Volume 7 Number 1 January-March, 2015

Transcription

1 Volume 7 Number 1 January-March, 2015

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3 International Journal of Nursing Education EDITOR Prof. R K Sharma Dean (R&D), Saraswathi Institute of Medical Sciences, Hapur, UP, India Formerly at All India Institute of Medical Sciences, New Delhi editor.ijphrd@gmail.com INTERNATIONAL EDITORIAL ADVISORY BOARD 1. Leodoro Jabien Labrague (Associate Dean) Samar State University,College of Nursing and Health Sciences, Philippines 2. Dr. Arnel Banaga Salgado (Asst. Professor) Psychology and Psychiatric Nursing, Center for Educational Development and Research (CEDAR) member, Coordinator, RAKCON Student Affairs Committee,RAK Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates 3. Elissa Ladd (Associate Professor) MGH Institute of Health Professions Boston, USA 4. Roymons H. Simamora (Vice Dean Academic) Jember University Nursing School, PSIK Universitas Jember, Jalan Kalimantan No 37. Jember, Jawa Timur, Indonesia 5. Saleema Allana (Senior instructor) AKUSONAM, The Aga Khan University Hospital, School of Nursing and Midwifery, Stadium Road, Karachi Pakistan 6. Ms.Priyalatha (Senior lecturer) RAK Medical & Health Sciences University,Ras Al Khaimah, UAE 7. Mrs. Olonisakin Bolatito Toyin (Senior Nurse Tutor) School of Nursing, University College Hospital, Ibadan, Oyo State, Nigeria 8. Mr. Fatona Emmanuel Adedayo (Nurse Tutor) School of Nursing, Sacred Heart Hospital, Lantoro,Abeokuta, Ogun State, Nigeria 9. Prof Budi Anna Keliat, Department of Mental Health Nursing University of Indonesia 10. Dr. Abeer Eswi (Associate Prof and Head of Maternal and Newborn) Health Nursing) Faculty of Nursing, Cairo University, Egypt 11. Jayasree. R (Senior Teacher, Instructor H) Salalah Nursing Institute, Oman 12. Dr. Khurshid Zulfiqar Ali Khowaja (Associate Professor) Aga Khan University School of Nursing, Karachi, Pakistan 13. Mrs. Ashalata Devi (Assist. Prof.) MCOMS (Nursing Programme), Pokhara, Nepal 14. Sedigheh Iranmanesh (PhD) Razi Faculty of Nursing and Midwifery, Kerman Medical University, Kerman, Iran 15. Billie M. Severtsen (PhD, Associate Professor) Washington State University College of Nursing, USA NATIONAL EDITORIAL ADVISORY BOARD 1. Dr.G.Radhakrishnan (PhD, Principal) PD Bharatesh College of Nursing, Halaga, Belgaum, karnataka, India Dr Manju Vatsa (Principal, College of Nursing) AIIMS, New Delhi. 3. Dr Sandhya Gupta (Lecturer) College of Nursing, AIIMS, New Delhi NATIONAL EDITORIAL ADVISORY BOARD 4. Fatima D'Silva (Principal) Nitte Usha Institute of nursing sciences, Karnataka 5. G.Malarvizhi Ravichandran PSG College of Nursing, Coimbatore, Tamil Nadu 6. S. Baby (Professor) (PSG College of Nursing, Coimbatore, Tamil Nadu, Ministry of Health, New Delhi 7. Dr. Elsa Sanatombi Devi (Professor and Head) Meidcal Surgical Nursing, Manipal Collge of nursing, Manipal 8. Dr. Baljit Kaur (Prof. and Principal) Kular College of Nursing, Ludhiana, Punjab 9. Mrs. Josephine Jacquline Mary.N.I (Professor Cum Principal) Si-Met College of Nursing, Udma, Kerala 10. Dr. Sukhpal Kaur (Lecturer) National Institute of Nursing Education, PGIMER, Chandigarh 11. Dr. L. Eilean Victoria (Professor) Dept. of Medical Surgical Nursing at Sri Ramachandra College of Nursing, Chennai, Tamil Nadu 12. Dr. Mary Mathews N (Professor and Principal) Mahatma Gandhi Mission College of Nursing,Kamothe,Navi Mumbai, PIN ,Cell No.: Dr. Mala Thayumanavan (Dean) Manipal College of Nursing, Bangalore 14. Dr. Ratna Prakash (Professor) Himalayan College of Nursing, HIHT University, Dehradun Uttarakhand 15. Pramilaa R (Professor and Principal) Josco College of Nursing, Bangalore 16. Babu D (Associate Professor/HOD) Yenepoya Nursing College, Yenepoya University, Mangalore 17. Dr. Theresa Leonilda Mendonca (Professor and Vice Principal) Laxmi Memorial college of Nursing, A. J. Towers, Balmatta, Mangalore, Karnataka 18. Madhavi Verma (Professor) Amity College of Nursing, Amity University Haryana 19. LathaSrikanth (Vice Principal) Indirani College of Nursing,Ariyur,Puducherry 20. Rupa Verma (Principal) MKSSS college of nursing for women, Nagpur 21. Sangeeta N. Kharde (Professor) Dept. of OBG Nursing KLES's Institute of Nursing Sciences, Belgaum 22. Dr. Suresh K. Sharma (Professor) (Nursing) College of Nursing, All India Institute of Medical Sciences, Rishikesh (UK) Sudha Annasaheb Raddi (Principal & Professor) Dept of OBG Nursing, KLEU's Institute of Nursing Sciences, Belgaum

4 International Journal of Nursing Education NATIONAL EDITORIAL ADVISORY BOARD 24. Rentala Sreevani (Professor & HOD) Dept. of Psychiatric Nursing,Sri.Devaraj Urs College of Nursing, Kolar, Karnataka 25. Accamma Oommen (Associate Professor and Head) Department, Child Health Nursing, Sree Gokulam Nursing College, Trivandrum, Kerala, India 26. Shinde Mahadeo Bhimrao (Professor) Krishna Institute Of Nursing Sciences Karad Tal-Karad Dist Satara Mahashtra State 27. Dr. Judith A Noronha (Professor and HOD) Department of Obstetrics and Gynaecological Nursing,Manipal University 28. Prof.Balasubramanian N (Head) Psychiatric Nursing, Shree Devi College of Nursing,Mangalore 29. Mrs. Harmeet Kaur (Principal) Chitkara School of Health Sciences, Chitkara University, Punjab. 30. Mrs. Chinnadevi M (Principal) Kamakshi Institute of Nursing, Bassa wazira, Bhugnara Post, The Nurpur, Dist Kangra, HP, 31. Dr.Linu Sara George (Professor and Head) Department of Fundamentals of Nursing, Manipal College of Nursing Manipal 32. Juliet Sylvia (Professor and H.O.D) Community Health Nursing, Sacred Heart Nursing College, Madurai 33. Dr. (Prof). Raja A (Professor & HOD) Department of Medical Surgical Nursing,Sahyadri College of Nursing,Mangalore Beena Chako (Professor) PSG College of Nursing, Coimbatore. Tamil Nadu 35. Anitha C Rao, Professor and Principal, Canara College of Nursing, Kundapur, Karnataka 35. Dr.N.Gayathripriya (Professor) Obstetrics and Gynaecological Nursing, Sri Ramachandra University, Chennai SCIENTIFIC COMMITTEE 1. Padmavathi Nagarajan (Lecturer) College of nursing, JIPMER, Pudhucherry 2. Mrs. Rosamma Tomy (Associate Professor) MGM College of Nursing, Kamothe, Navi Mumbai 3. T. Sivabalan (Associate Professor) Pravara Institute of Medical Sciences (DU), College of Nursing, Loni, Maharashtra 4. Ms Daisy J Lobo (Associate Professor) MCON, Manipal, Karnataka 5. Sanjay Gupta (Assistant Professor) M.M. College of Nursing, Mullana (Haryana) 6. Prashanth PV (Nursing Supervisor) M.O.S.C Medical College Hospital, Kerala 7. V. Sathish (Academic Officer) Allied Health Sciences, National Institute of Open Schooling Ministry of Human Resource Development,Government of India 8. Dr. Suman Bala Sharma (Associate Professor) Govt. Medical College and Hospital (GMCH) 9. Smriti Arora (Assistant Professor) Rufaida College of Nursing, Faculty of Nursing, Hamdard University,New Delhi Rajesh Kumar (Asst. Professor) SGRD CON(SGRDISMR),Vallah Amritsar Punjab 11. Baskaran. M (Assistant Professor) PSG College of Nursing, Coimbatore, Tamil Nadu, 12. Mr. Kishanth (Olive.Sister Tutor) Department of psychiatric Nursing,College of Nursing, JIPMER, Pondicherry Mr. Mahendra Kumar (Associate Professor) Savitribai phule college of nursing, Kolhapur 14. Bivin Jose (Lecturer) Psychiatric Nursing, Mar Baselios college of Nursing, Kothamangalam, Kerala 15. Poonam Sharma (Assistant Professor) INE, Guru Teg Bahadur Sahib (C) Hospital, Ludhiana,Punjab. 16. Kapil Sharma (Associate Professor) INE,G.T.B.S.(C) Hospital, Ludhiana (Punjab) Print-ISSN: , Electronic - ISSN: , Frequency: Half yearly (Two issues per volume). International Journal of Nursing Education is an international peer reviewed journal. It publishes articles related to nursing and midwifery. The purpose of the journal is to bring advancement in nursing education. The journal publishes articles related to specialities of nursing education, care and practice. The journal has been assigned international standard serial numbers (print) and (electronic). The journal is covered by Index Copernicus, Poland and is included in many international databases. We have pleasure to inform you that IJONE is a double blind peer reviewed indexed international journal and is now covered by EMBASE ( Scopus), Indian citation index, GOOGLE SCHOLAR, INDEX COPERNICUS (POLAND), EBSCOHOST (USA), and many other international databases All Rights reserved The views and opinions expressed are of the authors and not of the International Journal of Nursing Education. The Journal does not guarantee directly or indirectly the quality or efficacy of any products or service featured in the advertisement in the journal, which are purely commercial. Editor Dr. R.K. Sharma Institute of Medico-legal Publications 4th Floor, Statesman House Building, Barakhamba Road, Connaught Place, New Delhi Printed, Published and owned by Dr. R.K. Sharma Institute of Medico-legal Publications 4th Floor, Statesman House Building, Barakhamba Road, Connaught Place, New Delhi Design & Printed at M/s Vineeta Graphics, Subash Colony, Ballabgarh, Faridabad Published at Institute of Medico-legal Publications 4th Floor, Statesman House Building, Barakhamba Road, Connaught Place, New Delhi

5 International Journal of Nursing Education I Contents Volume 07 Number 01 January-March Effectiveness of Ambulation During First Stage of Labour, on the Outcome of Labour among Primigravid Women in Selected Hospitals of Palakkad District, Kerala Deepthy Prabhakar, Linu Sara George, Sushmitha Karkada 2. Effectiveness of Planned Demonstration on Aseptic Medical Wound Dressing in Terms of Practice among Staff Nurses in Selected Hospitals in Mangalore Chinchu Maria, Diana Lobo 3. Effectiveness of Protocol-Based Postoperative Nursing Care among Post-Abdominal Surgery Patients Ameen Ahsan K P 4. Effectiveness of Video Assisted Teaching Programme (VATP) on Knowledge Regarding Prevention of Transmission of Methicillin- Resistant Staphylococcus Aureus (MRSA) among Nursing Students in A Selected Nursing Institution of Mangalore Shrithi M T, Sr. Lucy Rodrigues 5. Jacobson's Progressive Muscle Relaxation (JPMR) Training to Reduce Stress among People Living with HIV Prameelarani Bommareddi, Blessy Prabha Valsaraj, Shalini 6. Effectiveness of Peer Led Intervention Programme (PLIP) on Knowledge of Student Nurses Regarding Management of Neonatal Disorders Rajyashwaree Bhele, Smriti Arora, Urmila Bhardwaj 7. Effectiveness of Acupressure on Chemotherapy Induced Nausea and Vomiting and the functional status among Cancer Patients Receiving Cisplatin as Radiosensitizer Chemotherapy in Kasturba Hospital Manipal Anusree Augustine, Elsa Sanatombi Devi, Latha T 8. An Exploratory Survey of Determinants Influencing Birth Spacing among Married Women Residing in Selected Rural Areas of Mysore District Jetty Elizabeth Jose, Nisha P Nair, Sheela Williams, Vinay Kumar G, Sreekutty Divakaran 9. A study on Knowledge, Attitude and Practices of Female Multipurpose Health Workers (MPHW) on selected Components of Safe Motherhood Programme in the state of Maharashtra Saroj V Upasani R N 10. Issues in Treating Adhd among Children and Adults Kanchana M N, Sangamesh N 11. Effect of Swaddling on Pain and Physiological Parameters in Neonates During Heel Lance Shivani Thakur, Jyoti Sarin, Yogesh Kumar 12. Effectiveness of Clay Therapy on Anxiety Symptoms of Preschool Children Anu Mary Joseph, Ambika K, Sheela Williams 13. Correlating Perceived Burden among Care Givers of Psychiatric & Diabetic Patients- A Regression Analysis Pravati Tripathy, Venkat Epari Rao

6 II 14. Assess and Compare the Knowledge, Attitude and Expressed Practices of Married Women Regarding EC and MTP at Selected Rural and Urban Communities of District Ambala, Haryana Sushma Katoch, Sanjay Gupta, Poonam Sheoran 15. A Study to assess the Knowledge and Attitude of Higher Secondary School Students Regarding Nursing Profession in a Selected School in Kanyakumari District, South India Sheeba C1, V S Delphin, A Esakiammal, M Hephzibah Belsy, R Jamuna Rani 16. Effectiveness of Inflatable Lumbar Support (ILS) for the Prevention of Short Term Backache among Post-operative Female Patients Undergoing Lower Abdominal Surgery Under Spinal Anesthesia Bobby Sindhu, Elsa Sanatombi Devi, Jyothi Chakrabarty 17. Attitude Towards their Medications and Compliance Status among Clients with Chronic Illness in Mangalore Thereza Mathias, Christopher Sudhaker, Radha Aras 18. Impact of Leadership Development Package on Leadership Competencies of Head Nurses Usha Marath, Ramachandra 19. Assessment of Knowledge on Prevention of Iodine Deficiency Disorders (IDD) in Children among Mothers of Under Five of Selected Rural Community, Bangalore Chetan Kumar MR, Lingaraju CM 20. Assessment of Susceptibility to Hypertension among Staff Nurses Related to Selected Stress Factors Asishbala Mohapatra 21. Family Support Needed for Adolescent Puberty Endang Triyanto, Asep Iskandar 22. A Descriptive Study to assess the Knowledge Regarding Basic Life Support among Physiotherapy Students of Selected College in Mangalore Muhammed U V, Naseeha P K, Neenu Thomas, Priyanka V, Rahila K P, Syed Imran 23. Facilitating NCLEX-RN Success using Model Achieve in a Community based Program for Internationally Prepared Nurses Lilly Mathew, Claudette McFarquhar, Renee Wright 24. A Study to assess the Prevalence of Tobacco use among Class Fourth Workers of Krishna Institute of Medical Sciences University Karad, Maharashtra, India Vaishali R Mohite, Prabhuswami Hiremath 25. Effectiveness of Protocol on Situation, Background, Assessment, Recommendation (SBAR) Technique of Communication among Nurses During Patients' Handoff in a Tertiary Care Hospital Shalini, Flavia Castelino, Latha T 26. Effectiveness of Foot Massage on Level of Pain among Patients with Cancer Jeenath Justin Doss K 27. Magnesium Sulphate (Mgso4) Fomentation Verses Cold Compress for Reducing Intravenous Extravasation Mahadeo B Shinde, Namrata Mohite, Prabhuswami Hiremath 28. Effectiveness of Structured Teaching Programme on Knowledge Regarding Ethical Issues in Nursing Practice among Nursing Professionals Vaishali R Mohite, Prakash M Naregal, Rajshree Kadam 29. Utilization of Health Care Services by Rural Population-A Study from Western Maharashtra Mahadeo B Shinde, P M Durgawale 30. Awareness Regarding Uterovaginal Prolapse among Newar Parous Women Sita Karki, Arju Neraula 31. Prevalence of Anemia among Nursing Students Vaishali R Mohite, Jojy Kurian

7 32. Effectiveness of Planned Health Teaching on Knowledge Regarding Practices of Oral Hygiene among Children in Selected Schools Sunita H Tata, Vaishali Sidharth 33. Development of Nursing Audit Tool to assess the Reproductive Child Health Services Provided by Nursing Personnel Based on the Records Maintained at Urban and Rural Health Centers Nandaprakash P, B S Hakuntala 34. Effectiveness of Planned Teaching Programme on Knowledge of Staff Nurses Regarding Human Papilloma Virus and its Vaccine Mikki Khan, Manju Chhugani, Smriti Arora 35. Recurrent Miscarriages: Causes, Management and Impact by Applying the Transactional Model of Stress Shahnaz Anwar, Rafat Jan 36. Can Death of Women During Childbirth be Prevented- An Overview from Transcultural Perspective Zohra Kurji, Yasmin Mithani, Zahra Shaheen 37. A Study on Patient Safety Culture among Nurses in A Tertiary Care Hospital of Puducherry Balamurugan E, Josephine Little Flower 38. Practices of Tracheal Suctioning Technique among Health Care Professionals: literature Review Rozina Khimani, Fauziya Ali, Salma Rattani, Sohai Awan 39. A Study on Awareness and Anxiety Level of Primigravida Mothers on Labour and its Outcome, in a Selected Hospital, Mysore Bhavya S V, Parvathi N K, Bhagyalakshmi H S, Santosh Kumar, Munirathnamma 40. Effectiveness of Planned Teaching Programme on Knowledge Regarding Lifestyle Changes in Prevention of Premenstrual Syndrome among adolescents in Selected Schools of Mangalore Thabidha Joseph, Malitha Veera Monis 41. An Exploratory Survey to Identify the Determinants of Health Care Services Utilization by Under Five Children in a Selected Village of Jhajjar, Haryana Poonam Joshi, Manju Vatsa 42. Septic Shock: Early Goal Directed Management Can Save Lives Sana Hirani 43. Effectiveness of Informational Booklet on Management of Peptic Ulcer Patients Asishbala Mohapatra, Maya Patlia 44. Childbirth Education: Preparing Pakistani Mothers for Breastfeeding and Neonatal Care Challenges Zohra Kurji, Zahra Shaheen, Yasmin Mithani 45. A Study to assess the Stress and Coping among Widows Residing in Selected Areas of Udupi District Avita A A Fernandes, Suja Karkada, Ansuya 46. Perception on Women's Rights among Working and Non Working Women Shiney Easo, Shashidara Y N, Ansuya 47. A Retrospective Study to assess the Delay in Treatment Seeking and Factors Contributing to Delay in Seeking Treatment among the Caregivers of Persons Having First Episode Psychosis N Sujata, Sandhya Gupta, Mamta Sood 48. Teaching Physical Assessment Skills to International Nursing Students in New Zealand Gillianne Meek III

8 IV 49. A Study to assess the effectiveness of STP Regarding Knowledge on Nosocomial Infections in Newborns among the Staff Nurses Working at Nicus in Selected Hospitals at Tumkur District Kiran Patil 50. Socrates: Making us Think Mark R Adelung, Virginia M Fitzsimons 51. Prevention of Endotracheal Suctioning-Related Complications: A Comparison Between Manual and Ventilator Hyperinflation/Hyperoxygenation Amina Hemida Salem 52. Effect of Oral Cooling on Bolus 5-FUFA Induced Mucositis in Cancer Patients Sharma Preksha, Vatsa Manju, Sharma Atul 53. Quantitative Intervention and Evaluative Study on Hiv/Aids Awreness among Adolescent School Children Girija M 54. A Descriptive Study to assess the Prevalence of Alcohol use in Selected Community Area of Punjab Satinder Paul Kaur, Kanwaljit Gill 55. Factors Affecting the Utilization of University Health Centre by Undergraduates in Ogbomoso, South-West, Nigeria Florence O Adeyemo 56. Randomized Controlled Trial of Simulation - Based Teaching versus Traditional Clinical Instructions in Nursing: A Pilot Study Among Critical Care Nursing Students Amina Hemida Salem 57. Effectiveness of Small-Group Sessions in Enhancing Students' Generic Skills at The Shifa College of Nursing, Islamabad, Pakistan Afshan Saleem Daredia 58. Adolescent Suicide: A primary Care Issue Ivreen Robinson 59. Effectiveness of School Based Teaching Programme (SBTP) for Teachers Regarding 'Prevention of Suicide among Students' in Selected Schools, Mangalore Meril manuel, Vineetha Jacob 60. An Experimental Study to assess the effectiveness of Specific Interventions on Alcohol use in Selected Community Areas of Sangrur, Punjab Satinder Paul Kaur, Kanwaljit Gill 61. Integrated Method is the Best Method of Teaching in Medical Education Prospective on Curriculum Development and its effects on Students' Learning and Performance Rita Rezaee, Leili Mosalanejad

9 DOI Number: / Effectiveness of Ambulation During First Stage of Labour, on the Outcome of Labour among Primigravid Women in Selected Hospitals of Palakkad District, Kerala Deepthy Prabhakar 1, Linu Sara George 2, Sushmitha Karkada 3 1 M.Sc. (N), 2Department of Mental Health Nursing, 3 Lecturer, Department of Maternity Nursing, Manipal College of Nursing, Manipal University,Manipal, Karnataka, India ABSTRACT Many women desire mobility during labour, which helps to enhance their physiological and psychological wellbeing. The purpose of the study was to determine the effectiveness of ambulation during first stage of labour, on the outcome of labour. Quasi experimental, post test only control group design was used in 60 samples. Statistical analysis of data revealed that ambulation during first stage of labour was effective in reducing duration of labour (t value = and p value <0.05) also in bringing positive behavioural response ( Mann-Whitney U test, p value< 0.05). Keywords: Ambulation, Outcome, Labour, Observation Record of Progress of Labour, Behavioural Response Observation Checklist INTRODUCTION Ambulation during labour is becoming more popular, although its impact on the progress of labour and on pain intensity remains unclear. During the first stage of labour the patient usually prefers to move about. During this period, therefore, she should not be compelled to take to her bed unless she feels so inclined 1. If the membranes are intact and the women is allowed to walk about, this attitude prevents venacaval compression and encourages descend of head 2. Duration of the first stage is shortened in 25% and cephalic moulding is not increased, the incidence of forceps delivery diminished in the ambulant group. 3 When allowed the freedom to ambulate, move, and change position during labor and birth, most women choose to do so and find this to be an effective form of pain relief 4. In health Behaviour News, it is reported that there are many advantages of mobility during labour, which include effective use of gravity, which aids in descend of baby s head. When women are upright, there is more room for the baby to move downward because the diameter of pelvis expands slightly. This puts less pressure on nerves in the spine, which reduces pain 5. Ambulation is a simple, safe and effective method that does not require any equipment or machinery or even prior preparation in the antenatal period. PURPOSE OF THE STUDY The purpose of the study was to determine the effectiveness of ambulation during first stage of labour, on the outcome of labour. If proved effective, ambulation can be used to reduce the use of intrapartum medications for augmentation of labour and pain and thereby to reduce the complications. OBJECTIVES OF THE STUDY Objectives of the study were to, 1. monitor the duration of labour and mode of delivery of primigravid women. 2. identify the behavioural response of the primigravid woman during first stage of labour using behavioural response observation check list.

10 2 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 3. Assess the neonatal outcome using record of outcome of labour. 4. Find the effectiveness of ambulation during first stage of labour in terms of *Maternal outcome duration of labor, mode of delivery and behavioural response *Neonatal outcome Birth injuries, Apgar score, 5. Find the association between duration of labour and selected variables.(age of the mother, birth weight of the baby) 6. Find the association between mode of delivery and selected variables.(age of the mother, birth weight of the baby) 7. Find the association between behavioural response and selected variables.(education, type of family) HYPOTHESES The hypotheses will be tested at 0.05 level of significance. H1: There will be significant difference in the mean duration of labour between the experimental and control group. H2: There will be significant difference in mode of delivery among experimental and control group. H3: There will be significant difference in behavioural response scores among experimental and control group. H4: There will be significant difference in neonatal outcome among the experimental and control group. H5: There will be significant association between duration of labour and selected variables (age of the mother, birth weight of the baby). H6: There will be significant association between mode of delivery and selected variables (age of the mother, birth weight of the baby). H7: There will be significant association between behavioural response and selected variables (education, type of family). METHODS AND PROCEDURE Design and sample: In this study the samples selected were 60 primigravid women, 30 each in experimental and control group. A quasi experimental post test only control group design was used and the sampling technique used was simple random technique (chit method). Even though the samples are assigned randomly, perfect matching of the samples between experimental and control group could not be done. Hence the approach was quasi experimental. Tools used: The tools used were demographic porforma, observation record on progress of labour (Partograph), record of outcome of labour, behavioural response observation checklist. Demographic porforma: This was developed to collect the background data,which contained seven items for obtaining information about hospital number, age, gestational age in weeks, educational status, occupation, type of family, religion. There were no scores for the items. Observation record on progress: of labour (Partograph) : The partograph prepared by WHO was selected with modifications. Space was provided for the record of time of onset of labour. The record of urine volume protein and acetone, gravida, para were excluded Record of outcome of labour: This tool was prepared to document maternal and neonatal outcome. Maternal outcome measured by this tool included mode of delivery including perineal tear. And the neonatal outcome included APGAR score, birth injuries and birth weight. Behavioural response observation checklist: This tool contained positive and negative behavioural responses in between contractions and during contraction. There were a total of 32 items in the observation checklist, which included 17 items and 15 items to be observed in between contractions and during contractions respectively. For positive behavioural responses, if the response is yes, then a score of 1, and if no then 0 score was given. On the other hand, for negative behavioral responses, if yes it was scored 0 and if no the score of 1 was given. Thus with reverse scoring, the behavioural response scores ranged from 0 to 32. To ensure the content validity, the suggestions from seven experts were solicited and necessary modifications were made. The experts included three doctors with specialization in Obstetrics and Gynaecology and four nurses with specialization in maternity nursing. The reliability of the tools were established by administering the tool to 20 primigravid women.inter

11 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 3 rater agreement was used.the reliability coefficient were 0.94, 1 and 1 for behavioural response observation check list, Partograph and record of outcome of labour respectively, which suggested that the tools were reliable. Pretesting of the tool was done in 5 primigravid.it was feasible to record the behavioural responses during labour and the outcome of labour using the tool. Ethical permissions: Administrative permission to conduct the research study was taken from the Dean of Manipal College of Nursing, Manipal. Ethical clearance for the study was taken from Valluvanad hospital and Ashwini hospital Palakkad district, Kerala. Administrative permission from the institutional heads was taken prior to the study. Permission was obtained from the chief doctors of Obstetrics and Gynaecology department of Valluvanad hospital and Ashwini hospital, Palakkad. Informed consent was taken from the samples prior to study. Intervention: Each woman in the experimental group was ambulated for an average of one to one and a half hours according to their tolerance and giving rest periods in between. The control group women were confined to bed most of the time. The primigravid women in both groups were observed for their behavioural response. Partograph was monitored and both maternal and neonatal outcome of labour was also recorded in the Record of outcome of labour Pilot study: Pilot study was conducted by taking ten primigravid women,five each in the experimental and control group from both Valluvanad hospital and Ashwini hospital, Palakkad. The study was found to be feasible. Data collecteion: Primigravid women who met the inclusion criteria were randomly assigned to experimental and control group. Each woman in the experimental group was ambulated for an average of one to one and a half hours according to their tolerance and giving rest periods in between. The control group women were confined to bed most of the time and those who ambulated for more than 30 mts were excluded from the study. The primigravid women in both groups were observed for their behavioural responses for any two hours during first stage of labour with the cervical dilatation ranging from four to seven centimeters. Behavioural responses were recorded on a basis of five observations in a period of two hours with a gap 30 minutes between each observation. Partograph was also monitored during the labour. The investigator motivated and encouraged the mothers in the experimental group to ambulate by considering their tolerance. Both maternal and neonatal outcome of labour was also recorded in the Record of outcome of labour. RESULTS In this study the samples were 60 primigravid women selected based on inclusion criteria.(30 each in experimental and control group) Table 1: Frequency and percentage distribution of sample characteristics (n = 30+30) Sample characteristics Control group Experimental group (f) (%) (f) (%) Age( in years) a) b) c) Educational status a) Upper primary b) High school c) PUC/ d) Graduation e) Post graduation f) Diploma Period of gestation in weeks a) b) c) d) 40 above

12 4 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 1: Frequency and percentage distribution of sample characteristics (n = 30+30) Sample characteristics Control group Experimental group Occupation (f) (%) (f) (%) a) House wife/unemployed b) professionals Type of family a) Nuclear b) Joint c) Extended Religion a) Hindu b) Christian c) Muslim Effect of ambulation in terms of maternal outcome Table 2 : Comparison of mean duration of labour ( in minutes) of women in experimental and control group. (n = 30+30) Group Mean Mean difference SD T value df p value Experimental Control The data presented in table 2 shows that the mean duration of labour in experimental group ( ) is lower than that of control group ( ) and the mean difference of duration of labour was minutes and the p value is 0.027, which is significant at 0.05 level of significance. Hence the null hypothesis was rejected, which implies that ambulation during first stage of labour reduced the duration of labour among primigravid women. Table 3 : Association between Mode of delivery and ambulation in both experimental and control groups (n = 30+30). Mode of delivery Experimental (f) Control (f) Chi square value df p value Normal Abnormal( vacuum delivery, perineal tear) 4 6 Data presented in table 3 shows that the p value is not significant at 0.05 level of significance. Thus the null hypothesis was accepted that there is no significance relation between mode of delivery and ambulation. Table 4: Comparison of behaviour responses of primigravid women in experimental and control groups (n = 30+30) Variable Groups Median Inter Z value p value quartile range Behavioural response score Experimental Control Data presented in table 4 shows that the p value is significant at 0.05 level of significance, hence the null hypothesis was rejected, which implies that ambulation was effective in bringing positive behavioural response among primigravid women in labour.

13 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 5 Table 5: Association between ambulation and neonatal outcome. Neonatal outcome Experimental (f) Control (f) Chi square value df p value Normal Abnormal( caput succedaneum) 5 6 Data presented in table 5 shows that the p value is not significant at 0.05 level of significance, hence the null hypothesis was accepted, which implies that there is no significant association between ambulation and neonatal outcome. Association between maternal outcome and selected variables Association between duration of labour and variables ( age of the mother, birth weight of the baby) was done using one way ANOVA and karl Pearson s test for correlation respectively. Association between mode of delivery and variables ( age of the mother, birth weight of the baby) was done using Pearson s chi square test and independent t test respectively. Kruskal Wallis test was used to assess the association between behavioural response and selected variables such as education and type of family. The p-values obtained in all the above associations were not significant at 0.05 level of significance. Thus the null hypothesis was accepted stating no significant association between the maternal outcome and selected variables. Thus it is interpreted that maternal outcome was independent of the variables under study. CONCLUSION Ambulation during first stage of labour was effective in reducing the duration of labour and to bring out good behavioural response in primigravid women.also ambulation did not have any adverse effect on neonatal outcome. It was observed by the investigator that, having the choice to ambulate is well accepted by women when they were told the potential benefits of ambulation. Also it is a cost effective intervention which the nurse can implement independently. DISCUSSION The findings of the present study indicated that ambulation during first stage of labour is effective in reducing the duration of labour among primigravid women. This result is supported by a systematic review, which included 21 studies with a total of 3706 women, done to assess the effects of upright positions(walking, sitting, standing, kneeling) versus recumbent positions (supine, semi recumbent, lateral) for women in the first stage of labour on the length of labour, and other outcomes. Results showed that the duration of labour was approximately one hour shorter for women randomised to upright as opposed to recumbent positions. 6 A systematic review was conducted in which different comfort measures were used during labour to assess the safety and efficacy, of which one was maternal movement and positioning. The result showed that the intervention was effective in reducing labour pain and improving the obstetrical outcomes and is safe when used appropriately 7. This result supports the finding of the present study that ambulation during first stage of labour is effective to bring out good behavioural response in primigravid women during labour Based on the present study, the following recommendations were made 1. A similar study may be undertaken to determine the effect of ambulation on the physiological parameters of the women in labour. 2. A comparative study can be conducted to assess the effectiveness of ambulation versus selected antenatal exercises in reducing the duration of labour among primigravid women. 3. A study can be conducted to assess the relationship between the parturient s positions and perceptions of labor pain intensity among primigravid women. 4. A study can be conducted to assess the maternal and fetel complications due to adoption of supine position in labour. 5. An exploratory study can be conducted to assess the acceptability of ambulation as an intra partum intervention among the parturients and midwives attending labour. 6. A comparative study on the effect of nurse administered back massage versus ambulation for coping up with labour pain among primigravid women in labour.

14 6 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 ACKNOWLEDGEMENT I express my sincere and heartfelt gratitude to Dr Anice George, Dean, Manipal College of Nursing, Directors of Aswini hospital and Valluvanad hospital for facilitating this study with necessary administrative permissions. I express my deep sense of gratitude to Mrs Sonia R B D souza and Mrs Maria Pais, Department of Maternity Nursing, Manipal college of Nursing, for their constant encouragement and support. I greatefully acknowledge the doctors and nurses of Valluvanad and Aswini Hospital, Ottapalam, for their constant support and valuable advice. My sincere thanks to all primigravid women who cooperated and participated in this study. I render thanks to all the people who directly or indirectly helped me to complete this work. Conflict of Interest: None declared. Source of Funding: Self. REFERENCES 1. Williams JW. Obstetrics: a text-book for the use of students and practitioners. New York: D. Appleton, Dutta DC. Textbook of Obstetrics.5 th ed.culcutta: New central book agency; Díaz AG, Schwarcz R, Fescina R, and Caldeyro- Barcia R. Vertical position during the first stage of the course of labor, and neonatal outcome. Eur J Obstet Gynecol Reprod Biol Sep;11(1):1-7.available from pubmed. 4. DeClercq E., Sakala C., Corry M., Applebaum S., & Risher, P. (2002). Listening to mothers: Report of the first national U.S. survey of women s childbearing experiences. New York: Maternity Center Association. The Journal of Perinatal Education 2007(Suppliment); 16(1), available from http// Com. 5. Szalavitz M. Stand and Deliver? Upright labour positions reduce pain, Speed birth.us Eastern time.2009 April 14.Available from http// 6. Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labor. Cochrane Database Syst Rev Apr 15;(2).avilable from http// 7. Simkin P, O Hara M. Non pharmacological relief of pain during labour: Systematic reviews of five methods. American Journal of Obstetrics and Gynecology, :

15 DOI Number: / Effectiveness of Planned Demonstration on Aseptic Medical Wound Dressing in Terms of Practice among Staff Nurses in Selected Hospitals in Mangalore Chinchu Maria 1, Diana Lobo 2 1 MSc Nursing Student, 2 Associate Professor, Medical Surgical Nursing Department, Laxmi Memorial College of Nursing, Balmatta, Mangalore ABSTRACT Wound dressing procedures are very common and if wound contamination is limited, then there is a less chance of infection1. In India, it is reported that 10,000 of Indians are dying every year due to wound infection. The main causes postulated for the development of wound infections in India are the indiscriminate use of antibiotics, failure of many hospitals to follow basic infection control methods like hand washing, gloving, sterilization, overall lack of hygiene in public hospitals and in the Government hospitals2. Systematic assessment, early detection maintaining aseptic precautions and continuous monitoring are some ways of preventing wound infections3. The investigator felt a strong need to conduct a planned demonstration on aseptic wound dressing technique which would help the staff nurses to develop proper practice and skill in aseptic wound dressing. Keywords: Effectiveness, Planned Demonstration, Aseptic Wound Dressing INTRODUCTION A wound is defined as a disruption of the integrity and function of tissues in the body. Wound care is an art rather than a science. Wound infection is a common preventable cause of morbidity and mortality 4. The management of wound begins by identifying the overall wellbeing of the patient. Maintaining quality and following aseptic principles while doing wound dressing procedure by the nurses is very essential to prevent spread of infection, to control the complications and for better healing 5. In India, it is reported that 10,000 of Indians are dying every year due to wound infection. The main causes postulated for the development of wound infections in India are the indiscriminate use of antibiotics, failure of many hospitals to follow basic infection control methods like hand washing, gloving, sterilization, overall lack of hygiene in public hospitals and in the Government hospitals 2. A study was conducted to assess the knowledge and practice of nurses regarding wound care in Tirupati. The findings revealed that 75% nurses had moderately adequate knowledge, 25% had adequate, and 50% of nurses were found to have a satisfactory performance. Later it was proved that direct education could lead to of increase the quality of wound dressing procedure. So continuing education programmes coupled with motivation and provisions of adequate facilities from healthcare establishments are essential to create a feeling of personal and professional adequacy 6. During clinical experience, the investigator came across with patients having delayed wound healing due to improper dressing practices of staff nurses. To prevent infection it is important to maintain a clean possible sterile area while cleaning the wound including proper hand washing and application of dressing as per physician s order 7. Therefore the investigator felt a strong need to conduct a planned demonstration on aseptic wound dressing technique which would help the staff nurses to develop proper practice and skill in aseptic wound dressing. OBJECTIVES OF THE STUDY 1. To determine the practice on aseptic medical wound dressing technique among staff nurses before planned demonstration as measured by an observation checklist.

16 8 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 2. To evaluate the effectiveness of planned demonstration in terms of practice of aseptic medical wound dressing technique among staff nurses. 3. To find out the association of the practice scores with selected demographic variables. Hypotheses All hypotheses were tested at 0.05 level of significance. H 1 : There is significant difference between mean pretest practice scores and mean post-test practice scores of staff nurses. H 2 : There is significant association of practice scores with selected demographic variables. The conceptual framework of the present study was developed by the investigator based on the Weidenbach s Prescriptive Theory 8. MATERIAL AND METHOD A quasi experimental one group time series design was adapted for the study. Setting of the Study The study was conducted in the medical and surgical wards of three selected hospitals at Mangalore - K. M. C. Hospital, Unity Hospital and City Hospital Research and Diagnostic Centre. Sample By using purposive sampling technique 30 staff nurses were selected. METHOD OF DATA COLLECTION Prior to the data collection permission was obtained from the concerned authority of the organization for conducting the study. The data collection period extended from to Prior to the data collection, permission was obtained from the concerned hospitals authorities for conducting the study. Subjects were selected according to the selection criteria and confidentiality was assured. Written consent was obtained from the subjects. Subjects were assigned through purposive sampling technique. A pre-test was done on the staff nurses during medical wound dressing using observational checklist. Aseptic medical wound dressing technique was taught individually to the subjects. A post-test was conducted to observe the performance of aseptic medical wound dressing 3 times after the demonstration on the third, fifth and seventh day following the intervention of demonstration using the same observation checklist. FINDINGS Section A: Description of demographic variables of staff nurses The present study findings show that majority of the staff nurses (60%) are in the age group of years and (83.3%) are females. Most of them (56.67%) have completed B. Sc. (N). Majority of the staff nurses (50%) have 1 month-1 year experience and (60%) of staff nurses are working in the medical ward. Highest percentage of the staff nurses (83.3%) has knowledge from their own experiences. Section B: Level of Practice of Staff Nurses on the Aseptic Medical Wound Dressing Technique Data collection tools Based on the objectives, a baseline proforma and structured observational checklist were prepared and administered to evaluate the effectiveness of the planned demonstration of aseptic medical wound dressing technique. Content validity of tool was established by submitting to nine experts. The reliability of the tool was established by inter rater method and the correlation between the observation were measured by using Spearman rank co-relation method. The internal consistency of the observational checklist was, r=0.9 Hence, the tool was found to be reliable. Fig. 1. Cylinder diagram represents the pre-test and post-tests practice level of staff nurses on aseptic wound dressing

17 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 9 The data presented in Figure 1 shows that in pretest majority (66.7%) of the staff nurses have average practice on aseptic medical wound dressing whereas in post-test 1 majority (96.7%) of the staff nurses have good practice and in post-test 2 and post-test 3 all (100%)the staff nurses have good practice on aseptic medical wound dressing. Section D: Association of Practice scores with the Selected Demographic Variables Table 2: Chi- square test showing the association of the pre-test practice score with selected demographic variables N=30 Demographic variables Chi-square value Inference Age 0.83 Not significant Sex 2.57 Not significant Education 0.98 Not significant Years of experience 1.42 Not significant Present area of working 0.5 Not significant Source of knowledge 7.11 Significant df (1) χ 2 =3.814 Fig. 2. Ogive representing the pre-test and post-test 1, post-test 2, post-test 3 practice scores of Staff nurses on Aseptic Medical Wound Dressing The cumulative frequency distribution of the pretest and post-test practice scores presented in Figure 2 shows that the pre-test median (22) is less than posttest 1 (46), post-test 2 (49) and post-test 3 (49).The posttest 1, post-test 2 and post-test 3 ogive lies to the right of the pre-test ogive over the entire range showing that the post-test practice scores is consistently higher than the pre-test practice scores. Section C: Effectiveness of Planned Demonstration on Aseptic Medical Wound Dressing Technique among Staff nurses Table 1: Mean, SD,mean difference and t- value on the pre-test and post-test 1, post-test 2 and post-test 3 practice scores N=30 Parameters pre-test post-test 1 post-test 2 post-test 3 Mean SD Meandifference t value - *33.3 *33.8 *33.8 t 29 =2.262: P< 0.05 * significant The data in Table 1 shows the mean post-test practice scores are higher than the pre-test practice score (21.5±5.5). The calculated t value is greater than the table value (t 29 =2.262) at 0.05 level of significance. Hence the null hypothesis H 01 is rejected and the research hypothesis (H 1 ) is accepted. Table 2 shows that there is a significant association of source of knowledge of staff nurses with the pretest practice scores and there is no significant association found between age, sex, education, years of experience and present area of working with the pretest practice scores. Table 3: Chi-square test showing association of the post-test practice score with selected demographic variables N=30 Demographic variables Chi-square value Inference Age 0.5 Not significant Sex 3.5 Not significant Education 0.62 Not significant Years of experience 0.15 Not significant Present area of working 0.02 Not significant Source of knowledge 0.09 Not significant df (1) χ 2 =3.814 Table3 shows that there is no significant association found between age, sex, education, years of experience, present area of working and source of knowledge with the post-test practice scores. DISCUSSION In the present study a significant increase was observed in the practice scores of staff nurses after a planned demonstration on aseptic wound dressing technique. During pre-test the mean percentage is 74.13% and there is a significant increase in each posttests, in post-test 1 the mean percentage is 90.82%, in post-test %, and in post-test %.A similar study was conducted on effectiveness of clinical

18 10 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 teaching on 136 nurses regarding procedures in aseptic wound dressing at UK revealed that knowledge of nurses prior to education programme was 62.6% and after the educational programme it has improved to 88.7% well designed clinical teaching has demonstrated that aseptic precaution reduces the incidence of wound infection in high risk surgical patients by two-third with a corresponding reduction in mortality from wound infections 9. CONCLUSION Wound management has changed dramatically over recent years and is becoming an exciting and innovative area of patient care. Nurses have a critical role to play in the prevention and management of wounds since each nurse is professionally accountable for his or her practice 10. The findings of the study reveal that a planned demonstration on aseptic medical wound dressing was an effective strategy to improve practice among staff nurses. The nurses can learn about the aseptic measures maintained during the dressing preparation phase, dressing execution phase and the post procedure phase. ACKNOWLEDGEMENT The authors would like to thank Dr. Ashok Hegde and all other faculties in the General Surgery Department, A J Hospital for their valuable help in data collection and are grateful to all the staff nurses who willingly participated and formed the core and basis of this study. Authors are also deeply indebted to the Managing Trustee of Laxmi Memorial Education Trust. Ethical Clearance: Ethical clearance has been obtained from ethical committee. Source of Funding: Not received any financial support from any third party related to the submitted work (government granting agency, charitable foundation or commercial sponsor) I have no financial activities/ relationships outside the submitted work( For example: consultancy, employment, grants/grants pending, payment for manuscript preparation/ related educational presentations and others) Potential Conflict of Interest: I have no other relationships/condition/circumstances that present a potential conflict of interest. REFERENCES 1. Edward P. Contamination of the surgical field. Preoperative Nursing 2000 Mar;11(12): Mukerjhee V. nosocomial infection in India: dangerous proportions. [online]. Available from: URL: 3. Williams B, Waterson H. An examination of nurses practices when performing aseptic techniques for wound dressings. Journal of Advanced Nursing 1996; Lewis. Medical surgical nursing- assessment and management of clinical problems. New Delhi: Mosby Publications; P , Briggs M. The principle of aseptic technique in wound care. Professional Nursing 1999;11(12): Padmaja A, Arunasree H, Christina P. A quality assessment and effectiveness of structured teaching programme on wound dressing procedure among nurses at SVIMS University, Tirupati 2009; Julie J. Effectiveness of self instructional module on aseptic wound dressing practice among staff nurses in selected hospitals in Mangalore Wiedenbach E. The helping art of nursing. American Journal of Nursing;63: Smith G, Greenwood M, Searley. Ward nurses use of wound dressings before and after a bespoke education programme. Journal of Wound Care 2010;19: UKCC. Professional development-wound care. Nursing Times 1994;90(49):1-4.

19 DOI Number: / Effectiveness of Protocol-Based Postoperative Nursing Care among Post-Abdominal Surgery Patients Ameen Ahsan K P 1 Lecturer, Department of Fundamentals of Nursing, Manipal College of Nursing, Manipal University, Manipal, Karnataka ABSTRACT Aim: To find out the Effectiveness of protocol-based postoperative Nursing care among postabdominal surgery patients of selected hospitals at Mangalore Method: An evaluatory research approach with Quasi experimental, post-test only control group design was used for this study. Formal written permission was obtained from the authorities to conduct the study. Forty post abdominal surgery patients, who met the inclusion criteria, were selected from the hospital by purposive sampling technique. Outcome assessment was conducted among Group I using outcome assessment tool. The same tool was used to assess the outcome in Group II, 7 days after administration of post operative nursing care protocol. The data was analyzed using descriptive and inferential statistics Findings: The demographic data revealed that most of the subjects (60%) in Group I comes under the age group of years, in Group II 40% of subjects comes under the age group of below 25 years and years each. It also shows that more than half of the subjects in Group I (55%) and Group II (65%) are female, in Group I (65%) and Group II (75%) underwent abdominal surgery under general anesthesia and more than half of the subjects in Group I (60%) and Group II (60%) underwent elective surgery. The study showed that the mean outcome score of Group I (9.35) is higher than that of Group II (6.05). The association between outcome score and demographic variables like age, gender, type of anesthesia, type of surgery of Group I and Group II were not significant at 0.05 levels. Conclusion: The study showed that the outcome score of post abdominal surgery patients who received protocol based post operative nursing care is relatively lower than that of post abdominal surgery patients who received routine post operative nursing care. Hence it was concluded that protocol based post operative nursing care is effective in reducing the outcome score in terms of occurrence of selected post operative complications, duration of post anesthetic care unit stay and pain level of post abdominal surgery patients. Keywords: Post Abdominal Surgery Patients: Group I: Group II: Post Operative Nursing Care Protocol INTRODUCTION Abdomen the anterior portion of the body between the thorax and the pelvis; it contains the abdominal cavity, which is separated from the chest area by the diaphragm. The cavity, which is lined with a membrane known as the peritoneum, contains the stomach, large and small intestines, liver, spleen, pancreas, kidneys, gallbladder, urinary bladder, and other structures, called also belly and venter 1. Abdominal pain is one of the most common conditions that call for prompt diagnosis and treatment. Usually, though by no means always, other symptoms accompany the pain, but in most cases of acute abdominal disease, pain is the main symptom and complaint. The very terms acute abdomen and abdomen emergency which are constantly applied to such cases signify the need for prompt diagnosis and early treatment and means always surgical treatment 2

20 12 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 WHO estimates that worldwide almost 234 million major surgical procedures are performed each year 3. This translates into 1 for every 25 people in the world. Majority of the patients who undergo the procedure get well and go home. However, major complications ranges from 3% to 16% and rates of permanent disability or death range from 0.4% to 0.8% 4 Lang conducted a prospective observational study on 503 patients undergoing gastroenterological surgery. The main findings of the study were that approximately one half of the patients undergoing gastroenterological surgery had postoperative complications, which resulted in a two fold increase in the length of hospital stay and costs of care 5. Some of the reported benefits of protocols includes Improved patient outcomes, Standardizes patient care by providing consistency across all types and levels of provider experience, Decreases costs in ICU, Decreases morbidity and mortality, Gives structure to procedures and helps maintain continuity, Reduces the time delay that would have resulted if the nurse had sought medical approval before continuing with the treatment 6 METHODOLOGY An evaluatory research approach with Quasi experimental, post-test only control group design was used for this study. Formal written permission was obtained from the authorities to conduct the study. Forty post abdominal surgery patients, who met the inclusion criteria, were selected from the hospital by purposive sampling technique. Twenty Post abdominal surgery patients who received routine postoperative nursing care was included in Group I (control group) and Outcome assessment was conducted among Group I using outcome assessment tool. Then postoperative nursing care protocol was implemented in the post anesthetic care unit. 7 days after administration of post operative nursing care protocol The same tool was used to assess the outcome in Group II (post abdominal surgery patients who received protocol based postoperative nursing care, experimental group). The data was analyzed using descriptive and inferential statistics. FINDINGS OF THE STUDY Table 1: Sample characteristics of Group I and Group II by frequency and percentage N=20+20 Variables Group I Group II f % f % 1. Age (in years ) a. Below b c. 51 and above Sex a. Male b. Female Type of anesthesia a. Spinal b. General Type of surgery a. Elective b. Emergency Most of the subjects (60%) in Group I were of the age group years, in Group II 40% of subjects was under the age group of below 25 years and years each. More than half of the subjects in Group I (55%) and Group II (65%) were females. Majority of the subjects in Group I (65%) and Group II (75%) underwent abdominal surgery under general anesthesia. More than half of the subjects in Group I (60%) and Group II (60%) underwent elective surgery.

21 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 13 The data in the figure 3 reveals that the mean duration of PACU stay of Group I is 1.65 and that of Group II is 1.3 Fig. 1. Cylinder diagram showing the occurrence of selected post operative complications in Group I and Group II The data in Figure 1 reveals the following information regarding the chance of occurrence of selected post operative complications, vomiting in Group I is and in Group II is 28.33, hypotension is 11.67(Group I) and (Group II), tachycardia 6.67(Group I) 3.33 (Group II), Bradycardia 10(Group I) 5 (Group II), Tachypnoea 5(Group I) 6.67(Group II), Bradypnoea 5(Group I) 1.67(Group II), Bleeding from Incision 3.33(Group I) 3.33 (Group II), Abdominal Distension 1.67(Group I) 1.67(Group II) Temperature>98.6*f 11.67(Group I) 11.67(Group II). Fig. 2: 3. D bar diagram showing the mean pain level of subjects in Group I and Group II The data in the figure 2 reveals that the mean pain level of Group I is 4.25 and that of Group II is 2.25 Fig. 4: 3. D bar diagram showing the mean percentage of outcome score of subjects in Group I and Group II. Data in the Figure 4 show that the mean percentage outcome score of patients in Group II (15.51) is relatively lower than that of Group I (23.97). DISCUSSION The study findings inferred that the mean outcome score in post-abdominal surgery patients who received protocol-based postoperative nursing care (15.51) is significantly lower than the mean outcome score in post-abdominal surgery patients who received routine postoperative nursing care (23.97). Hence it was concluded that the protocol based post operative nursing care is effective in reducing the outcome scores in terms of level of pain, occurrence of selected postoperative complications such as, pyrexia (>98.6 o f), bleeding from incision, tachycardia (>100 bpm), Bradycardia (<60 bpm), tachypnoea (>20 bpm), Bradypnoea (<12bpm), hypotension (<90/60 mmhg), abdominal distension and vomiting, and the duration of post-anesthetic care unit stay among post-abdominal surgery patients. The findings of the study are consistent with the study conducted to find out the prevalence of intra abdominal surgery. The investigators concluded that abdominal surgery was more common in females than males with a ratio of 1.8:1 7. Fig. 3. Bar diagram showing the mean duration of PACU stay of subjects in Group I and Group II The findings of the study are consistent with an evaluatory study that was conducted among 60 patients to evaluate effectiveness of protocol-based nursing care of patients with intravenous line in Shanmuga Hospital at Salem. The result showed that after the interventions the nursing care outcome for

22 14 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 starting (t 58 =23.8), daily monitoring (t 58= ), and removal of intravenous line cannula (t 58 =25.336) at p<0.05 level of significance, concluded that protocolbased nursing care of patients with cannula was effective 8 Limitations Generalization cannot be made since study was confined to a limited number of subjects in selected hospitals. The study is limited to patients in the post anesthetic care unit only and Staff nurses were not observed CONCLUSION The mean percentage outcome score of patients in Group II (15.51) is relatively lower than that of Group I (23.97), this reveals that the protocol based postoperative nursing care is effective in reducing the outcome score of post abdominal surgery patients. Protocol based care enables nursing staff to put evidence into practice by addressing the key questions of what should be done, when, where and by whom at a local level. It provides a framework for working in multi-disciplinary teams. This standardization of practice reduces variation in the treatment of patients and improves the quality of care. Nurses must recognize the nursing protocols and how they can close the knowledge practice gap. Development of research based protocols for the care of patients may be more beneficial to provide improved healthcare and make better outcomes. The study findings will help to think and implement several possible practical measures in the fields of nursing education, nursing practice, and nursing research. Conflict of Interest: Nil Source of Funding: Nil Ethical Clearance: Institutional ethical committee clearance was sought before conducting the study. REFERENCES 1. Joyce MB, Jacobs EM. Medical surgical nursing clinical management for continuity of care. 5 th ed. W. B. Philadelphia: Saunders Company; Silen WMD. Cope s early diagnosis of the acute abdomen. New York: Oxford University Press; An estimation of the global volume of surgery: a modelling strategy based on available data. [online]. Available from: URL:http//: 4. Tidy C. Common post-operative complications. [online]. Available from: URL:http// : 5. Lang M, Nisken M, Mietlien P, Alhara E, Takala J. Outcome and resource utilization in gastroenterological surgery. British Journal of Surgery 2001;88: Huggins K. Lifelong learning - the key to competence in the intensive care unit. Intensive and Critical Care Nursing 2004;20: McIntyre R, Reinbach D, Cushieri RJ. Emergency abdominal surgery in the elderly. Journal of Royal College of Surgery, Edinburgh 1997;42: Suja J. A study to evaluate the effectiveness of protocol-based nursing care of patients with intravenous line cannula in a selected hospital at Salem. Nightingale Nursing Times 2010 Sep; 6: Acknowledgement: The author is extremely grateful to the nurses and hospital authorities who helped in implementing the protocol and completing the study.

23 DOI Number: / Effectiveness of Video Assisted Teaching Programme (VATP) on Knowledge Regarding Prevention of Transmission of Methicillin- Resistant Staphylococcus Aureus (MRSA) among Nursing Students in A Selected Nursing Institution of Mangalore Shrithi M T 1, Sr. Lucy Rodrigues 2 1 Lecturer, 2 Professor, Department of Medical Surgical Nursing, Fr. Muller College of Nursing, Mangalore ABSTRACT This study was conducted to find the effectiveness of video assisted teaching programme in increasing the knowledge level of nursing students on prevention of transmission of MRSA. An evaluative approach with pre-experimental (one group pre-test post-test) design was used for the study. The sample comprised of 60 nursing students selected by convenient sampling method. Pre-test was conducted by administering a structured knowledge questionnaire prepared by the investigator. After the pre-test, the VATP was given to the nursing students and post-test was conducted on the seventh day using the same knowledge questionnaire. The collected data were analyzed by using descriptive and inferential statistics (Paired't' test).statistical analysis of data revealed that the video assisted teaching programme was effective in improving the knowledge of nursing students on prevention of transmission of MRSA. Keywords: Effectiveness, VATP, Prevention of transmission of MRSA, Nursing students INTRODUCTION Hospital is one of the most likely places for acquiring an infection. It harbors a high amount of micro organisms that may be resistant to antibiotics and clients in the hospitals are at higher risk of getting infected by these organisms. Nosocomial infections are a significant problem throughout the world and are increasing. Nosocomial infections are commonly transmitted when hospital officials become complacent and personnel do not practice correct hygiene regularly.since medical staffs move from patient to patient, staff and students themselves serve as a means for spreading pathogens. Among the categories of bacteria most known to infect patients are the category Methycillin-resistant staphylococcus aureus (gram +ve bacteria). 1 Methicillin-resistant staphylococcus aureus (MRSA) is a type of staphylococcus bacteria which is resistant to the antibiotic methicillin and its one of the most common nosocomial infection. MRSA is especially troublesome in hospitals where patients with open wounds, invasive devices and weakened immune systems are at greater risk of infection than the general public. 2 Many nursing students and staffs are unaware of this condition and put themselves as well as patients at risk of getting MRSA infection. So when they are kept informed in the right way, at right time, many of the problems can be prevented. OBJECTIVES To determine the level of knowledge regarding prevention of transmission of MRSA among nursing students using structured knowledge questionnaire. To find the effectiveness of VATP on knowledge regarding prevention of transmission of MRSA in terms of gain in knowledge scores. To find the association between pretest knowledge score and selected baseline characteristics (gender, education programme, source of information).

24 16 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Hypotheses The Hypothesis will be tested at 0.05 level of significant H1: There will be significant difference between the mean pretest and posttest knowledge scores of nursing students on prevention of transmission of MRSA H2: There will be significant association of the mean pretest knowledge scores of nursing students on prevention of transmission of MRSA with selected baseline characteristics (gender, education programme and source of information) Design and sample MATERIAL AND METHOD The study was conducted among 60 students studying in selected nursing institution of Mangalore who were available during the period of data collection. Pre-experimental (one group pre-test posttest) design was adopted for the study for measuring the impact or effectiveness of a programme and the sampling technique used was convenient sampling. Tools used Tools used were Baseline characteristics and knowledge questionnaire regarding prevention of transmission of MRSA. Baseline characteristics This was developed to acquire the information regarding nursing students. It includes details like Gender, Educational programme, Sources of information regarding MRSA transmission Knowledge questionnaire regarding MRSA and its transmission. It consist of structured knowledge questionnaire to assess the knowledge regarding prevention of transmission of MRSA.This is divided into two sections: Section A consist of 15 items regarding MRSA infection, Section B deals with 7 items about Management and prevention of MRSA infection. Each item carries a score of 1.The maximum possible score was 22.The scores were interpreted as poor (0 40% ) Average (41 60%) Good (61 80%) Very good (81-100%). The tool as well video was tested for the reliability among nursing students other than the study sample. The internal consistency was computed using Karl Pearson s correlation coeffient with split half technique. The reliability coefficient was found to be 0.8. The tool was found to be reliable. There was no difficulty in understanding any of the items, so all items were retained. Intervention In this study video assisted teaching programme related to MRSA, and prevention of transmission of MRSA was given for the nursing students, after the pretest. It is a systematically developed instructions and teaching method with the assistance of video clips designed by the investigator to improve knowledge on prevention of transmission of MRSA. Pilot study The pilot study was conducted on 10 students in a selected nursing college. On the first day, pre-test was conducted by a structured knowledge questionnaire after which VATP on prevention on transmission of MRSA was administered. The post-test was conducted on the seventh day among same nursing students using same structured knowledge questionnaire. The tool and VATP were found to be feasible, practicable and acceptable. DATA COLLECTION The samples were selected based on the inclusion criteria. The purpose of the study was explained to them and confidentiality was assured to all the respondents. The nursing students were selected by convenient sampling. The pre-test was conducted on a total of 60 respondents following the administration of VATP. On 7 th day of pretest the post test was conducted by administering the same questionnaire for the young adults. FINDINGS The data were organised and presented under following headings Section I: Description of baseline characteristics Section II: Knowledge of nursing students regarding prevention of transmission of Methicillin - Resistant Staphylococcus Aureus (MRSA) Section III: Effectiveness of video-assisted teaching programme Section IV: Association between pretest knowledge score and baseline characteristics Section II: Knowledge of nursing students regarding prevention of transmission of Methicillin - Resistant Staphylococcus Aureus (MRSA)

25 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 17 Table 1: Assessment of the level of knowledge of nursing students. Level of knowledge Range of score Frequency Percentage Poor Average Good Very good Maximum Score =22 Data in Table 1 reveals that in the pre-test only 1.7% of the nursing student had good knowledge, 25% had average knowledge and majority (73.33%) of nursing students had poor knowledge on prevention of transmission of MRSA Section III: Effectiveness of video-assisted teaching programme Table 2: Distribution of nursing students according to the grading of Pre and Posttest knowledge score Score Grade Pre-test Post-test Frequency Percentage Frequency Percentage 0-8 Poor Average Good Very good Maximum score=22 Data in the Table 2 reveals that most of the nursing students (73.3%) had poor knowledge, 25% had average knowledge, only 1.7% had good knowledge in pre-test whereas in the post-test 15% of nursing students had average knowledge,63.3% had good knowledge and 21.7% had very good knowledge. Table 3: Frequencies, Percentage and Cumulative frequency distribution of pre test and post test knowledge score Knowledge score Pre- test Post-test F % Cf% f % Cf% Maximum score= 22 Data in the Table 3 reveals that in the pre-test majority (90%) of the nursing students had knowledge scores that ranged from 3-11, only 10% of the students obtained knowledge scores ranging from 12-15, whereas, in the post-test all the respondents acquired knowledge scores that ranged from 12-21

26 18 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 4: Mean, Mean Difference, Standard Deviation and t value of pre and post-test knowledge score of nursing students Group Mean knowledge Mean Standard df t value score difference deviation Pre- test Post-test Pre-test Post-test Nursing students * t 59 =1.67, p<0.05 *=Significant Data in Table 4 shows that the mean post-test knowledge score (16.10) was higher than the mean pretest knowledge score (7.35). The computed t value (t 59 =24.45) was higher than the table value (t 59 =1.67) at 0.05 level of significant. Hence, the null hypothesis was rejected and research hypothesis was accepted and it was inferred that the mean post-test knowledge score of nursing students on prevention of transmission of MRSA is significantly higher than the mean pre-test knowledge scores. This indicates that the VATP was effective in increasing the knowledge level of nursing students. Section IV: Association between pretest knowledge score and baseline characteristics Chi square test is used to find out the association between pretest knowledge score and selected variables. The P values obtained were not significant at 0.05 level except for educational programme. The computed chi square value for educational programme was Thus it can be interpreted that there is significant association between knowledge and educational programme. CONCLUSION Findings of this study reveal that nursing students lack knowledge related to MRSA and prevention of transmission of MRSA. The findings of the study are supported by the findings of the descriptive study conducted to assess MRSA knowledge among nursing students. A MRSA Survey was administered to nursing students to gauge their general knowledge about MRSA. The scores from the MRSA Survey indicated that nursing students had a knowledge deficit regarding MRSA 3. The effectiveness of VATP on prevention of transmission of MRSA was evident from the posttest score of nursing students. These results proved that the VATP prepared by the investigator has helped the nursing students to improve their knowledge on prevention of transmission of MRSA. On the whole the study showed that VATP was an effective teaching strategy. The findings of the research studies are consistent with findings of another preexperimental study conducted to assess the effectiveness of video assisted teaching programme (VATP) on knowledge of newborn care practices among 40 antenatal mothers in Mangalore. The study results showed that mean post-test knowledge score (36.73) was higher than the mean pretest knowledge score (16.90) which found VATP was effective (t39=23.70, P<0.05). The study concluded that VATP was effective in increasing the knowledge level of antenatal mothers on newborn care practices 4.The findings of the study also shows that educational programme influence the knowledge. These findings are supported by another descriptive exploratory study conducted in AIIMS to assess the knowledge and practice of staff nurses on infection control measure and the relationship between knowledge and practice.random sampling technique was used to select 50 nurses, out of which 66% were diploma nurses and 34% were graduate nurses. The result showed that the mean knowledge and mean practice of staff nurses regarding infection control measure were 73.1 %and 62.7% respectively. The mean distribution data further revealed that graduate nurses practice level (9.53) is higher than diploma nurses (9.24) and graduate nurses possess more knowledge (15.60%) than diploma nurses (14.09%) with regards to prevention and control of hospital acquired infection 5. Nurses and nursing students are the key providers of preventive, curative, and rehabilitative services to individual and communities. Thus they are in a better position to mould the health related behavior. The present study gives priority for continuing education programme as it upholds and maintains the knowledge and thus making them more competent. The VATP can be used as an informational and educational mode by the nursing personnel for educating the students. Nursing students as well as nursing staff should be trained to acquire knowledge regarding the condition and to plan out teaching programmes based on the same in the hospital and in the community setting.

