's physiological inclusion criteria
(Appendix A), indicated that the majority of the
participants room air partial pressure of oxygen (Pa02) was
between 50-59 Torr (35%). The oxygen saturation was between
86-92% (30%). The partial pressure of carbon dioxide
(PaC02) was between 35-45% (30%). Nineteen of the twenty
patients used oxygen while in the acute care center with
thirteen (65%) using a 2 liter flow rate (Tables 10-11).
Physiological data was not found in the studies reviewed.
ToaohinLPooLQioohomo
Eleven (55%) of the participants did net receive
additional education post-discharge. This is consistent
with the data previously mentioned regarding educational
opportunities pre-intervention. Of the nine participants
that received additional educational reinforcement, three
(15%) received information from the visiting nurse, five
(25%) from the physician's office, and one unspecified.
124
Instrument
The Pulmonary Rehabilitation Knowledge Test by Hopp
J.W., Lee, J.W., & Hills, R., (1989) was used as the
instrument to determine knowledge for pre- and post-
intervention scores (Appendix D & E).
The questionnaire was a forty question self-administered
test initially taken after consent was given and latter two
weeks post-discharge at home.
The instrument had a high internal consistency
(Chronbach's alpha = 0.86) and the tested instrument had a
reliability coefficient of 0.82 for thirty-nine questions.
Question #21 was eliminated due to five no answers. There
was an increase from the pre-test to the post-test scores
for the study data which remained consistent with the
reported validity of the instrument.
on i s ate 0 st t
The study sample was asked to complete all questions
even if unsure of answer. Several trends were noted among
the participants. The abbreviation for Chronic Obstructive
Pulmonary Disease (COPD) used in question #10 was not
understood by a majority of the subjects, due to five no
answers, this question was eliminated. The questions that
asked about sexual activity were not answered by three
participants (Question #5) and one participant (Question
#31). The questions regarding sexual activity were
125
scribbled out in one questionnaire and another wrote "I'm a
widow".
Readability of the questionnaire appears to be greater
than a fifth grade level. An example of readability is
question #39 that asks,"What is visual imagery?". There
were two "no responses" to that question. The responses of
the participants that withdrew from the study indicated that
the questionnaire's vocabulary was difficult for a lay
person.
The majority of "no response" questions were scattered
through out the questionnaire, it is the opinion of this
investigator, that the unanswered questions was an
indication of lack of knowledge in those areas. The majority
of ”no response" questions clustered around controlled
breathing (Questions #12, #14, #15, #16) and anatomy and
physiology (Questions #24, #26). The instrument dealt with
a multitude of issues but little reflection upon functional
ability of the client.
Methodologically, the instrument attempts to measure
multifaceted construct (knowledge of COPD) without benefit
of multiple items to reflect the varied dimensions of the
construct (such as; exercise, medications, anatomy, etc).
In summary, the instrument utilized for this study
appeared to be written with a readability level greater than
fifth grade with terminology that was not understood by all
participants. The "no response" questions were clustered
126
around questions concerning controlled breathing and anatomy
and physiology which may indicate a lack of general
knowledge in those areas. Methodologically, the instrument
attempts to measure a multifaceted construct without benefit
of multiple items to reflect the varied dimensions of the
construct.
It is the recommendation of this researcher, that the
instrument is not appropriate in the acute care setting. It
failed to capture the essence of knowledge for the patient
diagnosed with Chronic Obstructive Pulmonary Disease when
admitted with exacerbation of the disease. The length of
the questionnaire appeared to tire the participants as well
as the terminology and readability. Testing knowledge in the
acute care center should be limited to areas that pertain to
the immediate health and well being of the patient instead
of pertaining to multifaceted questionnaire. The
multifaceted construct was too varied from one question on a
specific subject to multiple questions on a different
subject. Further testing would be appropriate in the out-
patient arena with specific attention given to the
readability and vocabulary of the questionnaire.
W
The research question stated in this study was:
Is there a difference between one stage and three stage
educational format taught in the acute care setting to
127
patients diagnosed with Chronic Obstructive Pulmonary
Disease on patients' level of knowledge measured two weeks
post-discharge?
W
The research hypothesis is stated and is followed by
the findings of this study in relation to the hypothesis. A
brief discussion of study findings in relation to expected
relationships is presented.