27 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 19 Acknowledgement: I am grateful to my Principal, Prof. (Sr).Loredana korah and Prof. (Sr).Jacintha D souza and all those who have guided and helped me in completing my research study. Conflict of Interest no significant conflict of interest Source of Funding- self Ethical clearance: To conduct the research study ethical clearance was obtained from the institutional ethical committee of the college. Informed consent was taken from the nursing students before data collection. REFERENCES 1. Nosocomial infection. Available from: URL: nosocomial.in 2. Definition of Methicillin-resistant staphylococcus aureus. Available from: URL: art.asp?articlekey= Andrea Jennings-Sanders, Lucy Jury. Assessing methicillin-resistant Staphylococcus aureus knowledge among nursing students. Journal of Nurse Education today.2010 Nov; vol 30(8).Pp Jassintha. Effectiveness of video-assisted teaching programme (VATP) on knowledge of newborn care practices among antenatal mothers in selected hospitals of Mangalore. Unpublished M. Sc. nursing thesis submitted to Rajiv Gandhi University of Health Sciences, Bangalore; Aarti Vij. Swapna.N.Williamson.Shakti Gupta. Knowledge and practice of nursing staff towards infection control measure in a tertiary care hospital.journal of the academy of hospital administration. Vol 13

28 20 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Jacobson's Progressive Muscle Relaxation (JPMR) Training to Reduce Stress among People Living with HIV Prameelarani Bommareddi 1, BlessyPrabha Valsaraj 2, Shalini 3 1 M.Sc Nursing Post Graduate, 2 Associate Professor, 3 Assistant Professor, Department of Mental Health Nursing Manipal University, Manipal ABSTRACT The term AIDS refers only to the last stage of the HIV infection. AIDS can be called as our modern pandemic affecting both industrialized and developing countries. Purpose: To assess the stress as measured by Stress scale for people living with HIV, to determine the effectiveness of JPMR in terms of reduction in the mean posttest stress scores, to find factors contributing the stress and to find the association of stress among people living with HIV with selected demographic and disease specific variables. Method: One group pretest posttest design was used. Thirty People living with HIV admitted in District Hospital at ART center, Udupi were selected and demographic and diseases specific proforma and stress scale for people living with HIV were administered. Purposive sampling technique was used for the study. Results: Out of 14 subjects, the most experienced ART side effects were weakness 16.7% (14), followed by vomiting10% (3).Out of 21 subjects, 43.30% (14) had tuberculosis, 20% (6) had candidiasis. The least experienced opportunistic infections were pneumocystis pneumonia 6.70% (2).Out of 30 subjects, Maximum number of subjects experienced severe stress 43.3% (13).There was significance difference between mean difference of pretest and post test scores of stress (t=9.727, df=29, p=0.001). The JPMR training was effective in reducing the stress. Stress is dependent on CD4 count (?2=13.022, df=4, p=0.01). Conclusion: JPMR is a simple non-invasive, cost effective method that can be used for promotion of quality of life without any adverse effects on the people living with HIV. The result showed that JPMR training had a positive effect in reducing the stress and JPMR can be used as an effective alternative therapy. Keywords: JPMR, People living with HIV, Stress INTRODUCTION Acquired is obtained or received by a person that does not ordinarily exist within one s body. Immune deficiency is not an isolated disease but one which has a variety of symptoms leading to various disorders Corresponding author: Prameelarani Bommareddi M.Sc Nursing Post Graduate Department of Mental Health Nursing, Manipal University, Manipal Phone no: E mail: pramilabommareddy@yahoo.com and a set of diseases 1. The acquired immune deficiency syndrome (AIDS) is a fatal illness caused by retro virus known as human immunodeficiency virus (HIV) which breaks down the body s immune system, leaving the victim vulnerable to a host of life threatening opportunistic infections, neurological disorders or unusual malignancies 2. One of the special features of HIV infection is that once infected there is a high probability that a person will be infected for life. The term AIDS refers only to the last stage of the HIV infection. AIDS can be called as our modern pandemic affecting both industrialized and developing countries 1.Every day, over 6800 persons become infected with HIV and over 5700 people die from AIDS.

29 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 21 The HIV pandemic remains the most serious of infectious disease and a challenge to public health. In 2009, 2.6 million people were estimated to become newly infected with HIV 3. Stress is common in people with HIV. Because of this stress they develop anxiety and they will go to depression. Relaxation training is taught as a selfcontrol technique that the individual can use to reduce various forms of physiological over arousals that produce somatic symptoms. Relaxation training has been used to treat tension, headaches, migraine headaches, asthma, insomnia and hypertension (Lavige and Burns, 1981). Physical activity is an important means of reducing stress levels and preventing some of its damaging effects on the body. Exercise uses up the adrenaline and other hormones which the body produces under stress and relaxes the muscles. It will help to strengthen the heart and improve blood circulation too. Fukunishi et.al (2005) conducted a study in Tokyo Metropolitan Kaomagma Hospital, examined the efficacy of relaxation techniques in a sample of HIV patients without AIDS in the early stages after infection, by comparing the three groups: relaxation group (progressive muscle relaxation and modified autogenic training); ordinary supportive psychotherapy group, and finally no psychiatric treatment group. Scores for anxiety, fatigue, depression and contusion as measured by the profile of mood states (POMS), were significantly lower after relaxation than before. There were no significant differences in the POMS scores (except for anger) among the three groups. These two results suggest that a combination of progressive muscle relaxation and modified autogenic training is a useful method, which can be easily employed in HIV patients without AIDS 4. Progressive muscle relaxation was developed by Chicago physician Edmund Jacobson in the 1920 s. Jacobson theorized that anxiety and stress lead to muscle tension which in turn increases feelings of anxiety. When the body is in a relaxed state however, there is little muscle tension leading to decreased anxious feelings. Jacobson believed that one s body is relaxed; one s mind cannot be in a state of angst 5. Jacobson s muscle relaxation is simple non-invasive and cost effective, method that can be used for promotion of quality of life without any adverse effects. It is known people living with HIV undergo a lot of stress. Hence the researcher decided to check the usefulness of Jacobson s progressive muscle relaxation among these subjects. METHOD The study was undertaken in District Hospital at ART center Udupi from 19 th December 2011 to 14th January 2012 with the following objectives to assess the stress measured by stress scale for people living with HIV, to determine the effectiveness of JPMR in terms of reduction in the mean posttest stress scores, to find the association of stress among people living with HIV with selected demographic and disease specific variables. The design adopted for this study was one group pretest and posttest design. The pretest done on the day 1 for assessing the demographic, disease specific variables and stress among people living with HIV. A continuous ten sessions of supervised practice of JPMR was conducted followed by a post test on day 10 immediately after the practice. Purposive sampling technique was used. Samples age group between years and who were willing to participate in the study. Present study the researcher took the people living with HIV, who were admitted in the District Hospital. Informed consent was taken from the patients. All the tools were filled by the patient. The scales used were Demographic proforma, Disease specific proforma and Stress scale for people living with HIV. The demographic proforma was designed to collect the background information of the subjects. It consisted of 11 items. It consists of age, gender, educational status, religion, marital status, type of family, source of income, family income per month (in rupees), current occupation and job change after diagnosis. The subjects were asked to answer using a tick mark in the appropriate space provided on the right side of each item and also fill up the blanks appropriately. The items did not have any scoring as they were meant to collect the factual information. The disease specific proforma was designed to collect the information about the illness of the subjects. It consists of 6 items. The item includes duration after diagnosis (in years), CD4 count, HIV stages, opportunistic infections, ART side effects and previous history of psychiatric illness. This information is collected from the medical records of the subjects, not from the subjects directly. The Stress scale for people living with HIV was constructed by the researcher based on the HIV/AIDS

30 22 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 stress scale (Kenneth J. Pakenham and MachelleRinldis 2002), Perceived stress scale for people living with HIV/AIDS in China (Xiaoyou et al.2008), other literature, Perceived Stress Scale (Sheldon Cohen, 1988). The purpose of the scale was to identify the stress of people living with HIV. The five point Likert type scale consisted of 27 items which covered the areas on physical, psychological and social domains. The options were very often, fairly often, sometimes, almost never and never. Which were given a score of four, three, two, one and zero respectively. The maximum possible score was 108, which was arbitrarily divided as 1-36 mild stress, moderate stress and severe stress. Content validity To ensure the content validity, the tools along with blue print, objectives and the criteria checklist were given to nine experts from the field of psychiatry, clinical psychology, mental health nursing, pediatric nursing, HIV counseling and training. The experts were requested to give their opinions and suggestions in terms of agreement and disagreement. The validation of each tool was done based on the percentage of agreement among the experts. As per the suggestions given by the experts, required modification and simplification were done. Reliability: Cronbach s alpha was used to compute the reliability. The reliability of stress scale for people living with HIV was established by administering the tool to 20 people living with HIV admitted in the District Hospital, Udupi. The alpha value for the stress scale for people living with HIV was Procedure for data collection: Administrative permission for conducting the study was taken from the Dean, Manipal College of Nursing, Manipal University, Manipal. The researcher approached the superintendent of ART center, Udupi and explained the purpose of the study to get their cooperation. The time schedule for data collection was fixed. The data were collected from 02/01/2012 to 14/01/2012. The consent for study got from subjects. They were assured about the confidentiality of the information. The authors made sure that the subjects performed the relaxation training correctly. Subjects were supervised by the researcher for ten continuous days for each sample and posttest was given on the 10th day immediately after the JPMR. With the help of the ART staff members and ward sisters the subjects information is collected from the medical records. The information like duration after diagnosis (in years), CD4 count, HIV stages, opportunistic infections, ART side effects and previous history of psychiatric illness. Statistical analysis: Statistical package for social sciences (SPSS 16.0) software was used for statistical analysis of raw data. Frequency, percentage, paired t- test and Chi square test (p<0.05) ware applied. RESULTS The data was tested at 0.05 level of significance. Background information of the sample characteristics collected using demographic proforma. Out of 30 subjects, majority 66.7% (20) subjects belonged to age group of years. Equal number of males and females participated i.e. 50% (15).Most of the samples 33.3% (10) had only up to primary education, Hindus 46.7% (14). Maximum 63.3% (19) samples are married. Maximum 43.3% (13) samples belonged to nuclear family. All samples were financially supported by self / family members. Family income per month (in rupees) was less than 5,000 for majority i.e. 83.3% (25). Maximum 76.6% (23) samples were unskilled workers. Half of the samples changed their job after diagnosis. Background information of the sample characteristics collected using disease specific proforma. Out of 30 subjects, the diagnosis made for majority 80% (24) of people living with HIV within 2 years of duration. Maximum 46.7% (14) samples were having CD4 count less than 200. Half of them 50% (15) belonged to stage II of HIV. Majority 70% (21) samples were having opportunistic infections. Previous history of psychiatric illness i.e. 43.3% (13). Many of the subjects 46.7% (14) were suffering from ART side effects. The description of the samples based on ART side effects are: Out of 14 subjects, the most experienced ART side effects were weakness 16.7% (14), followed by vomiting10% (3).The least experienced ART side effects were headache, fever, hepatomegaly 3.30% (1). The descriptions of the samples based on opportunistic infections are: Out of 21 subjects, 43.30% (14) had tuberculosis, 20% (6) had candidiasis and followed by herpes zoster 10% (3). The least experienced opportunistic infections were pneumocystis pneumonia 6.70% (2). Description of stress among people living with HIV: Out of 30 subject s maximum number of subject s experienced severe stress 43.30% (13) followed by moderate stress 33.30% (10) and mild stress 23.40% (7) and source of maximum information is shown in Figure 1.

31 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 23 Effectiveness of JPMR on stress: Since the stress scores were following normal distribution, parametric paired t test was used. It is clear from table 1 indicates that the p value was Posttest stress scores are reduced compared to the pretest stress scores. JPMR is effective in reducing the stress. Effectiveness of JPMR on stress Table 1: Mean Standard deviation, Standard error, Standard deviation difference and t value of pretest posttest measurement of stress. n =sample size, df=degree of freedom Stress score Mean SD Standard error t value df P value Pre-test * Post-test *Significant n=30 Association between stress with selected demographic variables and disease specific variables: It is clear that there was no significant association between stress and selected demographic variables and disease specific variables except CD4 count. Stress is independent of the selected variables such as age, gender, educational status, religion, marital status, type of family, source of income, family income per month (in rupees), current occupation and job change after diagnosis, duration after diagnosis, HIV stages, opportunistic infections, ART side effects and previous history of psychiatric illness. Stress is dependent on CD4 count (χ 2 =13.002, df=4, p=0.01). CONCLUSION Severe stress experienced by people living with HIV. Weakness and vomiting are common ART side effects when compared to headache, fever and hepatomegaly in people living with HIV. Tuberculosis and candidiasis are common opportunistic infections followed by pneumocystis pneumonia in people living with HIV. Psychiatry illness is common among people living with HIV. Stress is likely to reduce CD4 count among people living with HIV.JPMR training is effective in reducing stress among people living with HIV. DISCUSSION In the present study it was observed that out of 30 subjects, maximum number of subject s experienced severe stress 43.3% (13), followed by moderate stress 33.3% (10) and mild stress 23.3% (7).The present study findings supports the results of another study conducted by Hand, Phillips and Dudgeon (2006) a study in USA on perceived stress in HIV infected individuals in physiological and psychological correlates. This study was to determine the correlation of perceived stress in an HIV infected predominantly African American population and to assess the multivariable effects on perceived stress. The samples selected were 79 HIV infected women and men. Data were collected using a structured self-report questionnaire. The study results showed that approximately 80% of the perceived stress. Pearson s r analysis showed significant correlations between perceived stress and state and trait anxiety, depression, HIV related symptoms, sleep quality, daytime sleepiness and fatigue 6. RECOMMENDATIONS 1. The similar study can be replicated on a large population of people living with HIV drawn from

32 24 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 different ART centers instituting probability sampling. 2. A pretest posttest control group study can be conducted to find the effectiveness of JPMR on anxiety, depression and stress. 3. Randomize control trail effectiveness on JPMR. 4. Effectiveness of JPMR in increasing the CD4 count. Acknowledgement: The authors wish to thank Dr. Anice George, Dean, Manipal College of Nursing Manipal, Manipal University, Dr.SureshShasthri, Regional Co-ordinator, KSAPS, Bangalore and Dr.B.M. Hegde, Medical Officer, ART center District Hospital, Udupi for giving permission to conduct study. Grateful acknowledgements to all the patients and their families, who willingly participated in this study. Conflict of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Source Funding: NIL Ethical Aspects: Administrative permission from the Dean, Manipal College of Nursing, Manipal University, Manipal. Administrative permission from Superintendent of ART center, Udupi. Informed consent was taken from the participants of the study. REFERENCES 1. HIV/AIDS Basic facts. Karnataka State Prevention Society. March 2002; Park K. Textbook of preventive and social medicine.21th edition. M/S BanarsidasBhanot Publishers: Jabalpur: India; Global report. UNAIDS report on the global AIDS epidemic Web site pub/globalreport. 4. Isao Fukunishi, Takashi Hosaka, Tomoko Matsumoto, Motoko Hayashi & Masayoshi Negishi, Liaison Psychiatry And HIV Infection : Application Of Relaxation In HIV Positive Patients. Regular Article Psychiatry and Clinical Neurosciences (1997), 51, ). 2005; 50: Townsend M C. Psychiatric mental health nursing concept of care 5th edition. Philadelphia: F. A Davis publishers; G.A. Hand, K.D. Phillips &W.D. Dudgeon. Perceived stress in HIV infected individuals: physiological and psychological correlates, University of South Carolina, Columbia, USA.AIDS Care, November 2006; 18(8):

33 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No.1 25 Effectiveness of Peer Led Intervention Programme (PLIP) on Knowledge of Student Nurses Regarding Management of Neonatal Disorders Rajyashwaree Bhele 1, Smriti Arora 2, Urmila Bhardwaj 3 1 M. Sc. Nursing Student, 2 Assistant Professor, 3 Associate Professor, Rufaida College of Nursing, Hamdard University, New Delhi ABSTRACT Introduction: A quasi-experimental study to assess the effectiveness of peer led intervention programme (PLIP) on knowledge of student nurses regarding management of neonatal disorders in selected college of nursing, New Delhi was conducted during Aug April The primary objective of study was to compare the knowledge of student nurses in the management of selected neonatal disorders in experimental group before and after the administration of PLIP and to determine the acceptability of PLIP among third year B. Sc. (H) student nurses. Method: The conceptual framework adopted for the present study was based on the systems model. The quantitative experimental research approach was adopted for the study with "quasi-experimental, pretest-posttest design." The present study was conducted among eighty five third year student nurses of Rufaida College of Nursing, New Delhi and Nightingale Institution of Nursing, Noida. Total enumerative sampling technique was applied.there were37 students in experimental group and 48 in control group.the experimental group was exposed to PLIP and the control group received conventional teaching using lecture method. The primary outcome variable knowledge was assessed using a valid, reliable (r=.8) and pre-tested structured knowledge questionnaire (SKQ). PLIP was administered by the researcher wherein the peer leaders were selected and trained to teach selected neonatal disorders to their peers. The pre-test and post-test scores of the students were assessed on day 1 and day 12 respectively. The acceptability towards PLIP was assessed on day 12 from the students in the experimental group. Results: The findings of the study revealed that mean post-test knowledge scores (51.43) of experimental group, were significantly higher than the mean post-test knowledge scores (31.41) of control group (p=0.00). Conclusion: PLIP is more effective in enhancing the knowledge B.Sc. Nursing students regarding management of selected neonatal disorders. Keywords: Peer Led Intervention Programme, Knowledge, Neonatal Disorders INTRODUCTION Peer-led health education in school is widely used. Peer education typically involves training imparted by a member of a given group to effect change among the rest of the members of the same group. Peer education is often used to effect changes in knowledge, attitudes, beliefs, and behaviors at the individual level. Advocates suggest it is an effective method based on the belief that information, particularly sensitive information, is more easily shared between people of a similar age. Critics suggest that this is a method not based on sound theory or evidence of effectiveness. 1 Social support and connectedness have been identified as important protective factors against a range of physical and psychological conditions. Research suggests that people are more likely to hear and

34 26 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 personalize messages, and thus to change their attitudes and behaviors, if they believe the messenger is similar to them and faces the same concerns and pressures. Peer education draws on the credibility that young people have with their peers, leverages the power of role modeling, and provides flexibility in meeting the diverse needs of today s youth. Numerous studies have demonstrated that peers influence youth health behaviors with regard to sexuality, violence and substance abuse. Peer education can support young people in developing positive group norms and in making healthy decisions. Shah S.et al 2 conducted a study to determine the effect of a peer led programme for asthma education on quality of life and related morbidity in adolescents with asthma. When adjusted for year and sex, mean total quality of life scores showed significant improvement in the intervention than control group. Clinically important improvement in quality of life (>0.5 units) occurred in 25% of students with asthma in the intervention group compared with 12% in the control group (p=0.01). Jahanfar S. et al 3 conducted a randomized controlled trial of peer-adult-led intervention on improvement of knowledge, attitudes and behavior of 530 university students regarding HIV/AIDS. The results suggest that relative to the control group, participants in the intervention group had higher levels of knowledge (pvalue= 0.001) and a better attitude (p-value =0.001). OBJECTIVES OF THE STUDY 1. To compare the knowledge of student nurses in the management of selected neonatal disorders in experimental group before and after the administration of PLIP. 2. To compare the knowledge of student nurses in the management of selected neonatal disorders between experimental and control group after the administration of PLIP. 3. To determine the association of knowledge scores of student nurses about management of selected neonatal disorders with selected demographic variables. HYPOTHESES The following hypotheses were tested at 0.05 level of significance. 1. H 1 There will be a significant difference in the mean pre-test and post-test knowledge score of student nurses in experimental group after administration of PLIP in the management of selected neonatal disorders as assessed by structured knowledge questionnaire. 2. H 2 There will be a significant difference in the mean post-test knowledge score of student nurses between the experimental and control group after administration of PLIP in the management of selected neonatal disorders. 3. H 3 There will be a significant association of selected variables with knowledge scores of student nurses exposed to PLIP related to management of selected neonatal disorders. METHOD The quantitative experimental research approach was adopted for the study with quasi-experimental pretest-posttest design. The ethical clearance was obtained from IRB, Jamia Hamdard. The present study was conducted among 85 third year student nurses of Rufaida College of Nursing and Nightingale Institute of Nursing. Total enumerative sampling technique was applied.there were 37 students in experimental group and 48 in control group.the experimental group was exposed to PLIP and the control group received conventional teaching. The primary outcome variable was knowledge which was assessed by a pre-tested structured knowledge questionnaire (SKQ). The knowledge questionnaire consisted of two sections. Section I comprised of items seeking demographic information of the subjects such as age of students, religion, percentage of B. Sc. Nursing 2 nd year, family income per month & parents education. Section II consisted of 60 MCQS. The content validity was established by seven experts from nursing and medical field. The reliability was assessed using KR 20 (r=.8). SKQ was divided into four sections i.e. neonatal hypothermia, neonatal seizures, neonatal sepsis, and neonatal jaundice having 15 items in each section. First the data was collected from control group which received the conventional teaching using lecture method. Then the data was collected from the experimental group who received PLIP. PLIP was administered by the researcher wherein the peer leaders were selected and trained to teach selected neonatal disorders to their peers. In order to be selected as peer leaders, a student had to obtain above 80% marks. Peer leaders were trained by the researcher. Onday 1, the pre-test i. e. SKQ was administered. Then PLIP was implemented (day-2, 3, 4, and 5) by peer leaders regarding management of selected neonatal

35 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 27 disorders i.e. neonatal hypothermia, neonatal seizure, neonatal sepsis, neonatal jaundice. Post-test was administered after the intervention on day 12 in order to evaluate the effectiveness of PLIP. The structured opinionnaire was administered on day 12 to assess the acceptability of PLIP. RESULTS The data collected was analyzed using descriptive and inferential statistics using SPSS 16. The level of significance was kept at 0.05 level. 1. Findings related to demographic variables of the sample. Table 1: Demographic Variables of Student Nurses in the Control and Experimental group. Demographic Variables Control Group Experimental df Fisher Exact Value p value (n 1 =48) Group (n 2 =37) Frequency % Frequency % Age of student 19-21yrs yrs yrs Religion Hindu Muslim Christian Others % in B. Sc. Nursing 2 nd year < 60 % ** % % % Family income per month < Rs * Rs Rs Rs > Rs Fathers Education Higher Secondary/ ** Bachelor s Degree Master s Degree Master s Degree & above Mothers Education Higher Secondary/ ** Bachelor s Degree Master s Degree Master s Degree & above * Significant at 0.05 level, ** Significant at 0.01 level N=85 The data presented in table 1 shows that there was a difference between the group in term of their percentage 2 nd year (p = 0.00), family income (p = 0.01), fathers education (p = 0.00), and mothers education (p = 0.00). But the groups were similar in terms of their age (p = 0.25), and religion (p = 0.04).

36 28 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 2. Findings related to knowledge scores of student nurses regarding management of selected neonatal disorders after PLIP HO 1 There will not be any significant difference between the mean pre-test and post-test knowledge score of student nurses in experimental group after administration of PLIP in the management of selected neonatal disorders as measured by structured knowledge questionnaire at 0.05 level of significance. Table 2: Mean, Mean Difference, Standard deviation of Difference, Standard Error of Mean Difference and t value of pre-test and post-test knowledge scores of experimental group. Experimental Group Knowledge Score Mean ± SD Mean D SD D SE MD df t Value p Pre-test ± ** Post-test ± 5.94 * Significant at 0.01 level n 2 =37 The data presented in table 2 shows that the mean post-test knowledge scores (51.43) of experimental group was higher than their mean pre-test knowledge scores (26.86) with a mean difference of The t value of for df 36 was found to be statistically significant at 0.01 level. This shows that the obtained mean difference of was a true difference and not by chance. Therefore the null hypothesis (HO 1 ) is rejected. Thus it can be inferred that the PLIP was effective in enhancing the knowledge of student nurses related to management of selected neonatal disorders. 3. The findings related to post-test knowledge scores between experimental and control groups. HO 2 There will not be any significant difference between the mean post-test knowledge score of student nurses between experimental groups exposed to PLIP regarding the management of selected neonatal disorders and control group, as evident from the structured knowledge questionnaire at 0.05 level of significance. Table 3: Mean, Mean Difference, Standard deviation of Difference, Standard Error of Mean Difference and t value of Post-test knowledge scores of Experimental and control group. Groups Post-test Knowledge Score Mean Mean D SD SE M SE D df t Value p Control Group (n 1 =48) ** Experiment Group (n 2 =37) *Significant at 0.01 level N=85 The data presented in Table 3 shows that the mean post-test knowledge scores (51.43) of experimental group, was higher than the mean post-test knowledge scores (31.41) of control group with a mean difference of This obtained mean difference was found to be statistically significant as evident from the t value of for df 83, at 0.01 level of significance. So the difference obtained is a true difference not by chance. Therefore, the null hypothesis HO 2 is rejected. Hence it can be inferred that the PLIP was more effective in enhancing the knowledge of student nurses regarding management of selected neonatal disorders as compared to conventional teaching. 4. Findings related to association between post test knowledge scores of experimental group and selected demographic variables HO 3 There will be no significant association between post-test knowledge scores of student nurses after the administration of PLIP and selected factors i.e.age, Religion, Percentage of previous year, Family income per month and parents educationas evident from the structured knowledge questionnaire at 0.05 level of significance.

37 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 29 Table 4: Association of Post-Test Knowledge Scores of Student Nurses with Selected demographic Variables in Experimental Group Selected Variable Category Frequency Knowledge Score Mean SD Test value p Age of student yrs (F) yrs yrs Religion Hindu (F).00 ** Muslim Christian Others % of Previous Year Examination < 60 % (t).03 * % Family income per month < Rs (F).01 * Rs10,000 20, Rs Rs >Rs 40, Fathers Education Higher Secondary/ (F).59 Bachelor s Degree Master s Degree Master s Degree & above Mothers Education Higher Secondary/ (F).55 * p value significant at 0.05 level, ** p value significant at 0.01 level Bachelor s Degree Master s Degree Master s Degree & above n 1 =37 Findings in table no 4 show that there was no significant association between knowledge scores and selected demographic variables like age, fathers education, and mothers education whereas there was a significant association between knowledge scores and selected demographic variables like religion, % of previous year examination and family income. Students practicing Christian religion; having above 60% score in previous year examination; and with low family income had higher mean knowledge scores. Therefore, null hypothesis HO 3 is partially rejected with regard to religion, % of previous year examination, and family income. DISCUSSION In the present study the knowledge of BSc nursing third year students on selected neonatal disorders significantly improved after the PLIP by the researcher (p=.00). The findings of the present study are congruent with the study done by Strange V and Forrest S 4 who conducted a randomized controlled trial of peer-led sex education in English secondary schools. Peer educators reported positive changes in sexual knowledge and changes towards more liberal attitudes, and believed the programme would have a positive impact on their confidence in relationships and on their sexual behaviour. The findings of the study are also similar to the study conducted by Li S. et al 5, on the effectiveness of a peer-led education intervention in HIV/AIDS prevention among high school Chinese children of migrant workers. A peereducation-based HIV/AIDS prevention was implemented for three months. The results during the baseline survey indicated that the level of knowledge on HIV/AIDS was lower in children of migrant workers. After three months of peer-led intervention, compared with the control group, students in the intervention group positively increased their HIV/ AIDS-related knowledge, modified their attitude and improved their protection self-efficacy. Compared with attitude, intervention was more effective in the improvement of knowledge and protection self-

38 30 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 efficacy, especially knowledge. The findings suggest that peer-led education was an effective method in improving knowledge, attitude and protection selfefficacy in Chinese children of migrant workers. CONCLUSION PLIP was effective in increasing the knowledge of student nurses regarding management of selected neonatal disorders. Similarly peer-led interventions can be adopted in the nursing practice area to demonstrate new equipment and technologies. Further studies can be done to compare different teaching strategies with PLIP and other outcome variables like attitude and practice can be assessed. Acknowledgement: I express my sincere gratitude to Dr. Manju Chhugani and all those who have directly or indirectly contributed to the successful compliment of this project as a fruitful and successful learning experience. Conflict of Interest: None Source of Funding: The study was funded by the main author herself. REFERENCES 1. A. R. Mellanby, J. B.Ree and J. H.Tripp. Peer-led and adult-led school health education: a critical review of available comparative research. Department of Child Health, University of Exeter, Exeter EX2 5SQ, UK. January 25, Shah S, Peat JK, Mazurski EJ, Wang H, Sindhusake D, Bruce C, Henry RL, Gibson PG. Effect of peerledprogramme for asthma education in adolescents: cluster randomised controlled trial. Primary Health Care Education and Research Unit, Auburn Hospital and Community Health Services, Auburn, NSW 2144, Australia JahanfarS,Lye MS, Rampal L.A randomised controlled trial of peer-adult-led intervention on improvement of knowledge, attitudes and behaviour of university students regarding HIV/ AIDS in Malaysia. Department of Public Health, Royal College of Medicine Perak, University Kuala Lumpur, 3 Greentown Street, Ipoh 30450, Malaysia Strange V, Forrest S. Peer-led sex education characteristics of peer educators and their perceptions of the impact on them of participation in a peer education programme. Social Science Research Unit, Institute of Education, University of London, UK. 5. Li S, Huang H, Cai Y, Ye X, Shen X, Shi R, Xu G.Evaluation of a school-based HIV/AIDS peerled prevention programme: the first intervention trial for children of migrant workers in China. School of Public Health, Shanghai Jiaotong University School of Medicine, Shanghai, People s Republic of China.Int J STD AIDS Feb;21(2):826

39 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No.1 31 Effectiveness of Acupressure on Chemotherapy Induced Nausea and Vomiting and the functional status among Cancer Patients Receiving Cisplatin as Radiosensitizer Chemotherapy in Kasturba Hospital Manipal Anusree Augustine 1, Elsa Sanatombi Devi 2, Latha T 3 1 Lecturer, Department of Medical Surgical Nursing, Father Muller College of Nursing, Mangalore, 2 Associate Professor, 3 Assistant Professor, Department of Medical Surgical Nursing, Manipal College of Nursing Manipal, Manipal University ABSTRACT Objective: To investigate the effectiveness of acupressure in reducing CINV, and to find the correlation between functional status and nausea experience. Method: 40 cancer patients receiving cisplatin as radiosensitizer chemotherapy were divided into experimental and control group (n=20 each). Both group received regular antiemetic medication; however the intervention group received finger acupressure to the selected acu-points for nausea and vomiting (Pericardium -6 & Heart -7) for 3 min on each point bilaterally (Total 12 minutes) twice daily for 3 days, starting from second day of chemotherapy. Both group reported nausea and vomiting using Rhodes index of nausea and vomiting. Functional status was assessed using functional status index. Results: Nausea experience was significantly lower in experimental group compared to the control group (P = 0.002) and a significant weak negative correlation was found between the nausea experience and functional status (P = 0.026). Conclusions: Nausea experience can have significant impact on the functional status of the cancer patients and acupressure can be useful for reducing chemotherapy induced nausea. Keywords: Acupressure, Nausea, Vomiting, Functional Status, Cisplatin, Radiosensitizer Chemotherapy, Cancer Patients INTRODUCTION Cancer is a disease process whereby cells proliferate abnormally; ignoring growth regulating signals in the environment surrounding the cell 1. Cancer is the leading cause of mortality in the developed world and increasingly becoming so, in the developing world. Cancer is the fourth most common cause of death in Corresponding author: Anusree Augustine Lecturer Father Muller College of Nursing, Kankanady, Mangalore Tel: anusree.augustin@yahoo.com the United States, causing > 500,000 deaths per year and 7 million deaths worldwide 2. In India it is estimated that there are approximately million cases of cancer at any given point of time, with around 7-9 lakh new cases being detected each year. Nearly half of these cases die each year 3. Cancer is associated with aging and has increased as life expectancy has increased. Tobacco is the most common cause of cancer death. Multiple modalities are commonly used in cancer treatment including surgery, radiation therapy, chemotherapy, and biologic response modifier therapy. Chemotherapy and radiation therapy are associated with numerous adverse effects such as bone marrow depression, increased susceptibility to infection, alopecia, nausea, vomiting etc. 1

40 32 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Chemotherapy induced nausea and vomiting (CINV) are two of the most distressing and feared toxicities of cancer treatment. Chemotherapy drugs vary in their emetogenicity (ability to induce vomiting). Cisplatin is classically the most emetogenic drug. Prevention of CINV is important for a number of reasons besides patient comfort. Control of CINV improves the tolerability of chemotherapy and the likelihood that patients will complete their regimen, which is particularly important for potentially curative treatment. Vomiting and nausea in cancer patients can also be detrimental to nutritional status, leading to a reduction in performance status and ability to tolerate further cycles of chemotherapy and diminishing the palliative benefits of treatment. Furthermore, once vomiting is established, it can be refractory to simple treatments 4. Introduction of various antiemetic treatments including high dose metoclopramide in 1980 and serotonin (5-HT3) receptor antagonists, in the early 1990s, potentiated by concomitant use of corticosteroids has improved control of nausea and vomiting without significant toxicity 5. However, chemotherapy related nausea is not as well controlled by these drugs and remains a significant problem. Kris MG et al. conducted a study to evaluate the incidence, course and severity of delayed nausea and vomiting, involving 86 patients undergoing high dose chemotherapy with cisplatin, 93% of patients experienced some degree of delayed nausea and vomiting despite antiemetic therapy 6. Similarly in a study conducted by Axelrod RS et al. on prevalence of nausea and vomiting in patients receiving daily (5/7) radiation therapy with weekly doublet chemotherapy, involving 21 patients, most of them with early nausea had continued or worsened experience of symptoms despite antiemetic therapy 7. Since pharmacological treatments have failed to completely manage CINV, exploring the complementary role of other, non-pharmacological, approaches that can be used in addition to pharmacological approaches becomes paramount. Research supports the effectiveness of acupuncture and acupressure for the treatment of CINV. Numerous studies have tested the effectiveness of acupressure band and finger acupressure for alleviating CINV. Lee J et al. conducted a review of acupressure studies for CINV control to evaluate the effects of acupressure, when combined with antiemetics for the control of CINV. Ten controlled acupressure studies were included in this review. The overall effect of acupressure was strongly suggestive but not conclusive. Differences in the acupressure modality, the emetic potential of chemotherapeutic agents, antiemetic use, and sample characteristics of each study made study-to-study comparisons difficult. Suggestive effects of acupressure, cost-effectiveness and the noninvasiveness of the interventions encourage researchers to further investigate the efficacy of this modality 8. Patients receiving cisplatin as radiosensitizer chemotherapy are under high risk for CINV as they are receiving the most emetogenic chemotherapy drug along with radiation therapy. Even though they are the most vulnerable population effectiveness of acupressure on CINV among this population is not yet experimented. Therefore the purpose of the study were to (a) investigate the effectiveness of acupressure in reducing CINV among cancer patients receiving cisplatin as radiosensitizer chemotherapy, (b) assess the functional status of cancer patients receiving cisplatin as radiosensitizer chemotherapy and (c) find the correlation between functional status and nausea experience. Sample and setting MATERIALS AND METHOD This study used a quasi experimental post test only control group design. A purposive sampling technique was used to select the sample from radiation oncology wards of Shridi Sai Baba Cancer and Research Centre which is a part of Kasturba Hospital Manipal, one of the largest health care centers in south India. The sampling criteria included (a) patients who had history of nausea in the previous cycle, (b) patients who receive 3 rd or 4 th cycle of radiosensitizer chemotherapy in case of weekly regimen and 2 nd cycle in case of 3 weekly regimen, (c) patients who receive chemotherapy between AM -1.30PM, (d) patients who are not critically ill, (e) patients who are willing to participate in the study, (f) patients who can read Kannada. Study sample comprised of 40 cancer patients receiving cisplatin as radiosensitizer chemotherapy. Among the 40 samples, 20 were assigned to experimental group and 20 to control group. Allocation of samples in experimental and control group was done by matching with major sample characteristics including gender and type of radiosensitizer regimen (weekly or 3 weekly).

41 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 33 Intervention procedure Researcher has successfully completed a ten days course in acupressure and certified from Pranav Naturopathy Center, Mangalore in July Data collection was done from December 2011 to February Study was started on the second day of chemotherapy. For the experimental group, along with standard antiemetics, acupressure was given in the morning (between am) and evening ( pm) for three days starting from the second day of chemotherapy. Acupressure was given by applying firm pressure using thumb, to the selected acu-points for nausea and vomiting (Pericardium -6 /P6, and Heart -7/H7) for 3 min on each point bilaterally (Total 12minutes ). Acupressure was withheld from control group, but they also received the standard antiemetics as per the order. Demographic data of the samples was collected using a demographic proforma which includes age, gender, marital status, religion, education, occupation, monthly income, place of residence, previous history of nausea and vomiting, knowledge on acupressure and habits of alcoholism, smoking, or tobacco chewing. Clinical information of the samples was obtained using a clinical proforma which includes diagnosis/type of cancer, stage of cancer, details regarding radiosensitizer chemotherapy (type of regimen, total prescribed cycle, present cycle and dosage), total radiation dosage prescribed, total radiation dosage received, dosage per fraction, surgical management, feeding tube, details of antiemetics received, and other regular medications obtained. Outcome variables were nausea experience, vomiting experience and functional status. Nausea experience was assessed using nausea subscale derived from the Rhodes Index Nausea and Vomiting (RINV), with a potential range of score Vomiting experience was assessed using vomiting subscale derived from the RINV, with a potential range of score RINV is a 6-item, 5 point Likert-type self-report instrument which has tested reliability and validity. Permission to use RINV was obtained from the authors (Rhodes and Verna). Functional status was assessed using functional status index, a 5 point Likert scale which consists of 19 items with a potential range of score As the score increases functional status also increases. Reliability of translated RINV and functional status index was computed using Cronbach s alpha and reliability co efficient of functional status index = 0.96, RINV = 0.72, nausea subscale of RINV = 0.98, and vomiting subscale RINV = Both experimental and control group were asked to fill RINV every day before going to bed (between pm) for three days. They were also asked to fill the functional status index on the last day (4 th day of chemotherapy) along with the RINV. FINDINGS Data were coded and entered into SPSS version 16 for the statistical analysis. Sample characteristics were described using frequency, percentage, mean and standard deviation. The effectiveness of acupressure was assessed using RMANOVA. Correlation between functional status and nausea experience was assessed using spearman s rank correlation. Sample characteristics Majority of subjects in the experimental and control group were in the age group of > 40 years. Sixty five percent of subjects in both experimental and control group were male. Ten percent of the subjects in the experimental group and 30% of the subjects in the control group knew about acupressure. Thirty percent of the subjects in the experimental group and 35% of the subjects in the control group had the habit of alcoholism. Thirty five percent of the subjects in the experimental group and 30% of the subjects in the control group had the habit of smoking. Thirty five percent of the subjects in the experimental group and 40% of the subjects in the control group had the habit of tobacco chewing. Majority of the subject in the experimental and control group were diagnosed to have head and neck cancer. In both experimental and control group, 55% subjects received 3weekly sensitizer regimen. All subjects in the experimental and control group received total radiation dosage between 20-40Gy. All subjects received radiation dose of 2Gy per fraction. Twenty percent of subjects in the experimental group and 30% of the subjects in the control group had undergone prior surgical management. Thirty five percent of the subjects in the experimental group and 20% of the subjects in the control group had PEG tube. Ten percent of the subjects in the experimental group and 5% of the subjects in the control group had Ryles tube. Thirty five percent of the subjects in the experimental and 40% of the subjects in the control group received T. Metoclopramide as antiemetic.

42 34 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Effectiveness of acupressure on nausea and vomiting experience There was a significant difference in the mean scores of nausea experience between experimental and control group across the three assessment days with the experimental group reporting less nausea experience (F = , P = 0.002). There was a difference in the mean scores of vomiting experience between experimental and control group across the three assessment days with the experimental group reporting less vomiting experience which was not statistically significant ( F=2.405, P = 0.129). Table 1: Mean and standard deviation of nausea and vomiting experience n= (20+20=40) Day 1 Day 2 Day 3 Mean S.D Mean S.D Mean S.D Nausea experience Experimental group Control group Vomiting experience Experimental group Control group Table 2: RMANOVA for nausea and vomiting experience between groups F value df p value Nausea experience Vomiting experience Description of function status and its correlation with nausea experience. Mean functional status of the sample was with a maximum score of 68 and minimum score of 42. There was a weak negative correlation between functional status and nausea experience which was statistically significant (ñ = , P = 0.026). Table 3: Mean and standard deviation of functional status Mean SD Maximum Minimum Functional status n=40 Table 4: Relationship between functional status and nausea experience n=40 Variables Spearman s rho (ñ) p value Functional status Nausea experience DISCUSSION The current study revealed a significant difference in the nausea experience between experimental and control group (P= 0.002) across the three assessment days with the experimental group reporting less nausea experience. Present study also showed a difference in the vomiting experience between experimental and control group, across the three assessment days with the experimental group reporting less vomiting experience, even though it was not statistically significant (P= 0.129). This may be due to the fact that few patients vomited, and hence a large sample was necessary to capture the effects of acupressure on vomiting experience. Dibble SL et al.

43 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 35 conducted a randomized clinical trial, among 17 breast cancer patients, which showed a significant differences existed between the experimental and control groups in regard to nausea experience (p < 0.01) with the acupressure group reporting less intensity and experience of nausea 9. A study conducted by Shin YH et al. among 40 postoperative stomach cancer patients, showed a significant difference between acupressure group and control groups in the severity of nausea and vomiting (P < 0.01) the duration of nausea, (P < 0.01) and frequency of vomiting (P <0.01) 10. These study findings strengthen the effectiveness of acupressure in reducing chemotherapy induced nausea and vomiting. Current study supports the review of acupressure studies, done by Lee J et al. This reported that one quasi-experimental and two randomized finger acupressure trials revealed the positive effects of acupressure and finger acupressure were effective in controlling delayed nausea and vomiting. 8 Current study result showed a weak negative correlation (p= 0.026) between functional status and nausea experience. Study finding is supported by a prospective survey conducted by O Brien BJ et al. onimpact of chemotherapy-associated nausea and vomiting on patients functional statusamong 92 cancer patients receiving HEC or MEC, which showed that nausea had a greater impact than emesis on overall functioning (p = 0.05). 12 Drawbacks of our study being that effect of antiemetics was not controlled because the antiemetics therapy obtained by the experimental and control group were not standardised. We were not able to control other extraneous variables including age, type of cancer, previous history of alcoholism and feeding tubes completely due to sample shortage. Small sample size and purposive sampling limits the generalizability of study findings. Acknowledgement: The authors are thankful to the Dean, Manipal College of Nursing Manipal, Manipal University for giving support throughout our study period. Ethical Clearance: Study approval was obtained from institutional ethical committee of the study hospital (Kasturba hospital Manipal). Informed consent was obtained from the subjects before the starting the study Conflict of Interest: There was no significant conflict of interest for the researcher. Source of Funding: There was no research grant from any source for financing the study. REFERENCES 1. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth s text book of Medical surgical nursing. 10 th ed. Philadelphia: Lippincott; Foster C, Mistry NF, Peddi PF, Sharma S. Washington manual of medical therapeutics. 33 rd ed. St.Louis: Lippincott; Park K. Park s textbook of preventive and social medicine. 19 th ed. Jabalpur: Bhanot; Feeney K. Chemotherapy induced nausea and vomiting: prevention and treatment. Aust fam physician. 2007; 36(9): Grunberg SM, Deuson RR, Mavros P, Geling O, Hansen M, Cruciani G, et al. Incidence of chemotherapy-induced nausea and emesis after modern antiemetics: perception versus reality. Cancer [serial online], 2004 [cited 2004 April 12]; 100(10): Available from: InterScience/ Kris MG, Gralla RJ, Clark RA, Tyson LB, O Connell JP, Wertheim MS, et al. Incidence, course, and severity of delayed nausea and vomiting following the administration of highdose cisplatin. J Clin Oncol. 1985; 3(1): available from: pubmed/ Axelrod RS, Machtay M, Werner-Wasik M, Anne R, Schlossberg H, Laudadio M, et al. Prospective evaluation of incidence and pattern of nausea in patients receiving combined chemotherapy and radiotherapy (RT) above the diaphragm. J Clin Oncol. 2009; 27(3): Lee J, Dodd M, Dibble S, Abrams D. Review of acupressure studies for chemotherapy-induced nausea and vomiting control. J Pain Symptom Manage [serial online], 2008 [cited 2008 nov];

44 36 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 36(5) : available from: Dibble SL, Chapman J, Mack KA, Shih AS Acupressure for nausea: results of a pilot study.oncol Nurs Forum. 2000; 27(1):41-7.available from: pubmed/ Shin YH, Kim TI, Shin MS, Juon H. Effect of acupressure on nausea and vomiting during chemotherapy cycle for Korean postoperative stomach cancer patients. Cancer Nurs ; 27(4): Molassiotis A, HelinAM, Dabbour R, Hummerston S. The effects of P6 acupressure in the prophylaxis of chemotherapy-related nausea and vomiting in breast cancer patients. Complement Ther in Med. 2007; 15(1): O Brien BJ, Rusthoven J, Rocchi A, et al. Impact of chemotherapy-associated nausea and vomiting on patients functional status: survey of five Canadian centers. Can Med Assoc J. 1993; 149(3):

45 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No.1 37 An Exploratory Survey of Determinants Influencing Birth Spacing among Married Women Residing in Selected Rural Areas of Mysore District Jetty Elizabeth Jose 1, Nisha P Nair 2, Sheela Williams 3, Vinay Kumar G 1, Sreekutty Divakaran 1 1 M.Sc Nursing, 2 Assistant Professor, Dept.of Community Health Nursing, 3 Professor, Principal, Dept. of Medical Surgical Nursing, JSS College of Nurisng, Mysore ABSTRACT Background: Birth spacing is one of the fundamental pillars of safe motherhood and a reproductive right. It is an important life saving measure for mothers and children. Adequate birth spacing could be logical alternative strategies for fertility control. Analysis of birth spacing determinants undoubtedly provides useful information on reproduction and family formation. From the many underlying causes of maternal mortality, the contribution made by unplanned pregnancies is particularly important. A variety of demographic and socio economic characteristics influence women's spacing practices Method: A descriptive exploratory survey was used in the study. Two hundred (200) married women who are in the age group of 19 to 45 years and conceived minimum two times were selected by nonprobability purposive sampling technique. Data were collected using structured interview schedule. The data were collected and analyzed using descriptive and inferential statistics. Results: Descriptive and inferential statistics were used to analyze the data. The study findings revealed that the family had more influence on birth spacing (0.913), followed by biological and medical condition (0.326), Health services (0.286), Behavioural factors (0.276) knowledge and practice (0.171) and least influence by society and religion (0.149). When all the determinants taken together in regression analysis, knowledge and practice, and society and religion showed not significant influence on birth spacing (p > 0.05). Family, behavioural factors, biological and medical conditions, health services has significant influence on birth spacing (P<0.05). Conclusion: Thus, it was concluded that certain determinants were having significant influence on birth spacing among married women. It was also evident from the findings that, majority of married women (49%) were having <2 years of birth spacing duration. Keywords: Determinants; Birth Spacing; Married Women INTRODUCTION Birth spacing is one of the fundamental pillars of safe motherhood and a reproductive right 1.It is an important life saving measure for mothers and children 2. Based on recommendations of a WHO, a birth to conception interval of at least two years should be maintained to reduce the risk of adverse maternal, perinatal and infant outcomes further, many researchers suggest that a 3-5 year inter-pregnancy interval is associated with a lower risk of miscarriage, new born death, and maternal death 3. Having too many pregnancies or pregnancies too closely spaced can negatively impact the health of the mother and her infant 4. Poor birth spacing practices significantly brings in rise of morbidity & mortality of any country which further increases burden on health care system 2. The National Family Health Survey (NFHS-3), coordinated by the International Institute for Population Sciences (IIPS) reports that, the infant mortality rate (deaths per 1,000 births) for births spacing less than 2 years apart is 86, dropping to 50 for births months apart, and to 30 for births months apart. Hence it infers poor management of

46 38 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 birth intervals. By state, infant mortality is highest in Uttar Pradesh (73) and lowest in both Kerala and Goa 5. Unintended pregnancies and births have a potentially devastating impact on both the individual and society. According to U.S. Census Bureau, International Programs Division, the world population reached 7 billion in 2011 and is expected to reach 10.5 billion in 2050, and we are growing by 78 million a year. In 2025 India, with 1.46 billion people, will have overtaken China, with the population 1.39 billion, as the world s most populous nation 6. At this crucial juncture, the study of fertility becomes of paramount importance for population control. A variety of demographic and socio economic characteristics influence women s spacing practices. Social scientists believe that differences in birth interval lengths are explained by varying breastfeeding patterns 7, contraceptive use, frequency of intercourse, incidence of abortion and fecundity 8. Differences in other factors such as women s roles and status and the value of children may also influence the birth intervals. There is no doubt that the socioeconomic, demographic, health and cultural background of a country, also affect the birth spacing. Women s education and age at marriage are the other widely analysed determinants of birth intervals 9. A cross sectional study was conducted at rural areas of Manipur to investigate the significant determinants on closed birth intervals. The data was collected among 740 eligible women, by using stratified random sampling technique. A pre- tested semi-structural interview schedule was used as a tool. The study results revealed that desired number of sons by wife has 40% risk of short birth interval. And those couples having only a girl child were high risk of (14%) inadequate birth spacing comparing with those having at least a son child. The finding suggested that one month increase in duration of the breast feeding can lead to 4% increase in the duration of birth interval. It also revealed there is marked difference in birth spacing duration in different religion. Islam couples were 22% more risk of short birth interval. The study results projected that age at marriage of wife, sex of the previous child and the religion have high significant impact on the dynamics of closed birth interval 10. The present study is initiated to investigate the differential pattern of duration of waiting time to conception of women in the rural areas of Mysore Districts with respect to various demographic, behavioural and socio-economic factors. It will be helpful to design evidence-based strategies for fertility control. OBJECTIVES OF THE STUDY 1. To find out the determinants influencing birth spacing among married women. 2. To find out the extent of determinants influencing birth spacing among married women. 3. To determine the relationship between birth spacing and determinants influencing birth spacing among married women. 4. To determine the association of determinants influencing birth spacing among married women with their selected personal variables. HYPOTHESES H 1 : There will be a significant relationship between birth spacing and a. Knowledge and practice. b. Family c. Behavioral factors d. Biological and medical condition e. Society and religion f. Health services H 2 : There will be significant association of determinants influencing birth spacing among married women with their selected personal variables METHODOLOGY A descriptive exploratory survey was used in the study. Two hundred (200) married women who are in the age group of 19 to 45 years and conceived minimum two times were selected by non-probability purposive sampling technique. Data were collected using structured interview schedule. 1. Porforma for selected personal variable 2. Structured interview schedule to explore determinants influencing birth spacing and to find out the extent of determinants influencing birth spacing.

47 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 39 FINDINGS Section I: Description of selected personal variables The study consists of 200 samples. The selected personal variables are described and analyzed under sub headings of the age, religion, education, spouse education, occupation, spouse occupation, income, age at marriage, number of children, type of family, duration between two consecutive pregnancies, exposure to any other education program as shown in Table 1. Table 1: Frequency and percentage of distribution of samples according to selected personal variables n = 200 Selected personal variables f Percentage (%) 1. Age (in years) % % % % 2. Religion Hindu % Muslim 34 17% Christian 6 3% Any other 4 2% 3. Education No formal education 40 20% Primary school education 72 36% High school education 70 35% PUC and above 18 9% 4. Education of the husband No formal education 64 32% Primary school education 50 25% High school education 62 31% PUC and above 24 12% 5. Occupation House wife % Coolie 22 11% Employee 8 4% 6. Occupation of the husband Coolie % Employee 76 38% Business 14 7% Unemployed 4 2% 7. Family income per month % % > % 8. Age at marriage Below 20 years % years 32 16% Above 25 years 4 2%

48 40 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 1: Frequency and percentage of distribution of samples according to selected personal variables(contd.) Selected personal variables f Percentage (%) 9. Number of children One 32 16% Two % Three and above 34 17% 10. Type of family Nuclear family % Joint family 70 35% 11. Duration between two consecutive pregnancies <2 years 98 49% 2-3 years 78 39% 4-5 years 12 6% >5 years 12 6% 12. Knowledge about birth spacing Yes % No 68 34% Source of information Electronic media 26 13% Family members 38 19% Friends 18 9% Health personal 38 19% Print materials 12 6% Section 2: Description of determinants influencing birth spacing among married women Table 2: Mean, Median, Standard deviation, Maximum score of determinants influencing birth spacing among married women Sl No Items Maximum Score Mean Mean Percentage Median SD n = Knowledge and Practice % 3.00 ± Family % 2.00 ± Behavioural Factors % 3.00 ± Biological and Medical Condition %.00 ± Society and Religion % 3.00 ± Health Services % 4.00 ±.844 n=200 The data presented in Table 2 shows that the mean scores obtained for the Health services is highest (3.46) followed by the Society and religion (2.94), Behavioural factors (2.85), Knowledge and practice (2.77) and Family (1.63). The biological and medical condition got less mean score (0.29). Section 3: Extent of factors that influencing birth spacing Table 3: Multiple regression values of extent of determinants influencing birth spacing among married women Sl No Items StandardizedCoefficient SE p 1 Knowledge and Practice Family Behavioural factors Biological and Medical conditions Society and Religion Health Services R 2 =0.715 n=200

49 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 41 Data presented in the Table 3, shows that the family has more influence on birth spacing (.913), followed by biological and medical condition (.326), Health services (.286), Behavioural factors (.276) knowledge and practice (.171) and the least influence by society and religion (.149). When all the determinants taken together in regression analysis, knowledge and practice, and society and religion show not significant influence on birth spacing (p > 0.05). A family, behavioural factor, biological and medical conditions, health services has significant influence on birth spacing (P <.05). All these variables show 71.5% influence on birth spacing. Table 4: Correlation coefficient of birth spacing and determinants influencing birth spacing among married women Sl No. Variables Mean score R n = Birth spacing and Knowledge and Practice * 2 Birth spacing and Family * 3 Birth spacing and Behavioural factors * 4 Birth spacing and Biological and Medical condition * 5 Birth spacing and Society and Religion * 6 Birth spacing and Health Services * r (198)= ; P=0.05; * = Significant The data presented in Table 4 shows that the r values obtained for birth spacing and various determinants like knowledge and practice (r=0.76), family (r=0.77), behavioral factors (r=0.82), biological and medical condition (r= 0.55), society and religion (r=0.77), and health services (r=0.66) are found significant at 0.05 level of significance. Thus, null hypothesis H0 1 is not supported and the research hypothesis is supported, indicating there is significant positive correlation between all the given determinants and birth spacing. This implies that all the given determinants have a significant influence on birth spacing. Table 5: Chi-square values between birth spacing and with their selected personal variables n=200 Selected personal variables <2 YearsF 2 Years and AboveF d (f) Chi square value 1. Age (in years) Religion Hindu Other than Hindu Education No formal education #9.14* Primary school education High school education PUC and above Education of the husband No formal education Primary school education High school education PUC and above 10 14

50 42 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 5: Chi-square values between birth spacing and with their selected personal variables (Contd.) n=200 Selected personal variables <2 YearsF 2 Years and AboveF d (f) Chi square value 5. Occupation House wife * Employee Occupation of the husband Coolie #4.49 Employee Business Family income per month > Age at marriage Below 20 years years And Above 25 years 9. Number of children One Three and above Type of family Nuclear family * Joint family Knowledge about birth spacing Yes No Source of information Electronic media #16.36* Family members Friends 2 16 Health personal Print materials 6 6 χ 2 (1) = 3.84, χ 2 (2) = 5.99, χ 2 (3) = 7.82, χ 2 (4) = 9.49, p <0.05, * = Significant, # = Yates Correction The data presented in the Table 5 shows that, the computed Chi-square value for association of determinants influencing birth spacing among married mothers with their selected personal variables is found to be statistically not significant at 0.05 levels of significance except for mothers education and occupation, type of family and source of information having significant association with birth spacing at 0.05 level of significance. Hence, the findings partially support the null hypothesis H0 2 and the research hypothesis, inferring that determinants influencing birth spacing among married women are partially influenced by their selected personal variables. CONCLUSION The findings of the study revealed that, influence of family, behavioral factors, biological and medical conditions, facilities provided by the health services have a significant influence on birth spacing. Thus, it was concluded that certain determinants were having significant influence on birth spacing among married women. It was also evident from the findings that, majority of married women (49%) were having <2 years of birth spacing duration. This emphasis the urgent need of health education program in institutional setting as well as community setting

51 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 43 regarding importance of birth spacing and various birth spacing measures. It gives noticeable effect in the success of family planning program and thereby lessen the population explosion. Acknowldgement: We express our thanks to married women who participated in the study and the authorities who provided permission to conduct the study. Interest of Conflict: Health of the mother and the child is equally important. For improving the health of the mother, the resting period between pregnancies which allows the mother to recuperate from pregnancy. The findings of the present study revealed that, majority of married women (49%) were having <2 years of birth spacing duration, hence nurses have pivotal role in organizing and executing creative awareness programs for all vulnerable sections of society to improve knowledge, develop positive attitude and increase the practices of birth spacing methods ETHICAL CLEARANCE: Ethical clearance was obtained from the ethical committee of the college. Funding Sources: Not obtained any funds from any sources. REFERENCES 1. New findings on birth spacing: Three to five years is the optimal interval. [Internet]. 2010[cited 2011 Oct 23]. Available from: pagename= Programs_ Birth_ Spacing_ Optimal_Interval. 2. USAID.Optimal Birth Spacing.An Activity of the CATALYST Consortium. [Internet]. 2010[cited 2011 Oct 23]. Available from: smrh_obsi_overview.pdf 3. The Third National Family Health Survey (NFHS3) [Internet]. [cited 26/10/2005]; Available from: 20of% 20Findings%20(6868K).pdf. 4. Population report. Issues in World Health [Internet] [cited 2011 Sep 10]. Available from: The Johns Hopkins Bloomberg School of Public Health, Web site: The Third National Family Health Survey (NFHS3) [Internet]. [cited 26/10/2005]; Available from: Summary%20of%20Findings%20(6868K).pdf. 6. National Family Health Survey (NFHS-3) Volume I. International Institute for Population Sciences. Deonar, Mumbai. India. September Madhu K, Chowdary S, Masthi R. Breast feeding practices and newborn care in rural areas: a descriptive cross-sectional study. Indian journal of community medicine Jul:34(3): Wardatul Akmam. Women s Education and Fertility Rates in Developing Countries with Special Reference to Bangladesh. Eubios Journal of Asian and International Bioethics.2002:12(2): Black JM, Hawks JH. Medical Surgical Nursing. 8th edition. Missouri; Saunders Elsevier; 2009: p Laishram Hemochandra1, Naorem Sharat Singh, A.K. Ashakumar Singh. Factors Determining the Closed Birth Interval in Rural Manipur. Journal of Human Ecology.2010: 29(3):

52 44 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / A study on Knowledge, Attitude and Practices of Female Multipurpose Health Workers (MPHW) on selected Components of Safe Motherhood Programme in the state of Maharashtra Saroj V Upasani R N Principal, KDA Nursing College, Mumbai, Maharashtra, India ABSTRACT Background: The lifetime risk of maternal death in India refers to the risk of complications of pregnancies and child birth. The present Nurse midwife or Auxiliary Nurse Midwife plays the pivotal role in delivering the safe motherhood services, with this understanding the present study was undertaken by the investigator in the Maharashtra state. Objectives: A study was planned to assess knowledge, attitude and practices of FMPHW (Female Multipurpose Health Workers) in relation to essential Antenatal care of women, and to find out attitude of FMPHW in relation to selected components of essential care. Material and Method: A non experimental; descriptive cross sectional study was carried out on 531 female multipurpose health workers of (tribal, tribal - non tribal and non tribal areas) Nashik district of Maharashtra. The random sampling technique was used to select the study subjects. A self prepared and pre tested semi structured questionnaire and observation check list was used to gather the data. The legal and ethical aspects were considered during the data collection. The descriptive statistics (frequency, percentage) and inferential statistics (t test) applied wherever required. Results: It was found that the mean score of knowledge was found to be similar in all the three areas (74 to 75). The mean score of attitude was highest (88) in the samples from tribal area as compared to other two areas, whereas the practice score of samples was less in tribal - non tribal areas than tribal and non tribal areas. There was a varied knowledge deficit and lack of practice was noted on various aspects of safe motherhood. Conclusion: The female multipurpose health workers need adequacy of current knowledge and skills while providing essential antenatal care to the client in their allotted population. There is need to promote participants knowledge and practice is relation to care of pregnant women having bad obstetric history and pregnancy associated problems, and to minimize the gap between basic training to up to date skills by having on the job or hands on training. Keywords: Knowledge, Attitude, Practice, Female Multipurpose Health Workers and Safe Motherhood Programme INTRODUCTION The life time risk of maternal death in India refers to the risk of complications of pregnancy and child birth. The maternal mortality is the sensitive indicator of health services. Govt. of India had launched Child Survival and Safe motherhood Programme with an aim of reducing the maternal mortality less than two per thousand deliveries by 2000 AD 1. The Auxiliary Nurse Midwife or Female Multi Purpose Health Workers plays major role in the delivery of safe motherhood activities. Hence they were provided modular training of CSSM to promote

53 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 45 maternal and child health services at sub centers and primary health centers. Nursing today is undergoing evolutionary changes with advances in basic sciences and technology use in patient care. A professional nurse must assume numerous responsibilities and competencies. Here the nurse needs to have improved body of knowledge and competency which could be possible through continued nursing educations 2. The reinforcement of knowledge and skill leads to enrichment of knowledge, desirable practices and positive attitude of the service providers 3,4. In view of these the present communication was carried out to study the knowledge, attitude and practice of female multipurpose health workers on selected components of safe motherhood programme in Maharashtra, to signify the need for special attention to reduce the maternal mortality with emphasis to rural and remote places of India. OBJECTIVES 1. To assess knowledge, attitude and practices of FMPHW (Female Multipurpose Health Workers) in relation to essential antenatal care of women. 2. To find out attitude of FMPHW in relation to selected components of essential care 3. To study existing practices of FMPHW in relation to selected components of essential antenatal care as a part of safe motherhood programme 4. To assess practices of FMPHW (10% of total samples randomly selected) in relation to antenatal checkups. 5. To find out limitation to implement the selected components of essential ANC care in the area of practice. 6. To study selected variables in relation to knowledge attitude and practices FMPHW toward essential antenatal care. MATERIAL AND METHOD The present non experimental; descriptive cross sectional study was conducted with an aim to evaluate the knowledge, attitude and practices of Female Multipurpose Health Workers (FMPHW) on selected components of Safe Motherhood Programme. The study was carried out at Nashik district of Maharashtra, having typical geographical distribution of tribal, tribal non tribal and non tribal areas. The approval by institutional research/ethics committee of SNDT University was obtained. The sample comprised of 531 (tribal: 158, tribal non tribal: 182, non tribal: 191) MPHW appointed at primary Health Centers and Sub centers of Maharashtra. Along with, fifty (10%) samples were selected to observe the practices. The probability method; random sampling technique (homogenous) was used to select the samples. The content validated and pre tested semi structured questionnaire and observation check list was used to collect the data. After seeking informed consent, self written responses were obtained from samples by the researcher. The responses were voluntary and no probing questions were asked. The data was analyzed as per geographical division of Nasik district as samples were appointed respectively. The collected data was organized and analyzed based on the objectives by using descriptive and inferential statistics. P <0.05 was considered as statistically significant level. The conceptual frame work was developed to understand the inter connection of concepts and outcomes (fig. No: 1). RESULTS Findings related to socio demographic characteristics: Highest percentage (73.96%) of samples were belonged to years, majority of samples from tribal area (93.52%) and tribal non tribal area (62.14%) were allotted < 5000 population and (70.45%) of samples from non tribal area allotted > 5000 population to provide health services. All (100%) of samples were residing in head quarter areas, either in govt. quarters or in rented house in the same village. Maximum percentage of samples had > 8 years of work experience. Findings related to knowledge, attitude and practice on safe motherhood, and significant relationship of selected variables: The calculated mean score of knowledge was found to be almost same in all the three areas (74 to 75). The mean score of attitude was highest (88) in the samples from tribal area as compared to other two areas, while the mean score of practice of the samples was less in tribal non tribal areas as compared to other two areas. There was no significant difference between knowledge, attitude and practice with reference to higher and lower age group of tribal area compare to

54 46 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 other two areas. The service experience of samples showed varied relationship i.e. increase in the year of experience and decrease in knowledge score in tribal area, whereas samples from non tribal area having increase in year of experience showed increase knowledge score. There was a significant difference between the practice score of the samples having less year of experience in all three areas. The other variables like population allotment of the samples (<5000 or >5000) to provide health services, and residence of samples did not show any significant relationship. Findings related to knowledge and practice of samples with reference to selected components of essential antenatal care: Knowledge i. Adequacy in knowledge: Majority of samples knew the purpose and components of safe motherhood and RCH programme such as purposes and early registration of ANC, normal weight gain and blood pressure in pregnancy registration, factors related to bad obstetrics history, purposes of abdominal palpation and normal fetal heart rate etc. Most of the samples knew the purpose of Tetanus Toxoid injection (TT) during pregnancy and aware the signs and symptoms of anemia and correct doses of tab Iron Folic Acid administration ii. Knowledge deficit variedly, observed in all three areas: Around (50%) of samples did not know the formula to calculate Expected Date of Delivery (EDD) and the estimated ANC cases in allotted area. The knowledge about causes of low weight gain during pregnancy (i.e. worries, lethargy, hard physical work etc) and ill effects of low weight gain during pregnancy on the baby to be born (i.e. still birth, IUGR etc) were found to be less by the samples % did not know about the purposes of abdominal examination (esp. changes of fundal height as per the progress of pregnancy). Majority (80%) of the samples from tribal non tribal area did not know the correct schedule including booster doses of inj. TT. Most of the samples were aware of low HB (<7 gm %) as an indication of anemia, while few samples (< 10%) were not aware of the other signs of anemia like giddiness and dizziness etc. Practices related to ANC care i. Adequate practices among majority of samples: Higher percent (62 67%) samples carry out the general head to foot examination of pregnant women. The blood pressure and weight was checked for every pregnant woman by the samples as per availability of weight machine and BP apparatus. The responses of the samples from the three areas to administer inj. TT ranged between 85 93%. Most (71 80%) of samples carried out urine testing (sugar and albumin) and tested the serum HB level, remaining samples refereed the client to PHC or Rural hospital for blood grouping, typing, VDRL and HIV testing etc. Health teaching on place and preparation for delivery and next due date of ANC visits being told to the clients. ii. Inadequacy of practice: Majority of samples performed abdominal palpation lacking in fundal and pelvic palpation. Every sample did not check foetal heart sound due to unavailability of foetoscope and stethoscope in the center. Hand washing technique was not practiced mostly due to unavailability of tap, water and soap. The planned health teaching did not include mostly early initiation of breast feeding, advice on diet, and family planning though it was an important aspect of CSSM programme. Recording and reporting: System of MIS (Management Information System) is followed but difficulties faced to complete the records due to shortage of stationary materials, unawareness about the columns in R15 register. Factors affecting implementation of ANC care: Almost all samples had positive attitude towards antenatal women to discuss their doubts. It was noticed that there was an inadequate supervision, guidance by immediate supervisors. The overlapping job and assignment as basically appointed as multipurpose worker. The curriculum was not revised related to maternity care, newly appointed and transferred workers, monotony in reporting and recording system and knowledge deficit due to gap between basic training and current practices were the other factors which affect the implementation of ANC care. DISCUSSION Study findings revealed that samples from tribal area had higher mean score of attitude on safe

55 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 47 motherhood; it could be due to intensified CSSM programme in tribal areas. The most deficit area of knowledge was changes of fundal height as per the progress of pregnancy. It was consistent with results of Mishra A and Rajesh L that the common reason for deficit knowledge among health workers on abdominal examination was due to non usage of gravidogram or charts during the practice 5. Results showed that every sample under study did not check the foetal heart sound due to unavailability of foetoscope/stethoscope in health center. The hand hygiene was not practiced mostly due to unavailability of water and soap which is congruent with a study carried out by Sarkar B that the unavailability of equipments and amenities leads to poor implementation of health services and better outcomes. This emphasizes the importance of infrastructural facilities in client care 6. Further, findings revealed that samples from tribal non tribal area did not know the correct schedule of inj. Tetanus Toxoid and the immunization coverage, this finding was similar that of Hawaldar A and Aliahmad M who reported that one of the existing factors responsible for the inadequate immunization coverage is lack of awareness of services 7. The results of this study provide the important implications for understanding the safe motherhood and the need for appropriate knowledge and skill in carry out the practices. The findings of this study support the multidimensional notion of the health programmes and demonstrate the significance of awareness and attitude on the various domains of safe motherhood practice. CONCLUSION The study highlighted the strength and weakness of the areas of knowledge and practices of female multipurpose health workers while providing essential antenatal care to the client in their allotted population. Attitude of samples is not much influenced. There is need to promote samples knowledge & practices in relation to care of pregnant women having bad obstetric history and pregnancy associated problems. There is a gap between basic training and current practices, to minimize the gap needs jobs or hand on training with adequate guidance and supervision. To have more intensified activities on safe motherhood, to sensitize health care team to bring down the maternal mortality rate and better safe mother hood services in India. The supplementation of health information and education to pregnant women with involvement of partner guides to make safe motherhood programme a success. Fig. 1. Conceptual frame work Acknowledgement: The author expresses sincere thanks to the SNDT Women University, Govt. officials and all the Female Multi Purpose Health Workers for their kind cooperation and support rendered to complete the study. Source of support: Nil Conflict of interest: Nil Ethical clearance: Ethical clearance was obtained from the institutional research/ethics committee of SNDT Women University. REFERENCE 1. World Health Organization. Health Manpower requirement for achievement of Health for All by 2000 AD, Technical Research Series 717, 2007: National CSSM programme interventions module, MCH (1994, 1996) Division of Ministry of Health and Family Welfare, Govt. of India, New Delhi. 3. Health Information of India by Central Bureau of Health Intelligence DGHS, Ministry of Health and Family Welfare, New Delhi. Section 9; 1991: Chakrapani A and Vijaykumar M. Availability and accessibility and utilization of rural health services. Journal of Family Welfare. 41 (3); 2007:

56 48 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 5. Mishra A and Rajesh L. Female Health Workers Problems and Implications. Economic and Political Weekly. 25; 2009: Sarkar B. Safe Motherhood, Appraisal of present status in India. Journal of Obstetrics and Gynecology of India. 17 (3); 2008: Hawaldar A and Aliahmad M. Factors affecting Maternal and Child Health in city slum, existence from recent survey. The journal of Family Welfare. 41 (2); 2007: Choudhari RR. Training of health workers at gross root level for Safe Motherhood. Safe Motherhood Federation of Obstetric and Gynecological Societies of India, Bangalore; 2004: Coyaji and Banu. Safe Motherhood initiative strategies for India. Safe Motherhood, Federation of Obstetric and Gynecological Societies of India. 2000: Bhaskar K and Rao. How Safe Motherhood in India? Journal of Indian Medical Association, 93 (2): ICMR. Project to evaluate quality and coverage of Maternal and Child Health at PHCs, A study by Task Force : Kulkarni and Sumathi. Evaluation of CSSM training for health functionaries in Maharashtra. A Report by International Institute of Population Science, Deonar, Mumbai Chattergy and Akokendu. Strategies for Safe Motherhood. Journal of Indian Medical Association. 93 (2); 2005: Spradley and Barbara. Community Health Nursing and practice, 4th edition, Lipincott publication; 2008: Mukharjee and Soma. Towards Safe Motherhood. Journal of Indian Medical Association, 93(7); 2000:

57 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No.1 49 Issues in Treating Adhd among Children and Adults Kanchana M N 1, Sangamesh N 2 1 Assistant Professor and HOD Dept of Paediatric Nursing, 2 Principal and HOD Dept of Community Health Nursing Sri Kalabyraeshwara Swamy College of Nsg, Bangalore ABSTRACT Attention deficit hyperactivity disorder (ADHD) is a group of behavioral symptoms that include inattentiveness, hyperactivity and impulsiveness. Attention deficit disorder (ADD) is a sub-type of ADHD. Attention deficit hyperactivity disorder (ADHD) may affects all aspects of a child's life. Indeed it impacts not only on the child, but also on parents and siblings, causing disturbances to family and marital functioning. the adverse effects of ADHD upon children and their families changes from the preschool years to primary school and adolescence, with varying aspects of the disorder being more prominent at different stages. ADHD may persists into adulthood causing disruptions to both professional and personal Keywords: ADHD, ADD, Inattentiveness, Hyperactivity; Impulsiveness INTRODUCTION What is attention deficit hyperactivity disorder? A syndrome of disordered behavior, usually diagnosed in childhood, characterized by a persistent pattern of impulsiveness, inattentiveness, and sometimes hyperactivity that interferes with academic, occupational, or social performance.. What causes ADHD? 1. Genes. Inherited from our parents, genes are the blueprints for who we are. Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several genes that may make people more likely to develop the disorder. Knowing the genes involved may one day help researchers prevent the disorder before symptoms develop. 2. Environmental factors. Studies suggest a potential link between cigarette smoking and alcohol use during pregnancy and ADHD in children. In addition, preschoolers who are exposed to high levels of lead, which can sometimes be found in plumbing fixtures or paint in old buildings, have a higher risk of developing ADHD. 3. Brain injuries. Children who have suffered a brain injury may show some behaviors similar to those of ADHD. However, only a small percentage of children with ADHD have suffered a traumatic brain injury. 4. Food additives. There is currently no research showing that artificial food coloring causes ADHD. However, a small number of children with ADHD may be sensitive to food dyes, artificial flavors, preservatives, or other food additives. They may experience fewer ADHD symptoms on a diet without additives, but such diets are often difficult to maintain. What are the symptoms of ADHD in children? Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD.. To be diagnosed with the disorder, a child must have symptoms for 6 or more months and to a degree that is greater than other children of the same age. Children who have symptoms of inattention may Be easily distracted, miss details, forget things, and frequently switch from one activity to another Have difficulty focusing on one thin Become bored with a task after only a few minutes, unless they are doing something enjoyable Have difficulty focusing attention on organizing

58 50 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 and completing a task or learning something new Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities Not seem to listen when spoken to Daydream, become easily confused, and move slowly Have difficulty processing information as quickly and accurately as others Struggle to follow instruction Children who have symptoms of hyperactivity may Fidget and squirm in their seats Talk nonstop Dash around, touching or playing with anything and everything in sight Have trouble sitting still during dinner, school, and story time Be constantly in motion Have difficulty doing quiet tasks or activities Children who have symptoms of impulsivity may Be very impatient Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences Have difficulty waiting for things they want or waiting their turns in games Often interrupt conversations or others activities How is ADHD diagnosed? Children mature at different rates and have different personalities, temperaments, and energy levels.. ADHD symptoms usually appear early in life, often between the ages of 3 and 6, and because symptoms vary from person to person, the disorder can be hard to diagnose. Parents may first notice that their child loses interest in things sooner than other children, or seems constantly unfocused or out of control. Often, teachers notice the symptoms first, when a child has trouble following rules, or frequently spaces out in the classroom or on the playground. No single test can diagnose a child as having ADHD.. The pediatrician or mental health specialist will first try to rule out other possibilities for the symptoms. Between them, the referring pediatrician and specialist will determine if a child: Is experiencing undetected seizures that could be associated with other medical conditions Has a middle ear infection that is causing hearing problems Has any undetected hearing or vision problems Has any medical problems that affect thinking and behavior Has any learning disabilities Has anxiety or depression, or other psychiatric problems that might cause ADHD-like symptoms Has been affected by a significant and sudden change, such as the death of a family member, a divorce, or parent s job loss. A specialist will also check school and medical records for clues, to see if the child s home or school settings appear unusually stressful or disrupted, and gather information from the child s parents and teachers. Coaches, babysitters, and other adults who know the child well also may be consulted. The specialist also will ask Are the behaviors excessive, and do they affect all aspects of the child s life? Do they happen more often in this child compared with the child s peers? Are the behaviors a continuous problem or a response to a temporary situation? Do the behaviors occur in several settings or only in one place, such as the playground, classroom, or home? How is ADHD treated? Currently available treatments aim at reducing the symptoms of ADHD and improving functioning. Treatments include medication, various types of psychotherapy, education and training, or a combination of treatments.

59 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 51 Medications Stimulants such as methylphenidate and amphetamines are the most common type of medication used for treating ADHD. Although it may seem counterintuitive to treat hyperactivity with a stimulant, these medications actually activate brain circuits that support attention and focused Behavior, thus reducing hyperactivity. In addition, a few nonstimulant medications, such as atomoxetine, guanfacine, and clonidine, are also available. For many children, ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. Stimulant medications come in different forms, such as a pill, capsule, liquid, or skin patch. Some medications also come in short-acting, long-acting, or extended release varieties. In each of these varieties, the active ingredient is the same, but it is released differently in the body. Long-acting or extended release forms often allow a child to take the medication just once a day before school, so he or she doesn t have to make a daily trip to the school nurse for another dose. Psychotherapy Different types of psychotherapy are used for ADHD. Behavioral therapy aims to help a child change his or her behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a child how to monitor his or her own behavior. Learning to give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting, is another goal of behavioral therapy. Parents and teachers also can give positive or negative feedback for certain behaviors.. Therapists may teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond appropriately can also be part of social skills training. How can parents help? Children with ADHD need guidance and understanding from their parents and teachers to reach their full potential and to succeed in school. Before a child is diagnosed, frustration, blame, and anger may have built up within a family. Parents and children may need special help to overcome bad feelings. Mental health professionals can educate parents about ADHD and how it impacts a family.. Parenting skills training helps parents learn how to use a system of rewards and consequences to change a child s behavior Parents are taught to give immediate and positive feedback for behaviors they want to encourage, and ignore or redirect behaviors they want to discourage. In some cases, the use of time-outs may be used when the child s behavior gets out of control. In a time-out, the child is removed from the upsetting situation and sits alone for a short time to calm down Parents are also encouraged to share a pleasant or relaxing activity with the child, to notice and point out what the child does well, and to praise the child s strengths and abilities. Also, parents may benefit from learning stressmanagement techniques to increase their own ability to deal with frustration, so that they can respond calmly to their child s behavior. Sometimes, the whole family may need therapy. Therapists can help family members find better ways to handle disruptive behaviors and to encourage behavior changes. Finally, support groups help parents and families connect with others who have similar problems and concerns. Tips to Help Kids Stay Organized and Follow Directions Schedule. Keep the same routine every day, from wake-up time to bedtime. Include time for homework, outdoor play, and indoor activities. Keep the schedule on the refrigerator or on a bulletin board in the kitchen. Organize everyday items. Have a place for everything, and keep everything in its place. This includes clothing, backpacks, and toys. Use homework and notebook organizers. Use organizers for school material and supplies. Stress to

60 52 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 your child the importance of writing down assignments and bringing home the necessary books. Be clear and consistent. Children with ADHD need consistent rules they can understand and follow. Give praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behavior, and praise it What conditions can coexist with ADHD? Some children with ADHD also have other illnesses or conditions. For example, they may have one or more of the following: A learning disability. A child in preschool with a learning disability may have difficulty understanding certain sounds or words or have problems expressing himself or herself in words. A school-aged child may struggle with reading, spelling, writing. Oppositional defiant disorder. Kids with this condition, in which a child is overly stubborn or rebellious, often argue with adults and refuse to obey rule. Conduct disorder. This condition includes behaviors in which the child may lie, steal, fight, or bully others. He or she may destroy property, break into homes, or carry or use weapons. These children or teens are also at a higher risk of using illegal substances. Kids with conduct disorder are at risk of getting into trouble at school or with the police. Anxiety and depression. Treating ADHD may help to decrease anxiety or some forms of depression. Bipolar disorder. Some children with ADHD may also have this condition in which extreme mood swings go from mania (an extremely high elevated mood) to depression in short periods of time. Tourette syndrome. Very few children have this brain disorder, but, among those who do, many also have ADHD. People with Tourette syndrome have nervous tics, which can be evident as repetitive, involuntary movements, such as eye blinks, facial twitches, or grimacing, and/or as vocalizations, such as throat-clearing, snorting, sniffing, or barking out words inappropriately. These behaviors can be controlled with medication, behavioral interventions, or both. ADHD also may coexist with a sleep disorder, bedwetting, substance abuse, or other disorders or illnesses Do teens with ADHD have special needs? Most children with ADHD continue to have symptoms as they enter adolescence. Some children are not diagnosed with ADHD until they reach adolescence.. In these children, the disorder becomes more apparent as academic demands increase and responsibilities mount. For all teens, these years are challenging. Teens also become more responsible for their own health decisions. When a child with ADHD is young, parents are more likely to be responsible for ensuring that their child maintains treatment. But when the child reaches adolescence, parents have less control, and those with ADHD may have difficulty sticking with treatmen To help them stay healthy and provide needed structure, teens with ADHD should be given rules that are clear and easy to understand. Helping them stay focused and organized such as posting a chart listing household chores and responsibilities with spaces to check off completed items also may help Teens with or without ADHD want to be independent and try new things, and sometimes they will break rules. If your teen breaks rules, your response should be as calm and matter-of-fact as possible. Punishment should be used only rarely. Teens with ADHD often have trouble controlling their impulsivity and tempers can flare. Maintaining treatments, such as medication and behavioral or family therapy, also can help with managing your teenager s ADHD. Can adults have ADHD? Some children with ADHD continue to have it as adults. And many adults who have the disorder don t know it. They may feel that it is impossible to get organized, stick to a job, or remember and keep appointments. Daily tasks such as getting up in the morning, preparing to leave the house for work, arriving at work on time, and being productive on the job can be especially challenging for adults with ADHD. These adults may have a history of failure at school, problems at work, or difficult or failed relationships. Many have had multiple traffic accidents. Like teens,

61 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 53 adults with ADHD may seem restless and may try to do several things at once, most of them unsuccessfully. How is ADHD diagnosed in adults? Like children, adults who suspect they have ADHD should be evaluated by a licensed mental health professional. But the professional may need to consider a wider range of symptoms when assessing adults for ADHD.. To be diagnosed with the condition, an adult must have ADHD symptoms that began in childhood and continued throughout adulthood. Health professionals use certain rating scales to determine if an adult meets the diagnostic criteria for ADHD. The mental health professional also will look at the person s history of childhood behavior and school experiences, and will interview spouses or partners, parents, close friends, and other associates. The person will also undergo a physical exam and various psychological tests How is ADHD treated in adults? Much like children with the disorder, adults with ADHD are treated with medication, psychotherapy, or a combination of treatments. Medications. ADHD medications, including extended-release forms, often are prescribed for adults with ADHD. Antidepressants are sometimes used to treat adults with ADHD. The antidepressant bupropion (Wellbutrin), which affects the brain chemical dopamine, showed benefits for adults with ADHD. Older antidepressants, called tricyclics, sometimes are used because they, like stimulants or atomoxetine, affect the brain chemical norepinephrine. Adult prescriptions for stimulants and other medications require special considerations. For example, adults often require other medications for physical problems, such as diabetes or high blood pressure, or for anxiety and depression. Some of these medications may interact badly with stimulants. An adult with ADHD should discuss potential medication options with his or her doctor. Education and psychotherapy. A professional counselor or therapist can help an adult with ADHD learn how to organize his or her life with tools such as a large calendar or date book, lists, reminder notes, and by assigning a special place for keys, bills, and paperwork. Large tasks can be broken down into smaller, more manageable steps so that completing each part of the task provides a sense of accomplishment Psychotherapy, including cognitive behavioral therapy, also can help change one s poor self-image by examining the experiences that produced it. The therapist encourages the adult with ADHD to adjust to the life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks. CONCLUSION ADHD is relatively stable through early adolescence for more children.some children experience decreased symptoms during late adolescence and adulthood,but a significant number of these children carry their symptoms into adulthood.the goal for children with Lerning disability is to help them identify their areas of weakness and learn to compensate for them. Acknowledgement: I acknowledge my parents, husband, and Principal who helped me in completing the article. Conflict of Interest: The authors declared no potential conflicts of interest with respect to the publication of this article Source of Funding: Self funded Ethical Clearence: Ethical clearance was obtained from the appropriate authority. REFERENCES 1. Marlow DR, Redding BA. Text book of paediatrics Nursing.6th ed.philadelphia: Saunders Publication;2002: Ghai OP.Essential Paediatrics.6 th ed. New Delhi : CBS publication ;2008: Harpin VA (2005). The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. Journal of Archives of disease in childhood.90: Hockenberry MJ. Wong s essential of paediatric Nursing.7 th ed.elsevies publication;2005:new Delhi: en.wikipedia.org/wiki/attention_ deficit_ hyperactivity_disorder psychcentral.com/disorders/adhd/

62 54 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Effect of Swaddling on Pain and Physiological Parameters in Neonates During Heel Lance Shivani Thakur 1, Jyoti Sarin 2, Yogesh Kumar 3 1 Lecturer, Netaji Subhash College of Nursing, Palampur, Kangra, Himachal Pradesh, 2 Principal cum Director, 3 Assistant Professor, M.M. College of Nursing, M.M. University, Mullana, Ambala, Haryana ABSTRACT Neonates in the NICU experience multiple, painful, tissue-damaging procedures daily. Pain among neonates is often underestimated and untreated, producing untoward consequences. Keeping all this in view a study to determine the effect of pain and physiological parameters among neonates during heel lance with and without swaddling was carried out in Chandigarh child care center, Kotkapura, Punjab. Objectives of the study were to assess and compare pain and physiological parameters among neonates during heel lance with and without swaddling. The study was also intended to determine the relationship between pain and physiological parameters and to find the association of levels of pain with sample characteristics of the neonates with swaddling. The study was conducted in the month of December 2012 to January 2013 on 30 neonates selected through purposive sampling technique. The data was collected using Modified neonatal facial coding scale and physiological parameters record sheet. There was significant difference found in pain and heart rate of the neonates with and without swaddling. Moderate positive correlation was found between pain and heart rate during heel lance where as no significant relationship with oxygen saturation. No association of pain was found with the sample characteristics of the neonates at the time of heel lance. Keywords: Swaddling, Heel lance, Neonates, Pain, Physiological Parameters INTRODUCTION Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Neonates experience pain at least as similar as older children and have increased sensitivity with subsequent painful stimuli. 1 Neonates in the Neonatal Intensive Care nursery experience multiple, painful, tissue-damaging procedures daily. Pain among neonates is often underestimated and untreated, producing untoward consequences. 2 About 9,000 newborn infants are receiving intensive care in the U.S. today, and many will be exposed to medical procedures that cause pain, such as needle sticks and circumcisions. Babies often receive less pain-relieving medicine before invasive procedures or after surgery than adults do. An inflammatory response lasting from hours to days will follow, leading to increased pain sensitivity around the damaged tissue. 3 In the past, pain in neonates went untreated, primarily due to the mistaken belief that babies don t perceive or remember painful experiences. However, it has become clear over the last decade that newborns do feel pain and that their crying from pain is different to reflex crying. 4 A Prospective Study of Procedural Pain and Analgesia in Neonates shows that on average, each neonate was subjected to a mean ± SD of 14 ± 4 procedures per day. The highest exposure to painful procedures occurred during the first day of admission, and most procedures (63.6%) consisted of suctioning. Many procedures were estimated to be painful (pain scores >4 on a 10-point scale). 5 Pain is difficult to assess and even more challenging when its victims are very young or preverbal. 6 Additionally, the reduction of pain is a significant ethical concern in neonatal care. Because it is difficult to quantify pain in infants, neonatal nurses are obligated to recognize and reduce the pain of

63 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 55 procedures. 7 Emphasis on infant pain management has recently become prominent in the medical field. Studies shows that infants are still being under medicated, if medicated at all, for painful or invasive procedures. 8 Because the adverse effects of pain medications are more prominent in infants, nonpharmacological methods are preferred to manage pain if possible. These methods are also preferable because a physician order is not needed to implement them. 9 Research has shown that swaddling is a natural, cost- effective intervention to decrease pain perception in infants during heel lance, as well as during any painful procedures. MATERIAL AND METHOD A quasi experimental study was conducted on the month of December 2012 to January 2013 in the NICU of Chandigarh child care center, Kotkapura, Punjab. All the cases age d 28 days were selected who scheduled to have at least two heel lance per day. Data regarding age, gender, gestational age, birth weight, type of delivery, placement of neonate, number of painful procedures and number of heel lance per day were collected. Pain was assessed through Modified neonatal facial coding scale and data regarding physiological parameters (heart rate and oxygen saturation level) was collected through physiological parameter record sheet at the time of heel lance as depicted on pulse oximeter. Table 1. Components of Modified Neonatal Facial Coding Scale 1 Brow Lowering 2 Eyes Squeezed Shut 3 Deepening Of The Naso-Labial Fold 4 Open Lips (any separation) 5 Vertical Mouth Stretch 6 Horizontal Mouth Stretch 7 Taut Tongue 8 Chin Quiver 9 Lip Pursing 10 Tongue Protrusion (In Preterms) Statistical Analysis All the data was transferred to a Microsoft excel spreadsheet. Independent verification of data was done by a second investigator. We analyzed the data using SPSS 16.0 software. RESULTS 30 neonates (20 males and 10 females) were analyzed by means of pain and physiological parameters during the heel lance. These neonates presented to the Neonatal intensive care unit with at least two heel lance per day. The majority of neonates (60%) were in the age group of 0-7 days. Majority (70%) neonates were getting 3-5 painful procedures/day. Table 2. Sample characteristics of the neonates S. No. Sample characteristics f % 1 Age (0-7) Gender (Male) Gestational age (32-37 weeks) Birth weight (>2500 gram) Type of delivery (NVD) Placement of neonate (Under RW) 7 No. painful procedures per day (3-5/day) 8 No. painful procedures per day (1-2/day) The mean pain score of the neonates without swaddling (6.57, 6.73) was higher than the neonates with swaddling (5.17, 4.93) at the time of heel lance on Day 1 and Day 2 respectively. There was significant difference found in heart rate of the neonates with and without swaddling. The significant relation was found between pain and heart rate during heel lance where as no significant relationship with oxygen saturation level. No association of pain was found with the sample characteristics of the neonates at the time of heel lance. Mean pain scores of the neonates with swaddling were significantly lowered than the mean pain score of the neonates without swaddling at 0 seconds, 30 and 60 seconds of heel lance both on Day 1 and 2. Mean pain score at evening was higher on Day 1 and 2 both with and without swaddling. As the intensity of pain in neonates increased in evening both with and without swaddling, which shows the diurnal variations in the level of pain among neonates during heel lance. Mean heart rate was significantly high at 45 seconds on day 1 ( beats/min, beats/min) in the neonates without swaddling on Day 1 and 2

64 56 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 respectively. Heart rate renormalized at 90 seconds of heel lance. Mean heart rate was significantly high at 30 seconds on day 1 ( beats/min, beats/ min) in the neonates with swaddling on Day 1 and 2 respectively. Heart rate renormalized at 60 seconds of heel lance. Mean oxygen saturation was at lowest level at 45 seconds (91.16%) and at 30 seconds (91.76%) in neonates without swaddling on Day 1 and 2 respectively. Mean oxygen saturation was at lowest level at 45 seconds in the neonates (90.60%) in the neonates with swaddling both on Day 1 and 2 respectively. There is no significant effect of swaddling on the oxygen saturation level of the neonates. The significant moderate positive co-relation was found between pain and heart rate during heel lance where as no significant relationship with oxygen saturation level. No association of pain was found with the sample characteristics of the neonates at the time of heel lance. DISCUSSION The purpose of present study was to determine the effect of swaddling on pain and physiological parameters (heart rate and oxygen saturation level) in the neonates admitted in neonatal intensive care unit during heel lance in selected hospital of Punjab. Analysis of this study indicated the significant effect of swaddling on pain and physiological parameters of the neonates. The results of the present study showed that swaddling is effective in reducing the level of pain in the neonates i.e. from severe pain (6.57, 6.73) to moderate pain (5.17, 4.93) on Day 1 and 2 respectively. These findings were consistent with the another study findings that swaddling alone has been shown to decrease pain perception in preterm neonates. 10 Swaddling combined with positioning neonates upright during routine heel lance procedures offers nurses a non-pharmacologic method of neonatal pain reduction for heel sticks. 11 Swaddling was found to be moderate to highly effective at reducing pain experienced from heel lance procedures in both term and preterm infants. 12 The heart rate increase in the infants when in pain (after an initial decrease) and oxygen saturation decrease when a child is in acute pain. Study findings of present study revealed that there was significant increase in heart rate of the neonates after the heel lance whereas oxygen saturation level decreased. The heel lance resulted in concurrent increase in heart rate and state of arousal and in reductions in blood oxygen saturation level. 13 Findings of the present study also revealed that swaddling is effective in early renormalization of heart rate in neonates after the heel lance but there was no significant effect of swaddling on oxygen saturation level. The mean heart rate was higher and mean oxygen saturation was lower than their respective baseline values under the two interventions after heelstick (p <.05) and premature infants in swaddling returned to their baseline heart rate and oxygen saturation values in shorter time periods compared to those in containment. 14 The swaddling is an effective means of speeding up recovery from heel lance (decrease in HR, increase in arterial oxygen saturation), whereas in infants of 27 to 30 weeks postconceptional age, recovery after heel lance is not influenced by swaddling, except for an increase in arterial oxygen saturation levels when swaddled. 15 The premature infants in swaddling return to their baseline heart rate and oxygen saturation in shorter time periods compared with those in containment. 16 The present study reported that there was significant correlation between pain and heart rate of the neonates. The pain is moderately correlated with the heart rate in preterm neonates (r = ). 17 The present study revealed that the level of pain is not associated with the gender of the neonate whereas significantly associated with the gestational age of the neonates at 60 seconds of the heel lance. This study findings was contradictory to the findings of another study that pain scores were not influenced by gestation (p=0*917; p=0*907) or postnatal age (p=0-067; p=0415). Also, the female sex was associated with an increased pain score compared with male sex (p =0 035) in the term infants. 18 Swaddling is concluded as effective method in lowering and stabilizing the mean heart rate of the neonates whereas the mean oxygen saturation level of the neonate remain within a normal range after the heel lance.

65 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 57 CONCLUSION Child health nursing is no more task oriented, fragmented care but it demands of a nurse to provide holistic care to the children. Atraumatic care is the key element of such care which involves preventing and relieving pain. Swaddling is a natural, cost- effective intervention to decrease pain perception in infants during heel lance; as well as during any painful procedures. Swaddling was found to be effective in significantly renormalizing heart rate in the neonates. Although the swaddling had no significant effect on oxygen saturation level but it is maintained in normal range during swaddling. Acknowledgment: At the very outset. I would like to thank almighty for his presence. My sincere thanks goes to all participants of my study. Lastly and most importantly I am grateful to everybody who was important to success realizations of thesis. Funding: Self funding Competing Interests: None stated Ethical Consideration: Ethical approval taken from the M.M. University research committee REFERENCES 1. Bucher H; U Baumgartner; R Bucher; et al. Artificial sweetener reduces nociceptive reaction in term newborn infants. Early Hum Dev 2000;59(1): Coleman M M; Solarin K; Smith C. Assessment and management of pain and distress in the neonate. Advance Neonatal Care. 2002; 2: K.J.S. Anand, P.R. Hickey. Pain And Its Effects In The Human Neonate And Fetus. THE NEW ENGLAND JOURNAL OF MEDICINE 19 November Volume 317. Number 21: Puchalski M, Hummel P. The reality of neonatal pain. Advance Neonatal Care Sinno H. P. Simons, Monique van Dijk, et al. A Prospective Study of Procedural Pain and Analgesia in Neonates November 2003, Arch Pediatr Adolesc Med. 2003;157(11): Gayle Giboney Page. Are There Long-Term Consequences of Pain in Newborn or Very Young Infants. J Perinat Educ Summer; 13(3): Taddio A; Kata J. Circumcision on pain responses during subsequent routine vaccination. Lancet 1997; 349: Breanne Ziraldo. Infant pain management [Online], cited 2012Jan 21; Available from: /digitalcommonsliberty.edu 9. Kashaninia Z; Sajedi F; Rahgozer M; et al. The effect of Kangaroo care on behavioural responses to pain of an intramuscular injection in neonates. Journal for Specialists in Pediatric Nursing 2008; 13 (4): Yamada, J., Stinson, J., Lamba, J., Dickson, A., McGrath, P. J., & Stevens, B. (2008). A review of systematic reviews on pain interventions in hospitalized infants. Pain Research & Management, 13(5), Liaw JJ, Yang L, Katherine Wang KW. Nonnutritive sucking and facilitated tucking relieve preterm infant pain during heel-stick procedures: a prospective, randomised controlled crossover trial. Int J Nurs Stud Mar;49(3): Prasopkittikun T, Tilokskulchai F. Management of pain from heel stick in neonates: an analysis of research conducted in Thailand. J Perinat Neonatal Nurs Oct-Nov;17(4): Sara J Morison, Liisa Holsti, Ruth Eckstein Grunau, et al. Are there developmentally distinct motor indicators of pain in preterm infants. Early Human Development. Volume 72, Issue 2, June 2003: Huang CM, Tung WS, Kuo LL, Ying-Ju C. Comparison of pain responses of premature infants to the heelstick between containment and swaddling. J Nurs Res.2004;12 : Fearon I, Kisilevsky BS, Hains SMJ, Muir DW, Tranmer J. Swaddling after heel lance: agespecific effects on behavioral recovery in preterm infants.j Dev Behav Pediatr.1997;18 : Huang CM, Tung WS, Kuo LL, Ying-Ju C. Comparison of pain responses of premature infants to the heelstick between containment and swaddling. J Nurs Res.2004;12 : Morison SJ, Grunau RE, Oberlander TF. Relations between behavioral and cardiac autonomic reactivity to acute pain in preterm neonates. Clin J Pain Dec;17(4): J Alison Rushforth, Malcolm I Levene. Behavioural response to pain in healthy neonates. Archives of Disease in Childhood 1994; 70: F174- F176

66 58 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Effectiveness of Clay Therapy on Anxiety Symptoms of Preschool Children Anu Mary Joseph 1, Ambika K 2, Sheela Williams 3 1 MSc (N), 2 HOD of Pediatric Nursing, 3 Principal cum Professor & HOD, JSS College of Nursing, Mysore ABSTRACT Background: In present scenario, anxiety disorders are most common form of psychopatholology in preschool children with overall prevalence rate of 8-10%. One in 10 children aged 2-5 years fond to be experiencing anxiety. In that 9.5% have in the form of separation anxiety, social anxiety, specific fears, and generalised anxiety. Clay therapy provides diversion and brings relaxation, feels more secure in a strange environment, lessens stress and provides a means of release tension. Design: Quasi-experimental non equivalent pre test post test control group design. Sample and sampling technique: Non probability convenience sampling technique was adopted to select 60 preschool children, both in experimental and control group. Tool: Child anxiety symptoms inventory-4 teacher observation checklist. Results: The result of the study revealed that the significance of difference between the mean pre test and post test anxiety symptom score in experimental group which was statistically tested using paired 't' test and was found to be highly significant at 0.05 level of significance (t(29)=22.41;p<0.05 and the significance of difference between the mean post test anxiety symptom scores between experimental and control group which was statistically tested using independent 't' test was found to be highly significant at 0.05 level of significance (t(58)=11.3; p<0.05). The result also shown that the anxiety symptom scores of preschool children had no significant association with their selected personal variables. Conclusion: Therefore, the study concluded that clay therapy was effective method to reduce the anxiety of preschool children. Keywords: Effectiveness, Clay Therapy, Anxiety Symptoms, Preschool Children INTRODUCTION In present scenario anxiety disorders are most common form of psychopatholology in preschool children with overall prevalence rate of 8-10%. The Great Smoky Mountains study of 4500 children aged 3-7 years found a 3 month prevalence rate of for anxiety disorder of 3.5 percent with a higher rate in females than in males. In the current scenario, clay therapy act as a version of play therapy is employed as a therapeutic tool. Clay therapy is an adjunct to play therapy clay helps in the sensory motor and intellectual development.it also improves socialization and selfawareness 1,2,3,4.. One article reports that, clay therapy has many advantages. This therapy should be effective in very anger, anxious and child with attention deficit hyperactive disorder. Clay therapy helps the child to express his anger through rolling, folding, and pounding the clay. Clay therapy helps the children to move from crippling emotional experiences to flourishing opportunity for inner growth and healing 5. Clay therapy has many qualities such as its strength; malleability and its concreteness make it very responsive to human feelings. Gorys survey showed 25% of therapist used clay in their practice while in contrast 99% believed that clay has very therapeutic.

67 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 59 Accordingly clay figures which are made of earth may reflect the connection between the human mental world and the material world 6. The research studies found that clay has an inherent ability to express the feelings of anger there by reduction in anxiety. So clay acts as a natural catharsis. Though many research studies have been conducted in abroad on effect on clay therapy on anxiety, but in India no much published literature could be retrieved.hence the researcher felt the need of conducting this study to provide clay therapy for preschool children to assess the effect of clay therapy on anxiety in Indian Scenario. So that the evidence can be generated this can be adopted as complementary therapy to reduce the anxiety among preschool children. Statement of the Problem A study to assess the effectiveness of clay therapy on anxiety symptoms of preschool children in selected schools at Mysore. OBJECTIVES 1. To assess the anxiety symptoms of preschool children among experimental and control group. 2. To determine the effectiveness of clay therapy on anxiety symptoms of preschool children. 3. To determine the association of anxiety symptoms scores of preschool children with their selected personal variables. HYPOTHESES H 1 : The mean post test anxiety symptoms scores of preschool children who have undergone clay therapy will be significantly less than the mean pre-test anxiety symptoms scores of preschool children. H 2 : The mean post test anxiety symptoms scores of preschool children who have undergone clay therapy will be significantly less than mean post anxiety symptoms scores of preschool children who are not exposed to clay therapy. H 3 : There will be association of anxiety symptoms scores of preschool children with their personal variables. RESEARCH METHODOLOGY The research approach and design adopted for the study was quasi experimental, non equivalent control group pre-test post test design. In the present study clay therapy was administered to the experimental group for 3hours per day for 3days. In the present study population comprises of preschool children in schools at Mysore. Convenient sampling was used to obtain the sample of 60 preschool children in selected schools at Mysore, 30 each in experimental and control group. The modified child anxiety symptom inventory-4 teacher observation checklist was used to assess the anxiety symptoms of preschool children in the present study. The total anxiety score ranged from 0-75.The score was further divided arbitrarily as follows: < 25 : mild anxiety : moderate anxiety : severe anxiety. Section 1: Description of selected personal variables RESULTS Table: 1: Frequency and percentage distribution of preschool children in experimental and control group according to their selected personal variables SlNo Selected personal variables Experimental groupn=30 Control groupn=30totaln=60 1. Age in years 2. Gender f % F % F % a. 3-4 years % 09 30% % b years 12 40% 12 40% 24 40% c years % 09 30% % a. Male 15 50% 18 60% 33 55% b. Female 15 50% 12 40% 27 45% n=60

68 60 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table: 1: Frequency and percentage distribution of preschool children in experimental and control group according to their selected personal variables (Contd.) SlNo Selected personal variables Experimental groupn=30 Control groupn=30totaln=60 3. Type of family f % F % F % a. Joint % % % b. Nuclear % % 45 75% c. Broken family % % % d. Single parent 03 10% % % 4. Birth order of the child a. First order 15 50% % % b. Second order % 15 50% % c. Third order % % % 5. Number of siblings a. Single child 15 50% % % b % 15 50% % c % % % d n=60 Study findings revealed that both in experimental (40%) and control (40%) majority of samples were in the age group of years. In experimental group both males and females were in equal number where as in control group maximum samples were males. In this study, maximum samples in experimental group (73.33%) and control group (76.67%) belonged to nuclear family.majority of the samples in experimental group(50%) were first order children where as in control group majority of the samples (50%) were in second order children. Majority of the samples in experimental group (50%) were single child and in control group (50%) majority of samples were having one sibling. Section 2: Effectiveness of clay therapy a. Description of preschool children s anxiety symptoms scores among experimental and control group. Table 2: Mean, median, range, standard deviation of pre test and post test anxiety symptoms scores of preschool children in experimental and control group. Group Pretest Scores Post Test Scores Mean Median Range S D Mean Median Range S D Experimental Group n= ± ± 4.5 Control Group n= ± ± 4.84 n=60 Data presented in Table: 2 shows that, the pre test anxiety symptoms scores ranged from in experimental group and in control group as against possible range of The post test anxiety symptoms scores ranged from in experimental group and in control group.

69 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 61 Table 3: Frequency and percentage distribution of preschool children according to their anxiety symptoms among experimental and control group. Level of anxiety Experimental group control group Total n=30 n=30 n=60 f (%) f (%) f (%) Pre test mild Moderate 20 (66.67%) 22 (73.33%) 42 (70%) Severe 10 (33.33%) 08 (26.67%) 18 (30%) Post test mild 04 (13.33%) (6.67%) Moderate 26 (86.67%) 24 (80%) 50 (83.33%) Severe (20%) 06 (10%) Table 3 shows that both pre test and post test majority of preschool children having moderate anxiety symptoms. b. Reduction in anxiety symptoms scores: comparing pre test and post test scores i) Significance of difference between pre test and post test anxiety symptoms scores of preschool children among experimental and control group. Table 4: Mean, mean difference, SD difference, SEMD and Paired t value of pre test and post test anxiety symptoms scores of preschool children in experimental and control group Anxiety Score Mean Mean SD SEMD Paired difference difference 't'value Experimental Group(n=30) Pretest ± * Post test Control Group(n=30) Pretest ± Post test t (29) :2.05;p<0.05; * - significant: p>0.05( not significant) n=60 n=30 The data presented in Table- 5 shows that, in experimental group the mean difference between pretest and post test anxiety symptom mean score is To find the significance of reduction in anxiety, paired t test was computed and obtained the value of t (29) : is found to be significant at 0.05 level of significance. So it is inferred that clay therapy was effective in reducing the anxiety of preschool children. symptoms scores of control group is Hence it is inferred that there is no significant difference between mean pre test and post test anxiety symptoms scores among control group. ii) Significance of difference between the mean post test anxiety symptoms scores of preschool children among experimental and control group. The data presented in table-5 further shows that, the mean difference in pre test and post test anxiety

70 62 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 5: Mean, mean difference, SD difference SEMD and Independent t value of post test anxiety symptoms scores of preschool children in experimental and control group. Anxiety Score Mean Mean SD SEMD Independent difference 't'value Experimental group ± * controlgroup n= t (58): 2.00; p<0.05; *- Significant n=60 To find the significance of difference in mean anxiety among experimental and control group, the independent t test was computed and the obtained the value of t (58) =11.3 is found to be significant at 0.05 level of significance. Hence it is inferred that clay therapy is an effective strategy to reduce the anxiety symptoms of preschool children. Section 3: Findings related to association of anxiety symptoms scores of preschool children with their selected personal variables. The findings of the study also shows that, computed chi square values for association between pre test level of anxiety of preschool children and their selected personal variables are found to be not significant. There for, the null hypothesis is supported for all personal variables interfering that anxiety is not influenced by their selected personal variables. CONCLUSION Anxiety disorders are one of the primary mental health problems affecting children and adolescents today. But most commonly affects in the preschool children. In the present study, pre test findings showed that most of the preschool children had moderate anxiety symptoms scores. It is also evident from that pre test anxiety symptom scores was independent of their selected personal variables such as age, gender, type of family, birth order of the child and number of siblings. The clay therapy was effective in reducing the anxiety as t (58) =11.3 in post test, was statistically significant at 0.05 level of significance. The result also revealed that, there was no association between pre test anxiety symptoms scores with their selected personal variables.thus it was concluded that clay therapy is effective in reducing the anxiety symptoms of preschool children. Acknowledgement: We express our thanks to school teachers who participated in the study and authorities who provided permission to conduct the study. Interest of Conflict: School teachers play a vital role in identifying anxiety symptoms among preschool children at the early stage. In the present study, school teachers of selected schools of Mysore had adequate awareness regarding clay therapy, but none of them had previous experience in identifying the anxiety symptoms among children, hence nurses need to encourage the school teachers to integrate the awareness with practice of clay therapy for reduction of anxiety symptoms Ethical Clearance: Ethical clearance was obtained from the ethical committee of the college. Funding Sources: Not obtained any funds from any sources.. REFERENCE 1. Marilyn J Hockenberry, David Wilson. Essentials of paediatric nursing.6 th ed. Missouri: Elsevier publication; Anagold A, Egger H.L.Preschool age development [Internet]. 2007[cited 2011 Nov 10]. Available from: pub.com/ content/15/3/310.short. 3. Kristine M Pahl. Preventing anxiety and promoting social and emotional strength in preschool children: an universal evaluation of the funs programme[phd thesis]. Path ways health and research center. St Lucia, Qid: University of Queesland; 2009[cited 2012 Sep 24]. Available from: Univesity of Quceensland Library E Reserve 4..Susan Gaofolo. Play therapy for children [Internet]. 2007[cited2011Nov10]. Available from: play.html 5. Marvin Bartel D. Clay for toddlers and preschoolers how and why[internet]. 2011[updated 2011 July 10; cited 2012 Oct 10]. Available from: arted/clay&toddlers.htm 6. Paul R.White.Clay therapy [Internet] [Updated 2010 Feb 19; cited 2011 Sep10]. Available from: wwwclaytherapyclay.com.

71 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No.1 63 Correlating Perceived Burden among Care Givers of Psychiatric & Diabetic Patients- A Regression Analysis Pravati Tripathy 1, Venkat Epari Rao 2 1 Dean, SUM Nursing College, S'o'a University, 2 Associate Prof, Dept of Community Medicine, Institute of Medical Science, SOA University Bhubaneswar ABSTRACT The effects of stressors on the family members caring for physically and mentally ill persons have been referred to as caregiver's burden. Family members bear the major responsibility for the care and in supporting family members who are sick in firm and disabled. The affected person is dependent on the caregivers and their well being is directly related to the nature and quality of the care provided by them. These demands can bring significant levels of stress for the caregivers and can affect their own well being and quality of the life. Setting: A University Medical College Hospital, Bhubaneswar Sample Size: 30 in each group Sampling Technique: Non Probability Convenient sampling Study Design: Descriptive comparative survey Result: The study explored higher level of burden among care givers of psychiatric illness (mean 26.7, SD ) than care givers of chronic illness like diabetes (mean 11.93,SD 4.193). Even after controlling the influencing variables through regression analysis it showed gender have influence over percieved burden. Conclusion: There is a need for early assessment, education & counseling of care givers to prevent higher level of stress.they must be supported by others emotionally, socially & economically to avoid real danger to their physical & mental healh. Keywords: Perceived Burden, Stressors, Care Givers, Diabetic, Psychiatric Illness INTRODUCTION Being a care giver is the most thankless role in the world. Everybody gives the patient some slack as they should, But the care givers has the strees of life and then you put a catastrophic illness on top of it,. The strees goes through the roof. Marcia Wallace Family caregivers play a major role in providing care giving assistance to ill persons and their families. The effect of stressors on family members caring for a physically or mentally ill person has been referred to as care giver s burden. Caregiver s burden is a multi dimensional phenomenon reflecting physical, psychoemotional, social and financial consequences of caring for an impaired family members. The burden of family care givers of mental illnesses is an endless burden to the care givers..three types of burden faced by the family care givers, such as:- 1.Objective burden in coping with mental illness (financial burden, time and effort of care givers, disruption of daily routine and social life). 2.Subjective burden in facing the mental illness (feeling of loss, shame, worry, anger and hopelessness towards the client with mental illness). 3.Burden of management of problems of client with mental illness:- (assaults, mood swings, unpredictability, negative symptoms) 1

72 64 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Research suggest that diabetes with other associated diseases diminishes both patient and caregivers quality of life due to various life style and behavioral changes required to manage the condition. Psychiatric illness always carries an additional burden of social stigma. The mentally ill clients are considered as evil spirits and are being isolated from society which creates a greater strees among family members to care for the clients. Educating the family members about the care of the client with mental illness and increasing their understanding about that as like as other medical diseases. The psychiatric illness is also a psychological disease which can be cured by proper treatment with pharmacological regimen as well as supporting patient psychologically. Diabetic mellitus is a typical chronic medical condition that places serious constraint on patient s activities. There is a need for extensive education and behavioural changes to manage the condition. Lifestyle changes must incorporate careful dietary planning, eventual use of medications, the use of insulin, home blood glucose monitoring techniques.. Educating the care givers that mental illness and diabetes are long-term illness and it affects the client chronically as far as continuation of treatment is concerned. It is also essential part of treating psychologically ill client and chronically ill clients such as diabetes. The cost of families incurs in terms of economic hardship, social isolation and psychological strain are referred to as family burden. It is the care giver who remains under strees and confused always and thinks how to manage the day to day problems and analyse the consequences for future not only for the patients but for whole family members. Our experience and contact with such type of family members initiated us to take steps to evaluate the burden strees and counsel them regarding these two groups. It is very essential to know their burden or else one day they may get hospitalized for any physical or mental problem. OBJECTIVES OF STUDY To assess & compare the level of burden imposed on the family care givers of psychiatric clients& diabetic client To associate the level of burden imposed on the family care givers of psychiatric clients & diabetic client and its association with the sociodemographic variables To correlate the burden in regard to selected associated variables HYPOTHESIS H 01 There is no significance difference in the level of burden of family care givers of psychiatric client and the caregivers of diabetic client. H0 2 There is no significance association between the burden of care givers and the selected sociodemographic variables in both the groups BACKGROUND OF STUDY A comprehensive and practical plan for assessing the behavior of a family under strees and illness focused six major factors including family s past reaction to crisis, the structure of family, role of its members and degree of isolation from other social support system. 2 There is a significant knowledge gaps concerning the experience of families of persons with so-occuring substance and mental disorders and the impact of families on treatment of individuals with these disorders. 3 The impact of functional psychiatric illness on the patient family and emphasis of support, advice or information to the care givers from the professionals engaged in treating the patient have better outcomes. 4 Research suggest that misconceptions about mental illness, behavior disturbance, inadequate social support and the limited value placed on care giving contribute to maladaptation. 5 To assess the subjective quality of life (QOL) of family caregivers of sudanse type-i and type II diabetic outpatients, using the WHOW 26-ITEMS QOL instruments comparing with a general population sample, the study conducted found that type-1 caregivers have significantly lower QOL scores than type-ii caregivers and also than the general population. Other things are caregivers scored higher than patient. Caregivers who were sick, younger, single, less educated and caring for patient with more recent illness appeared relatively more vulnerable. Perceived burden of caregivers of chronically ill elderly obtained through a sample of 88 caregivers of elderly chronically ill persons and amount of burden experienced was recorded using Burden Interview (Zarit et al: 1986) and found that there was a positive

73 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 65 co-relation between increased activity of care performed by caregiver and caregiver s burden. Also it was found that son of a caregiver reported significantly less burden than the daughter or relatives. In a study to find out whether rural caregivers learn and provide gentle massage to their chronically ill loved one to relieve them from stress would find them burdensome and but realized the benefits from providing massage. Positive result suggested that providing caregivers with instruction on gentle massage techniques for their chronically ill loved ones may support and enhance rural caregivers perception of self-efficiency and self agency and thus possibly decrease caregiver s vulnerability to stress. MATERIALS & METHOD Total 60 samples were selected by convenient sampling technique 30 from each group of psychiatric and diabetic care givers. Tool was prepared by modifying Brazilian version of family Burden interview scale (FBIS) Performa. There were total 20 items on physical, mental stress of care givers.scoring was done by 3 scale rating,never-0,rarely-1,& always- 3.Care givers were asked to put tick mark in appropriate coloum what they feel. The reliability of the tool was measured by cronchbach alpha method and value found to be 0.07.Content validity was ensured from 5 experts.the care givers attending OPDs of psychiatric & diabetic Department were interviewed by using FBIS. The respodents were made comfortable to express their feelings & rate accordingly. Prior to data collection permission was sought from hospital authority & ethical committee. Data were analysed by using descriptive and inferential statistics. The demographic variables analysed by percentage,mean & SD & presented by tables & graph.the burden score analysed by mean & SD.The association of care givers characteristics with burden score interpreted by chi square test.the regression analysis demonstrated the true association of demographic variables with burden. in the age group of years and 30% & 20% were in age group of >51years in psychiatric & diabetic group respectively. Fig. 1. Ghraphical distribution of subjects according to age in year. In the education characteristics the illeterate mass were 3.3%,primary 16.7% & 20%,middle education 16.7% & 13.3%,high school 30% &23.3% and in higher educated level it is 33.3% &40% in psychiatric &diabetic group respectively. Fig. 2. Ghraphical distribution of subjects according to the levels of education. The graph presents the percentage wise distribution in duration of illness. Most of the patients (60%) were under treatment since 3-5 years in psychiatric group which might have triggered the stress.where as in diabetic group the duration is mostly (36.7%)since 1-2 years. RESULT The result shows the gender distribution in psychiatric group is 73.3% of male & 26.75% of female and 30% are male, 70% are female in diabetic groupthere is disparity in ditribution which may influence the study result.the age distribution as demonstrated in the graph shows 20%&33.3% were

74 66 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Fig. 3. Ghraphical distribution of subjects according to duration of illness A total of 60 care givers (30 care givers each of psychiatric and diabetic patients) were interviewed on their perceived burden of care. The mean score among the psychiatric care givers (26.7) was significantly higher than the care givers of diabetic patients (11.93) as seen in table 1. The differences in socio-demographic characteristics of the respective groups of care givers are described in the table 2. As it is evident there were significant differences in the distribution of care givers in the psychiatric and diabetic group of care givers, in terms of gender, type of family, income and the duration of care. A multivariable linear regression analysis was carried out to control for these differences in the distribution of the subjects across the groups of care givers. The results are shown in the table 3. It was observed that there was borderline association with the gender of the care giver and no other variable was significantly associated with the perceived burden. Table 1: Perceived burden score among care givers. Group N Mean Std. Deviation Std. Error Mean P value Burden score Psychiatry Diabetes Table 2: Distribution of study participants in terms of socio-demographic, economic and experience characteristics Variable Category Psychiatry Diabetes 1. Age of the care giver year 6 (20.0%) 10 (33.3%) Chisq. value = Year 7 (23.3%) 4 (13.3%) df = 3, P < (NS) years 8 (26.7%) 10 (33.3%) > 51 Years 9 (30.0%) 6 (20.0%) 2. Gender Male 22 (73.3%) 9 (30.0%) Chisq value = Female 8 (26.7%) 21 (70.0%) df = 1, P < (S) 3. Material Status Married 28 (93.3%) 23 (76.7%) Chisq value = Unmarried 2 (6.7%) 7 (23.3%) df = 1, P < (NS) 4. Type of Family Nuclear 20 (66.7%) 10 (33.3%) Chisq value = Joint 10 (33.3%) 20 (66.7%) df = 1, P < (S) 5. Education Illiterate 1 (3.3%) 1 (3.3%) Chisq value =.634 Primary 5 (16.7%) 6 (20.0%) df = 4, P < (NS) Middle 5 (16.7%) 4 (13.3%) High School 9 (30.0%) 7 (23.3%) Higher education 10 (33.3%) 12 (40.0%) 6. Experience Yes 5 (16.7%) 4 (13.3%) Chisq value =.131 No 25 (83.3%) 26 (86.7%) df = 1, P <.718 (NS) 7. Income (33.3%) 6 (20.0%) Chisq value = (53.3%) 7 (23.3%) df = 2, P < (S) > (13.3%) 17 (56.7%) 8. Duration of care 1 2 years 10 (33.3%) 11 (36.7%) Chisq value = years 18 (60.0%) 6 (20.0%) df = 3, P < (S) 6 10 years 1 (3.3%) 9 (30.0%) > 10 years 1 (3.3%) 1 (13.3%)

75 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 67 Table 3: Multiple linear regression analysis of associated characteristics of the care givers with the perceived burden score Unstandardized Standardized t Sig. 95.0% Confidence Coefficients Coefficients Interval for B B Std. Error Beta Lower Bound Upper Bound Constant Gender Family Income Duration of care Model: Enter method; R Square =.181, Adjusted R square =.121 CONCLUSION Quality of life reflects the health, happiness,life satisfaction & wellbeing and also influence to external & internal envirornment.burden creats stress which results while caring any family member from chronic illness.care givers stress level can run very high and there is a real danger of the care givers also becoming ill if they do not take care of themselves. The author has suggested certain tips for care givers to help them in balancing them in their role with their health and well being. Various tips are given to the care givers to balance their critically important care giving role with their own health and well-being. Take Care of Your Own Health Caregivers are at greater risk for contracting infectious diseases than the general public. This is probably due to the stress that being a caregiver entails, which can reduce the effectiveness of the immune system and lack of time in a busy care givers life to devote to one s health. Advice given to the cargiver s on keeping up with their vaccinations and yearly physical examination and appropriate medical surveilllance mammograms to keep themselves healthy. Depression is twice common among care givers as non-caregivers.it is important to recognise symptoms of clinical depression e.g if you find you are losing intrest in the things you normally enjoy the most, or getting angry for no resons or if you are avoiding friends and loved ones, you may want to see a doctors to be screened for depression Take time for yourself Caregivers often have the responsibility of employement in addition to the large amounts of time spent caring for their patients you should try to take sometimes for yourself everyday.sometimes a hot bath is enough, as long as you have some respite from the day where the only person you are focused on is you. Thus can do wonders for your emotional well-being. Get some exercise Physical activity, often gets neglected when giving care. Finding time to exercise, even for just twenty minutes a day, can help you maintain your physical health. Eat healthy When people are busy they tend to eat more fast food and junk food; or to skip meals entirely. However, even a little effort can improve your eating habits dramatically. Buy breakfast foods that you can eat on the go. Get fruits and vegetables to eat as snacks they are affordable and portable. Try to make dinner at home. If you don t have time to make dinner; get take out or delivery from a restaruant that have healthy meals options. Learn how to manage stress Learning new to manage stress can be difficult but it can make all the difference for your own health. Stay in touch with your friends and family members. If you need to ask them for giving care. Asking for help does not make you a failure; it just means you know your own limit. RECOMMENDATIONS Other simillar studies can be done like A study can be conducted to find out factors contributing to the maladaptation of caregivers of mentally ill clients and clients of other chronic medical illness.

76 68 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 To find out the impact of support, advice or information to the caregivers from medical professions during institutionalization or during OPD visit by using pretest post test control group design. Acknowledgement: We would like to thanks all the participants for their humble coperation. Also we express our gratitude to the Medical superintendent of the hospital & HOD, Dept of psychiatric & diabetic for kind approval to conduct the study. We sincerely thanks all the students those helped us in collecting data under our guidance. Ethical Consideration: Authours have taken due permission from the Medical Superitentdent & HODs of the respective Departments.Approval from ethical committee of the university was sought prior to data collection.care givers were properly informed regarding the objectives & implications of study. Conflict of Intrest: All HODs, doctors & participants coperated well to complete the data collection There was no source of any conflict from the organisation & others involved in study directly & indirectly 3. Townsend, Aloen L.; Biegel, David E.; Ishler, Karen J.; Wieder, Barbara; Rini, Amy. Families of Persons With Substance Use and Mental Disorders: A Literature Review and Conceptual Framework*. Family Relations, vol. 55, issue 4, October p G Fadden, P Bebbington and L Kuipers; The impact of psychiatric illness on the patient s family, The British Journal of psychiatriy, 1987, 150: Chung-Shan Medical University Update Current Data on Mental Health.(Report)Mental Health Weekly Digest ; Abdel W. Awadalla, Jude U. Ohaeri, Shafika A. Al-Awadi, and Adel M. Tawfiq, Diabetes mellitus patients family caregivers subjective quality of life:j Natl Med Assoc May; 98(5): Department of Psychiatry, Faculty of Medicine, Kuwait University, Safat. 7. Karin J. Faison, Sandra H. Faria and Deborah FrankCaregivers of Chronically Ill Elderly: Perceived Burden,Journal of Community Health NursingVol. 16, No. 4 (Winter, 1999), pp Funding: It was a self financed study REFERENCES 1. Lefley, H.P. Family Caregiving in Mental givers that they may suffer from any illnes,1996, London: Sage. 2. Carol Anderson; Susan Meisel, An Assessment of Family Reaction to the Stress of Psychiatric Illness: Psychiatric Services; 1976

77 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No.1 69 Assess and Compare the Knowledge, Attitude and Expressed Practices of Married Women Regarding EC and MTP at Selected Rural and Urban Communities of District Ambala, Haryana Sushma Katoch 1, Sanjay Gupta 2, Poonam Sheoran 1 1 Lecturer, 2 Kol Valley Institute of Nursing, Bilaspur, H.P., 2 Assistant Professor, 3 Principal, M. M. College of Nursing, M.M. University Mullana,Ambala ABSTRACT Emergency Contraception is a safe and effective method of preventing unwanted pregnancies following failure of contraception or unprotected sexual exposure, which in turn helps in reducing the maternal morbidity and mortality due to unsafe abortions. Unsafe abortions can be prevented by enhancing knowledge regarding Medical Termination of Pregnancy. Keeping all this in view a study to assess and compare the knowledge, attitude and expressed practices of married women regarding emergency contraception and medical termination of pregnancy was carried out in selected rural and urban communities of District Ambala Haryana. The objectives of the study were to assess and compare the knowledge, attitude and expressed practices of married women regarding emergency contraception and medical termination of pregnancy. The study also intended to determine relationship between knowledge and attitude scores of married women regarding emergency contraception and medical termination of pregnancy and also to find out association of level of knowledge and attitude of married women regarding emergency contraception and medical termination of pregnancy with selected demographic variables. 100 married women (50 women from rural communities and 50 from urban communities) were selected by convenience sampling technique. The data was collected using a structured knowledge interview schedule, an attitude scale and an expressed practices checklist. The results conclude that urban married women had more knowledge and more favorable attitude regarding emergency contraception and medical termination of pregnancy than the rural married women. The results further showed that the knowledge and attitude of rural and urban married women were positively correlated to each other. The demographic variables that is education status, job, occupation, monthly family income and number of children impose an impact on the knowledge and attitude of rural and urban married women regarding emergency contraception and medical termination of pregnancy. Urban married women had better expressed practices regarding emergency contraception and medical termination of pregnancy than the rural women. Keywords: Knowledge, Attitude, Expressed Practices, Married Women, Emergency Contraception and Medical Termination of Pregnancy INTRODUCTION Today, although a number of contraceptive techniques are available, yet contraceptive coverage continues to be poor in India, as most people are either ignorant or shy, do not want to use a contraceptive continuously regardless of sexual activity for fear of side-effects (pill or intra-uterine device), or do not like to use methods linked with coitus (barriers like condom or diaphragm).a more modern method of contraception known as the Emergency Contraception Pill (ECP) was approved and introduced in the National Family Planning Program in 2002 and made available over the counter (OTC) in

78 70 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Emergency contraception is a safe and effective method of preventing unwanted pregnancies following failure of contraception or unprotected sexual exposure, which in turn helps in reducing the maternal morbidity and mortality due to unsafe abortions. Emergency contraception means, the back-up methods for contraceptive emergencies which women can use within the first few days after unprotected intercourse to prevent an unwanted pregnancy. EC is not a regular Family Planning method and is intended for emergency use alone. 2 In India, a survey of 4000 women aged years in the state of Delhi revealed very low (3.2%) awareness about emergency contraception (6). Awareness in rural areas was less than 2%. 3 Though the law in India has permitted medical termination of pregnancy on broad legal grounds for over two decades, unsafe abortions carried out by unqualified providers show no signs of decreasing. Around 11 million abortions are carried out in India every year and nearly 80,000 women die during the process, according to an expert. A majority of abortions are performed by untrained hands and studies suggest that nearly 80,000 women die due to unsafe abortions.9 Safe and legal abortion is considered a key intervention for improving women s health and quality of life. Despite a liberal abortion law in India, (Medical Termination of Pregnancy Act of India 1971)12 of 6.7 million induced abortions every year13 only 10 percent are conducted under safe conditions. Most of the abortions, especially in the rural areas, are conducted illegally by untrained personal under unhygienic and unsafe condition. 4 This lead to a high maternal morbidity and mortality and contributes to about 9 to 12 percent of maternal deaths. 5 MATERIALS AND METHOD The present study was conducted among married women of selected Rural and Urban Communities of District Ambala, Haryana. A Non-experimental research approach and Descriptive comparative survey design was used. The setting chosen for carrying out the study was Civil Hospital, Ambala City. Total sample of study was 100 married women (50 from Rural and 50 from Urban Communities). Convenience sampling technique was used to select the sample. In view of the nature of the problem and to accomplish the objectives of the study, structured knowledge interview schedule, attitude scale and an expressed practices checklist was prepared focusing on knowledge, attitude and expressed practices of married women regarding emergency contraception and medical termination of pregnancy. Interview Technique was used for data collection. Validity was ensured in consultation with guides and experts in the field of nursing and community medicine. Reliability of the structured knowledge interview schedule was tested by KR 20 (r = 0.75) and for attitude scale and expressed practice checklist as calculated by Cronbach s alpha was found to be 0.77 and 0.74 respectively. After obtaining formal permission from concerned authority structured knowledge interview schedule, attitude scale and expressed practices checklist was used to collect the needed data. Both descriptive and inferential statistics was used to analyze the data. RESULTS The mean knowledge score of urban women(19.38) was higher than the mean knowledge score of rural women(16.80) indicating a higher knowledge of urban women. (table 1) Table 1: Mean, Mean Difference, Standard Deviation of Difference, Standard Error of Mean Difference and Z value of knowledge score of Married Women regarding Emergency Contraception and Medical Termination of Pregnancy N=100 Knowledge Score Mean M D SD D SE MD Z value Rural Married Women(n=50) ± * Urban Married Women(n=50) Minimum Score=0,Maximum Score= 34, Z (98)= 1.98 at 0.05 level of significance, * - Significant

79 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 71 The mean knowledge score of urban women (11.30) was higher than the mean knowledge score of rural women(9.38) with a significant z value of 3.63 showing a true difference between the mean knowledge score regarding emergency contraception. The difference was a true difference and not by chance. Hence it is concluded that the urban women had more knowledge regarding emergency contraception than the rural women. The findings further shows that the mean knowledge score of urban women (8.08) regarding medical termination of pregnancy was higher than the rural married women(7.42) with non significant z value of 1.40 showing that the difference was by chance.(table 2) Table 2: Area wise Mean, Mean Difference, Standard Deviation of Difference, Standard Error of Mean Difference and Z value of Knowledge Score of Married Women regarding Emergency Contraception and Medical Termination of Pregnancy N=100 Sr. no Content areas Group Mean M D SD D SE MD ZValue 1 Emergency Rural married women ± * Contraception (n=50) Urban married women(n=50) 2 Medical Termination Rural married women ± NS of pregnancy (n=50) Urban married 8.08 women(n=50) Maximum Score=34, Minimum Score=0,Z (98) = 1.98 At.05 level of significance, *Significant, NS- Not Significant The mean attitude score of urban women (137.04) towards emergency contraception and medical termination of pregnancy was higher than the mean attitude score of rural Women (135.06) with a mean difference of 1.98 was statistically non significant as shown by calculated z value(0.90) showing that the difference was not a true difference it was by chance. The data further inferred that there was no statistically significant difference between the attitude score of rural and urban women regarding emergency contraception and medical termination of pregnancy. (table 3) Table 3: Mean, Mean Difference, Standard Deviation of Difference, Standard Error of mean Difference and Z value of Attitude score obtained by Married Women regarding emergency contraception and medical termination of pregnancy N=100 Attitude Score Mean M D SD D SE MD Z value Rural Married Women(n=50) ± NS Urban Married Women(n=50) Minimum Score=200, Maximum Score= 40 Z(98)=1.98, NS- Not Significant The mean attitude score of urban women (64.48) towards emergency contraception was higher than the mean attitude score of rural women (63.52) with a mean difference of 0.96 was statistically non significant as shown by the calculated z value of 0.80, inferring that the difference in the attitude score of married women regarding emergency contraception was by chance and not a true difference. The findings further shows that the mean attitude score of urban women (8.08) towards medical termination of pregnancy was higher than the rural women (7.42) with a mean difference of 1.02, the difference was non-significant with a z value of 0.65 which infers that the difference in the attitude score of rural and urban women regarding medical termination of pregnancy was not a true difference and was by chance. It was further concluded that the difference in the mean attitude score of rural and urban women regarding emergency contraception and medical termination of pregnancy was by chance and not a true difference. (table 4)

80 72 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 4: Area wise Mean, Mean Difference, Standard Deviation of Difference, Standard Error of Mean Difference and Z value of Attitude Score obtained by Married Women regarding Emergency Contraception and Medical Termination of Pregnancy N=100 Sr no Content areas Group Mean M D SD D SE MD Z Value 1 Emergency Rural married ± NS Contraception women(n=50) Urban married women (n=50) 2 Medical termination Rural married ± NS of pregnancy women (n=50) Urban married women (n=50) Maximum Score=200, Z (98)= 1.98 at 0.05 level of significance, Minimum Score=40, *Significant, NS- Not Significant The coefficient of co-relation (r) between knowledge score and attitude score of rural women was 0.58 suggesting a significantly moderate positive linear correlation and also that the rural women with a higher knowledge score have more favorable attitude towards emergency contraception and medical termination of pregnancy and similarly the coefficient of correlation(r) between knowledge score and attitude score obtained by urban women was 0.68 suggesting a significantly moderate positive linear correlation and that the urban women with a higher knowledge score have more favorable attitude towards emergency contraception and medical termination of pregnancy. (table 5) The Chi square results showed that demographic variables that is education status, job, occupation, monthly family income and number of children impose an impact on the knowledge and attitude of married women regarding emergency contraception and medical termination of pregnancy. Table 5: Correlation between Knowledge Score and Attitude Score Obtained by Married Women regarding emergency contraception and medical termination of pregnancy Group Knowledge Score Attitude Score r Mean SD Mean SD Rural Married ± ± * Women (n=50) Urban Married ± ± * Women(n=50) N=100 r(98)= at 0.05 level of significance *Significant, NS-Not significant Among rural women 03 (6%) women had ever consumed emergency contraceptive pill whereas in urban women 07(14%) women had consumed it. In both the communities all the women,03(100%) rural women and 07(100%) urban women who had consumed the pill, consumed the pill within 72 hours of unprotected inter course. Among all married women 01 (14.3%) urban women had consumed it more than once while, none among rural women had consumed it more than once. The results indicate that only 01 (14.3%) urban women suffered from any side effect while no rural women suffered from any side effect after the consumption of the pill. The findings also shows that 01(02%) rural women have ever had a termination of pregnancy in the past where as 03(06%) urban women have had a medical termination of pregnancy in the past. The data also shows that in 03(06%) rural women, the present termination is being conducted after 12 weeks of gestation whereas in 02(04%) urban women it is being conducted after 12 weeks of gestation. The data shows that 49(98%) rural women were willing for the present termination of pregnancy and 02(04%) urban women were willing for the present termination of pregnancy. Hence urban married women have better expressed practices regarding emergency contraception and medical termination of pregnancy as compared to rural married women. (table 6)

81 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 73 Table 6: Frequency and Percentage Distribution of Expressed Practice Score of Rural and Urban Women regarding Emergency Contraception and Medical Termination of Pregnancy Sr. No Items Rural married Urban married women (n=50) women(n=50) Yes No Yes No N=100 F % F % F % F % 1 Have you ever consumed emergency contraceptive pill? 2 Did you consume it within 72 hours of unprotected intercourse? 3 Did you consume it more than once? Did you suffer from any side effects after consumption of the pill? 5 Have you ever had a medical termination of pregnancy in the past? 6 Is the present termination being conducted before 12 weeks of gestation 7 Are you willing for the present termination of pregnancy? DISCUSSION The present study showed that rural women 29(58%) have below average knowledge regarding emergency contraception and medical termination of pregnancy and in urban women 15 (30%) possess average knowledge towards emergency contraception and medical termination of pregnancy. A similar findings from a study conducted by Najafi F et al (2012) 7 at Public University of Malaysia showed that half the 294 subjects who participated had a low knowledge, 33.0% a moderate knowledge and 17.0% a good knowledge about the emergency contraceptive pill. The data findings of the present study showed that among rural women 03 (6%) women had ever consumed contraceptive pill whereas in urban married women 07(14%) women had consumed it, was similar to the findings of a study conducted by Puri Sonia(2009) 8 only 1.4% of the study sample had consumed emergency contraceptive pill followed by another study by Najafi et al(2012) 7 showed that 11% of respondents had used emergency contraception. The findings further shows that 01(02%) rural married women have ever had a termination of pregnancy in the past where as 03(06%) urban married women have had a medical termination of pregnancy in the past. A similar findings in a survey conducted by Mittal Sunita, Bahadur Anupama, Sharma Jai Bhagwan(2008) 9 showed that of 185 women only 22 had heard of medical termination of pregnancy and 15 had undergone medical termination of pregnancy with satisfaction. The data of the present study also showed that in 03(06%) rural married women, the present termination was being conducted after 12 weeks of gestation whereas in 02(04%) urban married women it was being conducted after 12 weeks of gestation. Perera Jennifer(2004) in her study among Srilankan women seeking termination of pregnancy concluded the study that in 90% of 210 women the gestational age at termination of pregnancy was less than 10 weeks. Cknowledgment: At the very outset, I would like to thank almighty for his presence. I extend my sincere thanks to all the participants of my study. Lastly and most importantly I am grateful to everybody who was important to success realizations of thesis. Funding: Self funding Competing Interests: None stated Ethical Consideration: Ethical approval taken from M.M. University research committee. REFERENCES 1. Khan M.E et al. Key opinion leaders views regarding emergency contraception in India.Population council. February Also available at: 2. Gilda Sedgh, Rubina Hussain, Akinrinola Bankole and Susheela Singh Women with an

82 74 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method Occasional. The World Bank: Unmet need for contraception Population reference bureau. Unmet need for Contraception: Fact sheet. Report No. 37. June 2007 Also available at: factsheet.aspx 3. Mittal S, Aggarwal P. Interventions for emergency contraception. The WHO Reproductive Health Library ( A commentary). Also available at: fertility/contraception/cd001324_mittals_com/ en/ind ex. html 4. Bedi N, Kambo I, Dhillon BS, Saxena BN, Singh P. Maternal deaths in India-preventable tragedies (An ICMR task force study). Journal of Obstetrics and Gynaecology in India. 2001; Vol-51:pp National Population Policy-2000, Government of India. 6. Roy M, Lahiri BC, Ghosh BN. KAP study on MTP acceptors and their contraceptive practice. Indian Journal of Public Health Apr-Jun;22(2): Najafi F et al. Emergency contraception: knowledge, attitudes and practices among married Malay women staff at a public university in Malaysia. Southeast Asian Journal of Tropical Medicine and Public Health. 2012; 43(6): pp Puri Sonia et al. Emergency contraception in women of slums in North India. Journal of Family and Reproductive Health. October 2009; 3(3):pp Mittal S, Bahadur A, Sharma JB. Survey of the Attitude to, Knowledge and Practice of Contraception and Medical Abortion in Women Attending a Family Planning Clinic. Journal of Turkish-German Gynecological Association, Vol. 9(1); 2008; pp29-34.