Hyeetheeie: Pulmonary education taught in the acute care
setting employing three separate teaching interventions will
lead to a higher level of pulmonary information than a
single teaching intervention as measured two weeks after
discharge.
o e s: There is no difference between a single
and three teaching interventions on a higher level of
pulmonary knowledge when taught in the acute care center.
Analysis of variance computed on the mean scores of the
pre- and post-intervention indicated that the within group
variation was greater than the between group variation which
indicated that the null hypothesis was true.
There was no statistical significance between the mean
scores of the pre-intervention to post-intervention scores
after the covariates (number of places and taught) were
statistically controlled for the control and experimental
group (Table 13-14).
128
A paired T-test indicated that the grand means for the
post-intervention (30.00) scores were greater than the pre-
intervention (24.65) scores, and were statistically
significant at .000 (Table 15). However, from the previous
results, the difference between the increase in knowledge
scores for the experimental and control group was net
significant. Due to the small sample size and the results
of the statistical data the alternative hypothesis is
rejected and the null hypothesis is acdepted for this study
sample.
Milazzo (1980) indicated a positive relationship when
health learners received formal education. Health learners
exhibited a greater knowledge with formal education than
those who received informal teaching. Heringa et al. (1987)
concluded that there was a change from pre-test to final
performance scores with a significantly higher score for
those participants who had structured education
(experimental group) compared to nonstructured education
(control group) (p=0.05). The mean knowledge score
improvement for both the experimental group (p=0.015) and
control group (p=0.033) that was statistically significant.
Rubinfeld et a1. (1988) noted that the subjects with past
exposure to educational material on asthma showed higher
scores than did the subjects who had not received exposure.
In summary, the analysis of variance indicated that
there was no difference between the pre-intervention and the
129
knowledge difference scores. However, there was a
difference in the post-intervention scores. Furthermore,
when the covariates were statistically controlled, there was
no statistical difference between the pre- and post-
intervention scores.
The increase of the mean pre-intervention scores over
the post-intervention scores, as determined by the Paired-T
test, indicated that both groups did learn from the teaching
interventions. This interpretation is consistent with
previous research (Milazzo, 1980: Heringa et al. 1987:
Rubinfeld et al. 1988) that indicated a positive
relationship from pre-test scores to post-test scores and
that past educational exposure indicated higher post-test
scores (Rubinfeld et al. 1988). The results of this research
indicates that the increased frequency of educational
exposure regardless of the teaching format increases the
likelihood of patient learning.
It is the opinion of this researcher that although this
research did not meet statistical significance, the fact
that the increase in scores occurred in all subjects
following instruction is of great elinieel significance.
The increase in scores may net be attributed to the variety
of educational format taught, however, the significance in
this research may be attributed to eemnnnieetiene teeeineee
Wandmmmwm
exent. The interaction that occurred between the nurse and
130
the patient fostered a learning environment. The nurse
researcher had a vested interest in teaching each
participant the course material appropriate for each group.
The participant knew the expectations of the study prior to
consent. The interaction that occurred within this research
influenced the transaction and subsequently, goal
achievement was attained. This concept is consistent with
King's conceptual framework.
Repeated exposures to education appears to successfully
link learning to each new exposure based upon the patient's
need at that time. It is the individual who must accept the
responsibility for learning and ultimately compliance.
Additionally, it appears that it is not the amount of time
the nurse spends with the client for each educational
session that is significant but the quality of the time
through repeated exposures in a teaching-learning context
that is paramount for successful learning. Therefore,
learning to be most effective needs to include instruction
in ways to supplement the patient's own learning needs,
resulting in increased assumption of the responsibility of
self-care.
W
The null hypothesis was accepted and the alternative
hypothesis was rejected for this study sample. The
connotation of this data indicates that there was no
difference in learning between a single teaching
131
intervention and three separate teaching interventions for
this study sample. However, the grand means did indicate an
increase from the pre-intervention to the post-intervention
scores which is consistent with previous research findings.
Furthermore, it is not the mode of educational format that
is significant for learning to occur but frequent
communication between the nurse and client.
' t ons 0 th ud
Limitations of this study may have effected the
possibility of obtaining statistically significant
relationships include:
(1) Sample size was originally intended to be forty
subjects. However, due to Diagnostic Related Grouping
effect on hospitalization, the severity of disease
of the subject population, and the difficulty with the
questionnaire, a sample size of twenty (n=20) was
obtained.