83 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No.1 75 A Study to assess the Knowledge and Attitude of Higher Secondary School Students Regarding Nursing Profession in a Selected School in Kanyakumari District, South India Sheeba C 1, V S Delphin 2, A Esakiammal 2, M Hephzibah Belsy 2, R Jamuna Rani 2 1 Reader, 2B.Sc.(N)., Christian College of Nursing, Neyyoor & Post, Kanyakumari Dist, Tamil Nadu ABSTRACT Nursing has been called as the oldest of the arts and youngest of the profession. Nursing is a service oriented profession and nurses are regarded as "care professionals". Generally, it was assumed that nursing did not need an education to the level that of other health profession and nursing was kept at lower level in the administration setup. But now the thought about nursing is entirely different and also recognition and placement of nursing is entirely positive. Higher secondary education is the turning point of students' life and the students are kept in a position to choose their future career. If this category of students are given adequate information regarding nursing, many can select nursing as a career without confusion and the profession can flourish in future. So, it is the responsibility of the nursing personnel to impact knowledge regarding nursing profession among school students. The aim of the study was to assess the knowledge and attitude of higher secondary school students regarding Nursing Profession in a selected school in Kanyakumari District, South India. A descriptive study design was adopted for the study. Data were collected from 100 students studying in 11th standard. The study showed that 60% of the students had moderately adequate knowledge and 90% of them had unfavorable attitude towards nursing profession. Keywords: Nursing Profession, Care Professionals, Higher Secondary Education, School Students, Nourishing INTRODUCTION Nursing is an art to be cultivated and a profession to be followed. Nursing has been called as the oldest of the arts and youngest of the profession. 1 The word Nursing evolved from the Latin word Nutricius which means nourishing. 2 In olden days, nursing was considered as a profession of wound cleaning and people thought nurses were always under the control of doctors. But today, the view towards nursing has been changed. Nursing is a service oriented profession and nurses are regarded as care professionals. 3,4. The doors of nursing field are widely opened now-a-days. Corresponding author: Sheeba C Kariyavilai, Mondaikad Post, Kanyakumari Dist, Tamil Nadu, Pin Phone: Mobile: sheeba.1978@gmail.com The goal of nursing education is to prepare today s students to meet the challenges of tomorrow. Generally, it was assumed that nursing did not need an education to the level that of other health profession and nursing was kept at lower level in the administration setup. But now the thought about nursing is entirely different and also recognition and placement of nursing is entirely positive. 5 Need for the study Higher secondary education is the turning point of each student s life and the students are kept in a position to choose their future career. So, it is the responsibility of the nursing personnel to impact knowledge regarding nursing profession among school students. Since there is a limited literature available on this issue, the investigators were interested to do the study on this topic. The conceptual framework for this study is based on Sunrise Model. The aim of the study was to assess the knowledge and

84 76 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 attitude of higher secondary school students regarding Nursing Profession in a selected school in Kanyakumari District, South India. METHODOLOGY A descriptive study design was adopted for the study. Setting and study sample Data were collected from 100 students studying in 11 th standard at L.M.S. Girls Higher Secondary School, Neyyoor, Kanyakumari District, South India for four weeks. The school has strength of 1180 students with all facilities. The samples were selected using simple random technique. RESULTS Knowledge of Students Regarding Nursing Profession The overall knowledge of students regarding nursing profession is presented in Fig:1. Each item was individually analyzed and it was found that 36% of them stated that nursing is a profession and 74% of them knew the duration of B.Sc Nursing as 4 years, 90% of them responded correctly about the basic qualification for B.Sc (N). Eighty percent of them responded that B.Sc (N) is a regular course and only 8% of them knew the eligibility criteria for entering into nursing. Measures The tool consisted of two parts: the knowledge questionnaire has 20 items and each item has one correct response and three wrong responses. Score 1 was allotted for each correct response and 0 for wrong response. The total score was 20. The total score was converted into percentage and interpreted as follows: Above 75% is considered as adequate knowledge, 50-74% is considered as moderately adequate knowledge and below 50% is considered as inadequate knowledge. The attitude questionnaire consisted of 20 statements where the students were asked to state their opinion as strongly agree, agree, neither agree nor disagree, disagree and strongly disagree. Positive statements were scored as 4, 3,2,1,0. Reverse scoring was given for negative statements. Total score was converted into percentage and above 75% was considered as most favorable, 50-74% as favorable and below 50% as unfavorable attitude. Content validity was determined by obtaining the opinion of experts in nursing and statistical field. A pilot study was done and the questionnaires were found to be relevant to the setting of the study. Data collection procedure: The data were collected from the students after getting written consent from the Headmistress of the School and verbal constent from the students. The questionaire were distributed to the students and asked them to tick their responses. The gathered data were analyzed and interpreted in the light of objectives. Fig. 1. Knowledge of students regarding nursing profession Only 39% of the students answered that the students should complete 17 years when they join for B.Sc (N) course. Only 37% of the students knew that the college should be recognized by the Indian Nursing Council and concerned University and the State Government. Ninety three percent of them knew that the government allot seats to the atudents on the basis of merit. Attitude of students regarding Nursing Profession The overall attitude regarding Nursing Profession is presented in the Fig:2. 76% of students felt that only girls can enter into nursing and 87% of them responded that only low class family members select nursing as their careers. Sixty five percent of them agreed that nurses can take decision on their own regarding nursing care of patient. 75% of them had the opinion that nurses are prone to develop diseases since they are working in hospital.

85 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 77 Fig. 2. Attitude of students Regarding Nursing profession Fifty seven percent of them felt that nurses undergo only practical training and 54% of them stated that nurses cannot take care of their family because of night duty. 51 %of them felt that many nurses undergo sexual harasment during their duty and 76% of them agreed that Nursing and Nurses are respected by the society. Fifty seven percent felt that the fee structure to study Nursing is high and 73% of them felt that nurses are under the control of doctors. Ninety three percent felt that nurses look neat and tidy and 67% of them felt that nurses can earn more money in abroad as soon as finishing their course in India. There was no association between knowledge and attitude of students (á 2 =2.704 at d(f)=4). CONCLUSION In ancient period, the nurses had not hold a responsible role in decision making because of the low status given to them. But later the nurses had analysed what activities are vital for the delivery of quality nursing care and they took a stand about the destiny of Nursing. Even though the status of Nursing has improved and nursing is considered as a profession, the knowledge regarding nursing profession among Higher Secondary School Students is inadequate. If this category of students are given adequate information regarding nursing, many can select nursing as a career without confusion and the profession can flourish in future. Acknowledgement: Nil Ethical Clearence: Taken from Dissertation committee of Christian College of Nursing Neyyoor. Source of Funding: Nil Conflict of Interest: Nil REFERNCES 1. Mckeon, E & Gonzale R (2004), Nursing Workforce Development Program. American Journal of Nursing Susan. E (2002) In Favour of the Bachelor s degree. American Journal of Nursing Gebbie. M.K (2002), Holding Society and Nursing Together. American Journal of Nursing Moyer A.B., Wittman A.R (2008) Nursing Education, New Delhi, Jaypee Brother s publications Mennick. F (2004) Are Hospital Bad for Nursing Health? American Journal of Nursing.21.

86 78 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Effectiveness of Inflatable Lumbar Support (ILS) for the Prevention of Short Term Backache among Post-operative Female Patients Undergoing Lower Abdominal Surgery Under Spinal Anesthesia Bobby Sindhu 1, Elsa Sanatombi Devi 2, Jyothi Chakrabarty 3 1 Final Year M.Sc. Nursing Student, 2 Professor, 3 Associate Professor, MCON, Manipal University, Manipal, Karnataka ABSTRACT Introduction: Backache strikes nearly 85% of the population at some time of their life. Majority of the backache is due to stress and strain of back muscles, ligaments and tendons. Today the incidence of post- operative backache is increasing and positioning the patient as well as the anesthetic technique of surgery places an important role to develop post- operative backache.1 Objectives: To analyze the effectiveness of lumbar support in preventing post- operative backache as measured by Verbal Descriptive Scale (VDS) and also to find its association between post-operative backache and age, occupation, BMI, type of surgery, position during surgery and also the duration. Method and material: A 10 point Verbal Descriptive Scale pain scale was used to evaluate the postoperative backache of both experimental (30) and control group (30). Result: The median of 2nd and 5th day VDS pain score between both the groups were significantly different (Z value is in experimental group and in the control group). The median reduction in the VDS pain score between the two groups is statistically significant (Z=-5.028) at p<.05. Conclusion: This study provides empirical evidence to the effectiveness of inflatable lumbar support for the prevention of post-operative backache and is found to have association with BMI. Keywords: Post-Operative Backache, Inflatable Lumbar Support, Verbal Descriptive Scale, Spinal Anesthesia and Lower Abdominal Surgery INTRODUCTION Backache is considered to be most common and most costly cause of morbidity and absenteeism from work and is usually seen among years, who are the pillars of country s economy. 1 Any adverse effect to the health of this group not only affects himself and his family but also affects the entire economic growth of the country. Therefore finding solution for backache is most essential to build up nation s health and wealth. Corresponding author: Elsa Sanatombi Devi Professor MCON, Manipal University Manipal , Karnataka, India sanatombi2010@gmail.com According to National Centre for health statistics states that backache is on the increase in India. In the health care field, the incidence of post-operative backache seems to have risen than the past. Hence the researchers were inquisitive to know whether the postoperative backache could be prevented with Inflatable Lumbar Support (ILS). MATERIAL AND METHOD With prior permission and ethical clearance from the respective hospital authorities, a total of 60 subjects (30 experimental +30 control) undergoing lower abdominal surgery under spinal anesthetic agents were selected through simple random sampling. Evaluative approach with quasi experimental post-test

87 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 79 only design was adopted for this study. Tools utilized for this study includes demographic data of the patients such as age, occupation, BMI,, type of surgery, duration and position during the surgery. Verbal Descriptive Scale was utilized to note the subjects pain score. (0-no pain, 1-2 mild pain, 3-6 moderate pain, 7-9 severe pain, and 10 worse pain). The Inflatable Lumbar Support (ILS) was designed and developed by the researcher. Reliability of the ILS was certified by the MNE department. It consists of an empty synthetic bag which is attached to the sphygmomanometer dial and bulb for pressure monitoring. Pressure calibrations were done at MNE with a pressure of mmhg pressure. Once the anesthetic agent was administered, the ILS was placed under the patient s back covering the lumbar region (L1 - L5). The Lumbar support was then inflated by raising the pressure between mmhg during the entire surgery and once the surgery was over the ILS was deflated and removed from under the patient s back. As per the policy of the hospital, post- operative pain medications and nursing care were not withheld from the patients of both the group. Post operative pain was assessed at 2 nd and 5 th post-operative day for both the groups with the help of VDS. RESULTS Majority, 24 (80%) controls and 15 (50%) experimental subjects were between the age group of years and with majority being unskilled workers or home maker. Most, 25 (83.3%) in both the groups were within the normal range in their BMI. Majority, 19(60.3%) of the experimental subjects underwent hysterectomy and 20 (66.6%) of the control subjects underwent lower segment caesarian section. The time taken for majority of the subjects, 56.7% and 76.7% of experimental and control ranged between minutes excluding the time of preparation before and after the surgery and 28 (93.3%) and 27(90)% of experimental and control group subjects were placed in supine position during the surgery. Findings revealed that 2 nd and 5 th day VDS pain score between the groups were significantly different (Z value = experimental group and Z= in control group). VDS pain score significantly decreased during the 5 th day assessment. Fig. 1. Bar diagram showing the median of 2 nd and 5 th day VDS pain score between the groups (n= 30+30=60) Data presented in the above bar diagram indicates that the median of 2 nd and 5 th day pain score on VDS showed difference between the control and experimental group ( Z value = , p<.05). Therefore subjects who had the ILS had lesser experience of post-operative backache when compared to the control group subjects. Table 1: VDS pain score on 5 th post-operative day using Mann Whitney test (n=30+30=50) Groups Median Interquartile Z values p values range Experimental group * Control group 3.25 Data presented in table 1 indicates that there is significant difference between the experimental and control group in terms of their VDS score postoperatively (Z= ). The study also revealed that there is association between BMI and post-operative backache (.024, P<.05) DISCUSSION The present study findings showed that there is significant difference in the experience of back pain between the control and experimental group postoperatively. Application of ILS helped patients to experience reduced pain on VDS. Study conducted by Dicken et al among 300 electively selected surgical patient of Queen s medical Centre, University of Nottingham showed that only 18% of the experimental subjects suffered from post-operative pain when compared to control group (28%). Backache was considerably reduced for patients who had lower abdominal surgery with more than 40 minutes of anethesia. 2

88 80 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 The present study showed association between post-operative backache and BMI. Study conducted in Singapore on the incidence of backache after spinal anesthesia among 105 subjects showed association between post- operative pain and BMI, duration of surgery and type of surgery. CONCLUSION Use of Inflatable lumbar support was effective in reducing the post-operative back pain. Study identifies that the type of surgery, duration of surgery and position during surgery are the main risk factors for patients undergoing surgery with spinal anesthesia. Anesthetic agents help relax the entire body. Due to relaxation of the Para spinal muscles, over flattening of the lumbar curve occurs especially if the surgery lengthens for more than 40 minutes either in supine or lithotomy position. This over flattening of the lumbar curve can cause post-operative backache. Hence ILS helps in supporting the lumbar area thereby reducing the over flattening and lessening the postoperative pain. Funding: Self-financed Acknowledgement: I acknowledge the Dean and the administrative heads of the respective departments and also the participants for allowing me to carry out the study successfully. Conflict of Interest: It is a fact that in any one year, more than half of the population will suffer from back pain on at least one occasion7 and that 10 15% of these patients will go on to develop chronic back pain.8 The back pain developed post-operatively cannot actually be decided whether it is due to spinal anesthesia or due to previous factors as multiple factors could lead to back pain. Prolonged surgery time as well as repeated spinal anesthesia and also not following postoperative instructions could lead to back pain postoperatively. The present study decided to look into if lumbar support could minimize back pain post operatively to enhance patients quality of life without having to experience back pain. Pain being one of the most common experiences of patients that could lead to poor post-operative recovery. Nursing interventions which are innovative in nature to improve patients prognosis need to be looked into to latch up with the trends in nursing care advances. REFERENCES 1. Mary AR. Post-operative backache. Nursing times Journal, 1988; 84: Dicken BJ, McGregor AH, Jamrozik KD. Trends in the management of post-operative low backache. BJS, 2005; 87 (38): Calhoun, MJ, Harvey et al. Nurses find solution to post operative leg and backache. 1998; 34 (8): 6 available at doc1g Dorte J, Confait H. Case studies of post-surgical backache. Journal of Manipulative and Physiological Therapies. August 2003; 27 (6): 4 Available at Andersson GBJ. Epidemiological features of chronic low-back pain. The Lancet 1999; 354: Van Tulder MW, Koes BW, Bouter LM. A costillness study of back pain in the Netherlands. Pain 1995 ; 62 : Haddox LD, Bonica JJ. Evolution of the Speciality of pain medicine and the multidisciplinary approach to pain. In: Cousins MJ, Bridenbaugh PO (eds). Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA: Lippincott Raven, 1998; Manning DC, Rowlingson JC. Back pain and the role of neural blockade. In: Cousins MJ, Bridenbaugh PO (eds). Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia, PA: Lippincott Raven, 1998;

89 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No.1 81 Attitude Towards their Medications and Compliance Status among Clients with Chronic Illness in Mangalore Thereza Mathias 1, Christopher Sudhaker 2, Radha Aras 3 1 Ph.D Scholar, at Yenepoya University, 2 Dean, Manipal College of Nursing, Mangalore, Manipal University, Karnataka, India, 3 Professor and HOD Department of Community Medicine, Yenepoya Medical College, Mangalore, India ABSTRACT Chronic diseases have emerged as a major killer globally. Nearly 60% of all deaths in the world are caused by chronic ailments. Medication plays a very significant role in treating patients with chronic illness. However, despite all the best intention and efforts on the part of the healthcare professionals, poor medication compliance can lead to unnecessary disease progression, disease complications, reduced functional abilities, a lower quality of life, and premature death. A study was conducted to assess the attitude towards their medications and compliance status using a non experimental descriptive design with survey approach. 200 patients living in the community at Mangalore with any of the five chronic conditions were selected through purposive sampling technique. The instrument used were attitude scale and Morisky medication Adherence scale (MMAS - 8 items)the results showed that 59% of the chronic patients had favorable attitude and 41% had neutral attitude and none had negative attitude..compliance to medications showed that 59% had low compliance status. There was no significant correlation between attitude and compliance status towards their medications. Keywords: Attitude, Medications, Compliance Status, Chronic Illness INTRODUCTION According to the Centers for Disease Control and Prevention, chronic diseases are the leading cause of morbidity and mortality, accounting for 70% of all deaths.. In India, chronic diseases contribute to an estimated 53% of the deaths and 44% of disabilityadjusted life 1. Chronic conditions are defined by the World Health Organization (WHO) as requiring ongoing management over a period of years or decades and cover a wide range of health problems such as heart disease, diabetes, asthma, AIDS, cancer and mental illness. The World Health Organization (WHO) reports that of the 35 million (60%) people who died from chronic diseases in 2005, half were under 70, and half were women. Of these, 72% deaths were estimated to have occurred in developing countries. One of the greatest challenges that will face health systems globally in the twenty-first centuries will be the increasing burden of chronic diseases (WHO, 2002) 2. Medication plays a very significant role in treating patients with chronic illness. The ultimate aim of any prescribed medical therapy is to achieve certain desired outcomes in the patients concerned. Furthermore, patients with these conditions are often required to take one or more medications indefinitely for maintenance of quiescent disease. The combination of quiescent symptoms and need for long-term treatment may affect patients daily use of these maintenance medications. Hence, therapeutic compliance has been a topic of clinical concern due to the widespread nature of non-compliance with therapy. Therapeutic compliance not only includes patient compliance with medication but also with diet, exercise, or life style changes. Compliance is defined as the extent to which a person s behavior coincides with the given medical advice and is a major factor contributing to the success of drug therapy. It was estimated that the compliance rate of long-term medication therapies was between

90 82 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 40% and 50%. The rate of compliance for short-term therapy was much higher at between 70% and 80%, while the compliance with lifestyle changes was the lowest at 20% 30%, Furthermore, the rates of noncompliance with different types of treatment also differ greatly 3. Chronic diseases are a serious public health issue, particularly because they require long-term therapy. Management of chronic diseases has a complex and adverse impact on health systems in countries like India, which are already burdened with the unfinished agenda of communicable diseases as well as maternal and child health problems. Ensuring access to medicines for treating chronic diseases, however, remains neglected in most developing countries. Generally, the focus is on improving access to medicines for treating infectious diseases. For chronic diseases, prevention is the priority. However, it is well established that in addition to prevention, treatment of chronic diseases should form an essential component of any comprehensive public health programme. 1 However, despite all the best intention and efforts on the part of the healthcare professionals, poor medication compliance can lead to unnecessary disease progression, disease complications, reduced functional abilities, a lower quality of life, and premature death. Lack of adherence also increases the risk of developing a resistance to needed therapies, more intense relapses, and withdrawal and rebound effects when medication is interrupted Because of this impact, compliance has been called the key mediator between medical practice and patient outcomes. One of the major factors influencing medication compliance is attitude towards the medications. Attitude towards medication is the mental frame of the patients as well as their families towards Drug or Medication and treatment compliance. This attitude can be positive or negative. Attitudes towards medication play an important part in the treatment for chronic illness. OBJECTIVES 1. To determine the attitude toward their medications among chronic clients 2. To determine their compliance status towards their medications 3. To find a relationship between attitude towards their medications and compliance status among chronic clients. 4. To find an association between attitude scores with selected demographic variables. MATERIALS AND METHOD Research design and Approach: A Non experimental research design with descriptive survey approach was adopted. Sample and sampling technique: A total of 200 patients living in the community at Mangalore with any of the chronic conditions were included in the study. The patients were selected through purposive sampling technique. The inclusion criteria include patients Patients with any one or more of the chronic illnesses (Type II Diabetes Mellitus, Hypertension, cardiac conditions, Asthma, Mental illness and renal failure) Client on medications since the last five years for chronic conditions such as hypertension, Diabetes, Asthma, mental illness and cardiac conditions and renal failure. Those able to read and write English and Kannada and with adequate comprehension ability. The exclusion criteria: patients in serious conditions, unconscious and who cannot comprehend instructions. Setting: Patients residing in their homes in Mangalore district were included for the study. Description of the tools: The tool had 3 sections. Section 1: consisted of demographic Performa which had 12 items pertaining to information regarding personal and chronic illness. Section 2: is a 5 point scale to measure the attitude of patients towards compliance to medications ranging from strongly agree to strongly disagree. The attitude scale had 24 items with equal number of positive and negative items. The attitude score was arbitrarily classified as unfavorable attitude (1-40), neutral (41-80) and favorable attitude (81-120). Section 3: The standardized Morisky Medication compliance scale (MMAS-8) 4 was used to assess the

91 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 83 compliance states among chronic patients. Scoring was as follows Adherence level Percentage Low Adherence (< 6) 32.1 Medium Adherence (6 to <8) 52.0 High Adherence (= 8) 15.9 Permission was obtained from the concerned authorities and the study subjects. Data was collected and analyzed using SPSS version Descriptive and inferential statistics were used to analyze and interpret the data. RESULTS The results were organized under the following sections Section I: Description of the demographic variables Section II: Determining the attitude towards compliance to medications. Section III: determining the compliance level of chronic clients towards their medications. Section IV: Relationship between attitude towards compliance to medications and compliance to medications. Section V: Association between attitude towards medications with selected demographic variables. Section I: Description of the demographic variables Of the 200 clients selected for the study, 39% were above the age of 60years, 28% were between 41 and 50 years of age, 26% were between 51 and 60 years and least (7%) were between 30 to 40 years of age. Majorities (62%) of the clients were females and 38% were males. Most (84%) of the clients were married and 12% were unmarried. Highest (38%) of the clients had only primary education, 24% illiterate, 22% had high school education and 16% were educated above secondary school.62% were unemployed and 70% had income less than Rs 5000.With regard to the chronic illness,48% had hypertension, 32% had diabetes, 21% had asthma, 8% had mental illness and 3% had renal problems. 28% of the clients had both hypertension and diabetes.68% of the sample were suffering from chronic illness since five to ten years and 22% had illness from 11 to 15 years.45% of the sample needs to be reminded for the impending follow-up and the family members(43%) remind the patient of the followup. Section II: Determining the attitude towards compliance to medications. This section deals with the description of the attitude scores towards their medications and presented in the form of tables and figures. Table 1: Frequency and percentage distribution of attitude towards their medications among chronic patients N= 200 Level of attitude Range f % Unfavorable Neutral Favorable Data in table 1 show that highest (59%) of the patients had favorable attitude towards their medications and 41% had neutral attitude towards medications. Table 2: Range, mean, median and standard deviation of attitude scores towards their medications among chronic clients N= 200 Attitude scores Obtained Maximum Mean Median SD range score Data in table 2 shows that the range of attitude scores was between , and the mean attitude score was i.e. attitude was favorable towards their medications. Section III: Determining the compliance level of chronic clients towards their medications: compliance to medications among clients with chronic illness was assessed using MMAS-8 Fig. 1. Pie diagram showing the compliance status among chronic illness clients

92 84 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Figure 1: shows that 59% of the chronic illness clients had low compliance status, 37% had medium and only four percentage had high level of compliance to the medications in chronic conditions. Table 3: Range, mean, median and standard deviation of compliance scores towards their medications among chronic clients Compliance scores Obtained range Maximum score Mean Median SD N= 200 Data in table 3 shows that the mean, median and the standard deviation of the compliance score was 4.83, 5.5 and 2.34 respectively. Section IV: Relationship between attitude towards compliance to medications and the compliance status to medications. In order to find out if any correlation existed between the attitude towards compliance to medications and the compliance status, the following null hypothesis was formulated: H0: There will be no significant correlation between the attitude towards compliance to medications and compliance status. The null hypothesis was tested using Karl Pearson correlation coefficient ( r value). Table 4: Karl Pearson correlation ( r value) between attitude scores and compliances cores Towards their medications N=200 Correlation between attitude scores and compliance scores Variables r value df P value Attitude Compliance status Karl Pearson coefficient of correlation was computed in order to find the correlation between attitude and compliance scores of chronic clients towards their medications. The data presented in table 4 shows that there was a positive correlation between the attitude scores and compliance status of chronic clients towards their medications. But there was no significant correlation between attitude and compliance status towards their medications among chronic clients (r (1) = 0.53, p<0.01). Thus null hypothesis H01was accepted. Section V: Association between attitude towards medications with selected demographic variables The chi-square test was used to find the association of attitude scores with selected demographic variables. The following null hypothesis was stated H02: There is no significant association of attitude scores towards their medications among chronic clients with the selected demographic variables. Table 5: Chi-square test showing association of attitude scores with selected demographic variables S:no Variables χ 2 value df Table value P value Inference 1. Age P>0.05 NS 2. Sex 0, P>0.05 NS 3. Marital status P>0.05 NS 4. Educational status P>0.05 NS 5. Occupational status P>0.05 NS 6. Duration of illness P>0.05 NS 7. Source of information P<0.05 S 8. Reminder to take medications P<0.05 S 9. Accompaniment for follow-up P<0.05 S

93 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 85 The association between the attitude score and selected demographic variable was found by using Chi square test. The data presented in the Table 5 shows that there was no significant association of the attitude scores and selected demographic variables such as age (χ2=4.57p>0.05),sex (χ2=0.46p>0.05),marital status (χ2=5..71 P>0.05),educational status (χ2=6.57 P>0.05) occupational status(χ2=6.44p>0.05), and duration of illness(χ2= 1.80 P>0.05). Source of information (χ2=15.80 P < 0.05), need reminder to take medications (χ2=10.13 P< 0.05), and accompaniment for follow-up (χ2=8.30 P<0.05), has significant association with attitude scores. DISCUSSION This study revealed that (59%) of the chronic illness patients had favorable attitude towards their medications and 41% had neutral attitude towards medications. The range of attitude scores was between , and the mean attitude score was i.e. attitude was favorable towards their medications. The findings are consistent with a study which revealed that the majority of the respondents had a positive attitude toward drugs. 4.7% considered medication as negative as danger or necessary but evil 5. With regard to the compliance status, the study shows that 59% of the chronic illness clients had low (<6) compliance status, 37% (6 to <8) had medium and only four percentage (=8) had high level of compliance to the medications in chronic conditions. The study also shows that the mean, median and the standard deviation of the compliance score was 4.83, 5.5 and 2.34 respectively. Though the attitude is favorable towards medications still compliance status is poor which means other factors may contribute to poor compliance. Besides this, persons may also not reveal the appropriate attitude which he has. Patient may apparently show a favorable attitude when asked about it but may project a totally different picture within him with regard to compliance. The study shows that there was a positive correlation between the attitude scores and compliance status of chronic clients towards their medications. But there was no significant correlation between attitude and compliance status towards their medications among chronic clients (r (1) = 0.53, p<0.01). Association between attitude and selected demographic variables showed that there was no association between age, sex, marital status, educational status, occupational status and duration of illness. However the demographic variables such as Source of information (χ2=15.80 P < 0.05), need reminder to take medications (χ2=10.13 P< 0.05), and accompaniment for follow-up (χ2=8.30 P<0.05), has significant association with attitude scores. Contradictory findings were revealed in a study where age and gender influenced attitude but socio economic status did not influence attitude 5. Patients with chronic conditions have to take their medications for a long time. If patients get regular information about their medications which is reliable this tends to improve the attitude and there by reenforces the need for the medications among chronic clients. One of the factor influencing medication intake is forgetfulness. However if family members remind the patient regarding medications and accompany them for the follow up, the attitude of the family is the improvement of the patient. So the patient also will feel the need of the medications and thus compliance status will be improved. CONCLUSION The study concludes that the attitude of chronic patients towards their medications is favorable and none have unfavorable attitude towards medications. Most of the patients have low compliance status to long term medications. There was a positive correlation between the attitude scores and compliance status of chronic clients towards their medications. Source of information, reminder to take medications and accompaniment for follow-up has significant association with the attitude of the patient towards their medication. Acknowledgement: I thank all the experts who validated the attitude scale. My sincere thanks to all the clients for their cooperation in the study. Conflict of Interest: Nil Source of Funding: self Ethical Clearance: Permission was obtained from the District health office, Mangalore. Informed consent was obtained from the study participants. The participants were explained regarding the purpose of the study and confidentiality was assured.

94 86 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 REFERENCES 1. Dr. Prabhakaran D. overview of chronic diseases available at directors-message.php. 2. Kotwani A. Access to essential medicines and standard treatment for chronic diseases. Indian J Pharmacol. 2010; 42(3): Jing J, Grant ES, Vernon MSO, and Shu CL. Factors affecting therapeutic compliance: A review from the patient s perspective. Ther Clin Risk Manag ; 4(1): Morisky DE, Ang A, Krousel-Wood M, Ward H. Predictive Validity of a Medication Adherence Measure for Hypertension Control. Journal of Clinical Hypertension 2008; 10(5): Sweileh MW and Arafat TR. Attitudes toward medications: a pilot study in palestine.the Islamic University Journal. 2006; Vol.14(2); P.21-30, 6. Zheng SK, Heng YK, Seng B, Ling MHH, Chang YJ. Assessing Attitudes of Patients towards Chronic Disease Self-management in Singapore. Archives of Pharmacy Practice. 2011; 2(1) Sharaf F. Impact of health education on compliance among patients of chronic diseases in Al Qassim, Saudi Arabia. International Journal of Health Sciences, 2010, Vol. 4(2), pp

95 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No.1 87 Impact of Leadership Development Package on Leadership Competencies of Head Nurses Usha Marath 1, Ramachandra 2 1 Professor cum Principal, Lisie College of Nursing, Lisie Hospital,Ernakulam Kerala, 2 Additional Professor of Nursing and Principal, College of Nursing, NIMHANS,Bangalore ABSTRACT Effective nurse leaders are needed to play key role in shaping a health care delivery system that addresses myriad health care needs. The main aim of the study was to find the impact of a leadership development package on leadership competencies of head nurses working in the clinical settings as reported by the participants and also as observed by the selected others It was found that the leadership development package would bring in significant changes in the leadership competencies of participants who had undergone the program. Keywords: Head Nurse, Leadership Competencies, Leadership Development Package INTRODUCTION Leadership is important in every sphere of activity, powerful leadership skills are needed by all nurses those providing direct care to those in top management positions. It has been noted that nurses progress to leadership positions largely uneducated, unsupported and with no or very little orientation or succession planning pertaining to leadership skills. Often leaders are appointed who have a nursing educational level in which leadership and management skills and competencies were not part of the academic preparation. There was no systematic or integrated leadership development program within and across nursing institutions in India. It was also observed that there was often an absence in explicit leadership connections among education, practice; administration and research. Leaders within each domain operated mostly in isolation. In order to bridge this gap various leadership development initiatives and approaches by Corresponding author: Usha Marath 4J1 J2, A-Block, Penta Queen Apartment P.O.Edapally, Ernakulam Kerala, India Phone: , ushamarath2000@yahoo.com universities, unions, and professional nursing organizations have been identified by the researcher being implemented in various other countries, but very few program have been identified for nurses in the Indian setting. Experience has shown that certain attributes and skills which are essential ingredients of leadership can be enhanced. Development of leadership development package (LDP) The LDP was modeled on Kouzes and Posner s five exemplary transformational leadership practices which were as follows: model the way, inspire a shared vision, challenge the process, enable others to act and encourage the heart. 1 The Leadership Development Package consisted of four parts. The Leadership Development Package consisted of four parts; Part A dealing with meaning, significance, difference between management and leadership and dispelling the myths of leadership. Part B Know yourself which includes orientation to LPI and 360 degree feedback to participants. Part C- Five Exemplary Leadership Practices and Part D- which includes self development activities for continued leadership development. The Leadership Development Package was administered for 4 days, 1 day per week for 4 weeks using various teaching/ training techniques.

96 88 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 DATA COLLECTION Tools for collecting quantitative data included, Demographic information tool, Leadership Practice Inventory (LPI) 2 - self and observer. Before starting with the study, ethical clearance was obtained and separate permission was obtained from each setting for the study. Informed consent was obtained from each participant of the study. Sixty participants from two leading private hospital with over five hundred beds, who were willing to participate in the study were selected. All participants of one hospital acted as the control group. Participants were asked to complete the self rated LPI inventory and were asked to select three observers for completing the LPI observer inventory which was given to the participants to be handed over to the observers for rating. The observers were directed to handover the completed form to a person who had been assigned to collect and give it back to the researcher within four days. The leadership development program was started on the fourth day for participants in the experimental group and was withheld for participants in control group. Subsequently three posttests were conducted for both groups, 30, 90 and 180 days after the last day of intervention. RESULTS AND DISCUSSION The data gathered from the subjects was downloaded into the Statistical Package for the Social Sciences for quantitative analysis. Quantitative data was analyzed using descriptive and inferential statistic of frequency, percentage and standard parametric paired t test. All the participants of the study were female and the age ranged between 32 to 56 years, with the highest percentage (60 %) falling between the ages 41 and 50 years. Majority of the participants had only a diploma in nursing (81.66 %), % held a Post Basic B.Sc nursing degree and only 5 % had a B.Sc nursing, and none held a masters degree in nursing. 50 % of the participants had more than 15 years of experience. 50% of head nurses were employed in the current position for a period between 11 to 15 years and in the current organization for a period more than 15 years. None of the head nurses had undergone any formal leadership training program. These results compare well with the study findings, where it was reported that today s nurse leader was in his or her late 40s to early 60s with an average age of Nursing literature supports that nurse leaders need significant experience if patient care outcomes are to improve. In yet another study, it was reported that in 1,116 nurses, the mean age was 39 years and they had eight years of unit experience, 13 years of hospital experience, and 16 years of total nursing experience. 4 With the majority of head nurses having only a diploma in general nursing, and no formal leadership training, it is clear that the nurses have picked up the leadership competencies as they performed on the job. Leadership competencies Both self and observer reported three highest mean pretest and posttest scores were for the leadership practices enable others to act, encourage the heart and model the way whereas least scores were for the leadership practice inspire a shared vision and challenge the process among subjects in both groups. The study findings were found to be similar to, in a study with 36 registered nurses (RNs) who had currently licensed in Virginia, reported that the most frequently engaged in leadership practice of nurse managers as viewed by their staff nurses was Enable, followed by Encourage, Model, and Inspire, and then Challenge. 5 The findings about the importance of enabling others to act, and encouraging the heart according to the researcher, was not unexpected given the nature of nursing and the need for these leaders to provide an environment that will enable their staff to deliver nursing care to patients. Also not unexpected, was the importance of modeling the way for if the nursing leaders don t walk their talk and role model the behaviors that they value, no one will be ready to follow them. In reference to this study it would be interesting to know more about why the leadership practices of inspire a shared vision and challenge the process were ranked lower by the leaders and also observers. The culture of nursing educational programs tends to generate cohorts of nurses who were docile, obedient, dedicated to the hospital, and willing to work cheaply. Even the nursing superintendents themselves were usually docile and obedient, avoiding confrontation with the medical and administrative hierarchy at all costs. 6 Self rated leadership competencies The mean posttest scores for all the five leadership practices showed an increase from the pretest level.

97 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 89 The paired t value for all the five leadership practices from mean pretest scores through all the three mean posttest scores was found to be significant at even level (see table 1) Table 1. Comparison between mean self pretest score and mean self post test scores for each of the five leadership practices among head nurses in experimental group. Leadership practices Paired difference Paired t value Significance Mean SD SEM Model the way Mean pretest-mean * 1 st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest Inspire a shared vision Mean pretest-mean * 1 st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest Challenge the process Mean pretest-mean * 1 st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest Enable others to act Mean pretest-mean * 1st Posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest Encourage the heart Mean pretest-mean * 1 st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest df-29 * level of significance 0.05 N-30 But in contrast with the experimental group a steep decrease in mean self second posttest scores was seen for all the five leadership practices when compared with the mean self pretest scores and even though the mean self third posttest scores showed an increase it was not greater than the mean self pretest scores for all five leadership practices in the control group. The t value for the second posttest for all the five leadership practices was significant even at level (see table 2).The sudden decrease in the mean second posttest scores may be due to the negative impact of the nurses strike which took place in many private hospitals in the district during the period of study. 7

98 90 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 2 Comparison between mean self pretest score and mean self post test scores for each of the five leadership practices among head nurses in control group. Leadership practices Paired difference Paired t value Significance Mean SD SEM Model the way Mean pretest-mean st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean rd posttest Inspire a shared vision Mean pretest-mean st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean rd posttest Challenge the process Mean pretest-mean st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean rd posttest Enable others to act Mean pretest-mean st Posttest Mean pretest- mean * 2 nd posttest Mean pretest mean rd posttest Encourage the heart Mean pretest-mean st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean rd posttest df-29 * level of significance 0.05 N-30 Observer rated leadership competencies The mean posttest scores for all five leadership practices as rated by the observers showed an increase from the pretest through all three posttest time periods in the experimental group. The paired t value for all the five leadership practices was found to be significant at even level (see table 3). Table 3 Comparison between mean observer pretest score and mean observer post test scores for each of the five leadership practices among head nurses in experimental group Leadership practices Paired difference Paired t value Significance Model the way Mean SD SEM Mean pretest-mean 1 st posttest * Mean pretest- mean 2 nd posttest * Mean pretest mean 3 rd posttest * N-30

99 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 91 Table 3 Comparison between mean observer pretest score and mean observer post test scores for each of the five leadership practices among head nurses in experimental group (Contd.) Leadership practices Paired difference Paired t value Significance Mean SD SEM Inspire a shared vision Mean pretest-mean * 1 st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest Challenge the process Mean pretest-mean * 1 st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest Enable others to act Mean pretest-mean * 1st Posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest Encourage the heart Mean pretest-mean * 1 st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest df-29 * level of significance 0.05 N-30 In case of subjects in the control group, a slight decrease in mean posttest observer scores could be identified in all leadership practices across the different time periods for head nurses. The paired t value shows that all the posttest mean observer scores for the leadership practices inspire a shared vision and challenge the process was significant at 0.05 level. The paired t value shows that the second and third posttest mean observer score for the leadership practice model the way was significant at 0.05 level. The first mean observer posttest score for model the way and all other mean observer posttest scores of the leadership practices enable others to act and encourage the heart have not shown any significant changes as shown by the t value(see table 4). Table 4 Comparison between mean observer pretest score and mean observer post test scores for each of the five leadership practices among head nurses in control group. Leadership practices Paired difference Paired t value Significance Mean SD SEM Model the way Mean pretest-mean st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest N-30

100 92 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 4 Comparison between mean observer pretest score and mean observer post test scores for each of the five leadership practices among head nurses in control group. (Cond.) Leadership practices Paired difference Paired t value Significance Mean SD SEM Inspire a shared vision Mean pretest-mean * 1 st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest Challenge the process Mean pretest-mean * 1 st posttest Mean pretest- mean * 2 nd posttest Mean pretest mean * 3 rd posttest Enable others to act Mean pretest-mean st Posttest Mean pretest- mean nd posttest Mean pretest mean rd posttest Encourage the heart Mean pretest-mean st posttest Mean pretest- mean nd posttest Mean pretest mean rd posttest df-29 * level of significance 0.05 N-30 The mean difference for all leadership practices measured by the 360-degree Leadership Practices Inventory showed a statistically significant increase by the end of the program, when measured against the scores at the beginning of the program among participants in the experimental group than those in the control group. This indicates a positive change in leadership practices, as measured by the self and observers which was found to be significant at level. With control group in this study, the positive result stems primarily from observer and self-report methods and strengthens the validity of the leadership study results. Educational activities like the leadership development program was reported as a significant factor contributing to increased leadership practices in many studies Implication for nursing management Leadership is not quality that is emphasized in nurse s training, nor is it an ability that comes naturally to most nurses. Nurses should be provided with regular training program to update their knowledge and skill so as to manage change in the hospital. Nursing leaders and healthcare administrators may use the study findings to develop and implement leadership development program in order to improve work place efficiency. Robust theory and research on interventions to develop and promote viable nursing leadership for the future are needed to achieve the goal of developing healthy work environments for health care providers and optimizing care for patients. CONCLUSION In today s healthcare, nursing managers must demonstrate leadership styles that are appropriate for constantly changing, complex and turbulent healthcare delivery system. Working as a nurse leader requires complex skills and competencies that could affect not only staff, but also patients.ultimately; articulation of nursing practice through a leadership perspective

101 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 93 could create a clearer understanding of the value of nursing within the health care system. Acknowledgement: My deep gratitude to the Director and Nursing superintendent of the respective hospitals for granting me permission to conduct the study and providing all basic support in completing my study. Conflict of Interest: Nil Source of Funding: Self REFERENCES 1. Kouzes, J. M., & Posner, B. Z.The Leadership Challenge (3rd ed.). San Francisco: Jossey-Bass Kouzes and Posner LPI self and observer.pfeiffer, An Imprint of Wiley, San Francisco, CA Sherman, R., Bishop, M., Eggenberger, T., & Karden, R.Development of a leadership competency model from insights shared by nurse managers. Journal of Nursing Administration 2007; 37(2): Grossman, S., Valiga, T.M., The New Leadership Challenge.F.A. Davis, Pennsylvania Cummings, G., Macgregor, T., Davey, M., Lee, H., Wong, C. & Lo, E. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Journal of Nursing Studies 2010; 47: Wagner JI, Cummings G, Smith DL, Olson J, Anderson L, Warren S. The relationship between structural empowerment and psychological empowerment for nurses: a systematic review. J Nurs Manag 2010; 18(4): Newredindian. Kerala Nurses on Strike. February 22, wordpress.com/2012/02/22/kerala-nurses-onstrike/ 8. Tourangeau AE. Building nurse leader capacity. J Nurs Adm 2003; 33: George V, Burke LJ, Rodgers B, et al. Developing staff nurse shared leadership behavior in professional nursing practice... three studies. Nurs Adm Q 2002; 26: Wessel-Krejci JW, Malin S. Impact of leadership development on competencies. Nurs Econ 1997; 15: Wolf MS. Changes in leadership styles as a function of a four-day leadership training institute for nurse managers: a perspective on continuing education program evaluation. J Contin Educ Nurs 1996; 27:245 52, Cunningham G, Kitson A. An evaluation of the RCN Clinical Leadership Development Programme: Part 1. Nurs Stand 2000; 15: Cunningham G, Kitson A. An evaluation of the RCN Clinical Leadership Development Programme: Part 2. Nurs Stand 2000;15: Tourangeau AE, Lemonde M, Luba M, Dakers D, Alksnis C. Evaluation of a leadership development intervention. Can J Nurs Leader 2003; 16: Krugman M, Smith V. Charge nurse leadership development and evaluation. J Nurs Adm 2003; 33:

102 94 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Assessment of Knowledge on Prevention of Iodine Deficiency Disorders (IDD) in Children among Mothers of Under Five of Selected Rural Community, Bangalore Chetan Kumar MR 1, Lingaraju CM 2 1 Lecturer, RV College of Nursing, Bangaluru, 2 Asst. Professor, JSS College of Nursing, Mysore ABSTRACT India is the second most popular country in the world with a population of 1027 million (2001 census). The magnitude of the problem in India is far greater than what had been estimated in 1960s, when it was estimated that about 9 million persons were affected by goitre. Currently, no less than 140 million people are estimated living in goitre endemic regions of country The study objectives are To assess the knowledge on prevention of iodine deficiency disorders in children among Mothers of under five. And To associate knowledge on prevention of iodine deficiency disorders in children among Mothers of under five with their selected demographic variables. Research Approach was A quantitative research approach was selected to assess the knowledge on prevention of iodine deficiency disorders (IDDs) in children among Mothers of under five of selected rural community, Bangalore. Descriptive survey design was used In this study demographic variables are age, gender, religion, on prevention, educational qualification and various source of information. Setting is a physical location in which data collection takes place in a study. the present study was conducted in rural community in Bangalore. Population is identified as the entire aggregation of cases that meet a designated set of criteria. The target population for the present study consists of all 60 Mothers of under five from rural community Bangalore. The sample for the present study was 60 Mothers of under five who fulfil inclusion criteria are considered as the samples. The Non Probability Convenience Sampling technique was used to assess the knowledge on prevention of iodine deficiency disorders in children among Mothers of under five of selected rural community, Bangalore. Conclusion: In this study 80% of the sample had inadequate knowledge, 20% of them had moderate level of knowledge and none of them were found as adequate knowledge. In this study the overall knowledge found to be 37.8%. The results of Chi-square analysis indicated that there was significant association between knowledge scores with demographic variables such as educational status and. Hence research hypothesis (H2) was accepted, that there is significant association between the knowledge on prevention of iodine deficiency disorders among Mothers of under five with their selected demographic variables Keywords: Knowledge, Iodine Deficiency Disorders, Mothers Of Under Five INTRODUCTION Iodine is an essential trace element; the thyroid hormones thyroxine and triiodotyronine contain iodine. In areas where there is little iodine in the diet, typically remote in land areas where no marine foods are eaten, iodine deficiency gives rise to goitre (so- called endemic goitre), as well as cretinism, which results in developmental delays and other health problems. According to World Health Organization (WHO) in 2007, nearly 2 billion individuals had insufficient iodine intake, a third being of school age. Thus, iodine deficiency is more common in mountainous regions of the world where food is grown

103 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 95 in soil poor in iodine. Therefore iodine deficiency is the single greatest preventable cause of mental retardation, is an important public health problem 2. The disorders caused due to deficiency of nutritional iodine in the food or diets are called Iodine deficiency disorders (IDDs). Iodine is an essential element which is required at micrograms daily for normal human growth and development 1 High prevalence of goitre and cretinism exists in Himalayan and sub-himalayan areas including Jammu and Kashmir, Arunachal Pradesh. In our country, it is estimated that more than 200 million people are at risk of IDD while the number of persons suffering from goitre and other iodine deficiency disorder is above 70 million. Sample surveys have been conducted in 28 States and 7 Union Territories which have revealed that out of 324 districts surveyed so far, 263 are IDD endemic i.e. the prevalence of IDD is above 10 percent 5. Iodine is essential for the normal growth and development and well being of all humans. The adult human body contains about 50 mg of iodine, and the blood level is about 8-12 micrograms/dl 3. The daily recommended iodine intake varies with age. To meet iodine requirements, the recommended daily intakes are: 50 micrograms for infants (first 12 months of age), 90 mg for children (2-6 years of age) 120 mg for school children (7-12 years of age), 150 mg for adults (beyond 12 years of age) and 200 mg for pregnant and lactating women. Most of it comes from what we eat and drink 4. The researcher personally experienced that lack of iodine intake will decrease mental and physical activities in school age children (6-12years). Mothers play a vital role in observing the daily activities of children. Iodine deficiency is a preventable disorder and early diagnosis can prevent complications. So it is essential for the mothers to have adequate knowledge on Iodine deficiency disorders (IDDs) that can enable them to identify deteriorating mental and physical ability in children thereby helping them to overcome life threatening problems. For effective implementation of the Program at the State level, the Ministry of Health is providing financial assistance to all the States/UTs for establishment of an IDD Control Cell, and IDD Monitoring Laboratory in addition to assistance for conducting surveys and Health Education & Publicity for consumption of iodated salt by the population. NEED FOR THE STUDY Globally 2.2 billion people live in areas with iodine deficiency and risk its complications. In India, 200 million people are at risk of iodine deficiency disorders (IDDs), 54.4 million people have goitre and 8.8 million people have IDD related mental/motor handicaps. It is a major public health problem in 211 of 245 districts surveyed. Many studies conducted all over India have shown high prevalence of goitre.. In the sub- Himalayan goitre belt of India alone, nearly 55 million are estimated to be suffering from endemic goitre, with an average goitre prevalence rate of about 36 percents. In one particular district (Gonda) of Uttar Pradesh known to be highly endemic, the prevalence of neonatal hypothyroidism has been measured at the extremely high rate of 15 percent 7. In India, the endemic belt of goitre and cretinism mainly lies along the slopes, foot hills and plains adjacent to Himalayas extending over 2400km. Several pockets of endemic goitre are being identified in the Aravalli Hills in Rajasthan, Subvindhya hills of Madhya Pradesh, Narmada Valley in Gujarat, hilly arias of Orissa, Andhra Pradesh; tea estates of Karnataka and Kerala and the districts of Aurangabad, Pune. Inhabitants of most coastal areas are relatively free of goitre. The overall prevalence of total goitre among 6 to 12 years old children was about 4% which is below the cut off to indicate endemicity of IDD. The proportion is higher in Maharashtra (11.9 %) and West Bengal (9%) 8. For this purpose the investigator was interested to conduct study on assessment of knowledge on prevention of iodine disorders in children among Mothers of under five. Statement of the problem Assessment of knowledge on prevention of iodine deficiency disorders (IDD) in children among Mothers of under five of selected rural community, Bangalore. OBJECTIVES 1. To assess the knowledge on prevention of iodine deficiency disorders in children among Mothers of under five.

104 96 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 2. To associate knowledge on prevention of iodine deficiency disorders in children among Mothers of under five with their selected demographic variables. Assumptions 1. Mothers of underfive knowledge on prevention of iodine deficiency disorders in children may vary with their selected demographic variables. RESEARCH HYPOTHESES H1- There is a significant association between knowledge on prevention of iodine deficiency disorders in children among Mothers of under five with their selected demographic variables. Delimitations This study is delimited to 1. The study was limited among Mothers of under five of selected rural community from Bangalore, Karnataka. 2. The sample size is less so can t be generalize the study. MATERIALS AND METHODOLOGY A quantitative research approach was selected to assess the knowledge on prevention of iodine deficiency disorders (IDDs) in children among Mothers of under five of selected rural community, Bangalore. Descriptive survey design was used. Variable is a concept that has measurable changing attributes. Variables are qualities, properties or characteristics of persons, things or situations that change or vary. In this study demographic variables are age, gender, religion, educational qualification, and various source of information. The present study was conducted in rural community in Bangalore. The target population for the present study consists of 60 Mothers of under five from rural community Bangalore. The sample for the present study was 60 Mothers of under five who fulfil inclusion criteria are considered as the samples. The Non Probability Convenience Sampling technique was used to assess the knowledge on prevention of iodine deficiency disorders in children among Mothers of under five of selected rural community, Bangalore. Ethical consideration For the present study the investigator took into consideration ethical issues. There were no ethical issues confronted while conducting the study. 1. Informed consent was obtained from the study sample (Mothers of under five). 2. The subjects were informed that their participation was on voluntary basis and they had freedom withdraw from the study at any time. 3. No ethical issues arose during the study. ANALYSIS Table-01 Demographic Variables Of Mothers Of Under Five. n=60 Sl. No Variables Categories Frequency (60) Percentage(100) 1. Age in years Religion Hindu Christian Muslim Others specify Educational Status No formal education Higher secondary or below Pre university Graduates and above

105 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 97 Table 01. Demographic Variables of Mothers of Under Five. (Contd.) 4. Have you ever heard Yes about iodine deficiency disorders? No Source of information (n=53) Elders& Relatives Health personnel Mass media Others specify n=60 The data given in Table-01 depicts the frequency and percentage distribution of demographic variables among Mothers of under five with respect to knowledge on prevention of iodine deficiency disorders (IDDs) in children. The majority of the respondents were, aged between years. The age distribution showed that out of 60 Mothers of under five, 38 of them (63.3%) were aged between years, 14 of them (23.3%) were aged between years, 7 of them (11.7%) were aged between years and just 1 of them (1.7%) was between years. Religion wise distribution of the respondents indicated that 47 were Hindus (78.3%), 9 were Christians (15%) and 3 were Muslim (5%) and the remaining 1was in other category (1.7%). In relation to educational status, majority, 27 (45%), of the subjects had completed Education up to Higher secondary, 11 (18.3%) had No formal education and 22 (36.7%) had studied up to pre university. Most of the respondents 53 (88.3%) had heard about iodine deficiency disorders from various sources and only a few 7 (11.7%) had not heard about iodine deficiency disorders. In reference to source of information on prevention of iodine deficiency disorders, most of the respondents 26 (49%) had heard from mass media, 20 (37.7) from health personnel, 3 (5.6%) from elders/relatives and the remaining 4 (7.5%) had heard from other sources. Table 02. Assessment of Knowledge On Iodine Deficiency Disorders In Children Among Mothers Of Under Five. n=60 Level of knowledge Respondents knowledge Number Percentage (%) Inadequate knowledge (<50%) Moderate knowledge (51-75%) Adequate knowledge (>75%) 0 0

106 98 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 The above Table-02 shows that the majority of the respondents 48 (80%) had inadequate knowledge and 12 (20%) had moderate knowledge on prevention of iodine deficiency disorders (IDDs) in children. Table 03. Level of Knowledge on prevention of iodine deficiency disorders in children among Mothers of under five. n=60 Sl.No. Aspect of Knowledge Maximum Score levels of Knowledge Range Mean SD Mean% I. Introduction II. Etiology III. Clinical Manifestation IV. Management V. Prevention VI. Over all The above Table-03 shows the descriptive measures of knowledge on iodine deficiency disorders in children among Mothers of under five. The range of scores in the Introduction was 0-5 with a mean of 2.32 and standard deviations of 1.01 with mean score percentage of The range of scores in the knowledge area of Etiology were 0-4 with a mean of 2 and standard deviations of 1.04 with a mean score percentage 40. The range of scores in the knowledge area of types & clinical manifestation was 0-6 with a mean of 2.88 and standard deviations of 1.48, with mean score percentage of 36. The range of score in the knowledge area of management was 0-3 with a mean of 1.23, standard deviations of 0.69 and mean score percentage of The range of scores in the knowledge area of prevention was 1-8, with a mean of 4.42, standard deviations of 1.67 and mean score percentage of The range of scores for the overall knowledge on the prevention of iodine deficiency disorders were 4-20, with a mean of 12.85, standard deviation of 3.92 and mean score percentage of Table 04. Association between knowledge and selected demographic variables of Mothers of under five. n=60 Variables Categories No. (60) % Knowledge Chi-square value P-value median >median No. (32) % No. (28) % Age in years ,df=3, NS P> Religion Hindu , df=3, NS P>0.05 Christian Muslim Others specify Educational no formaa , df=2, S P<0.05 Status education higher secondary or above PUC Graguate Heard about IDD? Yes , df=1, NS P>0.05 No Source of Elders& , df=3, NS P>0.05 information (n=53) Relatives Health personnel Mass media Others specify Note: S = significant at 5% level ( ie., p<0.05); NS = Not Significant at 5% level (ie., p>0.05)

107 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 99 CONCLUSION The results of Chi-square analysis presented in tables-03 indicated that there was significant association between knowledge scores with demographic variables such as educational status.hence research hypothesis (H 2 ) was accepted, that there is significant association between the knowledge on prevention of iodine deficiency disorders among Mothers of under five with their selected demographic variables. Acknowledgement: Acknowledging to all the mothers of under five who are participated in this study. Conflit of Interest: Nil Source of Funding: Nil REFERENCES 1. Bruno de Benoist, Maria Andersson, Ines Egli, Bahi Takkouche and Henrietta Allen. Iodine status worldwide: WHO Global Database on Iodine Deficiency. Geneva, Switzerland: WHO; UNICEF. Iodine Deficiency Disorders and Universal Salt Iodization-South Asia Priorities. UNICEF-Regional office for South Asia publication; Darshani Sohi. A text book of nutrition for nursing course. 1 st edition. Jalandhar: S. Vikas and Co. publishers; WHO. Assessment of iodine deficiency disorders and monitoring their elimination- A guide for programme managers. 3rd edition. Geneva, Switzerland: WHO publication; Ministry of health and family welfare. Revised policy guideline on National Iodine deficiency disorders control program. New Delhi: Ministry of health & family welfare Publication; WHO. Assessment of iodine deficiency disorders and monitoring their elimination: 2nd edition. WHO publication; Park.K. Textbook of prevention and social medicine. 18 th edition. Jabalpur India: M/s Banarsidas Bhanot publications; S Brilakshmi. Nutrition sciences. 3rd edition. India: New Age international publisher; 2008.

108 100 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Assessment of Susceptibility to Hypertension among Staff Nurses Related to Selected Stress Factors Asishbala Mohapatra Professor, Hi-tech College of Nursing, Bhubaneswar, Odisha ABSTRACT The study was conducted to assess the susceptibility to hypertension among staff nurses related to selected stress factors, working at M.K.C.G. Medical College Hospital, Berhampur, Orissa. A descriptive survey with cross sectioned design was adopted. A total of 100 samples were included in the study. Convenient sampling technique was used. A structured questionnaire was administered. It was found that there is significant association between susceptibility to hypertension related to stress factors and demographic variables. Keywords: Susceptibility, Stress, Hypertension, Susceptibility to Hypertension INTRODUCTION Life is filled with a never ending array of challenges. Some of them are obstacles in accomplishing necessary daily tasks or cherished life goals. Others are opportunities for growth and positive changes in our lives. When confronted with a particular change, we may feel excited, anxious, sad, depressed, angry. Such feelings may cause symptoms like sleeplessness, restlessness, headache, gastro intestinal upset, palpitation, tremor etc. which signals a description of psychological balance. Usually, this description is brief, because we find ways to meet a challenge and to restore our well being when it is prolonged and not resolved, we are said to be under stress or stressed out OBJECTIVES 1. To assess the stress factors of staff nurse. 2. To compare the susceptibility to hypertension as categorized by WHO. 3. To find out the association between stress factors with susceptibility to hypertension. Review of Literature Stress is associated with manifestation of physical illness, i.e. myocardial infarction, coronary artery disease, hypertension etc. (Boyd. 1990) Various authors state that stress can have physical, emotional, intellectual, social and spiritual consequences. Physical stress can threaten a person s physiologic homeostasis, emotional stress can produce negative or non constructive feelings, about self. (Townsend C. 1990, Kozier et al, 1991). An expert team Peltzer, Karl, Shisana Olive, Zuma Khangelani, Van Wyk and Zangu Dinwayi (1995) has done the research study on job stress, job satisfaction and stress related illness among staff nurses. A cross sectional survey was conducted in a representative sample of 21,307 staff nurses from different hospitals in South Africa. Results indicate that the prevalence of stress related illness were 15.6 percent for hypertension, 9.1 percent for stomach ulcer, 4.5 percent diabetes, 3.3 percent minor mental distress, 3.1 percent major mental distress and 3.5 percent asthma. ASSUMPTION The information obtained from the staff nurses are assumed to be accurate. There is a relation between stress and hypertension. Some family factors lead to stress. Some profession factors leads to stress.

109 International Journal of Nursing Education. January-March 2015, Vol. 7, No HYPTOTHESIS H 1 There is a significant association between susceptibility hypertension rebated to stress factors. Conceptual Framework Theoretical framework selected for this study is based on Hars Selye s stress theory. (1976), the general adoption syndrome (GAS). Research Approach A cross sectional survey approach was used. Research Design Descriptive research design was used for this study. Setting of the study The study was conducted is different wands of MKCG MCH, Berhampur. Sample and sampling Technique The sample selected consists of 100 staff nurses who are working is different wards of the hospital. The sample was selected by using convenient (Purposive) Sampling. Development of tool A self structured questionnaire was prepared which consists of two parts. Section-A which consists of demographic data and Section B which consists of questionnaire. Validity of the tool: the Validity of the tool was done by eight (8) experts, which included physicians, statistician and nurse educators. Pilot Study: The pilot study was conducted among the staff nurses working at opthalmology department which is 1KM away from the main Hospital. Split half method was used to test the reliability by applying spearman s Brown formula and the tool was found reliable. (Rs0.73). Ethical Consideration: Informed consent was obtained from all the nurses who had participated in the study. Explanation was given regarding the purpose of the study ensuring confidentially. Due permission from authority was obtained. DATA ANALYSIS & INTERPRETATION The datas obtained were analyzed and interpreted in terms of objectives and hypothesis. Descriptive and inferential statistics were used for data analysis. The level of significance was set at The findings are presented under the following headings, Section I : Distribution of staff nurses according to their demographic variables. Distribution of staff nurses according to their, selected, demographic characteristics Sl No. Demographic Variables Frequency Percentage 1 Age in Years <30 years yrs yrs >50yrs Type of family Nuclear Joint Extended Three generation Education GNM B.Sc M.Sc Years of work experience 1-8 yrs yrs yrs yrs 15 15

110 102 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Distribution of staff nurses according to their, selected, demographic characteristics (Contd.) Sl No. Demographic Variables Frequency Percentage 5 Place of Posting ICU Casulaity General Ward Labour Room / OT Marital Status Married Unmarried Widow 5 5 Divorce Guardians Occupation Private Employee Govt. Employee Self Employee Dependent 8 Family Income <10, , > Family History at any disease Diabetes Cardiovascular disorder Rehal disorder None of the above Percentage wise distribution of staff nurses according to their age shows that 35(35%) were in the age group of 41-50yrs which was maximum and 15(15%) were in the age group of > 50yrs which was minimum. Distribution of staff nurses according to their type of family shows that 50(50%) were from joint family which was maximum and no one belongs to there generation family which was minimum. Distribution of staff nurses according to their education shows that 60(60%) were diploma nurses and 40(40%) were graduate nurses. Percentage wise distribution of staff nurses according to their work experience shows 35(35%) were belong to the age group years which was maximum and 15(15%) were in the age group yrs which was minimum. Distribution of staff nurses according to their place of posting shows that 35(35%) were working in the casuality which was maximum and 15(15%) were working in the labour Room / OT which was minimum. Distribution of staff nurses according to their marital status shows that 60(60%) were married which was maximum and 5(5%) each were divorce and widow which was minimum. Percentage wise distribution according to their guardian s occupation shows that 45(45%) were private employee which was maximum and 15(15%) each were govt. employee and dependent which was minimum. Distribution of staff nurses according to their family income reveals that 40(40%) were having per capita monthly income <10,000 which was maximum and 10(10%) were having per capita monthly income >20000 which was minimum. Distribution of staff nurses according to their family history shows that 30(30%) from each category were having the family history of diabetes, cardiovascular disorder and renal disorder from each category and 10(10%) were free from any hereditary disorder. Section II distribution of staff nurses according to the susceptibility to hypertension. Item wise analysis of the staff nurses and their stress and the susceptibility to hypertension. Factor wise analysis of the staff nurses and their level of stress and the susceptibility to hypertension.