(2) A convenience sample was obtained from an acute care
setting in a college city. Therefore, the results in
data may not be generalized to a larger population.
(3) The instrument utilized in this study has not been
widely used in research.
(4) The content taught in the teaching interventions
had not been tested in previous studies.
(5)
(6)
(7)
(8)
(9)
132
Pre-intervention testing may have affected the post-
intervention scores.
The physiological effects of hypoxemia and hypercapnia
on patients with COPD may interfere with cognition and
testing responses on the pre- and post-intervention
scores. Attrition occurred with three patients who
originally consented to participate in the study. The
patients withdrew once they began to answer the
questions in the initial questionnaire. Statements of
"being to tired", "unable to concentrate" were the
explanation for declining to participate.
The potential existed for investigator bias since
the investigator administered patient teaching.
The educational and reading level of the study sample
was diverse, however, the sample was randomly assigned.
There was no control for concurrent teaching while the
study participants were in the acute care center
(respiratory therapists, physicians, registered nurses,
etc.).
(10) There was no control for the post-test environment.
RECOMMENDATIONS AND CONCLUSIONS
Implications for nursing practice, nursing education
and future nursing research based upon the results of this
study will be presented in the following section with a
focus on King's conceptual framework that was adapted for
this thesis. Conclusions that are derived from this study
133
are included in this section with a discussion of the
findings.
W
In Chapter II of this study a conceptual model was
presented for health education which was adapted from
Imogene King's conceptual framework. The basic premise of
the hypothesis was that health education will lead to
internalization of knowledge and therefore, lead to a higher
level of knowledge was net statistically validated by this
study. However, the grand mean post-intervention scores
where significantly higher than the pre-intervention scores.
It is recognized that the statistical significance is not
conclusive based on the data from the Analysis of Variance
and Covariance.
Nevertheless, certain recommendations can be made for
nursing practice that are elinieelly_eignifiieent. These
recommendations are derived from the empirical data which
demonstrated that it was not the quantity of time spent
during each teaching session which was significant, but
rather the number of times in which the patients were
exposed to the data which increased their awareness.
Additionally, the mutual goal setting that occurred within
the dyadic transaction between the nurse investigator and
the study participant, may have fostered a climate for
readiness to learn.
134
The following recommendations are made which
incorporate the role of the CNS in advanced practice and
King's conceptual framework. According to King (1981 p.75),
" nursing care involves knowledge of communication with
usage of communication skills with a variety of
individuals". King states that communication is the
informational component of interaction. It is through the
intrapersonal and interpersonal communication that the
interchange of thoughts and ideas occur. The inescapable
conclusion of the empirical data is that education without
interpersonal communication is ineffective.
One of the roles of the clinical nurse specialist is
that of teacher, while teaching is a separate role, it
cannot be separated from the other CNS roles (Menard, 1987).
The role of teacher is the primary role of all nurses, but
has a special meaning for the CNS (Menard, 1987). The CNS
brings clinical expertise in the health teaching and health
assessment arena. Through anticipatory care in the primary
care setting the CNS provides health maintenance and health
teaching as an aspect of care.
Incorporating the roles of teacher and advocate, the
Clinical Nurse Specialist in primary care, can mobilize a
support network that is conducive for increased client
responsibility for self-care. The health care team,
including the client, works in a self-directed collaborative
'model utilizing joint accountability. An inference from this
135
research study tends to indicate that including the client
in joint decision-making or mutual goal setting will
increase learning and possibly enhance compliance. The
Clinical Nurse Specialist will need to continually assess
the client's level of knowledge and monitor behaviors in a
collaborative framework. Ultimately, focusing upon joint
accountability, the client will need to assume
responsibility within the health care team and for their own
responsibility for self-care.
Communication within the health care team is essential
to the realm of health education as is expressed in King's
conceptual framework. From the data promulgated through the
descriptive statistics of this study it becomes apparent
that the more exposure the client has to health education
the greater the value of adjunct exposure. This is
congruent with Gagne's definition of learning that is used
in this thesis which states that "Learning is a change of
human disposition or capability that persists over time and
is not simply attributed to growth" (Gagne, 1977).
The CNS working in a primary care setting has the
opportune moment to initiate health teaching. Based on the
findings of this study, 20% of the participants received
health education from the physician's office, and rated this
arena as the most helpful. It is at this time when the
client is not as physiologically or psychologically
136
compromised that anticipatory guidance in health care and
health maintenance can be effective.
The research data inferred from this study encompasses
communication, mutual goal setting and repeated exposure to
learning. The Clinical Nurse Specialist incorporating a
case-management framework within a primary care setting will
enhance the likelihood of assimilation of knowledge and
mastery of skills that are inherent for client self-care
through communication, mutual goal setting and providing
repeated avenues for learning concerning the clients' health
needs.
Case-management within the primary care environment
permits the Clinical Nurse Specialist an opportunity to
provide continuity between the acute care center, the
community and the provider. Communication to the support
network in the community regarding the client either via
telephone or letter provides reinforcement of the mutual
goals that have been agreed within the collaborative process
and plan for ongoing follow-up communication.
The clinical nurse specialist may elect to booster
teaching sessions across the chronicity of the disease and
incorporate family teaching to augment learning. The
frequent teaching sessions is congruent with the findings of
this study and previous research. However, the clinical
nurse specialist must be cognizant of the psychological
status of the client when planning to augment learning.
137
Factors to consider in this process include: age, family
support systems, time of day that the teaching is offered,
what effect the additional knowledge may have on the clients
daily life, fear of a specific teaching intervention (such
as testing), and additional psychological and physical
"baggage” that the client or nurse educator brings into the
transaction that may enhance or hinder readiness to learn.
Additionally, the rapport that may or may not develop
between the client and the nurse educator may effect
readiness to learn.
Learning may be augmented through the use of video
tapes and written material as determined from the results of
the instrument data. The CNS may elect to teach during or
after the health care visit or initiate a content or process
group based upon the needs of the clients in their primary
care practice. Instruments such as, the Pulmonary
Rehabilitation Health Knowledge Test by Hopp et al. (1989)
may provide the CNS with valuable insight into their
client's knowledge level. Based upon the data from similar
instruments that test the clients knowledge, the clinical
nurse specialist may determine a need for additional
teaching for a specific disease process. However, it is the
opinion of this researcher that the Pulmonary Rehabilitation
Health Knowledge Test is not appropriate for testing in the
acute care setting and additional testing is needed to
determine if this test is too general for the needs of the
138
client diagnosed with Chronic Obstructive Pulmonary Disease
in the primary care setting.
The clinical nurse specialist in advanced practice has
the opportunity to coordinate the teaching of the client and
provide continuous, comprehensive, holistic care. As the
client advocate, the clinical nurse specialist has the
opportunity to provide the additional impetus for health
education in the current frugal fiscal environment of
Diagnostic Related Group reimbursement and provide follow-up
care.
”Under the Medicare program, the home health benefit
reimburses only for intermittent skilled services required
in the acute and subacute phases of an illness or injury
(Jackson & Johnson, 1988)." Therefore, skilled teaching that
requires the client to be aware of signs and symptoms of a
disease and therapeutic self-care instructions must be done
during the acute and subacute phase of the illness with
follow-up in primary care.
Additionally, it is during the period that the client
is hospitalized (acute phase) and the two week (subacute)
interval post-hospitalization that supplementary teaching
and learning should occur. The clinical nurse specialist in
the primary care setting should coordinate with the CNS in
the acute care setting and in the home health setting to
augment additional teaching so repeated teaching exposures
lead to enhanced cognition. It is also essential that the
139
need for teaching be documented on the referral form for the
Visiting Nurses or other home health agencies to assure that
the teaching and reimbursement for the teaching will occur.
A serendipitous finding related to the timing of
discharge instructions is clinically significant. Nineteen
of twenty subjects received their teaching interventions
prior to the day of discharge and the nineteen subjects
improved their post-intervention scores. However, the one
subject received a one-time intervention (control group)
approximately two-hours prior to discharge and did not
improve their post-intervention score, in fact, scored three
points less. The inference of this serendipitous finding to
clinical practice is the presentation of educational or
informative information prior to discharge from an acute
care setting or prior to closure of an office visit. The
likelihood of retention will be greater if the client is
less stressed concerning closure of an event.