111 International Journal of Nursing Education. January-March 2015, Vol. 7, No Item Wise Analysis :- It comprises a table which consists of so many items related to stress factors (Professional and family), and their susceptibility to hypertension. It is a rating scale which consists of five (5) categories. (Never, Rarely, Sometimes, Mostly and always) it indicates that from the category Never 2(2%) were susceptible, from the category Sometime 12(12%) from the category Rarely 6(6%) from the category Mostly 20(20%) and from the category always 20(20%) were susceptible to hypertension. Factor Wise analysis Table II: Distribution of Staff nurses according to their level of stress related to selected factors. (N-100) Level of Stress Score Frequency Percentage No Stress (0-50) 0 0 Mild (51-100) Moderate ( ) Severe ( ) 1 1 Total To assess the level of stress, a five point scale was used. No stress, mild stress, moderate and severe stress. It shows that 10(10%) of the staff nurses were suffering from mild stress, 89(89%) of them were suffering from moderate stress and 1(1%) was suffering from severe stress. Section III :- Comparison of the susceptibility to hypertension with demographic variables shows that in the age group <30years out of 20,5 (25%) were susceptible which is lowest and in the age group (41-50yrs) out of 35,25,(71.4%) were susceptible which is highest. Type of family shows that, 35(70%) out of 50 were susceptible in case of joint family which is highest and 05(50%) out of 10 were susceptible which is lowest. Education shows that 45(75%) out of 60 were susceptible for them those who are 20(50%) out of 40 were susceptible for them those who are B.Sc (N). Percentage wise distribution according to the susceptibility to hypertension in relation to the years of work experience shows that 5(25%) were susceptible to hypertension having the work experience 1-8 years, which is lowest and 25(71.4%) were susceptible having the work experience years which is highest. Percentage wise distribution according to marital status in relation to susceptibility reveals that 40(66.6%) out of 60 were susceptible among married persons which is highest and 2(40%) out of 5 were susceptible among widow and divorce each which was lowest. Percentage wise distribution according to guardian s occupation in relation to susceptibility shows that 30 (66.6%) out of 45 were susceptible which was highest among private employee and 03(20%) out of 15 were susceptible which was lowest among the govt. employee. Percentage wise distribution according to family income in relation to susceptibility shows that 30(75%) out of 40. Were susceptible with family income <10,000 which is highest and 2(20%) out of 10 were susceptible with family income >20000 which was lowest. Distribution of staff nurses according to the family history of any chromic disease reveals that 23(76.6%) out of 30 were susceptible for those who are having the history of cardiovascular disease which was highest and 2(20%) out of 10 were susceptible for those having no history which was lowest. Section IV: Association between the susceptibility to hypertension related to Stress factors and demographic variables.

112 104 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table III N=100 Stress factors& Demographic Variables df Chisquare Table Value Remark Professional Factors S Family Factors S Age of Staff nurses S Type of Family S Education NS Work Experience S Marital Status S Family Income S Place of Posting S History of any Chronic Disease S P Value <0.05 Significant P Value >0.05 not Significant Findings reveals that there is no significant association between susceptibility to hypertension as compared to education where as significant association was found between the susceptibility to hypertension related to stress factors and demographic variables like age, type of family, work experience, marital status, family income, place of posting and history of any chronic disease in the family. Hence, research hypothesis is rejected for education and accepted for other demographic variables and stress factors. Nursing Practice IMPLICATIONS The findings of the study will help to Identify all the stress factors related to profession and family. Reduce and control stress and improve coping. Identify other stress factors and gender guidance and counseling services. Adopt adequate coping measures, awareness about the susceptibility to hypertension, regular check up to blood pressure and proper management will help to prevent hypertension. Nursing Administration The findings can be utilized to organize in-service education programme, continuing education so that the nurses who are working in the hospital will be aware about the stress factors, its relation to develop hypertension and consequences and remedial measures to be taken. The nurse administrator should take the responsibility for updating the knowledge of the nurses to avoid stress and adopt coping. Nursing Education The present study emphasizes on awareness of the stress factors, its control and coping mechanism among the staff nurses. Additional information should be imparted at nursing school and college level to the students to make them aware about professional factors which contributes to develop hypertension. They must be encouraged to adopt coping mechanism and become physically & Mentally healthy. RECOMMENDATIONS Similar study can be under taken for more and none diverse samples to generalize the findings. An experimental study can be conducted by considering all types of stress factors & their susceptibility to hypertension. A study can be conducted by considering all type of coping and preventive measures and their significance to prevent hypertension. Staff nurses teaching module to be prepared and tested to assess the effectiveness of module in reducing the stress of the staff nurse and to prevent hypertension. Acknowledgement: The author is grateful to the Principal, Berhampur College of Nursing, Nursing dean, SOA University, Bhubaneswar for Providing constant supervision, encouragement & Support.

113 International Journal of Nursing Education. January-March 2015, Vol. 7, No Conflict of Interest : Nil Source of Funding : No Funding (Self) REFERENCES 1. Polit D.F. and Hungler B.P., \Nursing Research, Philadelphia, Lippincott, 1999, Pp Brunner Lillian Sholtis/Suddarth, Dores Smith, Textbook of Medical Surgical Nursing, Lippincott company, Philadelphia London, Shafer s P. Medical Surgical Nursing 7 th Edn, the CV Mosby Company 1980, Pp Kothari C.R. 1998, Research Methodology Methods and Technique, New Delhi, Vishwa Prakashana, Pp Perry P., Fundamentals of Nursing 6 th Edn, Mosby Publishers, Pp Basavanthappa BT. Nursing Research Jaypee Publishers, Reprint edn, 2006, Pp Black J. Textbook of Medical surgical Nursing, Vol I, Mosby Publications, Pp Davidsons, Principles and Practice of Medicine, 19th Edn, Churchill and Livingstone, Pp Lewis, Collier and Hertkember, Medical Surgical Nursing Assessment and Management of Clinical Problem, 4 th edn, Mosby, Pp Keshab Swarnakar, Nursing Practices and Procedures, 1 st edn, NR Brothers Pp

114 106 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Family Support Needed for Adolescent Puberty Endang Triyanto 1, Asep Iskandar 1 1 Lecturer in Faculty of Medicine and Health Science Jenderal Soedirman University of Purwokerto Central Java Indonesia ABSTRACT Adolescents during their puberty will experience many physical and psychological changes that are very fast. Physical changes of puberty teens give effect to changes in psychological and social. Shape changes that accompany puberty include changes in cognitive, moral, emotional, social as a form of self-development of adolescents. Families have an important role to help youth grow and develop normally during puberty. Reality on the ground are still many families that have not been able fully to implement the family support to adolescents undergoing puberty. The purpose of this study to obtain the necessary family support during their teenage puberty. The design study is a qualitative phenomenology. Researchers conducted in-depth interviews of adolescent puberty. Data analysis using Colaizzi method. The first theme is the role of perceived family (support, negative attitudes and rules). The second theme is the expected behavior of adolescent family (needed, considered, understood, satisfied, given the right to argue, improved communication, allowed to play, directed and controlled). Researchers suggest the formation of adolescent peer counselor, clinical consultation and promotion family support for adolescent. Keywords: Puberty, Adolescent, Family Support INTRODUCTION One of the many stages of development to the attention of society and government is adolescence. Adolescents undergoing puberty is defined as the transition from childhood to adulthood. Puberty is a period when a child begins to experience sexual maturity and reproductive organs are ready to perform their reproductive function with rapid physiological changes 24. Adolescents during their puberty will experience many physical and psychological changes that are very fast. Physical changes of puberty teens give effect to changes in psychological and social. Shape changes that accompany puberty include changes in cognitive, moral, emotional, social as a form of self-development of adolescents 19. Nami describes the results of his study that adolescents who undergo puberty starts are required to behave in accordance with the demands of groups and norms 23. Teens will experience social change by increasing the activity with their peers, sometimes even leaving the values in the family. They want to be recognized group, as well as models of clothes and haircuts that can make hot parents, still done by recognized groups 2. During puberty, there is increased sexual drive due to hormonal changes 41. They began to have interest with the opposite sex, as stated, the interaction is erotic to experience sexual feelings with the opposite sex, is clearly indicated from 14 age years 39. Emotions are very labile teenagers is caused by an increase in sexual hormones that are so rapidly 15. Form of emotional teenage puberty circumstances, sensitive, reactive and critical of the events that occurred. This condition is often the cause of adolescent conflict with parents or peers, can even be a cause of juvenile delinquency 11. Sarwono research states that the environment is most influential on the success of teenagers undergoing puberty are family 29. Families should create conditions that support growth and development of normal adolescent physical, psychological and social 1. Reality on the ground are still many families that have not been able fully to

115 International Journal of Nursing Education. January-March 2015, Vol. 7, No implement the family support to adolescents undergoing puberty. Some 78% of teens say that no explanation was given his parents about the signs of puberty 16. Astuti describes in his research that the family who know all too well about the signs of adolescents who undergo puberty only 37 percent 5. Devi adds that 50% of children aged 12 years said that her parents did not pay attention on the subject of sex 6. According to the research of Karisma, lack of family support due to the economic, knowledge and family sources 20. Sarwono survey showed about 23% of teens who live in Baturaden has been doing pre-marital sex and performed since the age of 13 years 29. About 56 percent of teens Purwokerto already had sex with boyfriend free 3. Wahyu explained in the qualitative study that teenagers who work as commercial sex workers in Purwokerto, largely due to disappointment with his girlfriend and the absence of parental attention 38. Indifferent attitude of parents towards adolescent pubertal changes can be categorized as ineffective family support 12. Puberty as the most difficult stages of growth and development. METHOD This study uses qualitative methods to study the phenomenology of each issue by placing it in a natural situation and give meaning a phenomenon based on things that matter to people. Researchers chose the phenomenological approach of the experiences of adolescents in a family developmental tasks during their puberty. Participants of this study are adolescents who are undergoing puberty using purposive sampling. This study inclusion criteria: adolescent males aged years and has experienced a wet dream; adolescent girls aged years and has experienced periods; willing to become participants; adequate knowledge; teenager lived with his family, and be able to tell experience with both. The study was conducted in Purwokerto from August to November Data was collected through in-depth interviews with open-ended interview strategy. The main instrument of this research is the researcher. Data collection tool guidance on interviews, field notes and MP3 devices. Stages of data analysis using the method of Colaizzi about the support families need during their teenage puberty 35. RESULTS AND DISCUSSION Support the Family That Has Given To Young For The Puberty Based on the results of interviews conducted by researchers, the data found that adolescents during puberty undergo sensed a pattern of behavior of different family each adolescent. Perceived family support adolescents during puberty underwent a way to understand, advise, allow, meet the needs and teach. Perceived negative attitude teen family is a family concern that less, not explain, curb and do not give children the right to argue. These results are in line with the statement of Ervin who explains that the family support consists of emotional support, material and informational 10. Adolescents undergoing puberty experienced many problems arising from physical and psychological changes 28. Ingredients that, according to research Schad, adolescents who undergo puberty require family support in the form of emotional support, informational and material 30. Families should provide an adequate explanation of the changes during puberty, and how to overcome problems early on to his children. But from the results of this research is still very few families that do that. This study shows that the support of family information about the changes that occur during puberty are obtained teenager is still lacking 17. Adolescents undergoing puberty experienced an unstable emotion, so easily upset, easily stressed and irritable 14. Families have a responsibility to provide emotional support that helps solve adolescent problems and overcome emotional instability. The fact is the basis for the statement of experts that the most difficult developmental tasks the family is at the stage of adolescent development that are undergoing puberty 25. Often the family worries too much, so many teenagers are restrained and not given a chance to hang out with her friends 18. The attitude of restraint to adolescents undergoing puberty will influence the psychological development of adolescents 26. If families do restrictions on teens to hang out, then the result of what happens is that dependent children become teenagers, unable to relate with others 5. The attitude of restraint expressed adolescents in this study according to the statement Soetjiningsih that often

116 108 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 parents are too overprotective in children and adolescents do not give a chance to hang out with friends 33. Adolescents revealed that there are four ways in which families in enforcing the rules, to direct, alerting, giving examples and some others by force. Teenagers should be directed to enable them to be positive from the family rules when parents do career development 27. The role of the family like this become very important as a vehicle for transferring the values and as agents of cultural transformation 34. Sarwono adds that the family is the place to absorb the values, norms, attitudes and guidance in times of crisis that is puberty 29. The Adolescent Family Support Needed During Period Puberty Every teenager while undergoing puberty have different needs. According to Friedman support the family in adolescents during puberty consists of material support, emotional and informational 12. Once the researchers explore in depth, the expectations of her family against her teens during their puberty, revealed a wide range of support needs. Family support for adolescents who are expected to undergo puberty is to be noted, the desire that parents can act as a friend, give love, understood, informed and satisfied their needs. Parental attention, affection and understanding in the face of teenage parents will help teens achieve a stable emotional maturity 8. Teens want parents to be able to speak softly to her child, not by yelling. Gentle way of speaking that will make comfort for the teenagers, even they will be more open to parents if the family needs are met 21. This is consistent with Ramanda which states that when children run away from home, they want to go back when parents show a gentle attitude 26. Teens in this study also hoped that he be granted the right to argue for communication with his family. Communicating with children is a most effective way to avoid things that are not desirable 36. Results of analysis of research data by the study of Teresa, the correlation values obtained between intrapersonal intelligence in adolescents with communication 37. This indicates that there is a significant correlation between intrapersonal intelligence in adolescents with communication effectiveness. Communication in question is two-way, meaning both sides must be willing to listen to each other with a view of one another. Parents with twoway communication can find out the views and mindson, and instead the children can know what parents want 42. Democratic atmosphere in the household need to be created, all family members can express their opinions, without having to feel embarrassed especially feared by other family members, especially to parents 34. Hurlock explains that through relationships with peers, adolescents learn to think independently, take own decisions, accept or reject the views and values derived from the family and learn the patterns of acceptable behavior group 19. The opportunity to play with peers will enhance the ability of adolescent interpersonal communication. Studies conducted Stuart showed that teenagers who are given the opportunity to hang out with friends in a responsible manner are better able to communicate better than teens who curbed 36. Teens in this study allowed to reveal want to play with their peers. Families are required to meet the social needs of adolescents who undergo puberty by providing the freedom to hang out with their peers 17. Parents should not resolve the problem by way of an attitude as if he were interrogating or suggesting, as this will make the teenager is getting scared 8. Teenagers are given the opportunity to take responsibility by directing their actions and set an example will feel that he is given the trust by his parents. Hurlock explained that the guidance of older people are needed by adolescents as a reference for adolescents to behave 19. Parents in giving freedom to the teenager must be accompanied by instilling a sense of responsibility teens 13. Each adolescent s decision will bring positive and negative consequences. Various alternative consequences arising from the decision should be discussed teen parents with their teenagers 12. The ability of these parents can be realized with the role of family caregivers who will accompany the family in carrying out the developmental tasks of the family 14. Various necessary family support needs teenagers who are undergoing puberty can be the basis for the family to carry out the role of family in adolescents according to the needs of youth it self 22. The expected goal is indeed the right target in the sense that the expected teens, so teens can carry out the task of adolescent development. Especially during the adolescent developmental tasks undergo puberty according is comprised of: accepting diversity of

117 International Journal of Nursing Education. January-March 2015, Vol. 7, No physical change and its impacts; achieve independence from parents; develop appropriate gender identity and strengthen self-control over emotional 19. It is also similar to Santrock on the developmental tasks of adolescence during puberty is receiving physical condition themselves, get along with peers of both sexes and achieve social role as a man or a woman 28. CONCLUSION AND SUGGESTIONS Some participants still felt that given the pattern of family behavior is still lacking that indicated the existence of negative attitudes of the family. Negative attitude family consists of: a lack of family attention, does not explain, curb and do not give the right to argue. Family support needed adolescents during puberty consisted of emotional support, material and informational. Preparation of puberty and adolescence module family support families need to be developed as guidelines in providing support. Acknowledgement: Researchers would like to thank Jenderal Soedirman University has provided funding for this research. Researchers like to thank all the young people in Purwokerto has taken the time and are willing to research respondents. Conflict of Interest: No conflict of interest. Source of Funding: Source of funding research from Universitas Jenderal Soedirman University of Purwokerto. Ethical Clearance: Before the study was conducted are reviewed by team of research ethics. REFERENCES 1. Agustiani, A., (2006). Karakteristik dan Permasalahan Remaja yang Menjalani Masa Pubertas. From psikologi-remaja-karakteristik-danpermasalahannya/#more Allen, J. P., Insabella, G. M., & Porter, M. R. (2006). A social inter action model of the development of depressive symptoms in adolescence. Journal of Consulting and Clinical Psychology, 74(1), Link 3. Antono, A. (2006). Hubungan Perilaku Seks Pra Nikah Remaja dengan Tingkat Ekonomi Keluarga di Baturaden Purwokerto. Soedirman Nursing Journal 1(2) Arintha, S. (2009). Hubungan Antara Pengetahuan Remaja Pubertas Dengan Kesiapan Dalam Menghadapi Menarche. Jurnal Kesehatan Atmajaya 4(2):73 5. Astuti, S. (2007). Pendidikan Seks Anak dalam Keluarga. Media Informasi Penelitian Kesejahteraan Sosial. Media Keperawatan 1(1) 6. Devi, N. (2009). Gambaran Tingkat Pengetahuan Tentang Pubertas Pada Siswi Kelas VII Di SMP N 2 Sidoharjo Sragen. Media Keperawatan 3(2) 7. Dinas Kependudukan dan Pencatatan Sipil Banyumas. (2009). Data Dinas Kependudukan dan Pencatatan Sipil Banyumas Tahun Diakses dari 8. Dian, Permatasari. (2010). Pola Asuh Dalam Keluarga Dapat Membentuk Perilaku Remaja : Studi Kasus. Surabaya : Universitas Airlangga. 9. Dyah, Utami. (2010). Hubungan Antara Persepsi Komunikasi Orangtua-Remaja Dengan Konsep Diri Remaja. Soedirman Nursing Journal 5(1) 10. Ervin, Naomi, E. (2002). Advanced Community Health Nursing Practice : Population Focused Care. New Jersey : Prentice Hall. 11. Evita, P. (2009). Karakteristik Pubertas Remaja. Diakses dari beritadetail.php?id= Friedman, M., (2003). Keperawatan Keluarga : Teori dan Praktik. Edisi III. Jakarta : EGC. 13. Gerungan, Richardson, (2006). A Textbook of Children and Young People Nursing China : Churchil Livingstone Elservier. 14. Gunarsa, Singgih D. (2005). Psikologi Perawatan Remaja. Jakarta : BPK Gunung Mulia. 15. Guyton,A,C. (2006). Buku Ajar Fisiologi Kedokteran. Edisi 7. Bagian III, Alih bahasa Effendi & Melfiawati. Jakarta : EGC. 16. Hanifah, L. (2000). Faktor yang Mendasari Hubungan Seks Pra Nikah Remaja : studi kualitatif di PKBI Yogyakarta Jurnal Kedokteran Muhammadiyah 2(2) 17. Herien, S. (2003). Hubungan Pola Asuh Dengan Psikologis Remaja. Jurnal Makara Kesehatan 2(2) 18. Haque & Faizunnisa, (2008), Access to Reproductive Health Information in Punjab and Sindh Pakistan: The perspectives of adolescens and Parents. Dakses dari reproductivehealth/publication. 19. Hurlock, Elizabeth B., (2004). Psikologi Perkembangan Suatu Pendekatan Sepanjang Rentang Kehidupan Manusia. Edisi Kelima. Yogyakarta : Erlangga. 20. Karisma, Riskinanti. (2010). Hubungan Antara Pola Asuh Otoriter Orang Tua Dengan Kompetensi Sosial Pada Remaja. Buletin

118 110 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Kesehatan 6(1) 21. Kristina, A. (2006). Gaya Berdandan Remaja Surabaya : Study Etnografi Pada Remaja SMA Negeri 2 Surabaya. Buletin Kesehatan 2(1) 22. Kurniadarmi, E. (2005). Perilaku Agresif pada Anak Usia Sekolah dan Remaja Awal (Studi kualitatif). Buletin Kesehatan 1(2) 23. Nami, Utami. (2009). Hubungan Tingkat Stres Dan Kebersihan Diri Dengan Kejadian Akne Vulgaris Pada Remaja Di Sma Negeri 12 Surabaya. Jurnal Makara Kesehatan 8(2) 24. Neis & McEwen. (2001). Community Health Nursing : Promoting The Health of Populations. USA: WB Saunders. 25. Pardede, N. (2002). Tumbuh Kembang Anak dan Remaja. Edisi I. Jakarta : Sagung Seto. 26. Ramanda, R., (2003). Disfungsi Keluarga Dan Kebiasaan Remaja Kabur Dari Rumah. Jurnal Ners 1(2) 27. Reasoner, S. (2004). Social Puberty. Diakses dari Santrock, John W., (2003). Adolesence : Perkembangan Remaja. Jakarta : Erlangga. 29. Sarwono, S.W. (2008). Survey Perilaku Remaja di Baturaden Purwokerto. Soedirman Nursing Journal 3(2) Schad, M.M., Szwedo, D.E., Antonishak, J., Hare, A., & Allen, J.P. (2008). The Broader Context Of Relational Aggression In Adolescent Romantic Relationships: Predictions From Peer Pressure And Links To Psychosocial Functioning. Journal of Youth and Adolescence, 37 (3), Link 31. SDKI. (2007). Data Demografi dan Kesehatan Indonesia Diakses dari Shirley, A. (2006). Peran Orang Tua kepada Remaja Pubertas. Diakses dari health.detik.com/read/2009/08/05/131053/ /764/tanda-tanda-anak-masuki-masapuber 33. Soetjiningsih, Ranuh, Suraatmaja, Rusmil, Pangkahila, Fadlyana, dkk (2004). Buku Ajar Tumbuh Kembang Remaja dan Permasalahannya. Jakarta: Sagung Seto. 34. Stain, S. (2004). Adolescent Girls Perspective Of Family Interactions Related To Menarche And Sexual Health. Michigan State University Collage of Nursing, East Lansing. Qualitative Health Research 14(9) Stanhope, M., & Lancaster, J. (2002). Community & Public Health Nursing. 5 th P ed.st. Louis : Mosby 36. Stuart, S. (2002). Adolescent Health and Development. From Teresia, N. (2010). Hubungan Antara Kecerdasan Intrapersonal Pada Remaja Dengan Efektifitas Komunikasi. Jurnal Makara Kesehatan 9(5) 38. Wahyu P., (2005). Studi Fenomenologi : Pengalaman Perempuan PSK di Baturaden Purwokerto. Jurnal Ners 3(3) 39. Weis, M., (2000). Risk and Protective Factors Affecting Adolescent Reproductive Health in Developing Countries. Journal of Adolescent Health 27(9): WHO. (2005). What is the evidence on effectiveness of empowerment to improve health?. E88086.pdf. 41. Wong, Algreen, Arnow, et all. (2003). Nursing Care of Infants and Children. Canada : Mosby Elsevier. 42. Yusuf, Syamsul. (2009). Psikologi Perkembangan Anak dan Remaja. Bandung : PT Remaja Rosdakarya.

119 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No A Descriptive Study to assess the Knowledge Regarding Basic Life Support among Physiotherapy Students of Selected College in Mangalore Muhammed U V 1, Naseeha P K 1, Neenu Thomas 1, Priyanka V 1, Rahila K P 1, Syed Imran 2 1 4th year Bsc Nursing, 2 Lecturer, Department of Mental Health Nursing, Yenepoya Nursing College, Mangalore ABSTRACT Background: Basic Life Support consist of a number of life saving techniques focused on the medicine "CAB"s (previously known as ABC recently changed by the American Heart Association). The advanced cardiac life support, protocols, in addition to Basic Life Support protocol. It is very important that every physiotherapy students need knowledge about Basic Life Support. Objectives 1. To assess the level of knowledge among physiotherapy students regarding basic life support. 2. To determine the association between the knowledge regarding basic life support and selected demographic variables. Method: A descriptive approach was adopted for the study. The samples were selected using purposive sampling technique. The sample consisted of 60 physiotherapy students. The instruments used for data collection were demographic proforma and structured knowledge questionnaire, Based on the data collected from the questionnaire, the analysis was done. Result: Highest percentage of physiotherapy students (46.67%) belongs to the age group of years, 26.67% belongs to the age group of years, 16.67% belongs to the age group of years and 10% belongs to the age group of years. Area wise mean, SD, mean percentage of knowledge scores shows that highest mean score(50.663%)was the area assessment and resuscitation technique in circulation and breathing, were as lowest mean score(4.521%)was the area of Sequential step in BLS. The overall mean percentage score of physiotherapy students was %. The finding shows that %of the physiotherapy students had good knowledge and 73.33%physiotherapy students had average knowledge on Basic Life Support. There is no significant association between knowledge level of physiotherapy students regarding BLS and selected demographic variables such as gender and year of studying, and there is significant association between knowledge level of physiotherapy students regarding BLS and selected demographic variables such as course attended on BLS, age of the students. Conclusion: It can be concluded that the physiotherapy students had average knowledge regarding Basic Life support and no significant association were found knowledge score and their selected demographic variables. Keywords: BLS- Basic life support INTRODUCTION Basic life support is the level of medical care which is used for the victims of life threatening illness or injuries until they can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics, and by laypersons who have received basic life support training.basic life support is generally used in the pre-hospital settings, can be provided without medical equipment. Many countries have guidelines on how to provide basic life support [BLS] which are formulated by professional medical bodies in those countries.

120 112 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Resuscitation includes all measures that are applied to relieve patients who have stopped breathing suddenly and unexpectedly due to either respiratory failure. Cardiac arrest is one of the common causes of cardio respiratory failure. Cardiac arrest refers to a sudden state of apnea and circulatory failure. Cardiac arrest is synonymous with the term sudden death; it means that the victim s heart beats, circulation of blood and respiration have suddenly and unexpectedly stopped. Prompt action is vitally important for the success of basic life support when a person stopped breathing spontaneously, his heart also stops breathing. Clinical death has occurred within 4-6minutes, the cells of the brain, which are sensitive to the paucity of oxygen, begin to deteriorate. If the oxygen supply is not restoriate the patient suffer irreversible brain damage and biological death has occurs.1 Basic life support is the combination of oral resuscitation[mouth to mouth breathing], which supplies oxygen to the lungs, and external cardiac massage[chest compression] which is intended to re establish cardiac function and blood circulation. Basic life support also refers to as cardio pulmonary resuscitation. The three cardinal signs of cardiac arrest are apnea, absence of carotid and femoral pulse, and dilated pupils. The person s skin appears pale or grayish and feels cool. Cyanosis is evident when respiratory function fails before heart failure. 2 Basic life support consists of essential non-invasive life-saving procedures including CPR, bleeding control, splinting broken bones, artificial ventilation, and basic airway management. Emergency medical personnel are trained to use BLS skills, which may also include the use of specialized medical equipment and medications, depending on state laws. However, anyone can learn basic life support skills through an appropriate training program and become armed with the ability to save a life. 3 In order to maintain a sustain life; it is an obligatory for an individual to maintain intact vital physiological functions like breathing and circulation. If any sorts of insult physiological function there is a great threat to homeostatic balance and timely interventions are not implemented, may endangers the life of an individual. Whenever these vital functions are ceased, it is essential to restore the normal cardio-pulmonary function until advanced medical supports available. 4 Basic Life Support is the fundamental technique for the emergency treatment of cardiac arrest. The standardized training of cardio pulmonary resuscitation has been emphasized more than ever. Common people in developed countries have received popular education of cardiopulmonary resuscitation programme of Basic Life Support training.5 Cardiopulmonary resuscitation is the first assistance given to the collapsed person and is aimed at the prevention of further harm. The correct CPR measures can reduce suffering, be instrumental in speeding up subsequent recovery, prevent permanent disability and even save life. First few minutes following injury is called the golden time. Many complications and events that occur during this period, can convert a simple injury to death if unattended. 6 Defibrillation is an emergency procedure in which the clinician delivers an electrical current to the heart to terminate a life threatening dysarrythmia. Defibrillation is a common treatment for life threatening cardiac arrhythmias. Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called a defibrillator. This depolarizes a critical mass of the heart muscle, terminates the arrhythmia, and allows normal sinus rhythm to be re established by the body s natural pacemaker in the sinoatrial node of the heart. 7 CPR is a critical component of basic life support and the established first line before advanced life support. CPR as a potential life saver is associated with survival and has the potential to prevent sudden death. The American Heart Association (AHA) resuscitation guidelines recommended that all hospital staff who are in contact with the patients should have regular resuscitation training. 8 It is a vital that all health care members should be trained to perform basic life support so resuscitation measures can be initiated immediately when a cardiac or respiratory arrest occurs. Health care members also can be instrumental increasing community awareness of the need for the basic life support training and ensuring its availability. Each health care facility has policies and procedures for announcing cardiac or respiratory arrest and initiating interventions. In many institutions this emergency is called a code blue and announcement refers to as calling a code. A universal compression to ventilation ratio 30:2 is recommended for adult and in children and infant is only a single rescuer is present. If at least to rescuer are present at a ratio of 15:2 is performed in children and infants. In new born a ratio 3:1 is recommended

121 unless a cardiac case is known in which case a15:2is reasonable. 2 BACKGROUND International Journal of Nursing Education. January-March 2015, Vol. 7, No Basic Life Support consist of a number of life saving techniques focused on the medicine CAB s (previously known as ABC recently changed by the American Heart Association). The advanced cardiac life support, protocols, in addition to Basic Life Support protocol. It is vital that all the health care members should be trained to perform Basic life support so resuscitation measures can be initiated immediately when a cardiac arrest occurs. Physiotherapy students they are mainly focusing on orthopedic and rehabilitative care, they should have some knowledge about basic life support because they are also a health care providers. In view of the above needs the researcher strongly felt that physiotherapy students should have adequate knowledge on the Basic life support, so that person s lives could be saved. Fig. 1. Bar diagram showing age of physiotherapy students Table 2 and fig1 shows the percentage distribution of physiotherapy students according to their age. Majority of the physiotherapy students (46.67%) belongs to the age group of years, 26.67% belongs to the age group of years, 16.67% belongs to the age group of years and 10% belongs to the age group of years. OBJECTIVES 1. To assess the level of knowledge among physiotherapy students regarding basic life support. 2. To determine the association between the knowledge regarding basic life support and selected demographic variables. METHODOLOGY A descriptive approach was adopted for the study. The samples were selected using purposive sampling technique. The sample consisted of 60 physiotherapy students. The instruments used for data collection were demographic proforma and structured knowledge questionnaire. The content validity of the tool was established with the help of expert from related field. In order to establish the reliability of the tool, it was administered to 6 subjects. The reliability co-efficient of the tool was found to be.893 the pilot study was conducted on 5 samples, who met the sample criteria. The data obtained were analyzed in terms of the objectives and hypothesis by using descriptive and inferential statistics. The data of the main study was collected on 9 th July 2013 in Yenepoya Medical College Hospital, Mangalore, by administering structured knowledge questionnaire to 60 physiotherapy students. The collected data were analyzed using descriptive and inferential statistics. Fig. 2. Bar diagram showing gender of physiotherapy students. Table 2 and fig 2 shows the percentage of physiotherapy students according to their gender. Majority of the physiotherapy students are female (51.67%), 48.33% are males. Fig. 3. Bar diagram showing year of physiotherapy students.

122 114 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 2 and fig 3 shows the percentage of physiotherapy students according to their year of studying. Majority of physiotherapy students (33.33%) belongs to 2 nd year, 21.67% physiotherapy students belongs to 4 th year, 30% physiotherapy students belongs to 1 st year and 15% physiotherapy students belongs to 3 rd year. value 0.05 level of significance. So that the null hypothesis was accepted for these variables. DISCUSSION In the present study 10% of Physiotherapy students are belongs to the age group of years, 46.66% belongs to years, 26.66% belongs to years, and 16.66% belongs to 23-24years. The % of Physiotherapy students are males, % of students are females. 30% of Physiotherapy students are I years, 33.33% are II years, 15% are III Years and 21.66% students are IV years. The course of basic life support attended by % and not attended by %. In the present study % of Physiotherapy students have average Knowledge regarding basic life support and the % have good Knowledge Fig. 4 Bar diagram showing course of BLS attended Table 2 and fig4 shows the percentage of physiotherapy students according to their course of BLS attended. Majority of physiotherapy students (88.33%) belongs to BLS course attended and 11.67% physiotherapy students belong to BLS course not attended. Demographic data RESULTS Data presented in the table indicates that chi-square value of demographic variables that age, gender, year of studying and course of BLS attended and knowledge regarding Basic Life Support among physiotherapy students. It was significant at 0.05 level of significance. Thus it is concluded that knowledge score was dependent of selected demographic variables such as course attended on BLS and age of the students and knowledge score was independent on year of studying and gender. The values <5 was corrected by using Yates correction formula. The calculated chi-square value (course attended on BLS , age of the student ) was greater than the table value at 0.05 level of significance. So that the null hypothesis was rejected for these variables. The chi-square values (year of studying , and gender ) were less than that of table There is no significant association between knowledge level of physiotherapy students regarding BLS and selected demographic variables such as gender and year of studying, and there is significant association between knowledge level of physiotherapy students regarding BLS and selected demographic variables such as course attended on BLS, age of the students. CONCLUSION The research reveals that there is an association between knowledge score with selected demographic variables. Many studies also support that there is an association of knowledge score with selected demographic variables. In the present study, by assessing the knowledge level of Physiotherapy students regarding Basic life support, it was found that mean of Acknowledgement: We acknowledge our love and gratitude to all those who helped us throughout our study and especially to the participants who formed core basis of the study for their whole hearted co operation. Conflict of Interest: None Source of Funding: None Ethical Clearance: Yenepoya University Ethics Committee has been given Clearance to conduct the study.

123 International Journal of Nursing Education. January-March 2015, Vol. 7, No REFERENCES 1. Sr.Nancy. Stephanie s Principles and Practice of Nursing, Senior Nursing Procedures and Nursing Administration. N.R.Brothers publisher: Page No: Kozier and Erbs ;fundamentals of Nursing.8 th Edition.Published by Dorling Kindersley Pvt.Ltd; Licensees of Pearson Education in South Asia;Page No ; Luckmans.A text book of medical surgical nursing.w.b.saunders publication; TNAI A procedure manual.secretary General on behalf of TNAI. New Delhi: 1 st edition.2005:pp Chen Xiu-zhen, Zhang Rui-lian, Fu Yan-mei, Wang Tao. Survey of knowledge of cardiopulmonary resuscitation in nurses of community-based health services in Hainan province. Al Ame en Journal Medical Science. 2008, 1(2): Technical Report Series Available form: 7. Rod Brouhard. Types of basic life support Nov 12 Available form: Baksha F. Assessing the need and effect of updating the knowledge about CPR in experts June.Page

124 116 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Facilitating NCLEX-RN Success using Model Achieve in a Community based Program for Internationally Prepared Nurses Lilly Mathew 1, Claudette McFarquhar 2, Renee Wright 1 1 Assistant Professor, 2 Associate Professor, York College, Guy R. Brewer Blvd, Jamaica, NY ABSTRACT A group of health care professionals developed a re-learning model to be utilized in preparing internationally educated nurses who are facing challenges in successfully obtaining a nursing license to begin their practice in the United States. A community based project was initiated based on model ACHIEVE and the initial findings suggests that common areas of difficulty exists among internationally prepared nurses. The insight gained from this project can prove beneficial to the local and international nursing education community, in improving nursing education for global practice. Keywords: Re-Learning, NCLEX-RN, Nurses, Nursing Education INTRODUCTION After speaking with several foreign-trained nurses who have been unsuccessful in passing National Council Licensure Examination (NCLEX) after several attempts, it was felt that these nurses needed guidance as they prepared to take NCLEX exam. According to the recent report released by National Council on State Boards of Nursing (NCSBN), the rate of internationally educated nurses passing NCLEX-RN for the first time is 32.4% and for repeaters is 15.70% 5. Many of these potential nurses are currently working in the United States as Nursing Assistants or Medical Technicians. A discussion took place regarding this alarming issue among few nursing professors with expertise in various areas (cardiac, pediatrics, maternity, and medical-surgical nursing). The nursing professors discussed and developed ACHIEVE a re-learning model and utilized it by initiating a community based project to facilitate re-learning to achieve success in obtaining licensure in the United States. Corresponding author: Lilly Mathew Assistant Professor York College, Guy R. Brewer Blvd, Jamaica, NY lmathew@york.cuny.edu The United States population is growing at a rate that is outgrowing the available number of registered nurses needed to provide quality care 1. People are also living longer with chronic diseases and increased need for care 1. In the past, hospitals have recruited foreign registered nurses to help fill the nursing shortage gap 2, 6. Prior to practicing nursing in the US, graduate nurses (GN), (including foreign graduates) must pass the National Council Licensure Examination- Registered Nurses (NCLEX-RN), which many graduates frequently find challenging 3. The exam becomes even more challenging when the graduate is not successful on the first attempt. According to the NCSBN, the NCLEX-RN success rates of US educated first time test takers is 86.39% and 32.46% for foreign graduates 5. It becomes even more difficult for repeat test takers who succeed only at 15.70% 5. Not only does the high failure rate affect the self-esteem of the graduate nurse but it decreases entry into nursing practice and adds to the ongoing nursing shortage 4.The impact of failing the NCLEX-RN on the graduate nurses, especially foreign graduates and on the health care system piqued our interests to assist nursing students to succeed on the NCLEX-RN.

125 International Journal of Nursing Education. January-March 2015, Vol. 7, No MATERIAL AND METHOD ACHIEVE Model: A Process of Re-learning ACHIEVE a re-learning model, was developed based upon the teaching/learning experiences of nursing educators. The seven steps of the re-learning process can be beneficial and has the potential of wide range of application across education. Fig. 1. Steps of Re-learning Model Assess: Self-asses what is unknown to a current state of mind. Critique: Self-Critique current state of knowledge Highlight: Identify content areas that needs to be redeveloped Interpret: Interpret previously learned data accurately Examine: Self-Examine the depth of understandings Validate: Ensure that recalled information is accurate and applicable in current state of practice Evaluate: Self-Evaluate learning status on a continuous basis The faculty utilized model ACHIEVE by having the participants first assess the areas in nursing that they would like to review to relearn previously learned information. We assessed the participants by giving an assessment survey. Once the areas of difficulties were established we identified professionals that could facilitate the learners in re-learning those content areas. A place and location was selected to conduct this community based project. As this project was unfunded we depended on community sources available to carry out this project. We utilized a local community church to carry out this project. We selected candidates for this project who were willing to actively participate in a week long face to face content review and were willing to continue to followup and engage with the health-care professionals throughout their preparation. In the first session participants were asked if they had reviewed NCLEX-RN test-plan. It was shocking to find that 100% of participants were unaware that a test plan existed for NCLEX-RN review. During the course of a week health care professionals facilitated re-learning content areas by assisting the participants to self-assess and self-critique to identify the content area that needed review. Participants were asked to highlight content areas and create a log of areas that needed review as they were discovered. The participants were given questions to see if they were able to interpret it accurately, and were taught to reexamine their understanding after reviewing the content. Then they were asked to validate their answers. The last step was to self-evaluate their learning status. For Example: Students were given questions on areas of difficulty like Arterial Blood Gas (ABG) analysis. First they were asked to self-asses and critique if they knew these ABG values, and then were asked to highlight the values they were not able to recall or were unknown to them. Following which they were asked to read the question related to ABG and to interpret to their best ability what the question was asking them, and to self-examine to what depth they knew the content. Regardless, as an exercise they were asked to choose an answer, and to validate if that was correct or incorrect. During the validation process, they had to ask themselves what lead to the correct or incorrect answer, and they had the opportunity to understand /re-learn the content areas. Once this was established they were given similar questions to evaluate to see if learning and mastery of the content had occurred. FINDINGS Among the 10 participants we found commonality regarding the areas of difficulty identified. The participants were nurses that were trained in countries outside United States.

126 118 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 1: Identified areas of difficulty on NCLEX-RN Topics Percentage of participants rated as difficult Maternity 10% Pharmacology 80% Select all that apply questions 60% Video Clip/Audio Clip Questions 20% Dosage Calculation 40% Infection Control 30% Psychiatry 30% Fluid & Electrolytes 50 % Prioritization 20% Delegation 10% Diabetes 10% EKG Rythms 20% Respiratory/Cardiac 10% Evaluation of Project ACHIEVE After a week-long review of some of the identified difficult content areas utilizing ACHIEVE model. We asked the participants to rate if the effectiveness of these re-learning activities. Students evaluated each reviewed area as very effective, effective, some-what effective and not-effective. Only 80% of the participants completed the evaluation form. Table 2: Evaluation of content-reviewed using ACHIEVE Model Content Area Reviewed Very Effective Effective Some-What Not- Effective Effective NCLEX-Test Plan 90% 10% EKG Interpretation 50% 50% ABG Analysis 100% Maternity 70% 30% Infection Control 90% 10% Pharmacology 70% 30% Dosage Calculation 80% 20% Select All that apply questions 100% Discussion/ Conclusion It was interesting to learn that even though nurses are trained in different countries, they do have some common areas of difficulty, which makes it challenging for them to be successful in beginning their carrier in the United States. The highest rated areas of difficulty identified were pharmacology (80%), alternate item questions like select all that apply (60%), Fluid & Electrolytes (50%), and dosage calculation ( 40 %). The chances of success of the nursing candidates for NCLEX RN exam can be increased by placing a higher emphasis on learning these areas of difficulty in the basic nursing education program. Also ACHIEVE re-learning model can be utilized for teaching self-review, which is much needed as nursing covers vast content areas and it is difficult to review these contents. If candidates are encouraged to re-learn the previously learned content mainly through self-assessment, we anticipate that they will be successful in passing the board-exam, and begin their successful career in the United States. In the future, we plan to continue conducting project ACHIEVE in the community and study the effectiveness of utilizing ACHIEVE re-learning model for NCLEX-RN success among internationally educated nurses. Acknowledgement: Dr. Joanne Lavin, Director, York College Nursing Program New York Bible Assembly of God, Elmont New-York. Sherene Samu Pharm D. Pharmacist at Stony Brooke Medical Center, New York.

127 International Journal of Nursing Education. January-March 2015, Vol. 7, No Ethical Clearance: Participant anonymity was maintained during assessments and evaluation of project ACHIEVE. Participants volunteered to participate in this project. Conflict of Interest: Lilly Mathew, Claudette McFarquhar, and Renee Wright have no conflict of interest to disclose. Source of Support: There was no funding used for this project. REFERENCES 1. American Nurses Association. Understanding the nursing shortage and what it means for patients(internet) September Available from Menu Categories/The Practice of ProfessionalNursing/ workforce/nursing Shortage 2. Frith KH, Sewel JP, Clark DJ. Best practices in NCLEX-RN readiness preparation for Baccalaureate student success.(internet) Sep-Oct 46S-53S. doi: /01. NCN Available from : pubmed 3. HRSA.The registered nurse population (Internet) Available from HRSA.gov bhpr.hrsa.gov/healthworkforce/rnsurveys/ rnsurveyinitial2008.pdf 4. Lavin, J and Rosario-Sim, M (2013) Understanding the NCLEX-RN: How To Increase Student Success on the Revised 2013 Examination. Nursing Education Perspectives. June McFarquhar CV (2006). Registered nurses perception of factors leading to success on multiple attempts on the NCLEX-RN (Doctoral dissertation). Available from ProQuest Dissertation and Theses database (UMI) 6. NCSBN. Number of candidates taking the NCLEX Examination and percent passing (Internet). September Available from Pass_ Rates_ 2013.pdf 7. Pittman PM, Folsom AJ, Bass E. U. S. based recruitment of foreign-educated nurses: implications of an emerging industry. American Journal of Nurses, 2010; 110,

128 120 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / A Study to assess the Prevalence of Tobacco use among Class Fourth Workers of Krishna Institute of Medical Sciences University Karad, Maharashtra, India Vaishali R Mohite 1, Prabhuswami Hiremath 2 1 Professor & Principal, 2 Lecturer, Mental Health Nursing, Krishna Institute of nursing Sciences, Karad ABSTRACT Tobacco use is a major public health problem globally. According to the World Health Organization (WHO), tobacco is the second most important cause of death in the world. In India, it is responsible for over 8 lakh deaths every year. Aim of this study was to assess the prevalence of tobacco use among class fourth workers of Krishna Institute of Medical Sciences University Karad. A descriptive survey was carried out with sample size of 300 by purposive sampling technique. Structured Interview Schedule was used to assess the prevalence of tobacco use. The majority of samples were males 187 (62.33%) & belongs to Hindu religion237 (79%). The study, reveals that 51% of the total class forth worker's in Krishna Institute of Medical Sciences University Karad have experienced with at least any one kind of tobacco. Among all samples cigarette smoking was found 29 (9.67%), Beedi smoking was found with 22 (7.33%) and chewing tobacco was seen among 102 (34%) samples. Sex, Socioeconomic status and diet was highly significant with tobacco use. This study recommends that the need of health education regarding ill effect of tobacco is more important and the study can be conducted to find the prevalence of disease associated with tobacco use. Keywords: Tobacco, Prevalence, Class Fourth Workers INTRODUCTION Tobacco use is a major public health problem globally. According to the World Health Organization (WHO) (1), tobacco is the second most important cause of death in the world. It is currently estimated to be responsible for about 5 million deaths each year worldwide. In India, it is responsible for over 8 lakh deaths every year. Tobacco use is harmful and addictive. All forms of tobacco cause fatal and disabling health problems throughout life. India is the world s third largest tobacco growing country, which produces an average of tones every year. Prevalence of chewing tobacco was high in Mumbai (57%) among women and (46%) among men. In Karnataka prevalence of chewing tobacco is 13.9 % ( 2). Currently about one fifth of all worldwide deaths attributed to tobacco occur in India, more than 8 lakh people die and 12 million people become ill as a result of tobacco use each year. It is estimated that 5,500 adolescents start using tobacco everyday in India, joining the 4 million young people under the age of 15 who already regularly use tobacco (1). Considering the enormous complication associated with tobacco use, it is outmost importance to understand the factors leading to its initiation in young age and to plan strategies to reduce its intake. Objectives of the study were To assess the prevalence of tobacco use among class fourth workers & to associate the prevalence of tobacco use among class fourth workers of Krishna Institute of medical sciences university Karad with selected demographic variables. MATERIALS & METHOD A descriptive survey design is employed for the study at Krishna Institute of medical sciences university Karad. Total 300 Class-IV employees working at KIMS were selected by Simple Random sampling technique. Those willing to participate in study & both sex were included in the study and Who are not willing to participate in the study & not available during data collection were excluded from the study.

129 International Journal of Nursing Education. January-March 2015, Vol. 7, No RESULT Table 1: Distribution of samples according to demographic variable: Demographic Variables Frequency Percentage Sex a) Male % b) Female % Age a) % b) % C) % c) 45 & above % Religion a) Hindu % b) Muslim % c) Other % Monthly income a) % b) % c) More than % Type of family a) Joint % b) Nuclear % c) Expanded % Diet a) Vegetarian 30 10% b) Mixed % Education a) Uneducated % b) Primary % c) Secondary % d) Higher secondary % Table: 1 Shows the distribution of class forth worker s according to their demographic characteristics where in the majority of these worker s (36%) were in the age group of 45 & above, most of these worker s (79%) were Hindus, 49% workers were having income between & 46.67% of workers were having education up to primary level. Table 2: Prevalence of tobacco use among class four workers. The study reveals that 51% of the total class forth worker s in Krishna hospital, karad have experienced with at least any one kind of tobacco products & among these samples 102 (34%) are using smokeless tobacco like pan, Gutkha, and chewing tobacco where 51(17%) are smoking. Association of findings with demographic variables. In the present study, Diet and gender of the workers shows significant association with use of tobacco where as other demographic data are not significant. DISCUSSION A study conducted to estimate the prevalence of tobacco use among power loom workers in Mau Aima Town, District Allahabad, UP shows that the overall prevalence of tobacco use was 85.9%; the prevalence of smoking and tobacco chewing were 62.28% and 66.07%, respectively. Predominant form of tobacco use was cigarettes (78%) followed by khaini (20%) and Gutkha (2%) (3). In our study 51% of the total class forth worker s in Krishna hospital, karad have experienced with at least any one kind of tobacco products & among these samples 102 (34%) are using smokeless tobacco like pan, Gutkha, and chewing tobacco where 51(17%) are smoking. A cross-sectional study was done on 250 undergraduate male medical students in Lucknow to assess the prevalence of tobacco use and to find out the associated factors with the use of tobacco. Among the tobacco users (28.8%), smoking was found in 87.5% and tobacco chewing in the form of gutka, khaini, gulmanjan in 37.5% as the predominant means of the use of tobacco. The mean age of our sample was 23.5 years. Hostellers were found to be more frequent tobacco users as compared to day-scholars 4. In our study, it shows that years of age population smokes more and years group uses more smokeless tobacco & 35 was the mean age for use of tobacco. A Global Adult Tobacco Survey report (5) by government of India also stated that more than onethird (35%) of adults in India use tobacco in some form: smoking, chewing, application to the teeth and gums or sniffing. About 29 percent of adults use tobacco on a daily basis whereas a little more than 5 percent use it occasionally. In this study it show that about 87% workers uses on daily basis.

130 122 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 M Rani et al conducted the study to estimate the prevalence and the socioeconomic and demographic correlates of tobacco consumption in India. Thirty per cent of the population 15 years or older-47% men and 14% of women-either smoked or chewed tobacco, which translates to almost 195 million people-154 million men and 41 million women in India (6). The prevalence of tobacco use in Krishna Institute of Medical Sciences University Karad is 51% of the total class forth worker & among these samples 102 (34%) are using smokeless tobacco like pan, Gutkha, and chewing tobacco where 51(17%) are smoking. CONCLUSION The findings of the study highlight that an interventional program should be planned to improve health status among the class fourth workers in KIMS. There is a need for periodical surveys using more consistent definitions of tobacco use and eliciting information on different types of tobacco consumed. This could include organizing lectures at workshops and publishing articles on smoking cessation in bulletins and journals. They could thus provide basic interventions as well as background materials on smoking cessation relevant to the specific professional groups. Conflict of Interest: The authors have no conflict of interests related to the conduct and reporting of this research. Source of Funding: Source of fund for this project was by author itself. This study was not supported by any external funding. Ethical Clearance: Before conduct of the study ethical clearance was obtained by Ethical committee of institution. Participation was made voluntary and patients were told that they were free to leave at any time and that conûdentiality would be maintained at all times. Acknowledgement: We would especially like to express our sincere gratitude to the Dean of Krishna Institute of medical Sciences University, Krishna Hospital, Karad and all participants for their kind co operation throughout this study. REFERENCES 1. WHO. The Word Health report: shaping the future. Geneva: WHO; Gupta PC, Ray CS. Respirology, smokeless tobacco and health in India and south Asia. 3. Zaki Anwar Ansari Prevanace of tobacco use Among Power Loom Workers - A Cross-Sectional Study, Indian J Community Med January; 35(1): Ranjeeta Kumari and BholaNath, Study on the Use of Tobacco Among Male Medical Students in Lucknow, India, Indian Journal of Community Medicine April; 33(2): Tobacco Use and Cessation Counseling. Global Health Professionals Survey Pilot Study, 10 Countries, May 27, 2005 / 54(20); M Rani, S Bonu, Tobacco use in India: prevalence and predictors of smoking and chewing in a national cross sectional household survey, Tobacco Control 2003;12

131 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Effectiveness of Protocol on Situation, Background, Assessment, Recommendation (SBAR) Technique of Communication among Nurses During Patients' Handoff in a Tertiary Care Hospital Shalini 1, Flavia Castelino 2, Latha T 2 1 Lecturer, 2 Assistant Professor, Manipal College of Nursing, Manipal University, Manipal ABSTRACT Objectives: To find the effectiveness of Situation, Background, Assessment, Recommendation (SBAR) protocol in terms of difference in knowledge and practice among control and experimental group. Design: An evaluative approach was used. The study was conducted in a tertiary care hospital and consisted of 72 staff nurses and 72 handoff events by same staff nurses with 36 in both experimental and control group. Data sources: The data was collected through demographic proforma, structured knowledge questionnaire and practice checklist on SBAR technique during patients' handoff. The data was analysed by using descriptive and inferential statistics. Results: The mean post test knowledge scores of the experimental group increased from 3.47 (SD= 1.63) to 7.72 (SD= 1.649) which was higher than the mean post test knowledge scores 3.81 (SD=1.283) of control group. The mean post-test practice scores of the experimental group increased from 2.64 (SD= 0.723) to 4.47 (SD= 0.81) which was apparently higher than the mean post test practice scores 3.23 (SD=0.808) of control group. Independent t test was computed in order to evaluate the effectiveness of protocol on SBAR technique of communication and the p value obtained was (p<0.05) for both knowledge and practice. Conclusion: SBAR, Handoff, Protocol, Nurses, Patients, Knowledge, Practice Keywords: SBAR, Handoff, Protocol, Nurses, Patients, Knowledge, Practice INTRODUCTION Hand-offs help the staff to process the information and plan the care. In the health care setting, hand-offs include nursing shift changes, temporary relief or coverage, nursing and physician hand-offs from an emergency department, various transfers of information at the inpatient settings, and transfers to different hospitals and nursing homes 1. Corresponding author: Flavia Castelino Assistant Professor Manipal College of Nursing, Manipal University, Manipal . ID: castelinoflavia@gmail.com Communication problems are the number-one cause of sentinel events, because staff members hand off information about patients so often, they may not realize hand-off communication is a high-risk process. If staff members often do not allocate enough time to a hand-off, one or the other staff member may not get a complete picture of the patient s situation, and important information can be lost, and it is a common cause of error. A consistent format helps the staff member to accurately record and recall the amount of information and improves their ability to plan patient care. It also provides cues of important information to pass on, that is otherwise likely to be forgotten in the chaos of shift or unit changes 2.

132 124 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 The recommendations for improving patient handover includes using protocols for communicating critical information; providing opportunities for practitioners to ask and resolve questions during the hand-over 3. Among the recommended communication techniques, SBAR is a frame work for effective briefing of oncoming team members to rapidly get everyone on the same page so that, they can efficiently move forward together in a coordinated fashion. The SBAR provides a frame work to briefly present the patient or clinical situation. Nurses frequently use descriptive narratives while communicating patient s information, while physicians more commonly communicate in headlines with a concentration on actions. The SBAR can help to bridge this interdisciplinary gap, facilitate more mutually satisfying communication, and most importantly, assure that the other provider hears critical information. In potentially emergent situations, this simple framework not only enhances the clarity and efficiency of communication between team members but also assures that each person involved knows what is going on when they come to assist in a critical situation. The SBAR technique can help to get all information related to a patient in a same page and moving in the same page MATERIAL AND METHOD Participants: The study participants were 72 staff nurses (36 in experimental and 36 in control group) and 72 handoff events (36 in experimental and 36 in control group). Multistage cluster sampling technique was adopted. Study setting has nine zones (clusters). At the first stage of sampling, two zones each are randomly allotted into experimental and control group by lottery method. Sample consists of staff nurses, who have diploma and degree in nursing education and handoff patient report during the shift change. They are randomly selected from the randomly selected clusters at the research setting and the event of patient handoff by the same staff nurse during the shift change which is randomly selected numbers between one and five. Procedures: The data was collected between 28 th December 2012 and 13 th February 2013 after obtaining formal administrative permission, institutional ethical committee clearance and informed consent from the participants. On the first day demographic data was collected and knowledge on SBAR was assessed by using structured knowledge questionnaire. Practice was assessed by using structured practice checklist and observing the event. Then protocol on SBAR was implemented. The post test was conducted on 15 th day with the same questionnaire. MEASUREMENTS AND INSTRUMENTS Tool 1: Demographic data: it consisted of seven items such as age, gender, designation, professional qualification, experience and previous practice of SBAR. Tool 2: Knowledge questionnaire on SBAR technique of communication. It consisted of 14 multiple choice items. Tool 3: Practice checklist on SBAR technique during patient handoff. It consisted of 10 items. FINDINGS Part I: Demographic characteristics Table 1: Frequency percentage distribution of samples based on demographic variables. n=36+36=72 Sample characteristics Experimental group Control group f % f % Age in years Above 30 years Gender Male Female

133 International Journal of Nursing Education. January-March 2015, Vol. 7, No Table 1: Frequency percentage distribution of samples based on demographic variables. (Contd.) n=36+36=72 Sample characteristics Experimental group Control group f % f % Designation Junior staff nurse Senior staff nurse Professional qualification Diploma in Nursing BSc Nursing Experience as a staff nurse Less than 2 years years 1 month-5years years 1 months to 10 years Above 10 years Previous practice of SBAR Yes No Data presented in the table 1 show that most of the samples in experimental (58.3%) and control group (75%) were in age group between years. Majority of the samples of experimental (88.9%) and control group (94.4%) were females. Junior staff nurses comprised majority of the sample in both experimental (88.9%) and control (91.7%) group. Majority (86.1%) of samples from experimental and (80.6%) control group had a professional qualification of Diploma in nursing. The majority of the samples (47.2%), both from experimental and control group had an experience as a staff nurse of less than two years. None of them (100%) had practiced SBAR previously in both experimental and control group. Part II: Description of the pre-test and post-test knowledge and practice scores on SBAR technique of communication Table 2: Mean and standard deviation of pre test and post test knowledge and practice scores on SBAR technique of communication during patients handoff among experimental and control group. n= (36+36) =72 Experimental group Control group Pretest Post test Pretest Post test Knowledge Mean Standard deviation Practice Mean Standard deviation The minimum and maximum possible scores for knowledge questionnaire and were zero and fourteen respectively. The data in table 2 show that the mean posttest knowledge scores of the experimental group increased from 3.47 (SD= 1.63) to 7.72 (SD= 1.649) which was apparently higher than the mean post test knowledge scores 3.81 (SD=1.283) of control group. The minimum and maximum possible practice scores were zero and ten respectively. The data in table 2 show that the mean posttest practice scores of the experimental group increased from 2.64 (SD= 0.723) to 4.47 (SD= 0.81) which was apparently higher than the mean post test practice scores 3.23 (SD=0.808) of control group. The findings revealed that the protocol on SBAR technique of handoff helped to improve the knowledge and practice of handoff among experimental group of staff nurses.

134 126 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Part III: Effectiveness of protocol on SBAR technique of communication in terms of gain in knowledge and practice among experimental and control group Following null hypothesis is stated. H 01 There will be no significant mean difference between the post-test knowledge and practice scores among the nurses of experimental and control group Table 3: Independent sample t test of post test knowledge and practice scores among experimental and control group Mean Standard error 95% Confidence t df p value difference difference Interval of the Difference Lower Upper Knowledge * Practice * * =Significant, <0.05 From Levene s test equality of variances is assumed for knowledge and practice scores among experimental and control groups with P= Data in the table 3 show that mean difference is 3.91, standard error difference =.348, t (70) =11.25 with p=0.001 and 95% of confidence interval (4.61 to 3.22). Levene s test equality of variances is assumed for practice scores among experimental and control groups with P= Data in the Table 3 show that mean difference is 1.25, standard error difference =.189, t (70) =6.6, with p=0.001 and 95% of confidence interval (1.62 to.87). Hence the null hypothesis was rejected and research hypothesis was accepted. Thus it can be concluded that the protocol on SBAR technique of communication during patients handoff was effective in terms of improvement in knowledge and practice among nurses. DISCUSSION The findings of the present study are supported by an experimental study conducted by Karen S and Kesten among undergraduate nursing students at Washington in 2008 showed the mean change in knowledge (M = 23.1, SD = 16.1) reflects a statistically significant difference as measured by paired sample t test analysis (t = 14.5, p < 0.001). A one-tailed t test for unequal variances was used to analyze showed statistically highly significant difference (t = 2.6, p = 0.005). Thus the students who re-ceived role-play instruction in addition to didactic instruction (experimental group) performed significantly better on the skilled communication than the students who received didac-tic instruction alone (control group) 5. The results of prospective interventional study conducted by Catchpole KR et al in a cardiac ICU of tertiary treatment centre at Oxford with direct observation assessment of handover performance supports the present study findings. Results showed that the mean number of technical errors per handover reduced after the new handover protocol from 5.42 (95% CI ±1.24) to 3.15 (95% CI ±0.71), and the mean number of information handover omissions was reduced from 2.09 (95% CI ±1.14) to 1.07 (95% CI ±0.55). Researcher concludes that the introduction of the new handover protocol lead to improvements in all aspects of the handover 6. CONCLUSIONS This study concludes that the protocol on SBAR technique of communication during patients handoff among nurses was effective. So there is a need for imparting this protocol in practice. Acknowledgement: The authors wish to acknowledge the support received from registered nurses (subjects) and assistance received from the nursing administrators of the research setting. Conflict of Interest: The authors declare that they have no conflict of interest. Source of Funding: Self

135 International Journal of Nursing Education. January-March 2015, Vol. 7, No Ethical Clearance: Institutional ethical committee clearance was obtained before commencing the study. Informed Consent from the participants was obtained before data collection. REFERENCES 1. Walsh M, Ford P. Nursing Rituals. Research and Rational Actions. Heinemann Nursing, London p Strategies to Improve Hand-Off Communication: Implementing a Process to Resolve Questions. Joint Commission International Center for Patient Safety - Strategies to Improve Hand-Off May; 1-2. Retrieved from solutions on Memoire A. Communication during patient handover. WHO Collaborating Centre for Patient Safety Solutions May; 1(3): Retrieved from solutions on Marie J. Guise Do You Speak SBAR? Journal of gynaecology and neonatal nurses. 2006; 35(3): Karen S, Kesten, Role-Play Using SBAR Technique to Improve Observed Communication Skills in Senior Nursing Students. Journal of Nursing Education. 2011; 50(2): Retrieved from on Catchpole KR, Leval MR, Mcewan A, Pigott N, Elliott MJ, Mcquillan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Journal of Pediatric Anesthesia. 2007; 17(3): 470 8).

136 128 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Effectiveness of Foot Massage on Level of Pain among Patients with Cancer Jeenath Justin Doss K Assistant Professor, Joitiba College of Nursing, Lcit Campus, Visnagar Ta.,Bhandu Po., Mehsana Dist., North Gujarat ABSTRACT The reduction of pain of patients with cancer has an important role to play in enabling effectiveness of foot massage intervention as an independent nursing intervention. The objective of the study is to evaluate the effectiveness of foot massage on level of pain among the patients with cancer 1. The research design adopted was quasi-experimental time series pre-test, post-test with control group design. The conceptual framework for this study was based on Wiedenbach's helping art of clinical nursing theory (1964). The study has been conducted in Devaki cancer hospital and research institute, Madurai. Non-probability purposive sampling technique has been adopted to select the desired sample. The sample size was 60. As an intervention of 30 minutes of foot massage was administered for experimental group. The data was collected through Numerical Pain assessment scale which is from 0-10 range. The collected data were analyzed by using both descriptive and inferential statistical methods. 'F' test was used to evaluate the effectiveness of foot massage on level of cancer pain among the patients with cancer. The obtained 'F' value was The findings of the study revealed that foot massage helps in decreasing the level of pain among the patients with cancer. Keywords: Effectiveness, Foot massage, Cancer pain, Cancer INTRODUCTION Freedom from the pain should be a basic human right limited only by our knowledge to achieve it Liebenskind Ifmelrach (1989) Human Touch - is a powerful expression of care, acceptance and emotional nourishment. Many people with cancer wonder whether any complementary therapies can help them. Massage and other gentle body work techniques that focus on the positive effects of human touch are very popular complementary therapies. Touch is essential like food and water. According to World Health Organization (2009) Head and neck/oral cancer (HNOC) is the sixth most common cancer worldwide accounting for 4% of cancers in men and 2% of cancers in women. In some parts of the world, including Southern China and the Indian subcontinent, HNOC is a major cancer problem 2,4. People with cancer experience pain, anxiety and mood disturbance 11. Conventional treatments do not always satisfactorily relieve these symptoms and same patients may not be able to tolerate their side effects 3. Therapeutic foot massage as a cancer pain intervention appears to be safe and effective 7. Patients who receive massage have less pain, nausea and anxiety and report improved quality of life. The use of massage in cancer care centers and hospitals is on the rise 8,9.