In summary, it is through communication that all phases
of learning originate, and it is through learning that
retention, recall and acquisition of knowledge activates the
possibility of behavioral change. Although behavioral change
always remains, in the final analysis, a matter of
individual and personal choice, the possibility of change is
present only when alternatives, and the basis for those
alternatives are known only when effectively taught.
140
Effective didactics occurs through consistent repetition and
exposure.
The CNS needs to become an effective educator utilizing
teaching-learning theories and methodologies in adapting a
conceptual framework for their practice.
W
In this study patient learning was addressed. The
difference between a one time intervention and three
separate interventions was analyzed. Based upon the results
of this study, there appeared to be little difference
between multiple interventions and a single intervention
when repeated past exposures was removed as a covariate.
However, learning appeared to have occurred that was not
attributed to the intervention which is clinically
significant.
Undergraduate and graduate nursing students need to
focus on outcomes of care. According to the Michigan Peer
Review Organization criteria of April, 1989, adequate
discharge instructions need to be given to the patient or
"significant other". There also needs to be documentation
that the patients understood the discharge instructions. If
these and other criteria are not met the hospital will be
sanctioned. By the implementation of teaching and its
documentation, the acute care center both enhances the
141
learning opportunity of the client and safeguards against
financial sanctions during chart audits.
In these days of decreasing nursing populations and
increasing nursing demands, the requirement of additional
client instruction may seem to be an impossible task.
Effective instruction, however, is not accomplished
primarily by long sessions. Rather, it is accomplished by
repetitive short sessions. Two minutes of instruction
repeated five times is twice as effective as two ten minute
sessions, and is accomplished in half the time. Repetition
of the basics, not long lectures, leads to client retention.
For purposes of achieving documentary compliance with
Federally mandated outcomes, the charting of each short
instructional session verifies institutionally the teaching
component required under existing law. Accordingly, the
frequent short sessions not only are more effective for the
individual, they are also more effective with the
institutional time constraints in providing educational
exposure for the client.
In summary, education for the undergraduate and
graduate nurse must include an understanding of patient
outcomes and the financial sanctions that may occur if
proper documentation of teaching is not achieved.
Additionally, that frequent short educational sessions not
only are more effective for the individual, but also more
effective for the institution. It is the opinion of this
142
investigator, that required courses in education be mandated
for all levels of nursing education to assist the nurse in
the rudiments of delivering a concise and well-delivered
approach to patient education.
ImoliootioanoLNursinlBosoaroh
There are several implications for nursing research
derived from this study. They are described below.
1. Replicate the same study with a larger sample
population that is more diverse, socially, ethnically, and
educationally in order to increase the generalizability of
the findings and enhance the statistically significant
correlations.
2. Use of a video only as a single intervention compared to
a three step intervention that would include video, written
material and personal teaching to determine if there is a
difference in teaching format and patient learning.
3. Replicate the study with a different instrument. Test
pre-knowledge and gear the intervention to the pre-knowledge
deficits and gear knowledge to behavior change.
4. Additional research should be instituted on the amount
and type of educational exposure patients with chronic
diseases utilize and how it relates to patient education.
5. A longitudinal study could be implemented for newly
diagnosed COPD patients who have had not previous COPD
143
educational exposure that would incorporate outcomes such as
changes in behavior rather than test knowledge.
6. Evaluate the difference in learning between a content
group for COPD teaching and individual teaching sessions
using a different tool.
7. A longitudinal study for clients with a chronic disease
geared at family support systems and it's relationship to
acquisition of knowledge and behavioral change.
8. Replicate the study in a primary care setting with a
patient population other than COPD diagnosed with a chronic
disease to observe if changes vary according to setting.
9. Stricter control of the amount of time that the
participant completes the questionnaire. There should be a
maximum length of time for the completion of the pre-
intervention questionnaire in the acute care setting.
10. Incorporation of a standard clinical measure to
determine severity of disease. There is incongruence between
this study and other studies in the determination of disease
severity. A standard clinical measure will help determine a
more specific inclusion criteria for further research geared
toward patient education and learning.
11. Further research is needed to identify if knowledge
acquisition will lead to behavior changes and compliance
with health regimen assessing motivation and the ability to
learn.
144
12. Attrition occurred after the beginning of the pre-
intervention questionnaire. Comments similar to "I'm to
tired” or "I'm to sick" were the explanation for withdrawal
from the study. However, none of the participants withdrew
once the pre-intervention was completed and all post-
intervention questionnaires were returned via mail within
the specified time limit.