137 International Journal of Nursing Education. January-March 2015, Vol. 7, No MATERIAL AND METHOD With regard to effectiveness of foot massage on level of cancer pain, the obtained F value for level of pain in control group was not at significant level and in experimental group was that was highly significant at p<0.001 level. With regard to the association between the level of pain with their selected demographic variables and clinical variables such as age, sex, occupation, religion, duration of illness, type of pain, stage of cancer there were significant association found with sex and stage of cancer and others were nonsignificant. CONCLUSION The main conclusion from this present study is that most of the cancer patients with pain in experimental group had severe and moderate level of pain in pretest and mild level and no pain in posttest I, II and III. This shows the imperative need to understand the purpose of foot massage technique regarding reduction of pain among the patients with cancer and it will improve the quality of life which includes the stability in physiological, psychological, sexual, vocational and lifestyle aspects. The Schematic Representation of Research Methodology 5,6,10,12 FINDINGS Among patients with cancer pain, most of them were between years, female sex, Hindus, had 1-3 years of duration of illness, had chronic type of pain and were at second stage of cancer. Regarding the level of cancer pain in experimental and control group most of them reported severe pain on day 1 in both groups, on day 2 most of them reported moderate level of pain in experimental group and there were no measurable difference in control group, on day 3 most of them reported mild level of pain and no pain in experimental group and in control group where there were no greater changes. Acknowledgement: A journey is easier when we travel together. Interdependence is certainly more valuable than independence. This dissertation is the result of unbound, immeasurable contribution and support from many people. It is a pleasure that, I have an opportunity to express my gratitude to all of them. I honestly express my sincere thanks and gratitude to MY CLIENTS AND THEIR FAMILY for their cooperation. Source of support: Annai Meenakshi College of Nursing, Devaki Cancer Hospital Madurai, Tamilnadu,India. Ethical Clearance: Got permission from the college and Devaki Cancer Hospital Madurai, Tamilnadu,India. Conflict of Interest: The study was done only for 30 samples with no randomization, so generalization is possible only for the selected samples. The study covered a population of patients only with head and neck cancer and others were excluded.

138 130 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Foot massage was provided only for the Experimental group. REFERENCES 1. Bare,G.Brenda. Smeltzer,C.Suzanne. (2005). Brunner and Suddarths Text Book Of Medical Surgical Nursing. (8 th ed.) Philadelphia: Lippincott publication ; World health organization-cancer Black,M.Joyce and Jane Hokanson Hawks. (2001). Text Book of Medical Surgical Nursing. (1 st ed.) Philadelphia: W.B.Saunders company publication ; Abhinandan Bhattacharjee(2006). Prevalence of head and neck cancers in the north east -An institutional study. Indian Journal of Otolaryngology and Head and Neck Surgery 58 (1). 5. Dorothy, et al. (1995). Fundamentals Of Nursing Research. (2 nd ed.) USA: Jones and Bartlett publication Gupta, G.S. Kappor. (1990). Fundamentals Of Mathematical Statistics. (1 st ed.) New Delhi: Sultan Chand publications ; Safety and efficacy of massage therapy for patients with cancer. cancerinfo/treatment/cam Massage reduces pain. org/researchdb. html Touch Research institute. touch-research/) Kothari, C.R. (2004). Research Methodology Methods And Techniques. (3 rd ed.). New Delhi: New age International (p) Ltd publishers Lewis Sharon, M. Darkson Shannon Idolia, C. and Heitkemper,M.M. (2004). Medical And Surgical Nursing. (6 th ed.) Missouri: Mosby publication ; Mahajan, B.K. (1991). Methods In Biostatistics. (5 th ed.) New Delhi: Jaypee Brothers medical publishers

139 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Magnesium Sulphate (MGSO4) Fomentation Verses Cold Compress for Reducing Intravenous Extravasation Mahadeo B Shinde 1, Namrata Mohite 2, Prabhuswami Hiremath 3 1 Professor, 2 Lecturer, Medical Surgical Nursing, 3 Lecturer, Mental Health Nursing, Krishna Institute of Nursing Sciences Karad, Satara district) Maharashtra ABSTRACT Intravenous infusion of drugs, fluids and nutrients has become an indispensable practice in present day medical care. Venous canulation via peripheral intravenous catheters is the simplest and most frequently used method for administration of an infusion. It is associated with inherent complications, which can be mechanical or infectious. Majority 10(33.3%)of samples were in age group of yrs and 51-60yrs,with 19(63.3)female. Maximum (36.7%) were illiterate and secondary level educated up to the primary level and had the intravenous line for the five days. In cold compress Group, majority of (33.3%) samples were from age group between and 51-60, majority of 53.3% were males, maximum (43.3%) were educated up to secondary level and had the intravenous line for five days. In both the groups, majority of patients (73.3%) and (80.0%) were Hospitalized between 0-7days. In Magnesium Sulphate (MgSO4) fomentation pretreatment, (43.33%) samples experienced mild pain and (16.7%) of samples experienced pain severely. In post treatment, it was seen that 63.3% had no pain and 2(6.7%) were had moderate pain in Magnesium Sulphate (MgSO4) fomentation group. In cold compress group, 20(66.7%) of samples experienced moderate pain and 6 (20%) samples experienced severe pain. In the post treatment, it was seen that 17 (56.7%) had no and 11(36.7%) experienced mild pain. It was found that, the age group, sex, education, no of day's intravenous line present, site of intravenous line, duration of hospitalization and signs and symptoms of phlebitis shows no significant relationship with the treatment outcome in relieving intravenous extravasations in both the groups. While duration of extravasations and length of extravasations show significant relationship with the treatment outcome in both the groups. Therefore these findings indicate that the magnesium sulphate (MgSO4)fomentation is slightly better than the cold compress in reducing of intravenous therapy related extravasations. Keywords: Intravenous extravasations, Magnesium Sulphate (MGSO4), Cold compress INTRODUCTION Nurses are among the best placed professionals to recognize and deal with extravasations in the clinical setting. Nurses have a key role to play in identification Corresponding author: Mahadeo B Shinde Associate Professor (Medical Surgical Nursing) Krishna Institute of Nursing Sciences Karad. (Satara district) Maharashtra Ph: Mail: mahadeoshinde28@gmail.com Fax: and management of extravasations, and, of course, in preventing it. From maintaining a high standard of care in the delivery of intravenous drugs to managing the treatment strategy for extravasations, they have many important duties in this area. Nursing studies and literature pertaining to care of intravenous extravasations are limited, and the procedure adopted for intravenous related extravasations management is varied. Individual accountability requires nurses to evaluate the care they provide, and therefore it is important for them to have access to reliable researchbased knowledge to assess the reduction of intravenous extravasations. As in Indian setting where most of the people are poor and it is the cheapest and

140 132 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 easiest method for reducing intravenous infusion related extravasations. MATERIAL AND METHOD The aim of this study is to control the complications of intravenous extravasations and objectives were To compare effectiveness between magnesium sulphates (MgSo 4 ) fomentation verses cold compress in reducing to intravenous extravasations & To correlate the findings with selected sociodemographic variables. Keeping in view the objectives of the study, the researcher had selected the pre-test post-test quasi experiment as the research design for this study. This study was conducted in Krishna Hospital Karad, this Hospital has got two surgical wards, two medical wards, one orthopedic ward and one Intensive care unit (ICU), where all types of ill patients are cared. On an average there are 6 to 8 patients with intravenous extravasations per day. Total 60 Samples were selected by a non probable convenient sampling method. Samples with mild to moderate extravasations were listed and alternate samples were allotted to the magnesium sulphate (MgSo 4 ) fomentation and cold compress groups, this process was carried out until both groups had 30 samples each. Out of 60patients, 30 were selected for treatment with magnesium sulphate (MgSo 4 ) fomentation and 30 with cold compress. Patients, who could respond to pain, who were conscious, who have intravenous related mild or moderate and severe extravasations and those consent to participate in the study were included & Those who are who were unconscious, critically ill and delirious were excluded from the study. Data collection tool consist of two section, first section includes demographic data of the samples, duration of intravenous line (date of starting IV LINE), site of IV line, reason for starting Intravenous line, type of device and duration of hospitalization.second section includes Physical Parameters of the extravasations site like, Limb circumference, Length of extravasations in centimeters, Type of extravasations (on the date of starting treatment, Duration of extravasations, Signs and symptoms of phlebitis, Observational checklist for ongoing assessment of extravasations site FINDINGS The data shows that in the Magnesium Sulphate(MgSo 4 ) fomentation group, majority 10(33.3%)of samples were in age group of yrs and 51-60yrs,with 19(63.3)female. Maximum (36.7%) were illiterate and secondary level educated up to the primary level and had the intravenous line for the five days. In cold compress Group, majority of (33.3%) samples were from age group between and 51-60, majority of 53.3% were males, maximum (43.3%) were educated up to secondary level and had the intravenous line for five days. In both the groups, majority of patients (73.3%) and (80.0%) were Hospitalized between 0-7days. Table1 Descriptions of samples parameters related to the intravenous line. Characteristics Magnesium Cold compress Sulphate (MgSo 4 ) GROUP(B) N=30 Fomentation Group(A) N=30 Frequency % Frequency % Site of intravenous line Dorsal aspect of palm (Left hand) Forearm (Left hand) Wrist (Left hand) Dorsal aspect of palm (Right hand) Forearm (right hand) Wrist (right-hand) Duration of infiltration present 2 days days days days Sign and symptoms of phlebitis On date of starting treatment Pain, swelling Pain, swelling, redness Pain, swelling, redness, erythema

141 International Journal of Nursing Education. January-March 2015, Vol. 7, No The data presented in table 1 shows that in the Magnesium Sulphate (MgSo4) fomentation group And In cold compress group, majority (53.3%) of sample had intravenous line present on the Forearm (right hand). In the Magnesium Sulphate (MgSo 4 ) fomentation group, majority (50%) of samples had intravenous extravasations for 3 days. and in the cold compress also majority of (76.7%) samples had intravenous extravasations for 2 days. In Magnesium Sulphate(MgSo 4 ) fomentation group, the Sign and symptoms of phlebitis that is pain, swelling and redness was present in 76.7% patients On date of starting treatment, and in cold compress group, the signs and symptoms of phlebitis- pain, swelling and redness was present in 50% samples On date of starting treatment. Intensity of pain experienced by patient pretreatment, (43.3%) samples experienced mild pain and(16.7%) of samples experienced pain severely. In post treatment, it was seen that (63.3%) had no pain and (30%) had mild pain and (6.7%) moderate pain in Magnesium sulfate (Mgso 4 ) fomentation group. Intensity of pain experienced by patient pretreatment, in cold compress group, (66.7%) of samples experienced moderate pain and (20%) samples experienced severe pain. In the post treatment, it was seen that (56.7%) had no and (36.7%) experienced mild pain and (6.7%) in moderate pain. Table 2. Mean, SD of degree of intravenous extravasations in pre and post treatment in cold compress group. S.No No. Of Days Magnesium Sulphate Pre TreatmentN=30 Post TreatmentN=30 (MgSo 4 ) fomentation given Mean S.D. Mean S.D. 1 Day Day Day Data presented in above table shows that the pretreatment mean score of degree of intravenous extravasations was , and on day 1, 2, and 3 respectively. While mean on post treatment was decreased to , and respectively. This shows that there is significant reduction of degree of intravenous extravasations after treatment. Table 3. Mean and SD of intensity of pain before and after treatment with cold compress. S. No. No. Of Days cold compress given Pre Treatment Post Treatment Mean S.D. Mean S.D. 1 Day Day Day The above table shows, that the pretreatment intensity of pain was , and on days 1, 2 and 3 respectively and it decreased to , and respectively, indicating that cold compress was effective in reducing pain in intravenous extravasations. It is further found that there was no significant relationship with the outcome in relieving intravenous extravasations with age group, sex, education and number of days Intravenous line present show. DISCUSSION A study done by C Waitt reported that the rate of extravasations and phlebitis increases with the time that the cannula remains in place (1). Other study investigated that, the duration of cannulation has been found to contribute to the development of infusionrelated phlebitis and this may require the cannula to be replaced (2). Frequent cannula change is an added cost to treatment and may cause the patient pain and distress. It was found that the site of intravenous line in both the groups, maximum were on dorsal aspect of lefthand palm. A study Suggested that the Veins on the non-dominant forearm are most suitable, especially if the cannula has to remain in position for any length of time (1). Veins on the dorsum of the hand are easiest to cannulate, but are more uncomfortable no. for the

142 134 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 patient and more liable to block. In the present study, the mean of paired observations differences decreased from 0.1 on day one to 0.4 on day three. The difference is significant at p<0.05 on all three days indicating that magnesium sulphate (MgSO 4 ) fomentation was effective in reducing the degree of extravasations. Similar Results were found other study (3). In a supporting study explained that the application of heat improves blood flow to the involved area by causing vasodilatation (4). Another study suggested that in the case of most antineoplastic extravasations, ice or a cold compress should be applied 15 to 30 minutes four times a day, with the exception of the vinca alkaloids, where heat application is recommended (5). In the present study, there was a significant change in reduction of intravenous extravasations after treatment with magnesium sulphate (MgSO 4 ) fomentation. Results of study done by Goolsby TV and Lombardo FA supports the present study results. (6).while another study findings also supports the statement of Halvorson (1990) 4, who stated that application of cold causes vasoconstriction and therefore decreases blood flow to the involved area. Cooling of the tissues decreases the cell metabolism, increases blood viscosity, decreases muscle tension and results in anaesthetic effect by numbing tissue. CONCLUSION Study concluded that the magnesium sulphate (MgSo4) fomentation and cold compress both are effective in treatment of intravenous therapy related extravasations But the magnesium sulphate (MgSo4) fomentation is slightly better than the cold compress. Conflict of Interest: The authors have no conflict of interests related to the conduct and reporting of this research. Ethical Clearance: Before conduct of the study ethical clearance was obtained by Ethical committee of institution. Participation was made voluntary and patients were told that they were free to leave at any time, that being involved would have no harm on progression of treatment, and that conûdentiality would be maintained at all times. Acknowledgement: We would especially like to express our sincere gratitude to the Medical Director, Krishna Hospital, Karad and all participants for their kind co operation throughout this study. REFERENCES 1. C Waitt, P Waitt and M Pirmohamed, post graduate medical Research Journal January; 80(939): Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006; 81: M. Rhiner - G. E. Dean - S. Ducharme - Home Health Care Management & Practice - Vol. 8 - Issue pp Halvorson, G.A., Therapeutic heat and cold for athletic injuries.physician and Sportsmedicine 18 (5), See also page Weinstein, SM. 1997, Plumer s Principles & Practice of Intravenous Therapy. Sixth Edition. Lippincott, Pennsylvania. 6. Goolsby TV, Lombardo FA. Extravasation of chemotherapeutic agents: prevention and treatment. Semin Oncol Feb;33(1): Source of Funding: Source of fund for this project was by author itself. This study was not supported by any external funding.

143 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Effectiveness of Structured Teaching Programme on Knowledge Regarding Ethical Issues in Nursing Practice among Nursing Professionals Vaishali R Mohite 1, Prakash M Naregal 2, Rajshree Kadam 3 1 Principal, 2Lecturer, Child Health Nursing, 4 Lecturer, Medical Surgical Nursing, Krishna Institute of Nursing Sciences, Karad ABSTRACT Background: Nurses at all levels & areas of practice experience a range of ethical issues during the course of their day to day work. Ethically speaking, 'what should be done' in an individual, patientcare situation is at the heart of many practice dilemmas nurses face on a regular basis. Material and methods: Aim of the study was to assess the effectiveness of structured teaching programme on level of knowledge regarding ethical issues in nursing practice among 105 nursing professionals at selected hospital at Karad Maharashtra.Data was collected by using structured knowledge questionnaire on ethical issues in nursing practice. Results: results shows that in pre-test 2.85% had good knowledge, 16.5% had average & 80.9% had poor level of knowledge. In post -test 87.6% had good, 12.4% had average & no one was having poor level of Knowledge.T-test value shows that calculated paired't' value (t = 13.17) is greater than table value (t =11.26) hence there was significant difference was existing between pre test & post test knowledge scores so structured teaching programme was effective in improving the knowledge of nursing professionals. Chi-square test shows that here was no significant association of knowledge scores with any selected socio demographic variables. Findings of study reveals that structured teaching programme can make significant rise in knowledge levels of nursing professionals. Nurses frequently experience disturbing ethical issues in nursing practice that warrant focused attention by health service managers, educators and policy makers. Keywords: Effectiveness, Structured Teaching Programme, Ethical Issues, Nursing Practice Nursing Professionals INTRODUCTION Nurses at all levels & areas of practice experience a range of ethical issues during the course of their day to day work 1. Ethically speaking, what should be done in an individual, patient-care situation is at the heart of many practice dilemmas nurses face on a regular basis. A nurse s knowledge and skill are important forces that can contribute to the power to influence patient care in an ethical manner. 2 Ethical dilemmas arise daily when the nurse is confronted with a choice, in which ethical reasons both for and against the choice are equally desirable (Pierce, 1997). These issues are often emotionally charged 3. OBJECTIVES OF THE STUDY To assess the level of knowledge regarding the ethical issues in nursing practice among nursing professionals. To evaluate the effectiveness of structured teaching programme on knowledge regarding ethical issues in nursing practice among nursing professionals. To find out an association of knowledge scores regarding ethical issues in nursing practice with the selected sociodemographic variables.

144 136 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 MATERIAL AND METHOD Evaluatory research approach was used to assess the effectiveness of structured teaching programme on level of knowledge regarding ethical issues in nursing practice among 105 nursing professionals selected by non-probability purposive sampling technique.research design of the study was one group pre-test &post-test design and data was collected by using self structured questionnaire.data was analysed by using descriptive & inferential statistics. FINDINGS Part 1: Description of Demographic characteristics of nursing professionals Table 1: Distribution of nursing professionals according to demographic characteristics: Sr.No Demographic Variables Frequency Percentage 1. Age in years Gender Male Female Religion Hindu Muslim Christian Others Work Experience in Years Above Area of Experience a. Clinical b. Teaching Table 1: shows the distribution of nursing professionals according to their demographic characteristics, where in the majority (75.2%) were in the age group of years, most of the nurses (76.1%) were females, most of them (71.2%) belongs to Hindu religion, it was observed that a large majority (64.7%) held a post B.Sc Nursing education, 75.2% resides in urban area & majority had 1-5years of experience. Part 2: Analysis of Pre-test knowledge of nursing professionals regarding ethical issues in nursing practice. In order to assess level of knowledge of the nursing professionals The percentage score were graded arbitrarily as follows : <35% poor level of knowledge, 36-70% average level of knowledge and >70% good level of knowledge. Fig. 1. Distribution of nursing professionals according to pre-test knowledge level on ethical issues in nursing practice.

145 International Journal of Nursing Education. January-March 2015, Vol. 7, No Assessment of the pre-testknowledge of the nursing professionals on ethical issues in nursing practice revealed that most of the nurses (80.9%) had poor, 16.5% had average and 2.8% had good level of knowledge. Part 3: Analysis of Post-test knowledge of nursing professionals regarding ethical issues in nursing practice. Fig. 2. Distribution of nursing professionals according to posttest knowledge level on ethical issues in nursing practice. Assessment of the post test knowledge of the nursing professionals on ethical issues in nursing practice revealed that most of the nurses (87.6%) had good, 12.4% had average and no one had poor level of knowledge. Part 4: Analysis of effectiveness of structured teaching programme on knowledge regarding ethical issues in nursing practice among nursing professionals. Sr.No Test Mean Standard Calculated Table Deviation t value t Value 1. Pre-Test Post-test Table 2: Reveals that T-test value shows that calculated paired t value (t = 13.17) is greater than table value(t =11.26) hence there was significant difference was existing between pre test & post test knowledge scores so structured teaching programme was effective in improving the knowledge of nursing professionals. Part 5: Association of knowledge scores on ethical issues in nursing practice with Demographic variables of nursing professionals. The hypothesis was tested using chi- square test (x2).results shows that there was no significant association of knowledge scores on ethical issues with any selected socio demographic variables of nursing professionals. CONCLUSION The following conclusions have been drawn keeping in mind the findings of the present study: There has been growing public concern regarding the ethical conduct of healthcare professionals. Many of professionals are either unaware of their importance or unable to appropriately deal with these issues 4. Nursing profession requires knowledge of ethics to guide performance. The nature of this profession necessitates ethical care more than routine care. 5 Hence there is much need to assess the knowledge of nursing professionals on ethical issues in nursing practice & evaluate the effectiveness of structured teaching programme on knowledge regarding ethical issues in nursing practice among nursing professionals. Study concludes from the results that structured teaching programme can make significant rise in knowledge levels of nursing professionals. Nurses frequently experience disturbing ethical issues in nursing practice that warrant focused attention by health service managers, educators and policy makers to create awareness programmes on ethical issues in nursing practice. Findings of a similar study conducted to assess the Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados. The analyses of responses from 159 doctors and nurses comprising junior doctors, consultants, staff nurses and sisters-in-charge shows that 11% of the doctors did not know the contents of the Hippocratic Oath whilst a quarter of nurses did not know the Nurses Code. Nuremberg Code and Helsinki Code were known only to a few individuals. 29% of doctors and 37% of nurses had no knowledge of an existing hospital ethics committee. Since the findings of the study identify that learning at workplace has been valuable to gain knowledge about ethics and law 4. Conflict of Interest: The authors have no conflict of interests related to the conduct and reporting of this research.

146 138 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Source of Funding: Source of fund for this project was by author itself. This study was not supported by any external funding. Ethical clearance: Before conduct of the study ethical clearance was obtained by Principal of institute. Participation was made voluntary and nursing professionals were told that they were free to leave at any time, that being involved would have no harm on course progression, and that conûdentiality would be maintained at all times. Acknowledgement: We would especially like to express our sincere gratitude to the Medical Director, for his permission to conduct the study and support. REFERENCES 1. Johnstone, M, Da Costa, C and Turale, S 2004, Registered and enrolled nurses experiences of ethical issues in nursing practice,australian Journal of Advanced Nursing, vol. 22, no. 1, pp Parker, F., (Nov. 26, 2007) Ethics Column: The Power of One OJIN: Online Journal of Issues in Nursing. Vol. 13, No POSITION STATEMENT: Role of the Registered Professional Nurse in Ethical Decision-Making. Available from: URL: practice/positions/position6.htm 4. Seetharaman Hariharan, Ramesh Jonnalagadda, Errol Walrond and Harley Moseley, Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados, Available from: Alireza Mohajjel-Aghdam, Hadi Hassankhani,, Vahid Zamanzadeh,, Saied Khameneh, Sara Moghaddam, Knowledge and Performance about Nursing Ethic Codes from Nurses and Patients Perspective in Tabriz Teaching Hospitals, Iran, Journal of Caring Sciences, 2013, 2(3),

147 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Utilization of Health Care Services by Rural Population-A Study from Western Maharashtra Mahadeo B Shinde 1, P M Durgawale 2 1 Professor, Medical Surgical Nursing, Krishna Institute of Nursing Sciences Karad, 2 Professor & Head Department of Community Medicine, Krishna Institute of Medical Sciences, Karad ABSTRACT Client satisfaction with health services, therefore, has become one of the important components of providing accepted quality of care. Aim of study to assess the utilization of health care services by the rural community. Objectives-To assess the utilization of health care services by the rural community with special emphasis to community satisfaction and to determine the association of selected sociodemographic variables and level of satisfaction of community with health services.cross-sectional descriptive survey design and 1200 samples were selected by random sampling technique. Most of the respondents 64.3% of male, 35.7% were females and 27.6% of them were in years age. Majority 62.9% were Hindu and 20.4% of them were educated graduate and above. Results- Majority49.7% of them were averagely satisfied with availability of basic services,30% of them were highly satisfied with availability of basic services and 19.7% of them were low satisfied with availability of basic services. Majority 52.4% heads of families had satisfaction with Punctuality of doctors and staffs were averagely, 29.3 % heads of families had high satisfaction. And 18.3% of them were low satisfied with Punctuality of doctors and staffs. Majority 52.8% heads of families had satisfaction with Village health education by doctors and staffs were averagely, 29.2 % heads of families had high satisfaction. And 18.1% of them were low satisfied with Village health education by doctors and staffs. In the current study female, lower educated clients had higher levels of satisfaction. Two studies of client satisfaction with nursing care among a Jordanian population also reported that females had higher levels of satisfaction than males25. Keywords: Community Satisfaction, Health Services, Quality INTRODUCTION The current trend in healthcare delivery is to work towards providing people-centered, healthcare that puts the client at the center in the health delivery system. This means that clients views and assessment of services provided are critical in providing feedback for improving the quality of care provided 4.Over the years, India has gradually established the vast public health infrastructure in the country which currently Corresponding author: Mahadeo B Shinde Professor Medical Surgical Nursing Krishna Institute of Nursing Sciences Karad. (Satara district) Maharashtra Ph: Mail: mahadeoshinde28@gmail.com Fax: includes Sub-centres, Primary Health Centres and 3910 Community Health Centres providing health services to 72.2% of the country s population living in rural areas. In Maharashtra public health infrastructure currently includes Subcenters, and 1809 primary health Centers 1. The Subcenters are vital peripheral institutions for providing of primary health care to the people and play an important role in the implementation of various health & family welfare programs at the grass-root level. Of particular importance are the packages of services such as immunization, antenatal, natal and postnatal care, prevention of malnutrition and common childhood diseases, family planning services and counseling. They also provide elementary drugs for minor ailments such as ARI, diarrhea, fever, worm infestation etc. and carryout community needs assessment. Besides the above, the government implements several national health and family welfare programmes which

148 140 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 again are delivered through these frontline workers. Satisfaction has been said to be a major predictor of use of services, as it is essential if clients were to utilize services, comply with treatments and maintain a continuing relationship with practitioners 6. Following this thinking, there has been growing interest in measuring clients satisfaction, mostly through collecting the views of service users. These views have become important in the evaluation of healthcare delivery and have become a tool for health service performance evaluation. Client satisfaction is now viewed as an important measure of protection against potential problems in healthcare delivery, and is linked to changes in service delivery policies 7,8,9,10. So the researcher felt it is necessary to conduct this study. OBJECTIVES 1. To assess the utilization of health care services by community with special emphasis to community satisfaction in rural area of Satara district. 2. To determine the association of selected sociodemographic variables and withlevel of satisfaction of community. MATERIAL AND METHOD The research method adopted for the present study was observational descriptive approach. The investigator had selected cross-sectional descriptive survey design, and randomly selected sub centers of Satara district, one PHC from each talukas was randomly selected viz representing the district. The calculated sample size was 100 so all health workers (104) workings in selected by simple random sampling technique. The health workers who were permanent employee of health department, those who were willing to participate in the study and the heads of family above the age of 18 years were included in the study. Those who got promotional training were excluded. Data collection tool canonist of Section A, comprised the socio-demographic characteristics consisting of twelve items, Section B, consisted 2 items Community Responses regarding health services statements, Section C- Community Responses regarding health services, Section D-Reasons of Community for Using PHC Services and Section E-Level of community satisfaction of 16 community satisfaction statements measured on a three-point Likert scale. Quality assessment check list was used for assessment of quality of health services provided by health workers. This check list was standardized by government of Maharashtra and utilized by district quality assurance group visit. Descriptive statistics were used to analyze the data in this study. The analysis was based on completed questionnaires and extracted data emanating from records at the eleven sub centers. Data were imported into licensed copy of SSPS version 20 software. Analysis included frequency distributions of different types of facility available and health services provided by the health workers,level of job satisfaction among health workers and community satisfaction demonstrated by pie charts, bar charts and tables. Findings:/Results and discussion A total of 1200 heads of families were interviewed to capture their satisfaction with health services provided by health workers. All respondents were interviewed at home. Table 1.Demographic descriptions by frequency and percentage Descriptions Frequency Percentage Sex Male Female Age years years years years above 57 years Religion Hindu Muslim Christen Any other specify Education Illiterate Primary th -8th standard Matriculation Higher secondary Graduate and above A total of 1200 heads of families were interviewed to capture their satisfaction with health services provided by health workers. All respondents were

149 International Journal of Nursing Education. January-March 2015, Vol. 7, No interviewed at home. Most of the respondents 64.3% of male, and 27.6% of them were in years age group while 62.9% were Hindu and 20% of them were educated graduate and above and 12.3% were had no formal education(illiterate). The main occupation by which respondent earned their living was used as proxy for the economic status of respondent. Majority 22.2% were salaried,6.2% were unskilled worker,17.4% were agriculture,18.2% business,6.7%unemployed,6.5% were retired (13.1%) of housewife and 1% others. Housing and sanitation 37.8% was good,28.5% had poor and 33.8% had better. Majority 29.6% of them were in monthly income between ,23.6% were between Rs ,18.9% were in between ,and 12.3% were between while only 4.4 % of them were income more than Many providers concurred, noting that the majority 74.6% of private health facilities are far away from the rural area. Majority of respondents agreed that private services were not reliable. Other hand majority 80.6%of heads of families said that private services are costly. 78.9% were responded that private consulting fee high while 67.3% were agreed that private test charges high and 64.4% of heads of families had experienced that private drug prescription of outside medicines. Overall satisfaction with health services provided by health workers Exiting heads of families were interviewed to assess their level of satisfaction. 49.7% of them were averagely satisfied with availability of basic services,30% of them were highly satisfied with availability of basic services and 19.7% of them were low satisfied with availability of basic services. Factors contributing for satisfaction with health services provided by health workers Majority 53% heads of families had satisfaction with timing of service was average, 28.8% heads of families had high satisfaction. And 18.5% of them were low satisfied with timing of service. Majority 53% heads of families had satisfaction with quick counter were averagely, 28.6% heads of families had high satisfaction. And 18.4% of them were low satisfied with quick counter services. Half of the heads of families 50% had satisfaction with Infrequency of outside medicines were averagely, 30% heads of families had high satisfaction. And 19.4% of them were low satisfied with Infrequency of outside medicines. More than half 53.5% heads of families had satisfaction with Non-costly outside medicines were averagely, 28 % heads of families had high satisfaction and 18.6% of them were low satisfied with Non-costly outside medicines services. Majority 52.9% heads of families had satisfaction with Free medicines from doctors were averagely, 28 % heads of families had high satisfaction. And 18.5% of them were low satisfied with free medicines from doctors. Majority 52.4% heads of families had satisfaction with Punctuality of doctors and staffs were averagely, 29.3 % heads of families had high satisfaction. And 18.3% of them were low satisfied with Punctuality of doctors and staffs. Majority 52.8% heads of families had satisfaction with Village health education by doctors and staffs were averagely, 29.2 % heads of families had high satisfaction. And 18.1% of them were low satisfied with Village health education by doctors and staffs. Majority 51.4% heads of families had satisfaction with Regularity of field visits were averagely, 29.4 % heads of families had high satisfaction. And 19.2% of them were low satisfied with Regularity of field visits. Satisfaction with demographic characteristics The majority of heads of families were predominantly male. Pearson Chi-Square for gender and level of community satisfaction was less than.0001 it has proved that there is a significant association between gender and satisfaction in the rural area. There is no significant association between the occupation, income,housing and sanitation and community satisfaction with health services provided by health workers in rural area. In the current study female, lower educated clients had higher levels of satisfaction. Two studies of client satisfaction with nursing care among a Jordanian population also reported that females had higher levels of satisfaction than males 25.On the other hand, studies conducted among other populations reported that 4, 11 males were more satisfied than females. However, the effect of educational level in this study was consistent with studies conducted among both a Jordanian population and other populations. This suggested that the effect of gender seemed to change in different population, while the effect of education seemed to be more universal.

150 142 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 In relation to age, younger clients were more satisfied in this study. This finding contradicted the findings of the two Jordanian studies which reported that age did not affect client satisfaction levels. Moreover, studies that were conducted in different populations reported that older clients were more satisfied than younger clients. In this current study, no effect of perceived health status on client satisfaction level was reported. This contradicted with another satisfaction study s finding which reported that healthier clients tend to be more satisfied. 10 this lack of consensus in relation to age and perceived health status effects on clients satisfaction levels suggested that these two variables were not as important as gender and educational level. The current study concluded that clients were moderately averagely with the health services delivered in the selected sub centers. Policies in community health organizations should place more attention in coordinating their services especially by allowing their clients to be more actively involved in the planning of their own care. Also, staff development programs in community health organization should focus on increasing the ability of health workers to communicate more effectively with clients. Less educated clients tend to have higher satisfaction levels and the effect of gender seems to differ among different populations. Age and perceived health status seem to be less important determinants of client satisfaction. CONCLUSION In order to provide Quality Care in rural area, Indian Public Health Standards (IPHS) are being prescribed to provide basic primary health care services to the community and achieve and maintain an acceptable standard of quality of care. Community showed averagely satisfaction with services provided by the health workers in rural area thus further increase in satisfaction of clients would be possible by adequate drug supply, less waiting hours and transport facilities for emergencies. Conflict of interest: The authors have no conflict of interests related to the conduct and reporting of this research. Source of Funding: Source of fund for this project was by author itself. This study was not supported by any external funding. Ethical clearance: Ethical clearance and approval to conduct this research was obtained from the Research Ethics Committee Krishna Institute of Medical Sciences Deemed University, Karad. Permission to conduct the study was also requested from the District Health Officer Satara. Acknowledgement: We would especially like to express our sincere gratitude to District Health Officer Sataraand all participants for their kind co operation throughout this study. REFERENCES 1. hospital/district/default.htm 2. maharashtra.html 3. Indian public health standards 2007 Health Strategy Implementation Project 2003 Central Business Park, Clanminch, Tullamore Co. Offaly, Ireland. 5. Pereira LL, Takahashi RT. Audit in nursing. INCH: Kurcgant P, organizer. Nursing Administration. Sao Paulo: EPU, p [Links]. 6. Larsen D.E., Rootman I. (1976). Physicians role performance and patients satisfaction. Social Science Medicine Carr-Hill, R.A (1992). The measurement of patient satisfaction. Journal of Public Health Medicine, 14, pp Hall, J.A and Dornan, M.C (1988). Meta-Analysis of satisfaction with medical care: Description of research domain and analysis of overall satisfaction levels. Social Science and Medicine, Vol. 27, No. 6, pp Marshall, G.N., Hays, Ron D, Sherbourne, C.D., and Wells, K.B (1993). The structure of patient satisfaction with outpatient medical care The American Psychological Association, Inc., Vol. 3, No. 4, pp Strasser, S., Aharony, L and Greenberger, D. (1993 Summer). The patient satisfaction process: Moving toward a comprehensive model. Medical Care, Review, 50, pp Al-Hussami, M. (2008). A study of nurses job satisfaction: The relationship to organizational commitment, perceived organizational support, transactional leadership, transformational leadership and level of education, European Journal of Scientific Research, Vol. 22, No2: Tzeng, H.M. (2002). The influence of nurses working motivation and job satisfaction on intention to quit: An empirical investigation in

151 International Journal of Nursing Education. January-March 2015, Vol. 7, No Taiwan. International Journal of Nursing Studies, Vol. 39: Herzberg, F., Mausner, B., Peterson, R., &Capwell, D. (1957). Job attitudes:review of research and opinion. Pittsburgh: Psychological Services of Pittsburgh. 14. Robbins, S. (2003). Organizational behaviour. Tenth Edition. New York: Prentice- Hall. 15. Health Strategy Implementation Project 2003 Central Business Park, Clanminch, Tullamore Co. Offaly, Ireland 16. Pope C., and Mays N. (1993) Opening the black box: an encounter in the corridors of health services research. BMJ, 306: Williams, S. J. and Calnan M., (1991) coverage and divergence: assessing criteria of consumer satisfaction across general practice and hospital care settings. Social Science medicine 33(6): Owens, D. and Batchelor, C (1996) Patient satisfaction and the Elderly Social Science Medicine 42(11): ALC Motta, Leo E, Zagatto JR. Private Medical Audit System: practical approach to healthcare organizations. Sao Paulo: Iátria; Scarparo AF. Nursing audit - identifying notions and methods. [Dissertation]. RibeirãoPreto (SP): Nursing School of RibeirãoPreto, University of São Paulo; Indian public health standard XXII%20-% 20Manual%20for%...ý downloads.htm 24. David Locker and David Dunt, (1978), Theoretical and methodological issues in sociological studies of consumer satisfaction with medical care. Soc. Sci. Med vol.12 pp283 to Crow, R., Storey, L and Page, H, (2003). The measurement of patient satisfaction: Implications for Health service delivery through a systematic review of the conceptual, methodological, and imperical literature. Health technology Assessment 6(32).

152 144 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Awareness Regarding Uterovaginal Prolapse among Newar Parous Women Sita Karki 1, Arju Neraula 2 1 Assistance Professor, Department of Nursing, Dhulikhel Hospital, Kathmandu University school of Medical Science Dhulikhel, Kavre, Nepal, 2 Orthopedic Ward In-Charge, CMS, Teaching Hospital, Bharatpur, Nepal ABSTRACT The global prevalence of uterovaginal prolapsed (UVP) is estimated to be 2-20% in women under age 45 year1. At present 600,000 women are affected by the disease, among them 200,000 require immediate treatment in Nepal2. Objective: The objective of the present study was to assess the awareness regarding UVP among parous women. Method: A semi- structured interview schedule consisting of questions related demographic characteristics and awareness items related to UVP developed by reviewing literature. A total of 118 parous women who had given at least one child birth residing in Bhaktapur Municipality in Bhaktapur, Nepal, in April 2010 were included using a descriptive research design. Among total respondents 97 heard about UVP that more than half (55.1%) of the respondents were aware regarding the cause of UVP. Among the total respondents 58.5% were aware regarding the sign and symptoms of UVP. Most of the respondents (68.6%) were aware regarding preventive measures of UVP. Majority of the respondents (82.2%) were aware regarding the management of UVP and 55.9% were aware regarding the complication of UVP. Conclusion: The study concludes that out of 118 respondents 39% of the respondents were aware regarding the uterovaginal prolapsed. There was statistically significance between the occupation and awareness regarding uterovaginal prolapsed whereas there was no statistical significance between awareness and variables like education and experience of the respondent. Awareness raising programs could be beneficial to the mothers is correcting in the deficient areas of awareness regarding UVP. Keywords: Awareness, Parous women, Uterovaginal prolapsed (UVP) INTRODUCTION The global prevalence of UVP is estimated to be 2-20% in women under age 45 year 1. In Nepal, reproductive ill health is a major health problem and is least articulated by the general public because of lack of knowledge and it is a cultural taboo. The Government of Nepal s (GON) strategy reflects the commitment to the ICPD. Although the Government and donors have recently given more attention to safe motherhood issues, many have raised concerns that UVP is still neglected and often overlooked. The Government has adopted several policies and taken measures to make RH services available to all Nepalese citizens through the primary health care system. Eventhough at present 6, 00,000 women are affected by the disease among them 200,000 require immediate treatment in Nepal (TUIOM, 2006). So, the UVP is one of the most common causes of gynecological morbidity in Nepal. UVP is one of the major health problems of women in our country. UVP and its associated problems not only affect the women s health but also social and economic status of the women and their family. Among 2,268 women in Siraha and Saptari district of Nepal, 37% of women have uterine prolapsed 3.

153 International Journal of Nursing Education. January-March 2015, Vol. 7, No Another report from Nepal revealed that 40% of women with UVP are of reproductive age group having given to their first child 4. In the period of 3 months study at the Dr. Imamura Memorial Hospital and research center, Bhaktapur, 96 women were diagnosed with UVP 10. Parous women who have given birth are at high risk of having UVP as compared to nulliparous women. Lack of health education, low socioeconomic status and gender discrimination play direct role in developing this problem 5. Thus this study is important to assess the pre-existing awareness of parous women regarding UVP. The chances of Nepalese women suffering pregnancy complication are very high and consequently this risk increases as these women undergo multiple pregnancies during their reproductive age. Postnatal care and institutional deliveries are not common in Nepal. All these factors are directly playing role in the development of UVP 6. The status of women in Nepal is low and they are considered the least important members in many families, and thus they do not receive the care the need to prevent or teat genital prolapsed and prolonged labour, inappropriate care during delivery and inadequate rest in the postpartum period are common contributory factors to UVP. Pathological condition such as chronic cough is common factor in UVP. Therefore there is need to assess the awareness regarding UVP among parous women, their husband, family members and the community to prevent this disorder, and relieve such suffered women. General Objectives OBJECTIVES - To assess the awareness regarding UVP among parous women. - To find out the association between selected Sociodemographic variables such as education, occupation, experience and awareness level of parous women. METHODOLOGY Descriptive cross sectional research design was used in ward No.11 of Bhaktapur Municipality. Study population consisted of parous women residing in Bhaktapur Municipality and who had given at least one child birth. A semi- structured interview schedule consisting of questions related demographic characteristics and awareness items related to UVP developed by reviewing literature. The content validity of the instrument was established seeking opinion of gynecologist consultant and related nursing teachers. The instrument was then translated into Nepali language and opinion of language expert was obtained for comprehensibility and simplicity of language and for consistency of the content. The instrument was pre- testing on 10% similar women from ward no. 2 and 3 of the same Municipality. The study was conducted after obtaining approval from the Research Review Committee of Dhulikhel Hospital. Prior to collecting data, administrative approval was obtained from the Executive director of Bhaktapur Municipality. Systematic random sampling technique was used for the study. Data was collected by interviewing the eligible mothers through house to house visit. All eligible mothers available during data collection and gave informed consent were interviewed. None of the parous mother who were identified by house to house survey, refused to participate in the study. The collected data were reviewed daily for completeness and accuracy. Edited data were entered into the Statistical Package for Social Science Software (SPSS) version 16.0 for statistical analysis using descriptive statistics. The Demographic characteristics of the mothers are presented in Table 1 and awareness of mothers regarding UVP are presented in Table 2-4. Results Table 1 illustrates that more than half respondents (69.6 %) were under 40 years of age. All respondents were Newar having Hindu religion. 65.3% respondents are literate and among them 23.7 % had primary level education. Most of the respondents (63.6%) were house wife and second major occupation was agriculture with 15.3%. Most of the respondents (68.6%) had their first delivery above 20 years of age and 43.2% had second parity.

154 146 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table1: Socio-Demographic Characteristics of the Mothers Variables Frequency Percent Variables Frequency Percent Age group Occupation <40 years Housewife years Agriculture Business Service Educational level Age of mothers at the time of first delivery Illiterate <20years literate years Can read and write Primary level (1-8 class) Secondary level (9-10 ) Higher level (10+2- PhD) (n=118) Table 2 reveals that most of the mothers were aware that carrying heavy loads during postpartum period can cause UVP(72.2%) followed by having child at very young age 63.9%, prolong labour 52.8% and giving birth to big baby 39.2%. Causes related responses Table 2: Mother s Awareness about Causes of UVP Frequency Correct Responses Carrying heavy loads during postpartum period Multiparity Having child at very young age (18years) Having children in less interval (<5 yrs between two children) Constipation, obesity, chronic cough can also cause UVP in women Loss of tone of vagina Prolong labour Giving birth to big baby Physically weak Others(infection, sexual contact, carelessness) 2 2 (n=97) Percent Most of the mothers were aware that foul discharge per vagina is sign of UVP followed by felling of something comming out and backache and lower abdomen pain 64.9% and constipation 49.5%. that is shown in Table 3. Table 3: Mother s Awareness About Signs and Symtoms of UVP Sign and symptoms related Response Correct Responses Frequency Percent Foul discharge per vagina Feeling of something coming out per vagina Backache and lower abdomen pain Difficult to void or urinary incontinence Difficulty in walking Feeling of pelvic heaviness Constipation Less desire for intercourse n= 97

155 International Journal of Nursing Education. January-March 2015, Vol. 7, No Regarding preventive measures of UVP most mother were aware that avoiding heavy loads during, postpartum period can prevent UVP(84.5%), by maintaining nutritional diet, regular exercise in ANC period (81.4%) and conducting delivery by trained health personnel 79.4%. Table 4: Mother s Awareness About Preventive Measures of UVP Preventives measure related Response Correct Responses Frequency Percent Avoiding heavy loads during, postpartum period Medical attention should be sought as soon as problem is notice Nutritional diet, regular exercise and hygiene should be maintained in antenatal period Delivery should be done by trained health personnel Problem such as constipation, chronic cough should be cure on time Food rich in fiber and intake plenty of water Keeping tight pessary in vagina Regular exercise of pelvic floor Others(traditional healers) n= 97 All parous mothers were asked about management and complication of UVP that is presented in table 5. All mothers were aware that must go in hospital after UVP (100%), more than fifty percent that drug alone cannot cure UVP(62.9%) and 63.9% mothers told cystocele is the complication of UVP. Table 5: Mother s Awareness Related Management and Complication of UVP Management and Complication related response Correct Responses Frequency Percent Health seeking behaviors (Hospital) Drugs alone cannot cure the UVP Cystocele Hemorrhoids Secondary infection Rectocele Cervical cancer n= 97 Regarding education of the respondents (p=0.114) (OR=0.52), experience of respondents (p=0.183) (OR=1.94) had not significant association with awareness of UVP, but regarding occupation of the mothers (p=0.035) (OR=0.26), had significant association with awareness of UVP (Table 6). Table 6: Association between Socio demographic Variables and Awareness of UVP n = 118 Socio-demographic factors Awareness P-value Odd Ratio (CI, 95%) Aware Unaware Educational level Illiterate 12( 29.2) 29(70.7) literate 34 (44.1) 43(55.8) Experience gained Experienced 10(52.6) 9(47.3) Inexperienced 36(36.3) 63(63.63) Occupation Agriculture 3 (16.6) 15(83.3) Other occupation 43 (43) 57(57) Note- The number inside the bracket indicate percentage.

156 148 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 DISCUSSION In this study, the majority of the respondents were <40 years (69.6%), were literate (65.3%), all respondents were Newar, and Hindu religion. Major occupation of the mothers was house work (63.6%) and 15.3% were engaged in agriculture. Mean age of the respondent at the time of first delivery was 20years, whereas the mean parity of the respondents was second. In regards to knowledge related to UVP this study showed that the causes of UVP by carrying heavy loads during postnatal periods (72.2%), by multiparity (63.9%), having child at very young age (60.8%), having children at less interval (<5yrs) (57.7%), other condition like constipation, obesity and chronic cough (55.7%), by loss of the tone of vagina (53.6%), by prolong labour (52.8 %) and by giving birth to large baby (39.2%). This finding is supported by the findings of study of center for agro ecology and development, Nepal on UVP, done on western Nepal. It state that UVP is because of child bearing at an early age (43%), carrying heavy loads during pregnancy (43%), working immediately after child birth (37%), lack of care during postnatal period (32%), pressure on lower abdomen during child birth (28%), multiple birth (9%) 3. In present study majority of the respondents (68%) replied that foul vaginal discharge is the sign and symptom of UVP. In the same way, 64.9% said feeling of something coming out per vagina and backache/ abdominal pain, 63.9% replied difficult to void or urinary incontinence, 62.9% said difficult to walk, 56.7% replied feeling of pelvic heaviness. However more than half of the respondents was unaware of the sign and symptoms of UVP such as constipation and less desire for intercourse. These finding are supported by the findings of Bonetti, Erpelding and Pathak which reported of association of difficulty urinating, abdominal pain, backache, painful intercourse, burning micturation, foul vaginal discharge, difficulty in walking, sitting with the sign and symptoms of UVP 7. Majority of the respondents (84.5%) responded that UVP can be prevented by avoiding heavy loads during postpartum periods followed by 83.5% said medical attention should be sought as soon as problem is noticed, 81.4% replied that nutritional diet, regular exercise and hygiene should be maintained in the antenatal period and 79.4% replied delivery should be done by trained health personnel. In same way 74.2% said problem such as constipation, obesity and chronic cough should be cured in time followed by 72.2% of the respondents said food rich in fibre diet and intake of plenty of water can prevent UVP, 56.7% of respondent were aware about keeping tight pessary in vagina and more than 50% were not aware that regular exercise of pelvic organ can prevent UVP. This finding co-relates with the study conducted in western Nepal on UVP. It state that 39 % said having rest during postpartum period, not doing heavy work during pregnancy and postpartum period (36%), marrying at appropriate age (31%), having nutritious food, care during antenatal and postpartum period (22%) and delivery should be done by TBA (16% ) can prevent UVP 3. All respondent who had heard about UVP said that women should go hospital for treatment when she suffers from UVP. And 62.9% replied that drugs alone cannot cure the UVP. Most of the respondents (63.9%) responded that cystocele is the complication of UVP, 58.8% said hemorrhoids, 55.1% said secondary infection and 36.1% said rectocele as complication of UVP. This finding is supported by the Smeltzer S.C et.al [9] which has stated that infection, hemorrhoids are the complication associated with the UVP. The study reveals that 29.2% of illiterate and 44.1% of literate respondents were aware regarding UVP, which illustrate that literate are more aware than illiterate. Statistically not significant association as p- value is which is greater than 0.05, but in the study done in Kathmandu showed that women who were illiterate, almost all had UVP 3. The study reveals that among the respondent who are engaged in agriculture 16.6% and among other occupation 43% were aware regarding UVP, which showed that women of agricultural occupation are unaware regarding UVP. Statistically there is significant association as p-value is 0.03 which is less than 0.05.this is correlated with the study of Ravindran, [8] which showed that all most the women who had UVP were working in agriculture. In this study 52.6% from experienced and 36.3 % from inexperienced were aware regarding UVP so, this study might be useful for new planning or intervention to increase the awareness on UVP especially among the inexperienced women in future.

157 International Journal of Nursing Education. January-March 2015, Vol. 7, No CONCLUSIONS UVP is a significant problem among women in Nepal although it is preventable. So assessing the awareness of parous women regarding UVP, could be the effective measure to prevent UVP. Based on the findings, it is concluded that the parous Newar mothers residing in Bhaktapur municipality out of 118 respondents only 39% were aware regarding the UVP, which signifies that majority of the respondent were unaware regarding the UVP. UVP is the leading cause of morbidity among the women. Attention need to be paid more in the intensive planning of educational programme on deficient areas of awareness of parous for preventing UVP. Limitations of the Study The result of the study does not represent the whole population because it is a small scale community based study limited to the parous women residing in Bhaktapur Municipality of Nepal during the short period of data collection. The sample size also was not estimated by calculating formula. Hence the results may not be generalized. This study was not designed randomly; hence this might possibly affect the results. Interview schedule was used to find out awareness of parous women about UVP that is very sensitive issues so under or over reporting can be occurred. Acknowledgement: I am highly indebted to Prof. Mrs. Regina Singh for her sound advice, and guidance throughout this research work; and Mr. Kedar Manandhar (Lecturer, KUSMS) for his statically guidance contribution in enhancing further the quality of this research study. Ethical Consideration: Verbal and Written permission was obtained from institutional review committee of Kathmandu University Dhulikhel teaching Hospital before data collection. Verbal consent was taken from each respondents before interviewing them and were given due respect for acceptance of rejection of the interview. The confidentiality was ensured before the interview and obtained information was used only for the necessary research purpose. Fund: Self. Conflict of Interest: Nil REFERENCES 1. The advocacy project. [internet] WHO, (2006). Uterine prolapsed study report; Available 2. TUIOM, UNFPA, (2006). Status of reproductive morbidity in Nepal, Institute of medicine: Tribhuvan University. 3. Centre for agro-ecology and development (CAED), (2003). WRRP Activity Report # 2 & 4. Women Reproductive Rights Program (WRRP); Progress Reports. Sustainable Livelihood Program (SLP); 4. Subba B, Adhikari D, Bhattarai T.(2003). The neglected case of the fallen womb, Himal south Asian, Nepal. 5. Dr. Binod shah (2007). public health concern trust (phect-nepal), Documentary on utero-vaginal prolapse: An unseen grief of women, under ANMF Nepal. 6. USAlD, NDHS (2007). Ministry of Health and Population. 7. Bonetti; Erpelding; Pathak (2004) Listening to Felt Needs : Investigating Genital Prolapse in Western Nepal, Reproductive Health Matters, 12, (23): Sundari, Ravindran, T.K., R. Savitri and A. Bhavani (2000). women s experience of uterovaginal prolapsed [internet]; a qualitative study from Tamil Nadu, India, reproductive health matters Available at 9. Smeltzer SC,Bare BG,Hinkle JL Cheever KH (2009), textbook of medical surgical nursing 11th edition, wolter and kluwer, page no: Barbara Boner-Adler, Chandra Shrivastava, Klaus Bodner (2007), Risk factor for uterine prolapsed in Nepal, International urogynecol J 18:

158 150 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Prevalence of Anemia among Nursing Students Vaishali R Mohite 1, Jojy Kurian 2 1 Principal, 2 Assistant Professor, Dept of Child Health Nursing, Krishna Institute of Nursing Sciences, KIMS Deemed University, Malkapur, Karad, Maharashtra, India ABSTRACT Anaemia is considered a severe public health problem by World Health Organization when anaemia prevalence is equal to or greater than 40% in the population1. The prevalence of anaemia in developing countries is three to four times higher than in industrialized countries2. Adolescence is one of the most vulnerable periods in human life cycle where nutritional requirements increases due to the adolescent growth spurt. Anaemia is thus a frequent problem among adolescents, hence the prevalence of which may be particularly high in nursing students too. Objectives: To study the prevalence of Anaemia using Sahli's Haemoglobinometer among students of Krishna Institute of Nursing Sciences, Karad. Methodology: A Descriptive Survey Design was used to collect data from B.Sc. Nursing Students of Krishna Institute of Nursing Sciences, Karad. Purposive sampling technique was used to get a sample of 280 subjects. Data was collected using structured questionnaire for demographic data and Sahli's haemoglobinometer for haemoglobin estimation. Consent was obtained from the principal of the college and each subject. The results were calculated using descriptive and inferential statistics. Results: In this study haemoglobin estimation was done by Sahli's method. From 280 samples, 161 students had low Hb levels, in which 152 were girls and 9 were boys and are assumed to have anemia. Conclusion: From the study it can be concluded that more than half of the B.Sc. Nursing students of Krishna Institute of Nursing Sciences have less than normal Hemoglobin levels which indicate anemia. Keywords: Anaemia, Sahli's Method, Nursing students, Hemoglobin Estimation etc INTRODUCTION Anaemia is one of a wide spread public health problem in the world. Anaemia is not a disease but rather a sign of an underlying illness. Anaemia is a condition in which the number of red blood cells (and consequently their oxygen-carrying capacity) is insufficient to meet the body s physiologic needs. Specific physiologic needs vary with a person s age, gender, residential elevation above sea level (altitude), smoking behavior, and different stages of pregnancy. The prevalence of anaemia is an important health indicator 3. The prevalence of anaemia in developing countries is three to four times higher than in industrialized countries 2. Anemia is a life-long burden for women. It affects most of their infant and young children as well. Controlling anemia in these vulnerable groups could significantly reduce maternal and infant morbidity. It would also enhance intellectual and work capacity, thereby improving family, community and national socioeconomic development 5. A cross-sectional study was conducted under urban health training centre, with an aim to estimate the prevalence of anaemia among adolescent females and to study the socio-demographic factors associated with anaemia. The Sample size was of 296 adolescent females. The results show that the prevalence of anaemia was found to be 35.1%. A significant

159 International Journal of Nursing Education. January-March 2015, Vol. 7, No association of anaemia was found with socio-economic status and literacy status of parents. The study concludes that a high prevalence of anaemia among adolescent female was found, the anaemia affect the overall nutrition status of adolescent females. 4 The study was carried out in Maharashtra, India with an objective to assess the effectiveness of weekly supplementation of iron to control anaemia among adolescent girls. The project covered 498,793 people from four tribal, four rural blocks and all the urban slums of a city. The prevalence of anaemia was found to be 65.3%. 6. There are various clinical methods approved by world health organization (WHO) to estimate the hemoglobin in the blood in pathology laboratory. Some of these are Sahli s method of hemoglobin estimation, portable haemoglobinometer or HemoCue method, colorimetry-hemiglobincyanide method or cyanmethemoglobin method etc 8. Sahli s method is considered one of the best visual methods of assessing Hemoglobin. As the cost is less and based on the convenience, this method can be adopted for practical education in students and in laboratories. 7 Diagnosing anaemia and its underlying cause begins with taking a thorough personal and family medical history, including symptoms, and completing a physical examination. The main aim of this study is to explore the prevalence of anaemia and to find out the possible factors relating to cause of anemia in nursing students. MATERIALS AND METHOD Approach and Design: A quantitative research approach is used in this study. The research design adopted is Descriptive Survey Design. Sample and Setting: The population for the study comprised of the adolescents studying B.Sc. nursing course. A sample of 280 B.Sc. nursing students studying in Krishna Institute of Nursing Sciences, Karad were selected in this study using a purposive sampling technique and those meeting the sampling criteria. Methodology: The researcher obtained formal permission from Principal of Krishna Institute of Nursing Sciences, Karad to conduct the study. The tool for data collection included a structured questionnaire for demographic data and Sahli s method for estimation of hemoglobin. The questionnaire consisted of 15 items of demographic variables such as age, gender, religion, income etc. The researcher took help from the Department of Pathology for Hb estimation using Sahli s method. The written consent was obtained from each of the samples. The study was conducted after approval from the ethical committee of the institution. The conceptual framework adopted for the present study was based on Pender s Health Promotion Model. The subjects were asked to fill the questionnaire. Hb estimation was done by Sahli s method with help and guidance from Department Of Pathology, Krishna Institute of Medical Sciences. The Sahli s method involved pricking the subjects finger, collecting the blood drop using a pipette and then using the Sahli s haemoglobinometer for Hb estimation. The cutoff points for hemoglobin (Hb) levels were established on the basis of review of various literatures. For girls Hb level of 12 gm/dl and less was considered to be anemia and for boys 14 gm/dl. The data collected was then tabulated & analyzed. FINDINGS Personal Characteristics: The results show that, out of the 280 B.Sc nursing students selected in this study, % (80) were from 4th year, 27.17% (76) were from 1st year,26.78% (75) were from 3rd year and the least was 17.50% (45) from 2nd year B.Sc Nursing. Majority of the samples were in the age group of years, 43.21% (121), the least samples were in age group above 23 years, 7.50% (21).The other two groups had almost same number of samples 24.28% (68) in years and 24.64% (69) in years age group. Majority of the samples (93.57%) are females, males were only (6.40%) % of the samples are from a nuclear family % have a mixed diet where as 7.85% are vegetarian. In terms of height, the majority 61.07% have cm height, while only 1.07% are below 139cm. In terms of weight, 51.78% are between 40-50kg, 8.57% above 60 kg, 31.42% between kg, whereas the minority 8.21% belongs to below 39kg. 8.21% of subjects had a family history of anemia. Prevalence of Anemia: After the estimation of Hb by using Sahli s method, 152 girls out of 262 were found to have less than normal hemoglobin level and are considered as anemic. 9 out of 18 boys were found to have less than normal hemoglobin level and are considered as anemic.

160 152 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 A similar study was undertaken to find prevalence of Iron Deficiency Anemia (IDA) amongst nursing students. Seventy-two newly admitted nursing students were taken up for study after obtaining their informed consent. Subjects were given a written questionnaire to elicit anemia related symptoms. Blood counts were done on electronic counter and serum ferritin was assayed by Elisa. IDA was detected in 20.3% of apparently healthy females aged years 9. Table 1 Table showing Haemoglobin Level and Various Demographic Data Variables Haemoglobin Level FEMALES MALES >12 12 >14 14 Level Of Students 1 st year nd year rd year th year Age In Years years years years Above 23 years Type Of Family Joint Nuclear Expanded Broken Type Of Diet Vegetarian Non-Vegetarian Mixed Height Below 139cm cm cm Above 181cm Weight Below 39kg kg kg Above 60kg CONCLUSION From the study it can be concluded that Sahli s method was effective to estimate the haemoglobin level from the samples. In females 54.28% (146) students have anaemia and 39.28% (125) are not having anemia. In males 9 students having anaemia and 9 students do not. It is clear that in spite of being in the healthcare field many students are suffering from anemia. This result also calls for attention of everyone concerned to initiate further researches on the causes, related factors, possible hazards etc. of anemia. The Fig. 1. Sahli s Haemoglobinometer

161 International Journal of Nursing Education. January-March 2015, Vol. 7, No result also demands need for increasing awareness to all including those in health related fields in form of continuing education, awareness programs etc. ACKNOWLEDGEMENT Principal, Krishna Institute of Nursing Sciences, Karad Pathology Department, Krishna Institute of Medical Sciences, Karad Conflict of Interest: Nil Source of Funding: Self Ethical Clearance: Before conduct of the study ethical clearance was obtained by Principal of institute and the ethical committee. Participation was made voluntary and students were told that they were free to leave at any time, that being involved would have no harm on course progression, and that confidentiality would be maintained at all times. Informed consent was obtained from each participant. REFERENCES 1. Leyla Karaoglu, Erkan Pehlivan, Mucahit Egri, Cihan Deprem, Gulsen Gunes, Metin F Genc, Ismail Temel. The prevalence of nutritional anemia in pregnancy in an east Anatolian province, Turkey. BMC Public Health 2010, 10:329 DOI: / Fourth Report on the World Nutrition Situation. Geneva: ACC/SCN in collaboration with IFPRI. ACC/SCN (2000) 3. Assessing the iron status of populations: report of a joint World Health Organization/ Centers for Disease Control and Prevention technical consultation on the assessment of iron status at the population level, 2nd ed., Geneva, World Health Organization, Available from URL: micronutrients/anaemia_iron_deficiency/ pdf 4. Sanjeev M Chaudhary. Vasant R Dhage. A Study of Anemia Among Adolescent Females in the Urban Area of Nagpur. Indian Journal of Community Medicine October; 33(4): doi: / Klaus Kraemer. Michael B. Zimmermann. Nutritional Anemia. SIGHT AND LIFE Press. ISBN P.R. Deshmukh. B.S. Garg. M.S. Bharambe. Effectiveness of Weekly Supplementation of Iron to Control Anaemia among Adolescent Girls of Nashik, Maharashtra, India. J Health Popul Nutr March; 26(1): G.K. & Pal, Pal, Pravati. Textbook of Practical Physiology - 2Nd Edn. 8. V. P. Kharkar. V. R. Ratnaparkhe. Hemoglobin Estimation Methods: A Review of Clinical, Sensor and Image Processing Methods. International Journal of Engineering Research & Technology Vol. 2 Issue 1, 9. B.C. Mehta. Iron deficiency amongst nursing students. Indian Journal of Medical Sciences (9):

162 154 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Effectiveness of Planned Health Teaching on Knowledge Regarding Practices of Oral Hygiene among Children in Selected Schools Sunita H Tata 1, Vaishali Sidharth 2 1 Associate Professor, 2 Professor Bharati Vidhyapeeth Colledge of Nursing Pune ABSTRACT A quasi experimental study was conducted to assess the effectiveness of planned teaching on knowledge regarding practices of oral hygiene among children in selected schools by Convenient Sampling technique. 100 school children of age group 8-12yrs are selected. pre test was conducted using structured knowledge questionnaire to assess knowledge, following which planned teaching was administered with the help of A.V.aids. Seven days after planned teaching post test was conducted with same tools. The findings of the study revealed that mean post test knowledge score (19.760) higher than pre test knowledge score (7.800).The difference between the mean pretest and post test knowledge was highly significant at p < 0.05 level. The study concluded that planned teaching program me was effective in increasing the knowledge regarding practices of oral hygiene among children in selected schools. Keywords: Assessment, Oral Hygiene, Planned Teaching, Knowledge, Practices INTRODUCTION The health of children has historically been of vital importance to all societies because children are the basic resource for the future of humankind. A nation s most important and precious resource is its children who constitute its hope for continued achievement and productivity. In India 1/4 of the total population is in the age group of 5-14 years. Though mortality is not very high during this period, these children face many common health problems such as upper respiratory tract infections, worm infestation, dental caries, gingivitis, scabies etc. Children of this age group are less conscious about their health and they are more interested in play. Parents of this age group children Corresponding author: Sunita H Tata Director of Nursing Services & Associate Professor of Child Health Nursing, Krishna Institute of Medical Sciences & Krishna Hospital. Karad, India Ph id -tata.sunita@yahoo.in usually pay less attention to their children thinking that they are grownups. Oral health for healthy life Maintaining good oral hygiene is the most simple, economical way for a happy, healthy smile. It is easy to understand why oral hygiene is important. But poor oral hygiene can cause problems throughout the rest of body. Oral hygiene promotes a pretty mouth. Practicing good oral hygiene helps to preserve natural good looks. Smile is one of the first things that people notice and poor oral hygiene can speak volumes in an instant. Practicing good oral hygiene is the foundation of preventive dentistry, whose goal is to maintain healthy teeth and gums, and to prevent oral illnesses. A proper diet and plaque control works against dental decay and keeps expensive repairs to mouth to a minimum. Practice of good oral hygiene will keep energy levels high. When there is an infection in the mouth, it can cause the immune system to be constantly elevated. This can affect energy levels, making a person more tired, as well as increasing susceptibility to other illnesses.