13. Inclusion criteria incorporating oxygen saturation of
less than or equal to 93% was too rigid. Not all clients
diagnosed with COPD experience oxygenation difficulties in
the acute care setting. A preferred method for inclusion
criteria would be determination of the Pulmonary Function
Test. Use of the pulmonary function testing would evaluate
the purely mechanical ability of the client with regard to
ventilation.
14. King's conceptual framework incorporated for this study
remains applicable for further research involving client's
acquisition of knowledge. Mutual goal setting was not
included in this pilot study but should be incorporated into
further studies. The inference of this data indicates that
mutual goal setting may have lead to the participants
readiness to learn.
15. Participants point of optimum readiness to learn is an
area needed to be assessed in future research.
145
16. Reassessment and reinforcement of client learning in
the realm of behavioral change for patients diagnosed with a
chronic disease is an avenue for subsequent research.
17. Utilizing King's conceptual framework to ascertain if
transaction or the interaction that exists between the nurse
educator and the client is what facilitates acquisition of
knowledge or a combination of interaction and transaction.
18. A standardized severity of disease indicator needs to
be delineated for future research when dealing with patients
diagnosed with a chronic disease.
19. Timing of discharge instructions in the acute care
setting and retention of information after discharge is
indicated based upon the serendipitous findings of this
research study.
Summary
In Chapter VI a summary and interpretation of study
findings was presented. Findings were related to the
conceptual framework of this study. Recommendations for
nursing practice, education and research were delineated.
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APPENDIX A
SCREENING CHECKLIST
0h- 4!. 7 0; '; N 0 s! G 0 11!. '1; NS D
(Name, address, and telephone number to be destroyed after
return of post-test).
NAME
RESPONDENT ID NUMBER
ADDRESS
TELEPHONE
POST-TEST MAILED TO SUBJECT
POST TEST RECEIVED (DATE)
clix
RESPONDENT ID NUMBER
ADMITTING DIAGNOSIS
LENGTH OF STAY
DISCHARGE DATE
OXYGEN SATURATION (ROOM AIR)
PULSE
EAR
ABG
USING OXYGEN:
YES
NO
OXYGEN FLOW RATE
SATURATION ON OXYGEN
PCOZ
TEACHING INFORMATION:
CONTROL GROUP:
YES
NO
FAMILY PRESENT DURING TEACHING?
LENGTH OF TEACHING
EXPERIMENTAL GROUP:
YES
NO
FAMILY PRESENT DURING TEACHING?
clx
LENGTH OF SESSIONS:
#1
#2
#3
DAY 10 POST DISCHARGE
TELEPHONE CALL MADE TO ASCERTAIN CONTINUED PARTICIPATION:
YES, WILL CONTINUE
NO, WILL NOT CONTINUE
QUESTIONNAIRE MAILED OUT
QUESTIONNAIRE RECEIVED
YES
NO iF NO, RECALL PARTICIPANT
NO RESPONSE WITHIN 21 DAYS THE PARTICIPANT IS DISQUALIFIED:
YES
NO
DATE ENTERED INTO COMPUTER
IDENTIFYING DATA DESTROYED
clxi
APPENDIX B
LETTER OF EXPLANATION
This letter is to introduce you to a study which is being
conducted by Rosemary Zivic, R.N., a graduate student in the
Michigan State University College of Nursing.
This study' is. being conducted. to assist nurses in
determining how effective their teaching is for patients with
a lung disease. Through this study nurses may gain a greater
understanding of how they may best help people learn about
chronic lung disease.
Participation in this program will require approximately
one hour of your time in the hospital, and twenty minutes at
home. You will be asked to complete a survey asking questions
about yourself and your knowledge of chronic lung disease.
After the survey, you will be given an instructional session
at your convenience while in the hospital. Approximately ten
days after discharge, you will be sent a questionnaire in a
self-addressed stamped envelop to return as seon as possible
to Rosemary Zivic R.N.
Whether or not you participate in this study, or“withdraw
from it after you begin it, your medical care will be
unaffected. There is no physical risk to you.
Your identity will be kept strictly confidential; your
name will never be used in the study nor released to any one.
Your privacy will always be respected.