163 International Journal of Nursing Education. January-March 2015, Vol. 7, No Numerous recent studies have shown that ignoring oral hygiene could encourage heart disease and that there is a relationship between periodontal disease and a greater risk for developing problems with the heart and circulatory system. Poor oral hygiene can give systemic injuries. Pyorrhea is an infection of the gums and tooth-sockets. Pyorrhea is also the culprit of tooth loss. Bad breathe, also known as halitosis, is caused by poor oral hygiene. We travel into outer space, to the depths of the oceans, and can communicate almost instantly with just about anywhere on the planet, but we cannot maintain good oral hygiene. OBJECTIVES OF THE STUDY To assess the knowledge regarding practices of oral hygiene among children before planned teaching. To assess the knowledge regarding practices of oral hygiene among children after planned teaching. To compare the pre-test and post-test knowledge regarding practices of oral hygiene among children. To determine the association of knowledge regarding practices of oral hygiene among children with selected demographic variables. RESEARCH DESIGN: Pre and post test design SETTING OF THE STUDY: The study was conducted in three selected schools in Pune City. 1. Late rambhau mhalgi foundation purna prathmic vidyalaya.katraj pune. 2. Hujurpaga katraj prathmic shala,katraj pune. 3. Late. hiraman bankar vidyalaya,katraj pune. 4. Rajashree shahoo vidyamandir.ambegaon pune. Research Methodology: In the present study the investigator selected the pre test- post-test method. Keeping in view the objectives of the study, the investigator, gave the pre-test to the group prior to intervention. The intervention planned health teaching was given and same group was again assessed (the post-test)after7days. Plan for data Analysis Descriptive statistics:percentage,mean and standard deviation. Inferential statistics: paired t test. Major Findings of the study The analysis of the data revealed following findings. Table 2: Distribution of knowledge regarding practices of oral hygiene among school children. S.no Knowledge Score Pre Test N=100 Post Test N=100 Frequency Percent Frequency Percent 1 Poor(0-6) Good(7-15) Excellent(16-20) The above table shows that 71 percentages of children scored between 7-15 in pre test of knowledge regarding practices of oral hygiene while all 100 children scored between in post test of knowledge regarding practices of oral hygiene. Table No. 3. Distribution of mean, S.D. pre and post planned health teaching knowledge regarding practices of oral hygiene among school children S.No Characteristics Pre Test Scoren=100 Post Test Score N=100 Mean S. D. Mean S. D. 1 knowledge score The above table shows that there is a significant difference in the mean score of knowledge regarding practices of oral hygiene among school children before and after planned health teaching. The score of knowledge regarding practices of oral hygiene among school children has increased from mean score to

164 156 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table No. 4. Paired sample tests for knowledge regarding practices of oral hygiene among school childrenoral hygiene among school children S.No. Pair Paired difference T Value df P Value Mean S.D. S.E.Mean 1 knowledge score * *p< 0.05 The above table shows that Knowledge regarding practices of oral hygiene before and after planned health teaching of 100 observations with a difference mean of 11.96, standard deviation of and standard error mean is.21552; the computed t test statistic equals Since the P-value for the test is less than 0.05, the null hypothesis is rejected at the 95.0% confidence level. It shows that the planned health teaching is effective for improving the knowledge regarding practices of oral hygiene among school children. CONCLUSION This clearly indicates that planned health teaching on knowledge regarding practices of oral hygiene is effective in increasing the knowledge regarding practices of oral hygiene in school children. Acknowledgement: I heartfelt thanks to all those who helped completing my research study especially all the principals from school and school children. Conflict of Interest: None. Ethical Clearance: Yes, ethical clearance is obtained. Source of Funding: Self REFERENCES 1. Andrews GJ, Brodie DA, Andrews JP, Hillan E, Gail Thomas B, Wong J, Rixon L 2006 Professional roles and communications in clinical placements: a qualitative study of nursing students perceptions and some models for practice. Int J Nurs Stud. Sep;43(7): Almas K, Albaker A, Felembam N. 2000; Knowledge of dental health and diseases among dental patients, a multicentre study in Saudi Arabia. Indian J Dent Res. Oct-Dec; 11(4): Al-Otaibi M, Angmar-Månsson B. 2004; Oral hygiene habits and oral health awareness among urban Saudi Arabians. Oral Health Prev Dent.;2(4): Amin MS, Harrison RL 2006 Change in parental oral health practices following a child s dental treatment under general anaesthesia. Eur Arch Paediatr Dent. Jun;7(2): Blinkhorn AS, Wainwright-Stringer YM, Holloway PJ. 2001; Dental health knowledge and attitudes of regularly attending mothers of highrisk, pre-school children. Int Dent J. Dec;51(6): Bhowate RR, Borle SR, Chinchkhede DH, Gondhalekar RV Dental health amongst year-old children in Sevagram, Maharashtra. Indian J Dent Res. Apr-Jun;5(2): Best W.J and Khan J.V, (1992), Research in education, 5 th edition, Prentice hall of India, New Delhi. 8. Bedi R, Quarrell I, Kippen A The dental health of 10-year-old children attending multiracial schools in Greater Glasgow. Br Dent J. Mar 9;170(5): Blinkhorn AS, Wainwright-Stringer YM, Holloway PJ.Finlayson TL, Siefert K, Ismail AI, Sohn W Maternal self-efficacy and 1-5-yearold children s brushing habits.community Dent Oral Epidemiol. Aug;35(4): David J, Wang NJ, Astrøm AN, Kuriakose S Dental caries and associated factors in 12-yearold schoolchildren in Thiruvananthapuram, Kerala, India. Int J Paediatr Dent. Nov;15(6):

165 International Journal of Nursing Education. January-March 2015, Vol. 7, No Mahesh Kumar P, Joseph T, Varma RB, Jayanthi M 2005 Oral health status of 5 years and 12 years school going children in Chennai city - An epidemiological study. J Indian Soc Pedod Prev Dent. Mar;23(1): Poutanen R, Lahti S, Tolvanen M, Hausen H. 2006;Parental influence on children s oral healthrelated behavior. Acta Odontol Scand. ct; 64 (5): Sogi GM, Bhaskar DJ 2002 Dental caries and oral hygiene status of school children in Davangere related to their socio-economic levels: an epidemiological study. Indian Soc Pedod Prev Dent. Dec; 20(4): Okada M, Kawamura M, Kaihara Y, Matsuzaki Y, Kuwahara S, Ishidori H, Miura K. 14. Influence of parents oral health behaviour on oral health status of their school children: an exploratory study employing a causal modelling technique.int J Paediatr Dent Mar; 12(2):

166 158 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Development of Nursing Audit Tool to assess the Reproductive Child Health Services Provided by Nursing Personnel Based on the Records Maintained at Urban and Rural Health Centers Nandaprakash P 1, B S Hakuntala 2 1 Professor & HOD, Department of Community Health Nursing, Government College of Nursing Mysore Medical College and Research Institute, 2 Dean (Nursing), AECS Maaruti College of Nursing, Bangalore ABSTRACT Development of nursing (RCH) audit tool to assess the RCH services provided by nursing personnel based on the Records maintain at Urban and Rural Health Centers in Hassan District, Karnataka with following objectives. To Develop Nursing Audit Tool to Assess RCH services provided by Nursing Personnel based on their expected performance and to Audit the RCH service Records maintained by Nursing Personnel and also to assess the effectiveness of orientation programme on RCH services audit tool for Nursing Personnel at Urban and Rural Health Centers. Methodology: A Quantitative Retrospective and Prospective audit design was adopted for the study. The population was the RCH records maintained by FHWs working in PHCs of Hassan district Karnataka. Systematic Random sampling technique was used to audit RCH Records by using the prepared nursing (RCH) audit tool. Tool consists of 14 components with 575 items and 1150 scores. Tool Development: The content validity of the tool was 0.92 and discriminative index varied from 0.30 and 0.70 and difficulty index ranged from 0.39 and The reliability coefficient calculated by using Spearman Correlation Coefficient (test retest) method 'r' value was Internal consistency was tested by using coefficient alpha the value was Inter-rater reliability was found to be In retrospective audit 2042 in urban and 1822 records in rural health centers were audited, orientation and guidelines were provided to FHWs and after six months prospective auditing 946 in urban and 816 in rural areas RCH records were undertaken. Result: The study revealed that in urban health centres overall means score was 52.85% which was higher than the in Rural Health Centres 50.7%. The Wilcoxon Signed Rank Test Z value 3.10 indicated significant difference between Urban and Rural Audit Score at p <= 0.01 level. Whereas, in urban health centres the prospective audit score was 95.50% in which it was higher than the Retrospective Audit Score of 52.85%. The difference between the Retrospective and Prospective audit score was 42.65%, 'Z' value 3.30 is significant at p<= 0.01 level. In rural health centre the overall mean percent of retrospective audit score was 50.71% and prospective audit score was 93.78%. The difference between the Retrospective and Prospective audit score was percent. A Wilcoxon Signed Rank test Z value 3.31 in at p<= 0.01 level indicated statistical significance. Further, the Prospective Audit Score of RCH Services in urban Health Centers was 95.50% which was higher than the Prospective Audit score of Rural Health Centers 93.78%. The Wilcoxon Signed Rank Test 'Z' value 3.29 indicated significant difference between urban and rural area at p <= 0.01 level. Hence, the recording was better in the urban area. Outcome of the study is the nursing (RCH) audit tool to assess RCH services provided by FHWs which is valid, reliable, practicable acceptable and usable. Keywords: Audit, Reliability, Validity, Item Analysis, Retrospectives, Prospective Corresponding author: Nandaprakash P Professor & HOD, Department of Community Health Nursing, Government College of Nursing, Mysore Medical College and Research Institute, Irwin Road, Mysore Ph: , nandu8670@gmail.com. INTRODUCTION Nursing Audit is an important component of medical audit. Increase in the public awareness of their rights of safety and high cost of medical treatment

167 International Journal of Nursing Education. January-March 2015, Vol. 7, No necessitates that nurses should become more accountable for the care they deliver. 1 Nursing audit is one of the main tool to establish whether the best evidence is being used in nursing practice, as it compares actual practice to a standard of practice. Nursing audit identifies any gaps between what is done and what should be done and rectifies any deficiencies in the actual processes of care. 2 Audit is a quality improvement process that aims to improve client s care and outcomes by carrying out systematic review and implementing changes. It is central to the way in which services are monitored and standards changed to reflect best practice. 3 National audit provides a basis for establishing performance against national standards, benchmarking against other service providers and improving standards of care. For effective audit, clinical indicators are required that are valid, feasible to apply and reliable. 4 NEED FOR THE STUDY Audit can be a useful tool to measure, improve and monitor the quality of day-to-day obstetric practice. Nurses and doctors working in maternity units should consider the use of audit to improve quality of care from the women/mothers view. 5 Nursing Audit tool is an innovative tool that provides a way to independently assess the quality of RCH services. Hence the researcher developed nursing audit tool, to improve patient care, demonstrate deficiencies in the RCH services, encourage total coordination of health team planning for patient care, improves communication between all departments and services. MATERIAL AND METHOD Statement of the Problem Development of Nursing Audit Tool to Assess RCH services provided by Nursing Personnel based on the Records Maintained at Urban and Rural Health Centers. OBJECTIVES 1. To Develop Nursing Audit Tool to Assess RCH Services provided by Nursing Personnel based on their expected performance at Urban and Rural Health Centers. 2. To Audit the RCH Services Records maintained by Nursing Personnel at Urban and Rural Health Centers. 3. To assess the effectiveness of orientation programme on RCH Services audit tool for Nursing Personnel at Urban and Rural Health Centers. HYPOTHESES H 1 :- The Mean Retrospective Audit Scores of Urban Health Centers in RCH Services is significantly higher than the Mean Audit Score in rural Health Centers. H 2 :- The Mean Prospective Audit Scores of RCH Services is significantly higher than the Mean Retrospective Audit Score in Urban Health Centers. H 3 :- The Mean Prospective Audit Scores of RCH Services is significantly higher than the Mean Retrospective Audit Scores in Rural Health Centers. H 4 :- The Mean Prospective Audit Score of Urban Health Centers in RCH Services is significantly higher than the Mean Audit Score in Rural Health Centers. Delimitations The study was delimited to Assess RCH service records maintained at Urban and Rural Health Centers by FHWs in Hassan District. METHODOLOGY The Evaluative research approach and Quantitative Retrospective and Prospective audit design was used for the study. The study was conducted in 5 urban and 12 rural health centers in four taluks of Hassan district in Karnataka. The samples are RCH Service Records maintained by FHW s in selected health centers which were selected by systematic random technique. Sample Size The sample size for Retrospective audit in Urban

168 160 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Health Centers 2042 Records and in Rural Health Centers 1822 Records for Prospective audit 946 records in Urban Health Centers and 816 Records in Rural Health Centers. Ethical Consideration The study was approved by the research committee and consent was obtained from the FHWs. Data Collection Instrument: It consists of general information of health centre and 14 RCH Service components. In total there were 575 items with maximum score of 1150, each item has three options like Performed, Partially Performed and Not Performed. For each performed activity 2 scores for partially performed 1 score and if not performed 0 score was awarded. FINDINGS Content validity index of the tool was The items in the prepared tool had a discriminative value of 0.30 to The item difficulty value ranged from 0.39 to The r value of Test-Retest Reliability Coefficient was Internal consistency ((split half-method) of the tool was ( r ). The reliability of Cronbach s Alpha value was The Interrater Reliability value was Retrospective audit scores on RCH services in urban health centre ranged from 47 to 66%. The highest 66 % was in immunization services with mean and SD of ± 3.64 and the lowest 47 % with mean and SD of ± 1.08 in RTIs and STIs Services. Retrospective Audit on RCH Services in Rural Health Centre the scores ranged from 46 to 65 %. The highest 65 % was in immunization services with mean and SD of ± 3.52 and the lowest 46 % with mean and SD of ± 1.11 in RTIs and STIs Services. Z value of retrospective audit scores on RCH services in urban and rural health centre were higher ranged from 9.50 to whereas the mean retrospective score in rural ranging from 9.20 to The Wilcoxon Signed Rank test Z value indicated a significant difference at 0.01 levels; hence the recording was better in the urban areas. After six months of orientation, prospective audit was undertaken in both urban and rural health centers to evaluate the effectiveness of orientation programme six months RCH records related to 1 st March 2011 to 31 st August 2011 were audited in rural and in urban health centers from 1 st October 2011 to 30 th October 2011 (52 days). Prospective Audit scores on RCH Services in Urban Health Centre ranged from 92 to 98%. The highest recorded was 98% in Referral Services and the lowest 92% in maintenance of death register. Prospective Audit on RCH Services in Rural Health Centre the scores ranged from 91 to 96%. The highest 96% was observed in Antenatal services, postnatal services, Referral Services and Management of Respiratory Tract Infections and the lowest 91% was observed in maintenance of death register and safe abortion services. Z value of prospective audit of urban and rural health centres, the mean score of Prospective Audit in urban area were higher ranged from to Whereas the mean Prospective score in rural ranged from to Wilcoxon Signed Rank test Z value indicated 3.29 significant at 0.01 level in all areas. the difference in Retrospective and Prospective audit scores in urban health centre indicated that highest percentage of improvement 49 percent was observed in cancer and infertility and referral services and lowest improvement of 29 percent in immunization services. Retrospective and Prospective audit score in Rural Health Centre indicated that highest percentage of improvement 47 percent was observed in Cancer & Infertility and Referral Services. Z value of retrospective and prospective audit scores in urban health centre.

169 International Journal of Nursing Education. January-March 2015, Vol. 7, No Table 1: Z Value of retrospective and prospective audit scores in urban health centre Components of RCH Services Retrospective Prospective Wilcoxon Signed Rank Test Z Value Max Score Mean Sd Mean Sd Antenatal Services ** Intra-natal Services ** Postnatal Services ** Family Welfare Services ** Safe Abortion Services ** Rtis And Stis Services ** Cancer & Infertility ** Referral Services ** Death Register ** Immunization Services ** Supplementation Of Vitamin-a Services ** Management Of Diarrhoea ** Management Of Respiratory Tract Infections ** Adolescent Health Services ** Total ** ** Significant At 0.01 Level Ns : Non-significant The data presented table - 1 shows that in urban overall components of RCH services, the mean score of prospective audit were higher ranged from to Whereas the mean scores in retrospective data audit score were ranged 9.50 to Wilcoxon Signed Rank test Z value 3.30 was significant at 0.01 level in all areas. Z value of retrospective and prospective audit scores of rural health centre Table 2: Z value of retrospective and prospective audit scores of rural health centre Components of RCH Services Retrospective Prospective Wilcoxon Signed Rank Test Z Value Max Score Mean Sd Mean Sd Antenatal Services ** Intra-natal Services ** Postnatal services ** Family Welfare Services ** Safe Abortion Services ** RTIs and STIs Services ** Cancer & Infertility ** Referral Services ** Death Register ** Immunization Services ** Supplementation of Vitamin-A Services ** Management of Diarrhoea ** Management of Respiratory Tract Infections ** Adolescent Health Services ** TOTAL ** ** Significant at 0.01 level NS :Non-significant

170 162 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 The table - 2 shows that the component wise comparison of retrospective and prospective audit scores of rural health centre on RCH Services, the mean score of prospective audit score was higher ranging from to in all the areas where as the mean score in retrospective audit was ranging from 9.50 to The data presented in the table shows the Z value 3.31 were significant at p<=0.01 level in all areas. Overall mean difference between the Retrospective and Prospective Audit Scores on RCH Services in Urban and Rural Health Centre Table 3: The Overall Difference Between Retrospective and Prospective Audit Scores on RCH Services in Urban And Rural Health Centers Retrospective Prospective Difference Wilcoxon Signed Rank test Z value N Mean% SD N Mean% SD Mean SD Urban ** Rural ** ** Significant at 0.01 level NS = Not Significant The table 3 and Fig - 1 reveals that in urban health centers obtained retrospective audit in mean scores was 53% and SD was In the prospective audit score was 95.50% with SD The difference between the Retrospective audit and prospective audit score was 42.65% with SD It is evident that the calculated Z value 3.30 in at p<= 0.01 level indicate statistically significant. In rural health centre retrospective audit score was 50.71% and SD was 4.79 in the prospective audit score it was 93.78% with SD of The difference between the Retrospective audit and prospective audit score was 43.07% with SD It is evident from the calculated Z value was 3.30 in at p<= 0.01 level indicate statistically significant. The difference between Retrospective and Prospective score was a true difference and not a chance difference. This indicates that the nursing audit was significantly effective in improving the recording of RCH Services provided. HYPOTHESIS H 1 : The Mean Retrospective Audit Scores in Urban Health Centers of RCH Services is significantly higher than the Mean scores of Rural Health Centers. The Retrospective Audit Score of RCH Services was found to be 52.85% in Urban Health Centre which was higher than the in Rural Health Centre 50.71%. The Wilcoxon Signed Rank Test Z value was 3.10 indicated significant difference between Urban and Rural Audit Score at p <= 0.01 level. Hence, the above research hypothesis is accepted. H 2 :- The Mean Prospective Audit Score of RCH Services is significantly higher than the Mean Retrospective Audit Score in Urban Health Centers. In Urban Health Centre the Prospective Audit Score of RCH Services was found to be 96% in which it was higher than the Retrospective Audit Score of 53%. The Wilcoxon Signed Rank Test Z value was 3.30 indicated significant difference between Retrospective and Prospective audit at p <= 0.01 level. Hence, the above research hypothesis is accepted. H 3 :- The Mean Prospective Audit Score of RCH Services is significantly higher than the Mean Retrospective Audit Score in Rural Health Centers. The Prospective Audit Score of RCH Services in Rural Health Centers was 94% which was higher than the Retrospective Audit score of 51%. The Wilcoxon Signed Rank Test Z value was 3.30 which indicated significant difference between Prospective and Retrospective audit at p <= 0.01 level. Hence, the above research hypothesis is accepted. H 4 : The Mean Prospective Audit Scores in Urban Health Centers of RCH Services is significantly higher than the Mean scores of Rural Health Centers. It can be inferred that Prospective Audit Score of RCH Services in Urban Health Centre which was found to be 95.50%, was higher than the Prospective

171 International Journal of Nursing Education. January-March 2015, Vol. 7, No Audit Score in Rural Health Centre 93.78%. The data computed for statistical Wilcoxon Signed Rank Test Z value is 3.29 which indicated significant difference between Urban and Rural Audit Score at p <= 0.01 level. Hence, the above research hypothesis is accepted. CONCLUSION Recommendations: Periodical review of the tool is an essential component based on the policies and norms of Union Government and State Government. Acknowledgement: My sincere thanks to Government of Karnataka and Vinayaka Mission University for granting me permission and providing necessary facilities for conducting the study. Conflict of Interest: Nil Source of Funding: Self REFERENCES 1. Reena Jairus, Indarjit Walia (2011). Nursing Audit, Trained Nurses Association of India, 2011 June, volume. CII No Braithwaite J & Travaglia J.F. (2008). An overview of clinical governance policies, practices and initiatives. Australian Health Review 2008; 32(1): Stewart M.J & Craig D. (1988). Adaptation of the Nursing Audit to Community Health Nursing. Nursing Forum, 23 (4), Travaglia J & Debono D. (2009) Clinical audit: a comprehensive review of the literature. Centre for Clinical Governance Research in Health, UNSW, Eugene Justine Kongnyuy, Achille Kabore & Pierre-Marie Tebeu. (2009). Clinical Audit to Improve Obstetric Practice: What is the evidence? Clinical Audit, 11. Ethical Clearance: Obtained.

172 164 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Effectiveness of Planned Teaching Programme on Knowledge of Staff Nurses Regarding Human Papilloma Virus and its Vaccine Mikki Khan 1, Manju Chhugani 2, Smriti Arora 3 1 Tutor, 2 Principal, 3 Asisstant Professor, Rufaida College of Nursing, Jamia Hamdard, New Delhi ABSTRACT Background: Cancer of the cervix uteri is the most common female cancer in developing countries. Cervical cancer is preventable and is highly suitable for Primary Prevention. Education, practice of sexual hygiene, use of barrier contraceptives, ritual circumcision, screening of high risk cancer cervix groups and improving socio economic status can reduce the incidence of cervical cancer morbidity and mortality rate significantly. Objective: Majority of the staff nurses, have no knowledge about the cervical cancer, HPV, and the role of the vaccine in preventing cervical cancer. Since cancer of cervix is preventable with education about pap smear test and use of vaccine, thus the staff nurses must be knowledgeable about this entity. Staff nurses are important care givers in the hospital and community settings, if their knowledge is improved regarding HPV and its vaccine, they will educate the women, her family and community at large. In this context, we attempted to study the effectiveness of a planned teaching programme regarding knowledge of staff nurses regarding HPV and its Vaccine so that knowledge gained from this study can be utilized to make effective public health programmes. Method: The study followed a pre experimental, one group pre-test, post-test design. A sample of 30 staff nurses was selected by purposive sampling technique working in HAHC Hospital. The data was collected by using structured knowledge questionnaire. A Planned Teaching Programme (PTP) on Human Papilloma Virus and its vaccine was developed and administered to the group. The independent variable under study was the PTP and the dependent variable were the knowledge scores of staff nurses working in HAHC Hospital. Results: The data obtained was analyzed by using the descriptive and inferential statistics. The findings revealed that initially there was deficit in knowledge of the staff nurses (mean=24.66, SD=6.9), but after administration of PTP the post-test scores (mean=35.4,sd =5.8 ) in terms of knowledge were significantly higher than the pre-test scores (p?0.05). This indicates that the PTP on Human Papilloma Virus and its vaccine was effective in improving the knowledge of staff nurses. Conclusion: On the basis of the findings of the study it is concluded that PTP on HPV and its vaccine was effective in increasing the knowledge of staff nurses. Keywords: Planned Teaching Programme, Knowledge, HPV, Staff Nurses INTRODUCTION Human papillomaviruses (HPV) are common viruses that can cause warts. There are more than 100 types of HPV. Most are harmless, but about 30 types puts an individual at risk for cancer. These types affect the genitals and is spread through sexual contact with an infected partner. They can be either low-risk or highrisk. Low-risk HPV can cause genital warts. High-risk HPV can lead to cancers of the cervix, vulva, vagina, and anus in women. In men, it can lead to cancers of the anus and penis. Although some people develop genital warts from HPV infection, others have no symptoms. In women, Pap smears can detect changes in the cervix that might lead to cancer. Correct usage of latex condoms greatly reduces, but does not eliminate, the risk of catching or spreading

173 International Journal of Nursing Education. January-March 2015, Vol. 7, No HPV. Vaccines can protect against several types of HPV, including some that can cause cancer. 1 Staff nurses need access to adequate information about HPV and the vaccination. It is important for them to know that : HPV is transmitted through sexual activity and has a lifetime risk of 75-80%; that although HPV infections are common, most infections clear within 2 years; that an HPV infection is a necessary factor in the development of cervical cancer; and that the vaccine does not provide full protection against HPV infections (it does protect against HPV 16 and 18 which are responsible for 71% of all cervical cancers). Furthermore, a positive association has been found between knowledge on HPV and uptake. 2 Although knowledge on vaccine has been assessed among women and adolescents, the impact of a planned teaching programme on knowledge among staff nurses young adolescents has not yet been examined. This study assesses the extent to which staff nurses knowledge levels about HPV vaccination increase after the implementation of a PTP. OBJECTIVES To develop a Planned Teaching Programme on HPV and its vaccine. To evaluate the knowledge of staff nurses before and after administration of Planned Teaching Programme on HPV and vaccine. To find association between knowledge scores of staff nurses reporting HPV and its vaccine with selected demographic variables like age, professional qualification and work experience. METHODOLOGY Research Approach and Design: a quantitative (experimental) research approach was adopted. The research design selected for the present study is one group pre-test post-test design. Research Setting: The study was carried out at HAHC Hospital, Jamia Hamdard New Delhi. Population: In the present study, population comprised of staff nurses, who were working in HAHC hospital. Sample and sampling - The sample for this study comprised of 30 staff nurses working in HAHC hospital selected by purposive sampling. Sampling criteria -The inclusion criteria for staff nurses was: Staff nurses willing to participate in the study. Staff nurses available during the data collection period. Staff nurses able to understand English language. DATA COLLECTION TOOLS AND TECHNIQUES The following tool was developed in order to generate data 1. A structured knowledge questionnaire to assess the knowledge of staff nurses working in HAHC Hospital, regarding HPV and its vaccine. 2. Development of a PTP on HPV and its vaccine. Structured Knowledge Questionnaire (SKQ) SKQ was prepared by the researcher to assess the knowledge of staff nurses working in HAHC Hospital regarding the HPV and its vaccine. The selection of the content for a structured knowledge questionnaire was based on the review of literature, opinion of experts, informal discussion with peer group, which helped to determine the important areas to be included. The major steps taken for the development of the structured knowledge questionnaire were 1. Planning the structured knowledge questionnaire 2. Item construction 3. Establishing reliability and validity SKQ consisted of 3 sections Section I: It consisted of six items, to collect information on demographic data of the study participants. The characteristics included age, professional qualification, duration of experience in the hospital, duration of experience in HAHC Hospital, and any special training, in-service education related to HPV Vaccine. Section II: It consisted of 30 items, on various aspects of Human papilloma virus and its vaccine. The items were dichotomous questions or true/false items. Section III: It consisted of total 15multiple choice questions (MCQS). Each question had only one correct response.

174 166 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Content Validity: SKQ was submitted to seven experts including experts from field of nursing, doctors and expert as child birth educator. All the experts agreed 100% to the correct response listed in the structured knowledge questionnaire. The mean percentage of agreement for items from experts was 94.6% as determined with the criteria rating scale. Reliability of the Tool: The structured knowledge questionnaire was administered to five staff nurses in a selected hospital of Delhi to establish the reliability. The Kudar Richardson (KR-20) formula was used to calculate the reliability coefficient. The value of r was found to be 0.91 indicating high reliability of the tool. Scoring: The answer key was prepared for scoring the responses. The marking scheme was then specified i.e. a score of 70% and above was considered adequate knowledge and below 70% as inadequate knowledge. RESULTS Table 1: Frequency and percentage distribution of demographic characteristics of staff nurses. n=30 Sample Characteristics Frequency Percentage Age ( years) Professional Qualification General Nursing and Midwifery B.Sc. Nursing 6 20 Post Basic B.Sc. Nursing Professional Experience of Working in Hospital (years) 5-Jan Jun Nov Exposure to Inservice Education on HPV and its vaccine Yes No As shown in a total of 30 staff nurses participated in the study. Maximum number of staff nurses (53.3%) were in the age group of years, followed by 33.3% in the age of years, and 13.3% were in the age group of years. With regards to professional qualification of the subjects 66.6% (20) were GNM, 20%(6) B.Sc. nursing and 13.3%(4) Post Basic nursing respectively. Maximum number of staff nurses 60%(18) had 6-10 years followed by 13.3% (4) who had years of experience. Data reveals that only 16.6% of the staff nurses attended the in service education on HPV and its vaccine. Table 2: Frequency and Percentage of staff nurses based on knowledge scores before and after administration of PTP on HPV and its vaccine. Before PTP After PTP Category of knowledge Frequency Percentage Frequency Percentage Inadequate(0-70%) Adequate(>70%) n=30

175 International Journal of Nursing Education. January-March 2015, Vol. 7, No Data presented in table-2 indicates that before the administration of PTP only eight (26%) staff nurses were having adequate knowledge and 22 (73%) of the staff nurses were having inadequate knowledge. After the administration of PTP on HPV and its vaccine, only four (13%) were having inadequate knowledge and 26 (86%) were having adequate knowledge. Table3: Mean, median, standard deviation of pre-test and post test, knowledge scores of staff nurses. n=30 Range of obtained score Mean Median SD Pre test Post- test Maximum scores=45 3. Data presented in table-3 indicates that mean posttest knowledge score (35.4) of staff nurses regarding HPV and its vaccine was higher than the mean pre-test knowledge score(24.66) of staff nurses regarding HPV and its vaccine. Table 4: Mean, Mean difference, Standard deviation of difference, standard error of mean difference from pre-test and post-test knowledge score and t value obtained by nurses regarding HPV and its vaccine Mean Mean S.D t Value df difference Difference Pre-test * 29 Post-test 35.4 * significant at 0.05 level 4. The data presented in table-4 shows that mean post-test knowledge score was higher than mean pre-test knowledge score(24.66) of staff nurses regarding HPV and its vaccine with a mean difference of This obtained mean difference is found to be statistically significant as evident from t value. Thus, the difference obtained in the mean pre-test and post-test knowledge score is a true difference and not by chance. This reveals that the PTP developed regarding HPV and its vaccine was effective in improving the knowledge of staff nurses. CONCLUSION The following conclusions were drawn from the findings of the study: 1. Staff nurses working in HAHC Hospital were deficit in knowledge regarding HPV and its vaccine as assessed from the pre-test knowledge scores. 2. PTP was effective in improving knowledge of staff nurses working in HAHC Hospital as assessed from post-test knowledge score. 3. Knowledge and selected demographic variable of Staff nurses on Human papilloma virus after administration of PTP were not having significant association. The findings concluded that the PTP developed by the researcher was effective in improving the knowledge of staff nurses working in HAHC Hospital, regarding HPV and its vaccines. DISCUSSION The study reveals that staff nurses had low knowledge score regarding HPV and its vaccine. The finding of the data present indicated that there was improvement in the knowledge of staff nurses regarding HPV and its vaccine after the administration of PTP. The finding of the study are to some extent consistent with the study done by Ling WY 3 who conducted a study to assess teachers knowledge and perception of HPV, cervical cancer and HPV vaccine and concluded that 46.1% had never heard of HPV while 50.9% had never had a pap smear. However, 73.8% have heard of the HPV vaccine with

176 168 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 75% agreeing to have it. Ilter et al also concluded in their study that the professionals should be educated and trained about HPV, vaccination, and its relation with cervical cancer to increase the knowledge about it. 4 Implications of the Study Nursing is a profession and it must advance to the extent that it keeps pace with the advancing technology, innovations in practice and the growing needs of the consumers. With the changing trends in maternity, it is imperative for staff nurses to keep abreast with the changes. Limitations The study was conducted on small numbers of staff nurses due to limited time frame. Due to time constraint, no attempt was made to measure the retention of knowledge of the staff nurses, through retesting which limits the generalization of the study. Recommendations On the basis of the study, following recommendations are offered for future research The study can be replicated on a large sample to validate and replicate it s findings. A similar study can be done on obstetricians and other health personnel dealing with health problems of women. A similar study can be carried out in community setting. An exploratory study can be done to identify various factors responsible for the deficiency in knowledge of staff nurses regarding HPV infection and its vaccination. Acknowledgement: The author is thankful to all the staff nurses who participated in the study and Dr. Wasim for rendering statistical guidance Conflict of Interest: None. Source of Funding: This study was self financed as it was conducted as part of partial fulfillment of the requirements for the degree of M.Sc. Nursing Ethical Clearance: Ethical permission was taken from Jamia Hamdard Institutional Review Board. The study was conducted keeping all the ethical issues in mind. Consent was taken from all the samples of the study. The information provided by the sample was kept strictly confidential and were used for the purpose of research only. REFERENCES 1. HPV. Accessed from: medlineplus/hpv.html 2. Robine Hofman, Puck AWH Schiffers, Jan Hendrik Richardus, Hein Raat, Inge MCM de Kok, Marjolein van Ballegooijen and Ida J Korfage. Increasing girls knowledge about human papillomavirus vaccination with a pretest and a national leaflet: a quasi-experimental study. BMC Public Health 2013, 13: Ling WY, Razali SM, Ren CK, Omar SZ. Does the success of a school-based HPV vaccine programme depend on teachers knowledge and religion? A survey in a multicultural society. Asian Pac J Cancer Prev. 2012;13(9): Ilter E, Celik A, Haliloglu B, Unlugedik E, Midi A, Gunduz T, Ozekici U. Women s knowledge of Pap smear test and human papillomavirus: acceptance of HPV vaccination to themselves and their daughters in an Islamic society. Int J Gynecol Cancer Aug;20(6): doi: / IGC.0b013e3181dda2b9.

177 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Recurrent Miscarriages: Causes, Management and Impact by Applying the Transactional Model of Stress Shahnaz Anwar 1, Rafat Jan 2 1 Instructor, 2 Associate Professor, Affiliated with the Aga Khan University Hospital School of Nursing and Midwifery, Stadium Road, Karachi, Pakistan ABSTRACT The term recurrent miscarriage includes all pregnancy losses from the time of conception until 24 weeks of gestation.1 Miscarriage is a multifaceted biologic and psychological experience, affecting 1% of couples trying to conceive. The purpose of this paper is to discuss about the causes, impact, and management of recurrent miscarriage by using the transactional model of stress. The exact cause of miscarriage is unknown; but, increased anticardiolipin antibodies, increased maternal age translocation of parental chromosomes, anatomical variation such as septate uterus, and presence of genital tract infections can lead to miscarriage. It is a stressful event; and, women respond to it in a variety of ways. Some woman may end up in having altered marital relationships, and others may suffer from psychological problems such as sadness, anger, guilt, anxiety, and lack of interest. Thus, this puts the burden on the health care providers to identify and address medical and psychological issues; and encourage for follow-up counseling that is required to minimize discomfort and enhance coping strategies for living a happy life. Keywords: Recurrent Miscarriage, Transactional Model of Stress, Biological and Psychological Experience, Counseling, Coping Strategies INTRODUCTION A flower bloomed already wilting. Beginning its life with an early ending. (R.J. Gonzales) Life is full of surprises; and, out of those some bring happiness while some leads to sorrows. The news of having a baby makes the couple feel excited; but, to miscarry is a tragedy. The purpose of this paper is to discuss about the causes, impact, and management of recurrent miscarriage by using the transactional model of stress. Recurrent miscarriage is defined as the loss of three or more consecutive pregnancies. 1 Recurrent miscarriages affect 1% of couples who are trying to conceive; and, about 80% of miscarriages occur within the first trimester. Approximately 1 to 5 percent of pregnancies are lost at 13 to 19 weeks ; and, approximately 5% of couples trying to conceive have two consecutive miscarriages. 2 Moreover, approximately 1% of couples have 3 or more consecutive losses. The risk of pregnancy loss after 3 successive abortions is 30-45%. Age-related risk of miscarriage in years is 11-14%, years is 15-25%, years is 51%, and, e 45 years is 93%. 3 CASE PRESENTATION A 38 years old lady presented in the obstetric clinic with an 8 weeks pregnancy, gravida 5, para 1+3. Her obstetrical history showed 3 consecutive miscarriages (2005, 2006, 2007); and, she had only 1 alive baby boy born in During her last pregnancy, she took tablet ascard from first till eighth month. Her laboratory reports showed anticardiolipin antibody (Lupus Anticoagulant) IgG: 4.8 (<5), cardiolipin autoantibodies IgM: 3 (<3). DISCUSSION Transactional Model of Stress The causes, impact and management of recurrent miscarriages will be discussed by applying the transactional model of stress given by Lazarus and Folkman (1984). 4 Stress is a two way process; because, the environment produces stressors and the individual finds ways to deal with these. 4

178 170 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Therefore, recurrent pregnancy loss due to any of the above mentioned causes can lead to negative stress. Primary Appraisal of the Stressor In the above mentioned case, the couple had altered marital relationships, the woman was blamed for the loss; and she ended up in having psychological problems such as depression, bereavement and anxiety. During the primary appraisal the person appraises the situation as threatening, good, or harmful. Secondary appraisal can cause a primary appraisal; because, it includes feelings of being helpless and not being able to cope with the problem. 4 Stressor Literature suggests that increased antiphospholipid antibodies cause an antibody response against the phospholipids of the cell wall. As a result, it inhibits the trophoblastic function, and results in a local inflammatory response leading to the formation of thrombosis in the uteroplacental vasculature. As a consequence, due to decreased or diminished blood flow to the fetus, miscarriage occur or if the pregnancy continues; so there are high chances of intra uterine growth restriction. 5 In this case, the cause of recurrent miscarriage was the presence of increased anticardiolipin antibody. 5 to 15% of woman with recurrent miscarriages have high antiphospholipid antibodies. 6 Increased maternal age is also associated with a decline in quantity and quality of the remaining oocytes; thus, resulting in miscarriages. 3 As in this case, age of the patient could also be the other causative factor of miscarriage. The other causes can be the presence of robertsonian translocation of parental chromosomes that results in an inherited thrombophilic defect; and cause systemic thrombosis. 7 Septate uterus can lead to improper implantation of the embryo. Cervical weakness can increase the chances of second-trimester miscarriages. 8 In addition; the presence of bacterial vaginosis in the first trimester can be a risk factor for second-trimester miscarriage and preterm delivery. 9 Why is woman blamed when she miscarries? She is asked for what went wrong and why she did not take care of herself. In fact, why will a mother be happy when she miscarries? It is a very traumatic condition for her; because, as she conceives she has an emotional as well as a physical attachment with her baby from the first day. As days pass, this attachment becomes stronger and deep rooted. The feeling of being a mother makes her very special. She always chooses the best for her baby and waits for that special moment when she will deliver and hold her baby in her arms. Hence, no mother can be the enemy of her baby. But, studies suggest that, as a result of recurrent miscarriages, at times husband also held her wife responsible for losing the baby. 10 Sense of loss and feeling of inadequacy is very common after miscarriage. 11 Moreover, the marital relationship gets adversely affected and sexual changes occur. 12 In fact, to conceive is the result of the mutual act between the couple; thus, husband is equally responsible for the health and wellness of the baby. Poor quality of the marital relationship is associated with impaired psychological adjustment among women. 13 Furthermore, studies suggest that depression, bereavement and anxiety can occur; but, women are significantly more distressed than men. 13 It is important to identify the psychological factors related to miscarriage; because, those factors can present a threat to mental health and well-being of the woman. 14 According to a study, 15 miscarriage is a stressful experience for women, and their partners. 16 Moreover, it also has an impact on the whole family. 17 As suggested by a study, 18 coping strategies should be explored, assisting to find out the positive aspects of that event, and making the individual to realize that life does not end here; but, there are still good things to come.

179 International Journal of Nursing Education. January-March 2015, Vol. 7, No Secondary Appraisal of the Stressor In secondary appraisal, the subject determines whether the individual can cope with the given stressor; or what are the alternatives? Even if the stressor is determined as harmful in the first stage; and, if the subject decides he/ she can cope with it, the stress will be kept at minimum. But, in this case, the woman was not able to cope; and, she needed care. Comprehensive management focusing on psychological support and follow-up counseling is important. Health practitioners should address medical and psychological issues by using different techniques. Open discussion will help to identify the cause, monitor progress and provide an opportunity to counsel about the future pregnancies. A couple may be comforted to know that they can conceive; and, risk of pregnancy loss after three abortions is 30-45%. Father and other family members should not be neglected as they may also need psychological counseling. It is necessary to explain them about the normal grief process; and, explore about the feelings of guilt and self-blame. Opportunity to discuss dissatisfaction with medical care should be provided; because, at times woman may blame her medical practitioner for the loss. Health professionals should avoid I m sorry, as this might link with an acknowledgement of guilt or negligence. Follow-up for six months should be encouraged; because, the woman/ couple may develop pathological grief leading to an onset of depressive illness. It is necessary to identify support group to talk about similar experiences. Moreover, folic acid supplementation and, lifestyle modification should be encouraged focusing on weight loss, healthy eating habits and exercise. 19 For this patient, to prevent reduced placental flow and placental infarction injection clexane and tablet aspirin can be given to reduce pregnancy loss by 54%. 2 Cervical cerclage can be done for a weak cervix; and, metroplasty can be done for a septate uterus. 2 CONCLUSION Recurrent miscarriage is a condition that has various causes and effect. It is important to explore woman s experiences about it and its impact on their marital relationships and psychological health. It is important to address medical and psychological issues. Open discussion about the loss should be encouraged, progress should be monitored and counseling and follow-up about future pregnancies should be done. Loss is about the servant s SABR and the Creator s LOVE. Allah Most High desires to love a person through their patient endurance as He said: {And Allah loves the saabirin} (3:146) and He is with them, supporting them: {Truly, Allah is with the saabirin} (2:153, 2:249, 8:46, 8:66). Acknowledgement: My faculty members and colleagues Conflict of Interest: Not any Source of Funding: Self Ethical Clearance: Client s right of privacy is maintained and informed consent taken from the client. REFERENCES 1. Royal Collage of Gynecology. The investigation and treatment of couples with recurrent firsttrimester and second-trimester miscarriage, Michels TC, Tiu, A Y. Second Trimester Pregnancy Loss. American Family Physician 2007; 76: Petrozza JC, Cowan BD. Recurrent early pregnancy loss Retrieved from emedicine.medscape.com/article/ overview 4. Lazarus R, Folkman S. Stress, appraisal and coping. New York: Springer Publishing Company, Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). Journal of Thrombotic Haemostasis 2006; 4: Reindollar RH. Contemporary issues for spontaneous abortion. Does recurrent abortion exist? Obstetric Gynecology Clinical North America 2000; 27: Scriven PN, Flinter FA, Braude PR, Ogilvie CM (2001). Robertsonian translocations reproductive risks and indications for preimplantation genetic diagnosis. Human Reproduction 2001;16: Triolo G, Ferrante ACF, Accardo-Palumbo A, Perino A, Castelli A, et al. Randomized study of

180 172 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 subcutaneous low molecular weight heparin plus aspirin versus intravenous immunoglobulin in the treatment of recurrent fetal loss associated with antiphospholipid antibodies. Arthritis Rheumatoid 2003;48: Leitich H, Kiss LH, Kiss H. Asymptomatic bacterial vaginosis and intermediate flora as risk factors for adverse pregnancy outcome. Best Practice Resident Clinic Obstetrics and Gynaecology 2007;21: Maker C, Ogden J. The miscarriage experience: more than just a trigger to psychological morbidity? Psychological Health. 2003;18: Rai R, Regan L. Recurrent miscarriage. Lancet 2006, 368: Serrano F, Lima ML. Recurrent miscarriage: psychological and relational consequences for couples. Psychology and Psychotherapy: Theory, Research and Practice 2006; 79: Kagami M, Maruyama T, Koizumi T, Miyazaki K,Nishikawa-Uchida S, Oda H, Uchida H, Fujisawa D, Ozawa N,Schmidt L, Yoshimura Y. Psychological adjustment and psychosocial stress among Japanese couples with a history of recurrent pregnancy loss. Human Reproduction 2012; Magee PL, Macleod AK, Tata P, Regan L. Psychological distress in recurrent miscarriage: the role of prospective thinking and role and goal investment. Journal of Reproductive and Infant Psychology 2003; 21: Moulder C. Towards a preliminary framework for understanding pregnancy loss. Journal of Reproductive and Infant Psychology 1994; 12: Puddifoot JE, Johnson MP. Active grief, despair, and difficulty coping: some measured characteristics of male response following their partner s miscarriage. Journal of Reproductive and Infant Psychology 1999; 17: Defrain J, Millspaugh E, Xie X. The psychosocial effects of miscarriage: implications for health professionals. Families, Systems and Health 1996; 14: James DJ, Kristiansen CM. Women s attributions to miscarriage: the role of attributions, coping styles, and knowledge. Journal of Applied Social Psychology 1995; 25: Boyce PM, Condon JT, Ellwood DA. Pregnancy loss: a major life event affecting emotional health and well-being. MJA 2002;176:

181 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Can Death of Women During Childbirth be Prevented- An Overview from Transcultural Perspective Zohra Kurji 1, Yasmin Mithani 1, Zahra Shaheen 2 1 Senior Instructor, Aga Khan University School of Nursing and Midwifery, 2BScN, Advanced Diploma in ECD, IBCLC, MSc in International Primary Health Care. Chief Operating Officer, Catco Kids ABSTRACT Childbirth is an extremely complicated phenomenon and poses many challenges for the new mother. Support system from multiple levels is required for saving the mother and child's lives and achieving a positive outcome. Cultural beliefs play a key role during the antenatal phase. While many beliefs are helpful, there may be a few values and beliefs, which might be even be life-threatening. As healthcare professionals, it is important to understand them in order to provide care and intervene accordingly, in order to save lives. This paper will analyze a case study using transcultural theory. Keywords: Childbirth, Antenatal Phase, Transcultural INTRODUCTION This is a true story of a 23 years old Ms X, prenatal lady brought in to emergency room to a government hospital of Karachi, Pakistan. She was 28 weeks pregnant and a 7 th gravida. She was married at the age of 13 and her husband was a twice her age (late 20s). She was presented with the history of fall due to vertigo and had Per Vaginal bleeding, low abdominal pain, backache with no fetal movement. Ms X, on having these symptoms, went to a nearby clinic where she was prescribed some pain killer and was sent back home. Due to lack of proper assessment, diagnosis of high risk pregnancy, negligence and failure for proper referral to be given proper care, she continued to bleed. Moreover, she wasn t taken to any maternal child health hospital by her family a member (mother in law) because of her husband was not at home. In our male dominate patriarchal society, head of the family usually a male have a very strong decision making role and makes most of the decisions. The women in the family have passive or no power in making personal decisions. The next day, the poor lady was rushed to the hospital in pain accompanied by her husband where ultrasound revealed single dead fetus of 28 weeks and retro placental clots, indicative of placental abruption. She was immediately admitted with the diagnosis of 28 weeks pregnancy with IUD (intra uterine death). On further assessment, it was found that Ms X didn t have any antenatal checkups nor was she takes any prenatal iron or calcium supplement, as motherin-law did not permit her to take any medicines in pregnancy( a very strong culture belief where pregnancy is consider a normal phenomena not requiring any tablets or medicines for it). As placental abruption had taken place, emergency caesarian section was planned so that the bleeding could be stopped and Ms X could be saved from fatal complications. But regrettably her husband didn t want to go for C-Section for a dead baby and that too with the male consultant who was the only surgeon available. I felt helpless for not being able to do anything for the lady. Despite all the efforts by other health care providers to explain her husband and seek his consent we could not convince him and Ms X died of profuse bleeding secondary to severe blood loss. I can never forget the face of Ms X, who gave her life owing to various socio cultural factors and lack of quality health care system. Analysis of this incident reveals a lot of socio cultural determinates affecting a Pakistani women life. In our society, many socio cultural factors such as women are not allowed to seek self care for health, are financially dependent on husband, feels lack of power in a family, needs permission to visit to a doctor, not allowed to go outside without her husband and had no right to see a male doctor. Hence, this is not just the case of poor

182 174 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 health care accessibility but also a cultural issue, which leads to the violation of women s right to make decisions for them self and their families. After analyzing the situation in depth, a lot of questions arise, like why did the Ms X die? Was the problem preventable? Who was responsible for her death? Did anybody explore her culture during pregnancy? Did she go for antenatal counseling? Was she educated about the complications of pregnancy? Why her husband did not support her? Why did she die when the health facility was accessible? Was she suppressed? Was she an educated person? What happened to her children? Did her husband realize that she could have been saved? Evaluation of the above situation reveals that there are lots of disciplines related to the situation like sociology, psychology, anthropology and epidemiology applicable to the scenario but this paper will focus on epidemiology and anthropology. Anthropology study of society considers cultural norms that were dominant in this scenario. I will integrate Leininger Theory of Trans Cultural Nursing to analyze and suggest solutions for the above situation with the help of the Sunrise Model. Epidemiological Perspective The Epidemiology discipline helps health professionals to have an in-depth knowledge about diseases and its application to important clinical issues. It trains individuals to have focused approach to the regional problems and needs. Maternal mortality, as defined by the World Health Organization (WHO) is the death of a woman during pregnancy, childbirth or in the 42 days of the puerperium, irrespective of the duration and the site of the pregnancy. 2 Analyzing the epidemiology of maternal mortality, shows that the death of a woman in pregnancy causes a lot of damage and vacuum in the family s life. Literature supports that pregnancy is not a disease, and pregnancy related morbidity and mortality is preventable. As stated by Begum S and Nisa A Half a million women die each year due to pregnancy related complications and 95% of them come from developing world. The lifetime risk of a woman dying of pregnancy related causes in developing countries is 1:40 as compared to 1:3600 in developed world. 4 Maternal mortality is one of the major primary care problems in Pakistan. Every year 30,000 women die because of pregnancy related complications. And they are all preventable causes. It is estimated that about 500 maternal deaths occur per 100,000 live births each year in Pakistan.4 The causes of maternal mortality in Pakistan are hemorrhages, hypertension, embolism, sepsis, abortions and obstructed labour. 4 One of the studies done in Pakistan by Jaffery (2002) shows that over 80% of the deaths were due to direct causes with hemorrhage being the most common, followed by eclampsia and sepsis. 4 After going through literature of epidemiology, I am able to relate that in the case described above, the cause of maternal death was hemorrhage and lack of prompt treatment due to socio cultural factors. Therefore the above literature on epidemiology of maternal mortality shows that the rate of maternal mortality is very high in Pakistan and sadly, this is a preventable problem. Anthropological Perspective: Anthropology is the study of humans in the broad sense 6. This field of ology provides an understanding of the norms and cultural beliefs that drive behavior of individual s family & countries. Therefore, medical anthropology, a sub division of anthropology, deals with the cultural norms and folks that form the health care and health seeking behaviors of certain cultural groups. In this situation, Ms X died because of strong culture values and norms of not leaving the house without the husband s permission, not to see a male doctor even in an emergency situation, not taking iron tablets in pregnancy. In addition, the mother did not go for antenatal checkups mainly because of cultural hindrances. Her death could have been prevented if the mother and her family had received antenatal counseling keeping in view the cultural factors. Leininger s (1991) theory of Cultural Care, which is explained through the Sunrise Model provides guidelines based on conceptual and theoretical underpinnings that explores the worldview, life ways, and cultural values of the people. 6 8 The Sunrise Model

183 International Journal of Nursing Education. January-March 2015, Vol. 7, No expresses anthropology via seven social structure factors that influence the client s health practices, these are technological factors, religious and philosophical factors, kinship and social factors, cultural values and life ways, political and legal factors, economical factors and educational factors. 7 9 Leininger s theory of cultural care, diversity and universality mostly talks about the impact of people s belief from different cultures on their health. In addition, it guides health care professionals in term of what kind of care people want from them as per their cultural norms. This theory is the broadest nursing theory because it highlights holistic perspective of human life including the social structure, cultural history, values, environmental factor, language expiration and folk. Leininger believes that health professionals should receive information of the patient from emic perspective (insider views), the beliefs of the people and not etic view (outsider s knowledge). 7 9 After observation and interview the author of this model believes that health care professionals can plan patient care and decide whether the client s cultural beliefs need preservation, negotiation or restructuring, based on the impact it has on their health. While integrating this Transcultural theory, various cultural domains created obstacle for safe motherhood practices for her. Although my patient died in this situation, by integration of this theory into the situation, indicates that the client could have been saved if the health care professionals had identified cultural beliefs as a major barrier for the patient. Analysis shows that there was no availability of female doctor on duty who could provide culturally competent care. As health professionals, we know that there are people in our society who prefer female doctors for deliveries and we respect their belief. In this case, however, this factor was not even explored. In the religious and philosophical factor, there was violation of human, reproductive as well as sexual right by not allowing the patient to control her own body and health. In the kinship and social factor, there was a norm of the society to suppress women. Cultural values were also influencing the situation, e.g., early marriage culture, lack of female education, no concept of family planning, not taking any supplements during antenatal period. The economical factor in this case was that the patient was from low socio economic group. Finally, in the education domain, the couple was both illiterate. The Sunrise Model further states that diverse health systems should offer generic, folk, and professional care. CONCLUSION This model assisted in understanding the importance of transcultural care and the lifethreatening consequences of some beliefs. Therefore, as healthcare professionals, taking history from all dimensions mentioned in this model is extremely important for providing holistic care to clients. Working in academia, this discipline and integration is crucial in teaching students to become culturally competent nurses. 10 Acknowledgement: I would like to acknowledge everyone who have assisted me in writing this article; including my tutors, friends, family, and my dear husband and children. This would not have been possible without their unconditional love and support! Conflict of Interest: None Ethical Clearance: Not required Source of Funding: None REFERENCES 1. Ahamd R, Ahmad N. Study report on: health care waste management in Karachi. [on line]. Karachi: Available from: doc/ /healthcare-waste-in-karachi. [accessed 28 Oct 2009]. 2. Maryland C. Pakistan Demographic and Health Survey National Institute of Population Studies Islamabad, Pakistan. [on line]. Macro International Inc. June PDHS.pdf [accessed 26 Oct 2009]. 3. Sharma BR, Gupta N. Forensic considerations of pregnancy-related maternal deaths: An overview. Journal of Forensic and Legal Medicine.2009;16: Begum S, Nisa A, Begum I. Analysis of Maternal Mortality in A Tertiary Care Hospital to Determine Causes and Preventable Factors: [online] J Ayub Med Coll Abbottabad Vol.15(2).Available from:

184 176 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 shamshad%20maternal%20mortality.htm. [accessed 26 Oct 2009]. 5. Jafarey, S N. Maternal mortality in Pakistan- Compilation of available data. J Pak Med Assoc. 2002; 52 (12): Greenhalgh, T. The ologies (underpinning academic disciplines) of primary health care. Primary health care: Theory and practice Blackwell Publishing. p Finn J, Michigan BH, Transcultural nurses reflect on discoveries in China using Leininger s sunrise model. Jounnal of Transcultural Nursing.1996; 7(2): Leininger M. Cultural care theory: A major Contribution to advance Transcultural nursing knowledge and practices. Journal of Transcultural Nursing July; 13: Alligood MA, Tomey AM. Nursing Theory: Utilization and Application. 2 nd ed. Place of Publication: Mosby, Guatafson DL. Transcultarul nursing theory from a critical culture perspective. Advances in Nursing. 2005; Jan(28).

185 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No A Study on Patient Safety Culture among Nurses in A Tertiary Care Hospital of Puducherry Balamurugan E 1, Josephine Little Flower 2 1 Staff Nurse, Government General Hospital, Karaikal, Puducherry U.T, India, 2 Nursing Advisor to the Government of India, Nirhman Bhavan, New Delhi. India ABSTRACT Background: Patient safety culture is an important measure in assessing the quality of health care. There is a growing recognition of the need to establish a culture of hospital focused on patient safety. The current study aimed to assess the Nurses Perception of Safety culture in their respective working units. Method: The study was conducted in a tertiary care hospital of Puducherry among 141 randomly chosen nurses. Hospital Survey on Patient Safety culture Questionnaire was used to collect data regarding safety culture among nurses. Collected data were analysed using SPSS using appropriate descriptive and inferential statistics. Results: The mean age of the subjects was 30.2 years. Of the total 9 dimension assessed to measure the safety culture; team work within units was rated positively by 80.2% of the subjects followed by supervisors action prompting patient safety i.e. 74.7%, the least positively rated dimension was non punitive response to Errors i.e.42.7%. Overall Patient safety rating done by nurses revealed only 12.7 % of the subjects estimating excellent level of safety culture in their units, whereas majority estimating patient safety culture to be only acceptable i.e. 31.9%. While trying to correlate the overall patient culture rating with the different dimension of safety culture by nurses, a positive correlation existed between every dimension with overall patient safety culture perceived by nurses. Conclusion: Examining the safety culture of our hospitals can help to identify the existing gap in the system. The current study explored the areas that should be fixed to improve the safety culture of our hospitals. Future studies focused on patient safety events along with patient safety culture may yield more findings. Keywords: Patient Safety Culture; Nurse; Hospitals INTRODUCTION Patient safety is an important component of health care quality. Patient safety, including the measurement of patient safety culture is a top priority in developed countries today. Research shows that safety and efficient care requires all the various elements of a health care system be well integrated and coordinated. Patient safety in the context of health care organizations was highlighted following the Institute of Medicine (IOM) report To Error is Human: Building a Safer Health System This report argued for a safety culture in which adverse events can be reported without people being blamed and that when mistakes occur that lessons are learned. Therefore, if hospitals want to improve patient safety, it is important to know more about the views of their staff in relation to the culture of patient safety. Patient safety culture, also referred to patient safety climate, is the overall behaviour of individuals and organizations, based on a common set of beliefs and values that are aimed at reducing the opportunities for patient harm. Related research shows that when a positive patient safety culture exists, it will promote patient safety and help to improve patient safety standards, including the capacity and willingness to report minor errors, selfreporting errors, safety behaviours and safety audit rating. To date, many developed countries have

186 178 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 initiated the research into the role played by patient safety culture. But in a developing country like India research in this vital area is still limited. India has faced several high-profile incidents in which the safety of patients was grossly neglected. These include the deaths of 14 patients in the J.J. Group of Hospitals following the administration of contaminated glycerol, an incident that was probed by the 1997 Lentin Commission,the report of which held the physicians liable; the Hepatitis B epidemic in the district of Sabarkantha, Gujarat in which 94 persons died; the deaths of 18 pregnant women at Umaid Hospital in Jodhpur; and most recently, the fire at the AMRI hospital and Administration of Hepatitis Vaccine instead of Polio Vaccine in West Bengal. Investigating these incidents alone may not help in reducing these adverse events in future. It is very important to know the attitudes and belief of the health works in relation to patient s safety first. A strong patient-safety culture has been shown to be a successful predictor of medication errors and falls injuries outcomes for AHRQ-patient-safety indicators treatment errors, and accidents and injuries in the work place. It is very important to assess the safety culture of our hospital to plan intervention programme to curtail adverse events related to patient safety. Nurses being the front line care provider, spend most of their time in direct patient care activities than any other professionals. Hence it s in important to understand the safety culture behavior prevailing among our nurses to ensure patient safety. Hence the current study tried to explore the safety culture prevailing among nurses working in Indian setting. MATERIALS AND METHOD The present study was conducted in a Tertiary care hospital of Puducherry U.T between January to March, Subjects were chosen randomly from the nurse s attendance register who fulfilled the following inclusion criteria a) Nurses who were working in the current setting at least for the past 6 months.b) Nurses with grade II and Grade I designation and c) Nurses who consented to participate in the study. Every subject was explained about the study purpose and informed consent was obtained before actual data collection. Formal Ethical clearance to conduct the study was obtained before the subject s recruitment. Tools and Techniques To collect data regarding patient safety culture, Hospital Survey on Patient Safety Culture (HSOPSC) tool was used. It was developed by Agency for Healthcare Research and Quality (AHRQ) in It is a 32 items questionnaire with 10 dimension that measure the different aspect of patients safety culture. Those were as detailed in Table 1 Table 1: Dimension of Safety culture Dimension of Safety culture Items Teamwork Within Units 4 Supervisor/Manager Expectations & Actions 4 Promoting Patient Safety Organizational Learning Continuous 3 Improvement Management Support for Patient Safety 3 Feedback & Communication About Error 3 Communication Openness 3 Teamwork Across Units 4 Staffing 4 Non punitive Response to Errors 3 Overall patient safety Grade 1 Items were scored using a five-point scale reflecting the agreement rate on a five-point frequency scale. The percentage of positive responses for each item was calculated; negatively worded items were reversed when computing percent positive response. The reliability and validity of the tool was well established and reported elsewhere. DATA ANALYSIS The data collected were abstracted in the spread sheet and analyzed using SPSS for windows version 14. Descriptive statistics like frequency, Mean, Standard deviation and percentage were used to express demographic data and dimension of safety culture. Pearson correlation coefficient was used to find out the relation within different dimension of safety culture and Independent t test was used to find out association of safety culture with demographic variables. RESULTS The mean age of the subjects was 30.2 years. Majority of the subjects i.e. 50.3% of the subjects were working in medical units with professional experience less than 1 year but more than 6 months (48.2%). Most of the subjects were with Sister Grade II designation (65.2) involved in direct patient care with a diploma degree in nursing (72.3%).More details regarding demographic characteristic can be found in Table 2

187 International Journal of Nursing Education. January-March 2015, Vol. 7, No Table 2: Demographic characteristics of the subjects n=141 Demographic Variable Frequency Percentage Working Area Medical Unit Surgical Units Others (Diagnostics, Administrative) Professional Experience <1 year year More than 5 years Position Sister grade II Sister Grade I Education Diploma Holder Degree Holder Professional experience in the same unit <1 year year More than 5 years Working Hours per week 40 hours >40 hours Dimensions of patient safety Culture Of the different dimension assessed Teamwork within Units (80.2%) were the highest positively rated dimension followed by Supervisor Actions Prompting patient safety (74.7%) organizational learning continuous improvement (72.1%), communication openness (71.2%), Teamwork Across units(68.3%), Feedback and communication about error (68.2%), management support for patient safety (53.1%), Staffing( 52.1%), and non punitive response to Errors (42.7%). More details can be found in Table 3 Table 3: Response rate on Different Dimension off Safety Culture Dimensions of safety Culture Mean Standard Positive deviation response rate (%) Teamwork Within Units Supervisor/Manager Expectations & Actions Promoting Patient Safety Organizational Learning Continuous Improvement Management Support for Patient Safety Feedback & Communication About Error Communication Openness Teamwork Across Units Staffing Non punitive Response to Errors n=141 Overall patient safety grade While asked to rate the overall all patient safety grade in their respective units only 12.7% of the subjects reported that the patients safety action were excellent, whereas majority reported the patient safety action to be only acceptable (31.9%) More details can be found in Figure 1

188 180 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Relationship between patient safety actions with different dimension of Safety culture While assessing the correlation between different dimensions of safety culture with Overall all patient safety grade done by the subjects, every dimension was found to have a positive correlation with the overall patient safety grade. Details can be found in Table 4 Table 4: Correlation between patient safety culture dimensions. n=141 Dimension of Patient safety culture Pearson s Correlation Value P value Teamwork Within Units Supervisor/Manager Expectations & Actions Promoting Patient Safety Organizational Learning Continuous Improvement Management Support for Patient Safety Feedback & Communication About Error Communication Openness Teamwork Across Units Staffing Non punitive Response to Errors Association between demographic characteristics and Patient safety grade While trying to associate the different safety culture dimension with the overall all patients safety grade no association was found between the variables. DISCUSSION The current study explored the prevailing safety culture in relation to patient in a tertiary care hospital of pudhucherry U.T. This the first of its kind conducted exclusively among nurses. This adds its strength. The study found team work within the units to be rated highly by the subjects, which signifies the importance of team work contributing to patient safety. The least reported response in relation to patient safety was Non punitive response to errors, this finding demand the creation of a blame free environment for reporting errors in relation to patient care. These findings were similar to the findings of Hala A et al.unless a blame free environment is created the root cause of the incidents related to patient safety cannot be explored. Overall rating of patient safety grade in our study was in contrast to the findings of western studies but more similar to results of Asian studies. The positive correlation which existed between the dimensions of safety culture with the overall patient safety grading denotes the direct relation between the two concepts. It can be comparable with the finding of a western study which indicated a strong patient-safety culture to predict medication errors, falls injuries, outcomes for AHRQ-patient-safety indicators, treatment errors and accidents and injuries in the work place. Previous studies have reported association between demographic characteristics and patient safety dimensions. But in contrast in the present study no such association was found, it may be due to lesser sample size. CONCLUSION Examining the safety culture of our hospitals can help to identify the existing gap in the system. The current study explored the areas that should be fixed to improve the safety culture of our hospitals. Future studies are recommended in this area with a longitudinal design to indentify the effect of time in reporting safety culture. And further studies may also be conducted to assess the relation between safety cultures with actual patient safety errors. While culture can be easily defined as the way we do things around here, understanding culture and creating a given type of culture within a healthcare organization can be elusive, baffling, and challenging. Yet, the success of

189 International Journal of Nursing Education. January-March 2015, Vol. 7, No providing patients with the safest and highest quality of care is becoming recognized as being dependent upon a strong cultural foundation at the unit level. Policy makers and leaders should develop acceptable standards for patient safety system. This can be achieved through initiated and supported an effective safety culture assessment among all working nurses while providing patient care. Acknowledgement: The authors would like to extend their thanks to all nurses who participated in this study for their cooperation. Conflict of Interest: None Source of Funding: None REFERENCES 1. Aspden P, Corrigan J, Wolcott J: Patient Safety, Achieving a New Standard for Care. Washington, D.C.: The National Academies Press; Reid PR, Compton WD, Grossman JH, Fanjiang G: Building a better delivery system. A new engineering/health care partnership. Washington, D.C.: National Academies Press; 2005: Hughes RG, Clancy CM: Working conditions that support patient safety. J Nurs Care Qual 2005, 20(4): Kohn LT, Corrigan JM, Donaldson MS: To err is human: building a safer health system. Washington D.C.: National Academy Press; Schein E: Organizational Culture and Leadership San Francisco. San Francisco: Jossey-Basss; Ronald GS: Developing and operationalizing a culture of safety. Chinese Hospitals 2005, 9(12): Clarke S: Perceptions of organizational safety: implications for the development of safety culture. J Org Behavior 1999, 20(2): Zohar D: Safety climate in industrial organizations: theoretical and applied implications. J Appl Psychol 1980, 65(1): Zohar D: A group-level model of safety climate: testing the effect of group climate on microaccidents in manufacturing jobs. J Appl Psychol 2000, 85(4): Visvanthan S. The Great Indian Novel: The Lentin Report, Econ Pol Wkly 1999;34: Gandhi SJ. Hepatitis B outbreak investigation report in Sabarkantha District, Gujarat State, February Available at Pdf2011/May/Gandhi.pdf (accessed on 2 Jun 2012) 12. Gupta N, Srinivasan S. Serial maternal deaths in a tertiary care hospital: Some questions. Available at ed70.html. (accessed on 2 Jun 2012) 13. Nagral S. Fire in a hospital. Indian J Med Ethics 2012;9: Sorra J S, Nieva V F. Hospital survey on patient safety culture. Report number AHRQ, publication number Rockville, MD: Agency for Healthcare Research and Quality, Hala A. Abdou and Kamilia M. Saber. A Baseline Assessment of Patient Safety Culture among Nurses at Student University Hospital. World Journal of Medical Sciences 6 (1): 17-26, Yanli Nie. Hospital survey on patient safety culture in China. BMC Health Services Research 2013, 13:228 doi: / Fitzpatrick, J.J., D. Armellino and M.T. QuinnGriffin, Structural empowerment and patient safety culture among registered nurses working in adult critical care units. J. Nursing Management, 18: Neal, M.A. and P.M. Hart, The impact of organizational climate on safety climate and individual behavior. Safety Sci., 34:

190 182 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Practices of Tracheal Suctioning Technique among Health Care Professionals: Literature Review Rozina Khimani 1, Fauziya Ali 2, Salma Rattani 3, Sohai Awan 4 1 Nurse Specialist Critical Care, Areas Aga Khan University Hospital, 2 to Instructor, Faculty of Health and Community Studies, NorQuest College, 3 Assistant Professor and Director, Aga Khan University School of Nursing and Midwifery, 4 Associate Professor and Section Head, Otolaryngology Department of Surgery, Aga Khan University ABSTRACT The current study aims to assess tracheal suctioning practices among health care practitioners; nurses, critical care technicians and physiotherapist. Employing literature review as the methodology, multiple databases were searched focusing on three phases of tracheal suctioning (a) the pre suctioning phase, (b) the suctioning phase, (c) the post suctioning phase and complications related to tracheal suctioning. It was concluded that to provide quality care it is important that the evidence based practice guidelines should be followed. Keywords: Tracheal Suctioning, Tracheostomy, Evidence Based Practice, Nursing Skills, Health Care Professionals INTRODUCTION Tracheal suctioning is one of the critical nursing interventions to keep the airway patent by removing secretion via suctioning. This critical skill requires expertise with the knowledge to perform and facilitate a patient s effortless breathing pattern through effective secretion management. But this aspect of care is associated with the risk of injury therefore, the role of competent health care professionals (HCP) is vital in performing tracheal suctioning. The literature reviewed was obtained through different databases that includes: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, Science Direct, SpringerLink, and Google Scholar. Pre suctioning phase Prior to suctioning, patient assessment; monitoring the vital signs and chest auscultation is important 1, 2, 3. The reommended period for assessment is in each shift, before each suctioning, or depending on the patient s Corresponding author: Rozina Khimani Aga Khan University Hospital, School of Nursing and Midwifery, Stadium Road, Karachi 74800, Pakistan Phone: rozina.khimani@aku.edu need 1, 2, 4. Through evidence-based practices it is revealed that nurse are using their clinical judgment, nurses perform tracheal suctioning without using normal saline and they screen patients cardiopulmonary position before, during, and after the suctioning phase 5. Similarly an observational study conducted to assess the nurses practices of tracheal suctioning in the cardiac intensive care unit (CICU) and the general intensive care unit (GICU) in Ireland, it was revealed that among the CICU nurses (n=17) only two nurses, i.e. 12% out of 34, from CICU and four nurses, i.e. 14%, from GICU performed chest auscultation to assess the need of suctioning 7. While looking the entire pool as health care practitioners it was revealed that the patients with respiratory distress were monitored for occurance of tachypnea and deoxygenation throughout the suctioning process and based on patient s need, the HCPs selected a suitable sized of suctioning catheter 6. Along with assessment, informing the patient and taking consent prior to the suctioning have been identified as strategies for reducing the anxiety and distress of patients as they help in gaining maximum outcomes from suctioning 1, 2. It has been found that informing a client about the details of the procedure always ensures its smooth execution. Whereas, one study explicated that, out of 53, 28% of the nurses from the GICU were unable to communicate and explain procedures to the patients 7.