Please sign the attached consent if you are willing to
participate in this study. A summary of the results of the
study will be made available to you upon completion of the
clxii
study at your request. Should you have any questions either
before, or after, you sign the consent, please call me at 334-
2391.
Sincerely yours,
Rosemary C. Zivic R.N.
Graduate Student, MSU College of Nursing
clxiii
APPENDIX C
CONSENT
INFORMED CONSENT TO PARTICIPATE IN PULMONARY TEACHING STUDY
I, , consent to participate in the
nursing study, "The effects of pulmonary teaching on patients
in the acute care setting." This study is being conducted by
Rosemary C. Zivic R.N., a graduate student at Michigan State
University, College of Nursing. The purpose of this study
is to assist nurses in. determining’ how’ effective their
teaching is for patients with lung disease. This information
may benefit nurses and patients by providing a better
understanding of how nurses may best help people understand
chronic lung disease. As a participant in this study I
understand that:
1. After I sign this consent form, I will be asked to
complete a questionnaire on my knowledge of chronic
lung disease and will be asked some information
about myself. I understand that all my responses
will be strictly confidential.
2. There will be two teaching groups and that
participants will be assigned to one of the groups.
I will be randomly assigned to either the control
or experimental group. I
will be informed after the study into which group
I was placed.
3. I will receive information regarding chronic lung
disease while in the hospital. My family may be
clxiv
present at that time.
I will receive a telephone call from the nurse
researcher approximately ten days after discharge.
This telephone call will remind me of the study and
that a questionnaire is being mailed to me. I have
a right to withdraw from the study at this or any
other time without penalty.
The final questionnaire will be mailed to me with
a self-addressed stamped envelop with instruction
for completion.
My identity will remain anonymous. All responses
will be analyzed as group data and no individual's
responses will be identified in any written reports
of this research.
At the end of the study, the nurse investigator‘will
send me the correct answers to the first and final
questionnaire along' with information concerning
community education programs for pulmonary disease.
I understand that my participation in this study is
voluntary and that I am free to withdraw from
participation at any time by telling' the
investigator. There will be no penalty should I
choose to withdraw from the study, and refusal to
participate will not affect my care that I
receive.
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9.
10.
I specifically consent to Rosemary C. Zivic R.N.
having access to my medical records and the use by
her of information disclosed in the questionnaire
which I will answer, provided, that my name may not
be disclosed to any other person, institution, or
governmental agency, but may be used for statistical
purposes only.
Should I have any questions about this study, or
decide to withdraw, I can contact the investigator,
Rosemary Zivic at (517) 334-2391.
Participant's signature Date
Investigator's signature Date
If you are interested in receiving a written summary of the
results obtained in this study please check the box below:
( ) Yes, please send me study results
( ) No, I am not interested
Please mail to:
each participant
investigator file (will be kept separate from data)
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APPENDIX D
PRE-INTERVENTION DEMOGRAPHIC
QUESTIONNAIRE
INITIAL COPD QUESTIONNAIRE
This study is being conducted by Rosemary C. Zivic, R.N. ,
a graduate student in the Michigan State College of Nursing.
This study is being conducted to assist nurses in
determining how effective their teaching is for patients with
a lung disease. Through this study nurses may gain a greater
understanding of how they may best help people learn about
chronic lung disease.
Please try to answer ell of the questions. Check the
one correct or best answer for each question. If you are
unsure about the correct or best answer, answer with your best
guess. Please check only ene answer for each question. This
questionnaire should take approximately thirty minutes of your
time.
Do net put your name on the questionnaire so your answers
cannot be identified to you. There will be some questions
about yourself at the end of the questionnaire. I understand
that some of the questions are personal, so I want to
emphasize that your answers will be kept strictly
confidential. Eleese yait to fill out this gnestionnaire
until yeu ere elone ane net interrupted.
Thank you for taking part in this study. Hopefully, it
will help nurses better understand how to help people with
chronic lung disease.
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PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS TO THE BEST OF
YOUR ABILITY - W-
41. What is your marital status? Please check one
answer.
Married
Single, never married
Separated
Divorced
Widowed
42. When were you born? Please fill in the date.
43.
44.
45.
46.
47.
(month) (day) (year)
(Optional Question) What is your racial or ethnic
background? Please check one answer.
White/Caucasian
Black
Hispanic/Mexican American
Oriental
Other
What is the higheet level of education you have
completed? Please check one answer.
less than high school
High School graduate
more than high school
How long have you been diagnosed with COPD?
Please check one answer.
less than 6 months
7 months-1 year
13 months-2 years
3-5 years
6-10 years
11-15 years
longer than 15 years
How frequently have you been taught about Chronic
Lung Disease in the past twelve months? Please
check one answer.
NEVER
Once
Twice
Three times
Four times
Five times
More than five times.
Where did you learn about COPD? Please check e11
the appropriate answers.
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48.
49.
50.
51.
52.
I was not taught about COPD.
Hospital
Doctor's Office
Clinic
Visiting Nurses
Breather's Club
American Lung Association
Other If other, please specify
When you were taught about COPD which setting did
you find neet_he1pfpl? Please check one answer.
I was not taught about COPD.
None were helpful
Hospital
Doctor's Office
Clinic
Visiting Nurses
Breather's Club
American Lung Association
Other If other, please specify
How tregnently have you been hospitalized for COPD
in the past twelve months? Please check one
answer.
This is my first admission.
Once
Twice
Three
Four
Five
Six
Seven or more.
How many visits have you had to an emergency room
or urgent care for your COPD in the pest twelve
months?
One
Two
Three
Four
Five
Six
Seven or more.
Approximately, how many hours a day do you wear
oxygen at home?
Please write in the number of hours a day
you wear oxygen at home:(0-24).
How many liters of oxygen do you use? Please
check one.
I DO NOT use oxygen.
clxix
one liter
two liters
three liters
four liters
more than four liters.
53. How frequently have you seen your doctor over the
past twelve months? Please check one.
None.
Once in the past twelve months.
every six months.
every four months.
every three months.
every two months.
more frequently than once a month.
Thank you for completing this questionnaire. Your
responses will remain strictly confidential and your identity
will not be released to anyone. You will now be randomly
assigned to one of two teaching groups while in the hospital,
and asked to complete a questionnaire at home approximately
two weeks after discharge. You may withdraw from this study
at any time without penalty.
Rosemary Zivic R.N.
Graduate Student
Michigan State College of Nursing
FINAL COPD QUESTIONNAIRE
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APPENDIX E
POST-INTERVENTION DEMOGRAPHIC
QUESTIONNAIRE
This study is being conducted by Rosemary C. Zivic, R.N. ,
a graduate student in the Michigan State College of Nursing.
This study' is .being' conducted 'to assist. nurses in
determining how affective their teaching is for patients with
a lung disease. Through this study nurses may gain greater
understanding of how they may best help people learn about
chronic lung disease.
Please try to answer ALL of the questions. Check the
one correct best answer for each question. If you are unsure
about the correct or best answer, answer with your best guess.
Please check only ene answer for each question. This tinel
questionnaire should take approximately thirty minutes of your
time.
Do net put your name on the questionnaire so your answers
cannot be identified to you. There will be some questions
about yourself similar to the first questionnaire. Please
answer these questions in case there has been a change since
the first questionnaire.
clxxi
I understand that some of the questions are
personal, so I want to emphasize that your answers will be
kept strictly confidential. WW
9L-‘T ., 12' ' .1 - - a - a ,0; ‘ 2.92 o- 1 — 119 ‘2
Thank you for taking part in this study. Enclosed you
will find a self-addressed stamped envelop for the return of
the questionnaire. Please complete the questionnaire and
return it at your eerlieet convenience. There will be a set
of answers for both questionnaires sent to you along with
information about pulmonary education in the Lansing area at
the completion of this study.
PLEASE ANSWER ALL QUESTIONS TO THE BEST OF YOUR ABILITY.
41. How often have you been to the emergency room since yenr
leet_d_ieeherge from the hospital? Please check one
answer.
None
One
Three,
Four or more times
42. Approximately, how many hours a day do you wear oxygen
at home?
Please write in the number of hours a day you wear
oxygen. (write in number of hours: 0-24)
43. How many liters of oxygen do you use?
Please check one answer.
I DQ NQT use oxygen
One liter
two liters
three liters
four liters
more than four liters
clxxii
44. How often have you been seen by a Visiting Nurse at your
home since this peetgieeherge from the hospital? Please
check one answer.
I have net been seen by a visiting nurse.
One time
Two times
Three times
Four times
More than five times
45. Where have you received education about chronic lung
disease since your lee_t_