191 International Journal of Nursing Education. January-March 2015, Vol. 7, No Hypoxemia is one of the complications related to tracheal suctioning 2, 8. Hypoxemia is associated with cardiac arrhythmias, hypotension, cardiac arrest, and death, therefore, hyperventilation and hyperoxygenation are essential aspects of treatment 1. Hyperoxygenation is the administration of oxygen in greater amount than what the patient is receiving or requires 9. Hyperoxygenation and hyperinflation is found to be an effective intervention prior to suctioning in order to prevent suction induced hypoxia in adult patients 10. However, the careful oxygen administration is required in patients with chronic obstructive pulmonary diseases (COPD), as these patients cannot tolerate high oxygen flow 11. Tracheal suctioning and tracheostomy care are high-risk processes. To avoid adverse consequences, HCPs who execute these, whether they are experts or beginners, must follow the evidence based guidelines. It is also suggested that, patients should be hyperoxygenated and encouraged deep breathing, then manage four to six compressions with a manual ventilator bag or trigger the ventilator for hyperoxygenation 4. Another point to note during this phase is that, normal saline instillation is not recommended prior to or during suction. It is usually a misconception that it helps in liquifying secretions 9, 4, 8. The potential hazards of normal saline instillation include a fall in PaO2, lower respiratory track infection, and failure to remove all saline during suctioning 9, 12. Despite available evidences against the use of saline in tracheal suctioning, a survey found that 33% of nurses and therapists still use saline before and during suctioning 4. In fact, another survey, on 1665 nurses and respiratory therapists from 27 different sites in the United States, regarding saline instillation protocol, reported that 74% centers had a protocol which recommended saline instillation during suctioning 13. A quasi experimental study was conducted to assess the level of dyspnea with the use of saline during suctioning in which dyspnea was graded immediately after the suctioning, and at 10, 20, and 30-minute intervals. The findings indicated no beneficial use of saline; whereas, age variation highlighted that older patients, above 60years of age had decreased levels of dyspnea when suctioning was done without saline instillation. The study validated that saline instillation might precipitate a considerable increase in the level of dyspnea for up to 10 minutes after suctioning in patients older than 60 years of age 14. Similarly, the findings of another study reported that the use of saline instillation during tracheal suctioning decreased the mix venous saturation as compared to the patients, suctioning without saline instillation 5. The use of saline during suctioning also varies among health care professionals, such as nurses, doctors, and physiotherapists. Survey on saline instillation protocol and related practices of HCPs indicated that 79% hospitals use saline during suctioning, among which 58% physiotherapists use saline in their practices, while saline use by nurses and other medical staff was 42% 15. Pain is also one of the frequently associated complaint during tracheal suctioning 16. Tracheal suctioning was specifically an identified discomforting factor among 30% of the ICU ventilated patients. On a 0-10 scale, pain intensity during suctioning among patients with tracheostomy was reported to be at 7 or greater 17. Tracheal suctioning is an invasive and sterile procedure, therefore, all aseptic protocols, such as, hand washing before and after the procedure, gloves, apron, protectors and use of sterile catheter for each episode of suction should be followed to prevent patients from getting an infection 2, 4. Several diseases can occur during suctioning treatment due to noncompliance of standard precautions. The sterile procedure is essentially followed to avoid contamination of the airway. The tube must never be reused once it is opened and a new sterile catheter must be used for each session of suctioning 18. Compliance of infection control practices among HCPs needs to be emphasized to prevent complications related to the suctioning procedure and equipment. A study conducted in Ireland identified that, out of 53, only 30% of the nurses in GICU and 65% nurses, from 34 nurses, in CICU performed handing washing prior to suctioning. Moreover, 59% CICU and 29% of GICU nurses failed to maintain the sterility of the suction catheter till its insertion into the airway, which indicates an alarming situation 7. Another study was conducted on Infection Prevention (Werkgroep Infectiepreventie [WIP]) to find out whether some policies on tracheal suctioning (open and closed tracheal suctioning systems) are superior to others, in terms of anticipation of ventilatorassociated pneumonia (VAP). They found that there was no significant difference in the use of both open and closed tracheal suction systems in decreasing the rate of VAP. The study, however, clarifies that the

192 184 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 quality of the evidence is substantive. Investigations other than the anticipation of VAP should regulate the choice of the suction system 6, 19. The suctioning phase The suctioning phase is an active period for the removal of secretions. It is widely accepted that during tracheal suctioning, the catheter diameter should be one and a half times of the tracheotomy tube in diameter 1, 4. The tracheostomy suction catheter size can be easily calculated. The size of tracheotomy tube divided by 2 and multiplied by 3 will give the appropriate catheter size according to the tracheostomy tube ((14, 4). However, a study in two critical care areas in Ireland documented that 40% of the CICU nurses and 28% of the GICU nurses selected a larger sized suction catheter in comparison to the size of tracheotomy tube 7. Large catheter obstructs the airway resulting in hypoxemia during suctioning as well as trauma to the mucosal lining of the trachea 1, 2. Negative pressure is needed to remove tracheal secretions. Most of the literature recommends that the pressure range during tracheal suctioning should be from 70 to 150mmHg 1, 9, 2. However, it has been suggested that a pressure range between 70 to 120mmHg 20, 4. Furthermore, a pressure of 200 mm Hg can cause mucosal lining damage, alveolar collapse, and could also lead to bacterial colonization 2, 9. The whole procedure of tracheal suctioning should not take too long as it could cause hypoxia, bradycardia, and mucosal damage 11, 1, 9, 2. The recommended duration of tracheal suctioning is 10 to 15 seconds with 20 to 30 seconds intervals between passes 1, 4, 8. Each session of suctioning should comprise of three suction catheter passes at the most 11, 1, 9, 2. Furthermore, suction vacuum should always be applied during catheter withdrawal 2. Moreover, the suction catheter should not be inserted deeply into the trachea as it causes cough and vagal nerve stimulation at the bifurcation of the trachea (Carina). Where catheter encounter resistance, withdraw the catheter 1cm and then applies suction 1, 2. Tracheal suctioning can easily cause airway mucosal trauma when inappropriate suctioning methods are used. Suction can only be useful for extracting secretion from the airway. Unnecessary high vacuum pressure and extensive suction exercises should be avoided. It is important to pay special consideration to the possibility of complexity in patients who might be predominantly susceptible to mucosal injury, i.e., very young patients, or patients with thrombocytopenia or on general anticoagulant therapy 18. A randomized control trial study was conducted to relate and distinguish the alterations in endotracheal suction consequences in patients who routinely received 2 hourly suctioning and those who received it following an evaluation. The results verified a clear rise in nurses knowledge regarding endotracheal suctioning and indicated the effectiveness of procedures with minimal complications 3. Suctioning is a high risk process, which can cause hypoxemia, bleeding, cardiovascular instability, infection, atelectasis, elevated intracranial pressure, and can also create lesions in the tracheal mucosa. These complications can be avoided with the use of best practices 21. Post suctioning phase The patient s condition needs to be assessed following suctioning to evaluate the effectiveness of the procedure, which includes respiratory rate, oxygen saturation, and chest auscultation for the presence of secretions and bilateral air entry to the lungs 1, 2, 4, 8, 9. Oxygen therapy needs to be reconnected immediately after suctioning, ideally, within 10 seconds to prevent the patient from hypoxia 1, 2. Moreover, post suctioning documentation is essential which includes patient physiological and psychological response, color, odor, consistency and amount (COCA) of secretion 4, 9. Complications related to tracheal suctioning Endotracheal suctioning is, thus, imperative in order to decrease the danger of atelectasis and consolidation that might lead to insufficient ventilation. A number of risk and complications are related to the suction process. These include atelectasis, bleeding, cardiovascular instability, infection, hypoxemia, elevated intracranial pressure, and grazes in the tracheal mucosa. The key recommendations use evidence based guidelines to prevent and minimize these complications 21. A conducted a study with the objective of determining the impact of suction tube insertion and tracheal stimulation on the cerebrovascular and systemic vascular status in adults with severe

193 International Journal of Nursing Education. January-March 2015, Vol. 7, No traumatic brain injury. They tested thirty intubated and mechanically ventilated adults with brain injury. The participants average age was 31 +/- 15 years. The results showed that suction tube inclusion and tracheal stimulation, inaccessible from other constituents of the suctioning process, meaningfully enlarged cerebral perfusion pressure (CPP), mean arterial pressure (MAP), and mean intracranial pressure (MICP) 22. Moreover, a tracheostomy team approach can minimize the risk of complications pertinent to tracheal suctioning for which a study examined the mechanisms of tracheostomy through an inter professional team approach which consist of divers health cre professional possess expertise to care patients with tracheostomy. The findings indicated that tracheotomy teams increased the regularity of care through the expansion and application of inter professional protocol. These findings provided new ways of understanding the role of tracheostomy teams in effectively implementing complex protocols and mechanisms through which inter professional teams might produce positive consequences for tracheotomy patients 23. CONCLUSION Tracheal suctioning is an important aspect of airway management however, this aspect of care is associated with many rist factors therefore, its is important for health care professionals to follow evidence based guidelines to prevent complications and promote safety. Moever, the knowledge and competence of health care professionals play an important role in enhancing safety of the patient. Acknowledgement: I (Rozina Khimani, principal investigator) would like to acknowledge Division of Nursing Services, Aga Khan University, Hospital, Karachi, Pakistan. Conflict of Interest: The authors declare having no conflict of interest. Source of Funding: No separate funding was received for this study as the current study was done during graduate studies. REFERENCES 1. Day, T., Farnell, S., Haynes, S., Wainwright, S., & Wilson-Barnett, J. (2002). Tracheal suctioning: an exploration of nurses knowledgeand competence in acute and high dependency ward areas. Journal of Advanced Nursing, 39 (1), Freeman, S. (2011). Care of adult patients with a temporary trachesotomy. Nursing Standard,26 (2), Nance-Floyd, B. (2011). Tracheostomy care: An evidence-based guide to suctioning and dressing change. Journal of American Nurse Today, 6 (7), Wood, C. J. (1998). Endotracheal suctioning: a literature review. Journal of Intensive and Critical Care Nursing, 14, Kuriakose, S. A. (2008). Using the synergy model as best practice in endotracheal tube suctioning of critically ill patients. Journal of Dimensions of Critical Care Nursing, 27(1), Niel-Weise, B. S., Snoeren, R. L., & Broek, P. J. (2007). Policies for Endotracheal Suctioning of Patients Receiving Mechanical Ventilation: A Systematic Review of Randomized Controlled Trials. Journal of Infection Control and Hospital Epidemiology, 28(5), Kelleher, S., & Andrews, T. (2006). An observational study on the open-system endotracheal suctioning practices of critical care nurses. Journal of Clinical Nursing, 17, Russell, C. (2005). Providing the nurse with a guide totracheostomy care and mangement. British Journal of Nursing, 14 (8), Day, T., Wainwright, S. P., & Wilson-Barnett, J. (2001). An evaluation of teaching Intervention to improve the practice of endotracheal suctioning in intensive care unit. Journal of Clinical Nursing, 10, Atta, J. M., & Beck, S. L. (1992). Preventing hypoxemia and hemodynamic compromise related to endotracheal suctioning. American Journal of Critical Care, 1 (3), Barnett, M. (2005). Tracheostomy Management and care. Journan of Community Nursing, 19 (1), Halm, M. A., & Krisko-Hagel, K. (2008). Instilling Normal Saline with suctioning: Benificial technique or potencially harmful sacred cow? American Journal of Critical Care, 17(5), Sole, M. L., Byers, J. F., Zhang, Y., Banta, C. M., & Brummel, K. (2003). A Multisite Survey of Suctioning Techniques and Airway Management Practices. American Journal of Critical Care, 12(3), O Neal, P. V., Grap, M. J., Thompson, C., & Dudley, W. (2001). Level of dyspnoea experienced in mechanically ventilated adults

194 186 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 with and without saline instillation prior to endotracheal suctioning. Journal of Intensive and Critical Care Nursing, 17, Reeve, J. C., Davies, N., Freeman, J., & Donovan, B. (2007). The use of normal saline instillation in the intensive care unit by physiotherapists: a survey of practice in New Zealand. Journal of Physiotherapy, 35(3), Arroyo-Novoa, C. M., Figueroa-Ramos, M. I., Puntillo, K. A., Stanik-Hutt, J., Thompson, C. L., White, C., et al. (1998). Pain related to tracheal suctioningin awake acutely and critically ill adult: A descriptive study. Journal of Intensive and Crtical CareNursing, 24, Stotts, N. A., Puntillo, K., Stanik-Hutt, J., Thompson, C. L., White, C., & Wild, L. R. (2007). Does age make a difference in procedural pain perceptions and responses in hospitalized adults? Journal of Acute Pain, 9, Florentini, A. (1992). Potential hazards of tracheobronchial suctioning. Intensive and Critical Care Nursing, 8(4), Jansson, M., Ala-Kokko, T., Ylipalosaari, P., & Kyngas, H. (2013). Evaluation of endotrachealsuctioning practices of critical-care nurses An observational correlation study. Journal of Nursing Education and Practice, 3(7), Bond, et al. (2003). Best practice in the care of patients with tracheostomy. Nursing Times, 99 (30), Pedersen, C. M., Rosendahl-Nielsen, M., Hjermind, J., & Egerod, I. (2009). Endotracheal suctioning of the adult intubated patient-what is the evidence? Journal of Intensive and Critical Care Nursing, 25, Brucia, J., & Rudy, E. (1996). The effect of suction catheter insertion and tracheal stimulation in adults with severe brain injury. Journal of Heart and Lung, 25(4), Mitchell, R., Parker, V., & Giles, M. (2013). An interprofessional team approach to tracheostomy care: A mixed-method investigation into the mechanisms explaining tracheostomy team effectiveness. International Journal of Nursing Studies, 50,

195 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No A Study on Awareness and Anxiety Level of Primigravida Mothers on Labour and its Outcome, in a Selected Hospital, Mysore Bhavya S V 1, Parvathi N K 2, Bhagyalakshmi H S 2, Santosh Kumar 1, Munirathnamma 1 1 Assistant Professor, JSS College of Nursing, Mysore, 2 Staff Nurse, JSS Hospital, Agrahara, Mysore ABSTRACT Background: Children form one of the major age groups requiring attention to refractive errors because of the high prevalence of myopia, hypermetropia and astigmatism. Visual problems in children are important because of their impact on the child's development, education, future work opportunities and quality of life. School age children constitute a particularly vulnerable group where uncorrected refractive errors may have a dramatic impact on learning capability and educational potential. Method: The descriptive survey approach was adopted. The population consisted of primigravida mothers in Mysore. Convenient sampling was used to obtain the sample of 60 primigravida mothers in hospital of Mysore. The data was collected using structured knowledge questionnaire and modified Sheehan's patient rated anxiety scale to assess the knowledge and anxiety level of primigravida mothers on labour and its outcome. Results: Majority of primigravida mothers 70% were in the age group of years and majority 83% were belongs to Hindu. 46.6% were graduated in degree, 87% of them were housewives. 65% were in the gestational age of 36-38weeks. Majority of 68.33% of the primigravida mothers had average level of knowledge and majority of 51.66% of primigravida mothers had moderate anxiety on labour and its outcome. There is no significance relationship found between the knowledge and anxiety of primigravida mothers with their selected demographic variables. Conclusion: Being afraid of normal pregnancy and vaginal childbirth is related to the woman's general anxiety, dissatisfaction with life and disability to deal with new and demending life events. Anxiety during pregnancy and fear of delivery are thus not isolated problems, but are closely associated with the whole psychosocial network of the woman. Most of the Indian parturients still suffer from agony of labour pains due to lack of awareness. The awareness level needs to be improved about the availability of the labour, and reduction of anxiety where involvement of midwives are crucial in this education program. Keywords: Primigravida Mothers, Labour And its Outcome, Knowledge and Anxiety INTRODUCTION Childbirth is one of the most memorable and rewarding event of a couple s life. No matter how often a woman gives birth, each experience is an intimate and unique celebration of life. Though labour and delivery are not without pain and some degree of anxiety, if mother remains confident, well-informed and fully supported by health workers and partner, she is likely to have no problem handling the awesome task of bringing a child into the world 1. According to number of studies conducted the knowledge assessment of primigravida mothers, it states that the women are having poor level of knowledge regarding changes during pregnancy and labour for the first time in her life. Anxiety is common in life. It is more among primigravida mothers during labor and delivery. Mothers experience anxiety during their labor and delivery in hospitalization. Identification of anxiety and stress, helps nurses to plan provide holistic care

196 188 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 which helps mothers to have smooth hospitalization and minimizes anxiety. Providing psychological support is one of the most important needs during their labor and delivery on the labor table 2. A study was undertaken to assess women s knowledge and plans regarding intrapartum pain management at the Royal College for women in Australia. There were 496 participants. Antenatal pain management information was accessed by 98% of women. Sources most accessed were antenatal classes (55%), Multimedia (53%) and friends / relatives (46%). Antenataly 80% planned to use intrapartum pain management: natural methods were most popular (62% planed to use) and pethidine least (49% planned against). Intrapartum 19% used unwanted pain management mostly (67%) due to increased labor pain. Increased information access was associated with significantly higher use of natural methods and epidural analgesia as well as significantly higher satisfaction scores 3. A study was conducted among 100 pregnant women with extreme fear of child birth to find out conscious reasons for anxiety about labor. It was found that anxiety over delivery was related to fear of own incompetence (65%), fear of death of mother, infant or both (55%), intolerable pain (44%) or loss of control (45%). Many women (37%) had partners who had anxiety over the delivery. It was concluded that anxiety over childbirth is related to fundamental human incompetence and fear of death 4. A quasi experimental study was conducted among 60 primigravida mothers during the 3 rd trimester of pregnancy in antenatal clinic at Northern institute of the country. The study subjects were selected by probability convenient sampling techniques with the age range of 16 to 45 years. Anxiety assessment scale with 45 items was used to assess the level of anxiety. These items were divided into fear of women themselves, fear of coping during labour, fear concerning babies, signs and, symptoms. The maximum score were 45 and it was classified arbitrarily into 3 levels i.e., mild (0-15 scores) moderate (16-30 scores) and severe (31-45 scores). Results showed that majority of the primigravida mothers had moderate level of anxiety related to labour and delivery 5. Quasi experimental study conducted to assess the knowledge and anxiety level of primigravidae about labor in both experimental and control group, evaluate the effectiveness of the planned teaching program on knowledge and reducing anxiety about labor among primigravidae in the experimental group as compared to the control group. The study was conducted on 60 primigravidae (30 experimental and 30 control group) attending antenatal OPD S at KLE S Dr Prabhakar Kore Hospital and MRC, Belgaum using purposive sampling technique. Data was collected by using a structured knowledge questionnaire and standardized Zung self-rating scale. The result showed that knowledge score mean difference (MD) in experimental group was 16.8 and in control group it was 0.6. Therefore planned teaching program was effective method to gain knowledge about labor among primigravidae. The anxiety score MD was 37.6 in experimental group and in control group it was Study findings showed that there was positive correlation between knowledge and reducing anxiety in experimental group (rxy = 0.1). Therefore planned teaching program helped to gain knowledge and reduce anxiety about labor in primigravidae 6. OBJECTIVES OF THE STUDY 1. To assess the knowledge and anxiety of primigravida mothers on labour and its outcome using structured knowledge questionnaire and modified Sheehan s anxiety scale respectively. 2. To find relationship between the knowledge and anxiety level of primigravida mothers on labour and its outcome. 3. To find out the association between the knowledge and anxiety of primigravida mothers on labour and its outcome with their selected demographic variables. HYPOTHESIS H 1 - There will be significant association between the knowledge score of primigravida mothers with their selected demographic variables. H 2 - There will be significant association between the level of anxiety of primigravida mothers with their selected demographic variables. METHODOLOGY The research approach and design adopted for the study was descriptive survey approach. The population consisted of primigravida mothers admitted in the hospital at Mysore. Convenient

197 International Journal of Nursing Education. January-March 2015, Vol. 7, No sampling was used to obtain the sample of 60 primigravida mothers in selected hospital at Mysore. The data was collected using structured knowledge questionnaire and modified Sheehan s anxiety scale to assess the knowledge and anxiety level of primigravida mothers on labour and its outcome. FINDINGS Part I Sample characteristics Table 1: Frequency and percentage distribution of primary school teachers according to their selected personal characteristics Sample Characteristics f % AGE Years Years Years >35 Years - - CASTE Hindu Muslim Christian Others EDUCATION No formal education % Primary High school Degree MARRIED LIFE < 01 Year Years Years >5 years GESTATIONAL AGE 36 to 38 weeks to 41 weeks >41 Weeks 3 5 SOURCE OF INFORMATION Mother/Relatives Neighbours Health department 9 15 Friends Media N=60 The data presented in table 1 shows that majority of primigravida mothers (70%) were in the age group of less than years and majority (83.33%) were Hindu. (46.6%) of them had their degree. (45%) were in the married life of less than one year and (65%) of primigravida mothers were in the gestational age of 36 to 38 weeks. Majority (66.66%) had their mother/ relative as their source of information on labour and its outcome.

198 190 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 PART II Description of knowledge and anxiety scores Table 2: Frequency distribution of primigravida mothers according to their level of knowledge and anxiety on labour and its outcome in hospital. Variables Frequency Percentage Result Knowledge Inadequate knowledge Anxiety Moderate anxiety N=60 The data presented in table 2 shows that Majority 41(68.33%) of primigravida mothers had inadequate knowledge and Majority 31(51.66%) of primigravida mothers had moderate anxiety on labour and its outcome in hospital at Mysore. PART III Correlation coefficient was computed to the relationship between knowledge and anxiety scores of primigravida mothers on labour and its outcome. Table 3: Relationship between the knowledge and anxiety scores of primigravida mothers on labour and its outcome. Variables Correlation coefficient Table Value Level of significance Knowledge and anxiety S PART IV Association between the knowledge and anxiety level of primigravida mothers with their demographic variable on labour and its outcome. There is no significance association found between the knowledge and anxiety of primigravida mothers with their demographic variables. CONCLUSION Being afraid of normal pregnancy and vaginal childbirth is related to the woman s general anxiety, dissatisfaction with life and disability to deal with new and demanding life events. Anxiety during pregnancy and fear of delivery are thus not isolated problems, but are closely associated with the wholepsychosocial network of the woman. Most of the Indian parturients still suffer from agony of labour pains due to lack of awareness. The awareness level needs to be improved on the availability of labour and the involvement of midwives is crucial in each and every step of educating a woman on labour outcome. Acknowldgement: We express our thanks to primigravida mothers who participated in the study and the authorities who provided permission to conduct the study. Conflict of Interest: Nil Ethical Clearance: Ethical clearance was obtained from the ethical committee of the college. REFERENCES 1. Aresk.g B. Uddenberg N. Kjssler B. Postnatal emotional balance in women with and without antenatal fear of child birth, J.Psychosom, res 1984: 28: pg Barnett B, Paraker G. Possible determination and consequences of high levels of anxiety in primiparous mothers, Psychomed 1986: 16: Balla Geol. R. A study of the stress and primi gravida and primi Para mothers and their resultant emotional needs. Journal of Obstetric and gynecology April ; 3(6): J Psycosome. Reason for anxiety about child birth in 100 pregnant women. Obstet Gynaecol.1997 Dec; 18(4): P. Paikkeus, T.saisto. Obstructive and gynecology, Journal of child birth and pregnancy related anxiety; 18(22): Available from:- URL 6. Gayathri KV, Sudha A Raddi, MC Metgud, Effectiveness of planned teaching programme on knowledge and reducing anxiety about labour among primigravida in selected hospitals of Belgaum, Karnataka, available at: Text.aspx?ID=703&Type=FREE&TYP=TOP&I N=_eJournals/images/JPLOGO. gif & IID= 65 & ispdf=no Funding Sources: Not obtained any funds from any sources.

199 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Effectiveness of Planned Teaching Programme on Knowledge Regarding Lifestyle Changes in Prevention of Premenstrual Syndrome among adolescents in Selected Schools of Mangalore Thabidha Joseph 1, Malitha Veera Monis 2 1 2nd Year M.Sc Nursing Student, 2 Associate Professor, Dept. of OBG Nursing,Laxmi Memorial College of Nursing, Mangalor ABSTRACT Background: Adolescent girls constituted one fifth of the female population in the world.it is a time of intense physical, psychological and social development. Premenstrual syndrome, commonly called PMS, is a medical condition that has symptoms that affect many women of childbearing age. Life style changes helps in the prevention of pre menstrual syndrome Method: The pre experimental research approach was adopted. The population consisted of adolescent students in Mangalore.Stratified random sampling was used to obtain the sample of 100 students in selected schools of Mangalore. The data was collected by using demographic profile & structured knowledge questionnaire to assess the knowledge regarding lifestyle changes in prevention of premenstrual syndrome. Results: Majority of adolescent students (70%) were in the age group of years and majority (60%) attained menarche were in the age group of years.50% of the adolescent students were Hindus. Majority percentage (80%) belong to 8th-9th standard.majority percentage (90%) of them having more than Rs family income. Conclusion: Premenstrual syndrome affects women during their reproductive age, and is associated with physical, psychological and behavioral changes. In adolescents premenstrual syndrome particularly affect school functions and social interactions in negative way. Life style changes include dietary, stress, exercise helps to prevent premenstrual syndrome. Hence the researcher selected this study to find the knowledge of adolescent students regarding lifestyle changes in prevention of premenstrual syndrome. Keywords: Effectiveness, Knowledge, Planned Teaching Programme,Lifestyle, Adolescents INTRODUCTION Adolescence is the period between puberty and adult. Adolescence is defined as the period of physical and psychological development from the onset of puberty to maturity. During puberty, endocrine glands produce hormones that cause body changes and the development of secondary sex characteristics. Menstruation is a normal physiological impact in each girl s life. It is the monthly uterine bleeding of 28 days cycle from puberty till menopause. Menarche is the onset of first menstruation it may occur at any time between 10 and 16 years. 1 Menstruation is the visible manifestation of cyclic physiologic uterine bleeding due to the shedding of endometrium. Menstrual abnormality is an irregular condition in a woman s menstrual cycle. Many different factors can trigger menstrual disorders, such as hormone imbalances, genetic factors, clotting disorders, and pelvic diseases. Menstrual abnormalities include polymenorrhoea, oligomenorrhoea, dysmenorrhoea, ovarian dysmenorrhoea, Mittleschmerz s syndrome, pelvic congestion syndrome and premenstrual syndrome. 2

200 192 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Premenstrual syndrome was formally described in 1931 in a group of women who all suffered clinical symptoms of mood changes, headaches and weight gain. The symptoms occurred 7-10 days premenstrually and were relieved with the onset of menstruation, giving it the term premenstrual tension. This was then changed to premenstrual syndrome in Premenstrual syndrome is a disorder of nonspecific somatic, psychological or behavioural symptoms recurring in the premenstrual phase of the menstrual cycle. Symptoms must resolve completely by the last day of menstruation leaving a symptom free week. The symptoms should be of sufficient severity to produce social, family or occupational disruption. Symptoms must have occurred in at least four of the six previous menstrual cycles. 3 The exact causes for premenstrual syndrome are not known. Causes are prior affective disorder such as major depression or postpartum depression. Identical twins have a high concordance for Premenstrual syndrome. Central nervous system neurotransmitter that affect mood, behaviour and cognition. Other causes of premenstrual syndrome are abnormal level of oestrogen or progesterone, effect of ovarian hormones, altered prolactin and thyroid secretion, Low level of beta endorphins, abnormal production of prostaglandins increased adrenal activity, fluid imbalance, nutritional deficiency, hypoglycemia and vitamin deficiencies. 4 Over 150 different symptoms of premenstrual syndrome have been described. Some women will suffer physical symptoms; others only psychological symptoms, but most of them have combination of different symptoms, therefore every woman could potentially have her own experience of premenstrual syndrome. The severity of symptoms varies from cycle to cycle but the type of symptoms experienced will usually remains constant. The symptoms are of mild, moderate and severe. They are mainly classified into physical, psychological and behavioural. 3 Adolescents with premenstrual disorders have a poor health-related quality of life. Premenstrual symptoms might cause several difficulties including impairment in physical functioning, psychological health and severe dysfunction in social or occupational realms. Premenstrual Dysphoric Disorder (PMDD) have been shown to adversely affect health-related quality of life to a disabling degree, women with PMDD suffer impairment that is as severe as women with chronic clinical depression and that their luteal phase adjustment to social and leisure activities is even worse than women with other types of depression. Not all girls are affected by premenstrual syndrome very much but the physical and emotional symptoms are common. 5 The first step in managing Premenstrual syndrome is developing a healthful lifestyle. This includes eating a well-balanced diet, exercising, and managing stress. Eating a diet that is low in saturated fat and rich in whole grains, fruits, and vegetables. Decreased consumption of caffeine, alcohol, salt, and sugar, about two weeks before your menstrual period begins. Drink plenty of fluids such as water or juice. Exercise helps to improve circulation, reduce stress, and enhance mood. Moderate aerobic exercise at least three times a week tend to have fewer premenstrual symptoms. Relaxation techniques such as meditation, deep breathing, progressive relaxation, yoga, and biofeedback, can also help in relieving stress. 6 Pharmacological management including nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Advil), and naproxen (Aleve) may helps in relieving the symptoms such as headache, backache, cramps, and breast tenderness. Medications prescribed in the cases of severe depression or anxiety. Certain antidepressants useful to treat severe Premenstrual syndrome. Oral contraceptives have been prescribed to treat Premenstrual syndrome. The diuretic spironolactone can reduce the fluid retention of Premenstrual syndrome. Evening prime rose oil, Prostaglandin inhibitors, also effective in the treatment for premenstrual syndrome. 3 Hormonal treatment is advised when other medical treatment fails.complimentary therapies like acupuncture, homeopathy, herbalism, aroma therapy, reflexology, and hypnotherapy are also helpful in reducing premenstrual syndrome. 3

201 International Journal of Nursing Education. January-March 2015, Vol. 7, No According to the epidemiology of premenstrual syndrome globally women with premenstrual syndrome usually present both physical and mood symptoms. These are affecting approximately 20% to 30% of menstruating women. The average age at which women with premenstrual syndrome seek treatment is below 30 years. 7 The reported prevalence of about 20-40% shows that a significant group of women may be affected by PMS. Reports of PMS among adolescents in western countries indicate a prevalence ranging from 14 to 30%. 8 In India adolescent problems related to menstruation is 70.1%. Commonest being are dysmenorrheal and premenstrual syndromes (88.8%). 23% had missed school days for 1-3 days. 9 In Karnataka 33% of women have one menstrual problem or both. In India, the adolescent population constitutes more than one fifth (23%) of the total population. 10 A cross sectional study was designed to investigate the frequency of premenstrual syndrome. On 520 subjects selected from the University of Karachi (mean age 20±1.94).The PMS and menstrual cycle data of the individuals were collected from prism calendar and symptom thermal chart for three consecutive cycles. Based on observations all subjects were group as control (208) and PMS patients (312).The frequency (60%) with symptoms include irritability (71.05%), fatigue (86.84%), and bowel constipation (36.76%) and loose bowel (17.65%), appetite up (42.65%) and appetite down (51.47%). Breast tenderness (67.65%), abdominal blotting (47.06%), aggressiveness (29.41%), depression (13.24%) and insomnia (14.71%), labile mood (5.88%), and anger (7.35%). Elevated irritability and breast tenderness were observed in the age group (19-24) years, i.e., 92% and 82% respectively pd The study concluded prevalence and frequency of premenstrual syndrome. 11 A cross-sectional study was conducted to determine the frequency of reported physical or emotional premenstrual symptoms associated with dietary intake and other life style factors among 3302 midwives was selected by random sampling technique. The researcher found that the fiber intake was positively associated with breast pain (AOR = 1.39, p = 0.037) smoking (AOR = 1.60, p = 0.028) and passive smoke exposure (AOR = 1.56, p = 0.050) were positively associated with cramps and back pain. Premenstrual syndrome were also associated with co morbidities, early perimenopausal status, depressive symptoms, and symptom sensitivity. 12 OBJECTIVES OF THE STUDY 1. To determine the pre-test knowledge of adolescents on lifestyle changes in the prevention of premenstrual syndrome. 2. To evaluate the effectiveness of planned teaching programme on lifestyle changes in the prevention of premenstrual syndrome. 3. To find the association between lifestyle changes and selected demographic variables in Prevention of premenstrual syndrome HYPOTHESES The hypotheses will be tested at 0.05 level of significance. H 1 : The mean post test knowledge scores will be significantly higher than mean pre test knowledge scores. H 2 : There is a significant association of post test knowledge scores with selected demographic variables. METHODOLOGY The research approach and design adopted for the study was pre experimental approach. The population consisted of adolescents students in Mangalore.Stratified random sampling was used to obtain the sample of 100 adolescent students in selected schools of Mangalore. The data was collected using demographic profile and structured knowledge questionnaire to assess the knowledge of adolescents regarding lifestyle changes in prevention of premenstrual syndrome. Demographic profile consists of 5 items and structured knowledge questionnaire consists of 27 items

202 194 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 FINDINGS PART I: Description of the demographic variables of the sample. Table 1: Frequency and percentage distribution of adolescent students according to demographic characteristics N=100 Variables Frequency (f) Percentage (%) Age [in years] a b c Age at menarche a b c d. 16 and above 0 0 Religion a. Hindu b. Christian c. Muslim 5 5 d. Any others 0 0 Educational qualification a. 6th-7th standard b. 8th-9th standard c. SSLC 0 0 Family income a. < b c d. > The data presented in the table 1 shows that the majority of adolescent students (70%) were in the age group of years and majority (60%) attained menarche were in the age group of years.50% of the adolescent students were Hindus. Majority percentage (80%) belong to 8 th -9 th standard. Majority percentage (90%) of them has more than Rs family income. PART II: Description of knowledge of adolescent students regarding lifestyle changes influencing premenstrual syndrome Table 2: Frequency and percentage distribution of knowledge score of adolescents students regarding life style changes influencing premenstrual syndrome Level of Knowledge Range of score Pre-test Post-test F % F % Poor Average Good Total N=100

203 International Journal of Nursing Education. January-March 2015, Vol. 7, No (51%) of the adolescents had poor knowledge, and (17%) of them had good knowledge, whereas in the post-test maximum number (49%) of the adolescents gained good knowledge and (19%) of them had poor knowledge. Table 3: Range, mean, median, standard deviation and mean percentage of pre-test and post-test knowledge of adolescents regarding lifestyle changes influencing premenstrual syndrome Obtained range Mean Median Standard Mean% deviation Pre-test Post-test N=100 Data in Table 3 shows that the post-test knowledge range (8-25) was significantly higher than the pre-test knowledge range (6-24). The data also depicts that the mean and median of post-test knowledge scores x 2 = 17.02, M2 =18 was higher than mean pre-test knowledge scores x 1 =12.93, M 1 =9. The median value of post-test knowledge scores (18) was higher than the median value of the pre-test knowledge scores (9). Table 4: Area-wise mean, standard deviation of pre-test and post test knowledge scores of adolescent students regarding lifestyle changes influences premenstrual syndrome Areas of knowledge Maximum score Pre-test Post-test Mean SD Mean SD Premenstrual syndrome Causes Risk factors Diagnosis Symptoms Diet Stress Exercise N=100 The data in Table 4 shows that in all the areas mean post-test knowledge was higher than the mean pre-test knowledge scores. Table 5: Area-wise mean percentage and mean gain of pre-test and post-test knowledge score of adolescents regarding lifestyle changes influences premenstrual syndrome Sl. No. Areas of knowledge Mean percentage scores Mean Possible Mean actual Modified gain (%) gain (%) gain Pre-test Post-test a. Premenstrual syndrome b. Causes c. Risk factors d. Diagnosis e. Symptoms f. Diet g. Stress h. Exercise N=100

204 196 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Data in Table 5shows that, in all areas the mean percentage of post-test knowledge score was than the mean pre-test knowledge score. The mean percentage of the pre test score was the highest (55.2%) in the area of introduction to premenstrual syndrome and lowest (42%) in the area of diagnosis of premenstrual syndrome. Mean percentage post-test is maximum (68%) in the area of diagnosis and least (61.2%) in the area of exercises to premenstrual syndrome. The highest modified gain (44.82) is in the area of diagnosis and least (19.14) is in area of stress influences premenstrual syndrome. Table 6: Mean, Mean difference, standard deviation and t value on pre-test and post-test knowledge scores regarding life style changes in prevention of premenstrual syndrome Parameter Mean Standard Mean t value Deviation difference Pre-test * Post-test t 99 = 1.960, p<0.05 *Significant N=100 The data in Table 6 shows that the mean post-test knowledge score (17.02±4.51) was higher than the pretest knowledge score (12.93±4.81). The calculated t value (14.75) was greater than the table value (t 99 =1.960) at 0.05 level of significance. Hence, the null hypothesis H 01 was rejected and the research hypothesis was accepted. Table 7: Chi-square test showing association of post-test knowledge score with demographic variables Variables χ 2 Df Inference N=100 Age in years Not significant Age at first menstruation Not significant Religion Not significant Family income Not significant Educational status Not significant χ , p<0.05 (1) = The data in Table 7 shows that no significant association was found. Hence the null hypothesis was accepted for this variable. This finding reveals that the post-test knowledge score is not associated with any of the demographic variable CONCLUSION Adolescents are more prone to get premenstrual syndrome.in adolescents premenstrual syndrome might particularly affect school functions, and social interactions in a negative way.it also affect their families and their social relationship, including low self-esteem, low tolerance to stress and feelings of in adequancy.lifestyle changes regarding diet, stress and exercise helps in reducing premenstrual syndrome. Dietary restrictions help in alleviating the physical and psychological symptoms.reduction of stress is of great help in eliminating the symptoms. Exercise will reduce physical and emotional symptoms. Therefore, knowledge regarding lifestyle changes is essential to prevent premenstrual syndrome Acknowldgement: We express our thanks to adolescent students who participated in the study and authorities who provided permission to conduct the study. Conflict of Interest: None Ethical Clearance: Ethical clearance was obtained from the A.J Ethics committee Funding Sources: Not obtained any funds from any sources

205 International Journal of Nursing Education. January-March 2015, Vol. 7, No REFERENCES 1. Baraga VL. Textbook of gynaecology 2 nd ed.new Delhi: Ane Books Private Ltd.; P Dutta DC. Textbook of gynaecology including contraception. 5 th ed. Delhi: New Central Book Agency; P. 79, Aganger E, Allanach V. Gynaecological nursing, A practical guide. London;: Mosby; P Murray S, Mckinney E, orrie T. Foundation of maternal newborn nursing. 3 rd ed. London: W. B. Saunders; P Thomson Reuters ISI Web of Science. Journal of Society for development in new net environment in B&H. 2011;5(6). 6. Scholten A. Life script healthy living for women: life style changes to manage premenstrual syndrome. [online]. health/a-z/treatments_a z/by_condition/p/ lifestyle_changes_to_manage_premenstrual_ syndrome_pms.aspx 7. Johnson SR. The epidemiology of premenstrual syndrome. Primary Psychiatry 2004;11(12): Chau JPC, Chang AM. Effects of an educational programme on Adolescents with premenstrual syndrome. Oxford Journals Health Education Research 1999 Dec;14(6): John C. A study of menstrual problems in adolescent girls. [online]. Available from: URL: q=cache:dhfaqq7cvu8j: articles/original. pdf+study+ of+menstrualn problem s+in+adolescent+girls+by+dr.sr. christina &hl=en&gl=in&pid=bl&srcid=a DGEESisolaZnBwm NKOPoIKcnHc 255 jum bqw4as1xl7y_nwxdmyozfgge6ti9- z_61n8ljnzbvujg_ 0dn7PPiHpPKfaqlfp NRw BYTIUj6_guJMpU0WxRtjkr2R-dTByawm 3dYPj H1kW_&sig=AHIEtbT-kr-5kOw CCsu Pkdaz D1aEUqZgVw. 10. Bhatia JC, Cleland J. Self-reported symptoms of gynaecological morbidity & their treatment in south India. Studies on Family Planning 2005,26(4): Sitwat Z, Abid A, Arif A, Bansit A, Anwar QM. PMS and prevalence among university students in Karachi, Pakistan Int Res J Pharm 2013;4(4): Gold EB, Bair Y, Block G, Greendale GA, Harlow SD, Johnson S, et al. Diet and lifestyle factors associated with premenstrual symptoms in a racially diverse community sample: study of women s health across nations (SWAN). [online]. Available from: URL:

206 198 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / An Exploratory Survey to Identify the Determinants of Health Care Services Utilization by Under Five Children in a Selected Village of Jhajjar, Haryana Poonam Joshi 1, Manju Vatsa 2 1 Lecturer, 2 Principal, College of Nursing, AIIMS, New Delhi ABSTRACT This mixed method community based study identifies households, primary caregivers, under-five children, demographic factors and health care services characteristics and the pattern of health care services utilization for childhood illness. A cross-sectional household survey was conducted in a selected village of Jhajjar district of Haryana from June 2011 to June 2012, in which 1265 households were contacted. Total 340 primary care givers of children suffering from illness currently or during last 2 weeks were interviewed using a semi-structured interview schedule. Some primary care givers were randomly selected for in depth interviews. One way ANOVA and the Chi-square test were used to determine the association with selected variables (p<0.05, CI 95%). Qualitative data was transcribed analyzed for content and grouped into thematic categories. Majority of primary care givers were mothers 269 (79.1%), in the age group of years (149, 43.8%) with mean age 28.2±9.9 years (15-70). Majority of sick children 328(96.4%) were between 2months to 5 years, male (206, 60.6%). Majority of sick children suffered from cold and cough (218, 64.1%) During the current illness majority of PCGS 205(60.3%) had been to the private health care facility to seek the treatment. Significant relationship was found between the private health care facility utilization and the selected variables. Majority primary care givers despite low socio- economic status sought health care services from private sector. It was preferred mainly due to their availability and accessibility even in the evening and night time, faith, quick relief within reasonable amount and good individual attention by them without any loss of daily wages. Keywords: Health Care Services Utilization, Childhood Illnesses, Under Five, Primary Care Providers, Health Care Providers INTRODUCTION India being one of the developing countries is faced with an unparalleled child survival and health challenge. The country contributes 2.38 million of the global burden of 10.8 million under-five child deaths, which is the highest for any nation in the world. The 10.8 million annual child deaths are not distributed evenly over the 0-5 year age period. 1 More than 70% of all child deaths occur in the first year of life and of Corresponding author: Poonam Joshi Lecturer College of Nursing, All India Institute of Medical Sciences. New Delhi, India pjoshi69@rediffmail.com Tel: Fax: these nearly 40% occur in the first month of life (the neonatal period). Seven in 10 of under- five deaths are due to acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria or malnutrition and due to a combination of these illnesses. Under fives a highly vulnerable group constitute 13% of the total population in India. The mortality in the age group of 0-28 days is about 35 per1000 live births, infant mortality rate continues to be high at 47/1000 live births and under five mortality 61/1000 live births. 2 Under- five children fall sick despite precautions and care. It is the primary caregiver s response to the illness that can make a difference between life and death. High child mortality and morbidity in developing countries are highly associated with limited access to and poor quality of health care. Most of the deaths occur in impoverished rural

207 International Journal of Nursing Education. January-March 2015, Vol. 7, No communities, where poor access to basic health can result in lack of timely administration of inexpensive treatment. Even for many poor parents and their children, seeking medical help is a luxury and health services are often too far away. 3 The health service system in India has evolved from self-reliance in the past, i.e. using local wisdom for curative care and health promotion, to the systems depending largely on modern medical and health services approaches. Under the new systems, various levels of health services are arranged, basically from self care at family level to advanced health services provided by health specialists. The government sector is the main service provider, with increasing participatory roles of the private sector. Seeking care from health services is one the ways households contribute to health of their children. PCG s choice of health care provider (HCP) is often interplay of many factors like socio-economic factors 3 (family income, parental education, occupation and land tenure etc., environmental factors (water supply, sanitation, housing etc.) and health services (manpower, structure, referrals etc). 4 World over, several studies reveal disparities in child health outcomes across socio-economic levels and regions of the country 4-8, in India too health inequalities are found in the relationship between socio-demographic determinants and the utilization of child health services has not been under rigorous examination, as very few studies 5,7, 9 from India identify the determinants of health care services utilization in under five. No published literature explains the determinants and family dynamics of health care services utilization for sick under five children. Therefore the present rural community based study was planned. MATERIAL AND METHOD An exploratory community based mixed method (quantitative as well as qualitative) survey to find out determinants of health care services utilization by the parents for their under five children, was conducted between June 2011 June 2012 in a selected village of Jhajjar district of Haryana. The general population of the selected village was around 28,000 being served by a community health centre (CHC) and one primary health centre (PHC) within 2KM range. The village also housed many private ayush, ayurvedic, allopathic and homeopathic practitioners, chemist shops, and neem hakeems. The village was conveniently selected by the investigator. Population for determining health services utilization was primary caregiver of children below 5 years of age with a history of morbidity and mortality. It was assumed that utilization of health services from government sector may only be 30% (20-40%). The sample size was calculated as n= 4X p (100-p)/d 2 = 336; (p is the anticipated percentage of utilization of health facility from government sector and d is the permissible error). The ethical and administrative approval was taken from the Ethics Committee, Indian Nursing Council, Sarpanch of the selected village. Informed written consent was obtained from the subjects prior to study. A pretested semi-structured questionnaire containing information about the socio-demographic characteristics of the family, symptoms, duration of illness of child as per IMNCI guidelines, type of health facility used and the reason for the preferred type of care sought during the child illness(á = 0.90) and indepth interview with triggers was used for data collection. The tools and methodology were piloted in Sanganer district of Jaipur, Rajasthan. A list of houses having children below 5 year was prepared with the help of ASHA workers in the village. In door to door survey 1265 households were contacted. Total 340 primary care givers of children suffering from illness currently or during last 2 weeks were selected using consecutive sampling technique and interviewed using a semi-structured interview schedule. In-depth interviews were conducted by random selection of primary caregivers. Data was collected till the point of saturation. Sickness was defined as any child below 5 years having infection, pneumonia, diarrhoea, and fever for more than one day. A period of 2 weeks of illness was chosen as criterion to ensure better recall on the part of PCG. Inclusion criteria for primary caregivers was (i) consenting, (ii) having children below 5 years of age, (iii) currently sick or have history of illness in past 2 weeks, (iv) available at the time of study (v) understands Hindi or English. Statistical analyses were done using descriptive and inferential statistics with SPSS 17.0 version. One way ANOVA and the Chi-square test were used to determine the association with selected variables (p<0.05, CI 95%). The interviews were tape recorded, transcribed analyzed for content and grouped into thematic categories.

208 200 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 FINDINGS Majority of primary care givers were mothers 269 (79.1%), in the age group of years (149, 43.8%) with mean age (years) 28.2±9.9(15-70), married 335 (98.5%), housewives (244, 71.8%), labor (83, 24.4%), studied up to primary 102 (30%), belonged to Hindu religion (314, 92.4%), having monthly family income less than Rs.5000 (113, 33.3%), staying in joint family (216, 63.5%), own (241, 70.9%), kaccha house (95, 27.9%), for more than 20 years (178,52.4% ). Average number of family members and children in the family were 7(3-22) and 2 (1-9) respectively. Majority of families (192, 56.5%) were using hand pump/boring water for drinking purpose located inside or within 1/2 Km of radius, consuming water without any treatment (244, 71.8%). Majority were having electricity (253, 74.4%), and using septic tank (239, 70.3%) for defecation. Majority of sick children 328(96.4%) were between 2months to 5 years, male (206, 60.6%), first birth order (129, 37.9%) delivered at term (302, 88.8%), through normal vaginal delivery (276, 81.2%), with normal birth weight (246, 72.4%), at government hospital (117, 34.4%) same percentage of children were delivered in private hospital and 105(30.9%) were home deliveries. During the household interview sick children were assessed as per the IMNCI guidelines. Majority of sick children suffered from cold and cough (218, 64.1%) and remaining had diarrhea (84, 24.7%), fever (158, 46.5%), ear problem (39, 11.5%) and measles (12, 3.5%) respectively, however many sick children were suffering from more than one illness at the time of survey. Majority of sick children 238(70%) had one episode of illness in last 15 days with mean duration of illness in days 3.27± 2.6(2-15). None of the children had any danger sign. Fifty five percent of children were fully immunized, while partially immunized and not immunized were 117(34.4%) and 36(10.6%) respectively. Majority of children (80%) were taken to the government facility for immunization. Majority of children (179, 52.7%) had anemia of varying degree mild, moderate, severe 172(50.7%), 5(1.5%) and 2(0.6%) respectively. Another prevalent problem was malnutrition (171, 50.3%) of varying degree I, II,III,IV 63(18.5%), 61(17.9%), 32(9.4%) and 15(4.4%) respectively. On enquiry majority of PCGs of sick children (255, 75%) had no prescription slip to show however 167(49.1%) PCGs were continuing to give prescribed medicines During the current illness majority of PCGS 205(60.3%) had been to the private health care facility to seek the treatment while to chemist, government health care facility and both government and private were 57(16.8%), 45(13.2%) and 7(2.1%) respectively, however 26(7.6 %) had managed their sick children at home (Table 1). The PCG, who had been to both government and private health care facility (2.1%), first visited the private one followed by government facility due to unaffordable treatment at private facility for a long period of time. Table 1: Use of Health Care Facility Generally and Currently during Present Illness n= 340 Use of health care facility Frequency (%) Use of facility (generally) Government 62(18.2) Private 205(60.3) Chemist 51(15) Government + private 22(6.5) Use of facility during current illness Home management 26(7.6) Government 45(13.2) Private 205(60.3) Chemist 57(16.8) Both Government and private 7(2.1) Various reasons had been stated by PCGs during the interview for not utilizing the government health care facility (Table 2). Table 2: Reasons for not utilizing government health care facility during current illness n= 295 Reasons for not using government health care facility Frequency (%) Similar episode, Nearby chemist shop 57(19.3) Lack of personal attention, trust, faith on government facility 50(16.6) Related to employment (no leave, loss of wages) 41(13.5) No medicines available for children/same medicines for child and adult 38(12.5) No relief from government facility 34(11.3) Using home remedies (the illness being minor, not a serious one) 26(8.8) Long waiting time at government facility 20(6.6) New place (not aware of the government facility) 16(5.3) Long distance to travel 11(3.8) No one at home to accompany to the government facility, 2(0.6)

209 International Journal of Nursing Education. January-March 2015, Vol. 7, No Significant relationship was found between the health care facility utilization and the selected variables such as female PCGs (p= 0.001), PCGs studied up to 10 th standard (p=0.000), more house wives and labours (p=.000), illiterate and fathers working as labour (p=0.00), Hindu religion (p=0.01), own kaccha house (p= 0.00), home deliveries (p=0.01), family income (p= 0.009), no prescription available and adherence to treatment (p=0.00). Relationship between health care services utilization and other selected variables such as age of PCG, no. of family members, no. of children and age of sick child was checked using one way ANOVA test (p<0.05). The test did not show any significant statistical difference in health care services utilization among the groups with the selected variables. In-depth interviews helped the researcher in indentifying promoting and impeding factors to the utilization of health care services. Promoting factors The promoting factors for the utilization of health services provided by the government were no relief from private doctors, less distance, genuine treatment from government hospital; however utilization of PHC, CHC was less in comparison to district government hospital. All the caregivers (2.1%) had gone to private doctors before moving to the government hospital. Once the condition of child deteriorated or there was financial crisis due to prolonged treatment, parents opted for district level government hospitals. Box 1 Verbatim accounts for promoting factors No relief from private doctor I gave my child the prescribed medicines for two days from the private doctor. There was no relief. I gave him medicines. He continued to have the problem; there was no relief. There after I took him to government hospital. My child was immediately admitted in the hospital started with glucose and medicines. (PCG3) I should have taken him immediately to big hospital. I unnecessarily wasted my time. (PCG 3) Private Doctors are only concerned about making money. Patients are there for them to earn the money. (PCG5) Distance I just got one medicine from there and rest I was told to purchase from outside. I am giving him medicines. He looks little better now. I will continue the treatment for another 3 days. I hope He will be alright. Whenever my child is sick I prefer this hospital first as it is very nearby. (PCG 7) Genuine treatment in government hospital Treatment is good in government hospital only. Doctors sitting in government hospital give genuine treatment. There is lot of rush. In the morning you can see mad crowd. Doctors over there are very busy. Private Doctors are only concerned about making money. Patients are there for them to earn the money. (PCG5) I made a big mistake by going to the several private doctors. They just prescribed medicines without properly examining the child. When the condition was very serious, they just raised their hands and told me to rush the child to district hospital. (PCG 16) I gave her medicines for one day. There was no relief. She continued to have loose watery diarrhea. She passed more than times stool in a day. Next day I along with my mother in law took her to a private doctor. She was not looking normal to me. I called my husband, who is a plumber doing private job. We took her to civil hospital. She was seen in emergency department and kept overnight. Glucose was started and injections were given. She got better and next day evening we came back home. (PCG 16) The impeding factors for the utilization of health services provided by the government were many like poor health services at CHC including lack of medicines, lack of proper information, non-availability of doctors, no response to treatment, long waiting time, faith on private docotrs, perceived seriousness of illness, financial constraints arising due to loss of wages, lack of support system, new place, similar episode, individual attention by private doctors and availability and accessibility of health care professionals in the evening and night time.

210 202 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Verbatim accounts for Impeding factors Box 2 1. Poor health services at the CHC What I would have done with those two tablets? Also, they do not talk properly. (PCG2) [Lack of medicines, no satisfaction] Doctors and nurses did not tell me much about the child. I asked them but they said medicine has been written and he will be ok. Doctor asked me to purchase medicine from outside and sent me home. I started with treatment but my son did not improve. (PCG2)[lack of proper information] In this centre, most of the time paediatrician is not available. There is no point going there when I do not know whether I will find the doctor or not. In odd hours no one is available, only deliveries take place in the centre. (PCG 2,4) [Non-availability of doctors] There is no point going to the dispensary (CHC), when it is not sure whether doctor will be there or not. I take my child only for immunization there. (PCG4) [Non-availability of doctors] Moreover the doctor whom I go to is just charging very minimal amount and also gives me medicine. I don t see any pediatrician in CHC. (PCG 10) [Non-availability of doctors] For all problems, whether it is a child or an adult they have just one medicine to give. (PCG2) [Non-availability of drugs] Doctor sitting there prescribed me medicines and asked me to purchase from outside, as the syrups were not available. There was no improvement in child s condition. So my husband took the child to district hospital. (PCG5) [Non-availability of drugs] Medicine given by them did not suit my child. They had given me just two tablets and asked me to give one fourth to the child. I cannot waste my time for just two tablets (PGC 10) [Non-availability of drugs] 2. No response to treatment My wife took him to several doctors in CHC as well as private. After seeing no improvement, I decided to take him to district hospital. (PCG 15) 3. Long waiting time In CHC no one is available early morning and a very long waiting time. (PCG1) Treatment is given here as well there (CHC). I cannot say.., I don t know much about CHC. It takes lot of time to get the treatment from dispensary. (PCG1) 4. Faith We took our child to Mission Hospital (Private hospital) so that she gets cured immediately.(pcg1). He has a shop nearby and sells medicines. He is very blessed person, his medicine suits us, my child responds very fast to his treatment (PCG2) He (private doctor) had a good reputation as a child specialist. Everybody in the locality praised him. (PCG3) These English medicines are very strong and causes harm to the child. (PCG 14) [no of faith on allopathic medicines] My mother in law also tells me not to give English medicines very frequently (PCG 17). no of faith on allopathic medicines] 5. Perceived seriousness of illness I could not do anything at home at night. Just remained awake whole night, did not sleep even for a second and kept my child in my lap, early morning at 5 we rushed to private nursing home. (PCG1) 6. Financial constraints arising due to loss of wages My husband has a private job; it is not easy for him to take the leave. One day from work place means loss of pay? It is so costly to live here. We are poor, cannot afford to miss even a single day wage. (PCG2) My husband did not want to take leave from his work place. (PCG 6) If I go to sarkari hospital in the morning I will lose my one day earning. How will I feed all my 5 children. (PCG12) 7. Easy availability and accessibility of private doctors He (private doctor) is nearby, available all the time. I can show my child even when my husband is not around. (PCG2) 8. Lack of support system I could not think of taking her to CHC as there are other children at home and none to look after them. (PCG-8) In the PHC it is difficult for me leaving behind all household chores and go there. While here, I can go to this doctor as per my convenience. (PCG 11) When my husband comes back, I will decide what is to be done? You can imagine my mental condition. I am so tense. I am praying for the recovery of the child. (PCG 18) 9. New Place I do not know anyone here. Moreover they (doctors) are only there in the morning. I can only go after finishing household chores. (PCG-9) 10. Similar episode I am continuing with my old stock of medicines as he just had cough and cold few days back too. (PCG 13)

211 International Journal of Nursing Education. January-March 2015, Vol. 7, No DISCUSSION Role of private sector in health care has witnessed a continuous rise during past two decades. The major finding of the study is that a majority of the target PCGs utilized private health facilities first when their children developed any kind of illness (60.3%), that are similar to other studies which report frequent use of private sector even by poorer classes [Dileep TR etal (2002) 6, Willis JR etal (2009) 7, Hassan IJ etal (2000). 8 ] This surprisingly high rate of utilization might be attributable to the easy availability and accessibility of doctors as per the convenience of PCG and partly attributable to the relatively affordable treatment at private facility and good community relations. Uncertainty regarding availability of drugs/services and extremely formal procedures at public hospitals leading to long waiting time have been reported as some of the reasons for preference of private sector. The results of the present study are consistent with the studies by Hasan IJ etal (2000) 8, Van der S etal(1996) 10 and Thuan NT etal(2008) 11 showing less utilization of government health services among poor showing a lack of confidence in public health services by the people. However in the present study 80% of the children were immunized in the government facility suggesting the use of government facility mainly for immunization. Sur etal (2004) 12 reported that 60% of PCGs only went for allopathic system and 40% for ayurveda, homeopathy, traditional healers etc, while our study showed that only 13.23% PCGs used available government health facility for seeking treatment for sick children, 7.6% of PCGs used home remedies as they perceived the illness of the child mild, 16.76% had contacted nearby chemist shops for getting allopathic medicines for their children and remaining 62.4% had taken their sick children to the private doctors. None of the PCGs had reported of taking their children for auyurvedic, homeopathic doctor or the traditional healer. Taffa etal (2005) 13 while studying the factors affecting health seeking behaviour in Nairobi found that health care seeking was more for children below one year, but the present study showed that age group did not influence health seeking behavior/ utilization of health care services of PCGs. The present study revealed no gender difference in seeking treatment for the sick under five children that are congruent with findings of Pillai etal (2003) 9, Shellenberg etal (1992) 14. Association between socioeconomic status and health seeking behaviour studied by Pillai etal (2003) 9 reported that with low socioeconomic status parents frequently seek the government health care but our study showed that even people below poverty line, casual workers sought private care, probably fearing loss of job, loss of wages for the day, inability to get leave etc; moreover private clinics are opened till late evening, while in government facilities like primary health centre and community health centers, no pediatric doctors are available in the evening. Our study results showed that the government facility was primarily used for immunization of children (80%) as far as the use by the child is concerned. The long waiting time, lack of personal attention by the doctor, no trust on expertise of available doctors in government facility, non-availability of pediatric medicines in the facility were other reasons reported by the PCGs. The quality of drug in private facility is better than government health facility, the reason may be attributed to the limited budget of the government, cannot buy all available paediatric drugs in the market, moreover the drug provided to the PCGs at the government facility are in less quantity (2-3 doses), reduced from adult preparation or sometimes they are asked to buy them from outside which goes against the expectations of PCGs having free drugs available at the government facility and being issued to the general public. In the present study majority primary caregivers used local private practitioners and chemists as their first choice of health care provider but in few cases (2.1%), when the illness persisted longer they took their children to secondary level government hospitals due to financial constraints. The findings are congruent with other studies Mixed method approach helped in triangulation of data, which is the biggest strength of the study. The semi-structured questionnaire along with in-depth interview used for data collection provided greater understanding of utilization of health care services and increased its credibility and dependability. This study has several limitations. With the crosssectional study design in the present study causality could not be determined. The study was conducted in only one village which was conveniently selected is not sufficient enough to draw any concrete conclusion from the information collected and further limits the

212 204 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 generalization of the findings. Some probability of recall bias in case of children not sick at the time of interview but preceding 15 days is also there. Implications Authorities need to review the reasons reported by PCGs for not using government health care facility seriously and take appropriate steps to improve the management of health care services and ensure adequate nursing manpower in the rural areas. Health care providers specialized in child health should be necessarily posted in all the health care facilities round the clock. Availability of drugs in paediatric dosage should be ensured in the facility. RECOMMENDATIONS The study can be replicated taking sample from more than one village for more accurate results. To clarify the situation, and identify the priorities of the primary caregivers, further longitudinal studies are required. A comparison between private and public facilities in terms of health care services utilization can be made. CONCLUSION Private health care facility was preferred due to availability of doctors even in the evening and night, accessibility, faith, quick relief within reasonable amount and good individual attention. Priority of the government should be towards improvement in the quality of health care services directed towards childhood illness at CHCs and PHCs. Conflict of Interest: The authors declare no conflict of interest. Acknowledgement: The investigator is grateful to the primary caregivers of the sick under five children without their support and cooperation; present study would not have been possible. Funding: Self funded REFERENCES 1. UNICEF: The state of the world s children Oxford: Oxford University Press; SRS. Registrar General of India. Statistical Report, Vol.46(1). vital_statistics/srs_bulletins/srs_bulletin_ December_2011.pdf accessed on Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav.1995;36: Navaaneethan K, Dharmalingam A. Utilization of maternal health care services in southern India. Soc Sci Med2002; 55: Govindasamy P, and Ramesh BM. Maternal Education and the Utilization of Maternal and Child Health Services in India. International Institute for Population Sciences Macro International Inc, Calverton.1997 (5) National Family Health Survey Subject Reports, International Institute for Population Sciences, Mumbai, India. 6. Dilip TR, Duggal R: Incidence of non-fatal health outcomes and debt in urban India. [ / urban/ symposium 2002/ docs/ pres-paper/ paper-pdf/ dilip-paper.pdf] Accessed on September, Willis JR, Kumar V, Mohanty S, Singh P, Singh V, Baqui AH, Awasthi S, Singh JV, Santosham M, Darmstadt GL: Gender differences in perception and care-seeking for illness of newborns in rural Uttar Pradesh, India. J Health Popul Nutr 2009, 27(1): Hasan IJ, Khanum A: Health care utilization during terminal child illness in squatter settlements of Karachi. J Pak Med Assoc 2000, 50(12): Pillai RK, Williams SV, Glick HA, Poloky D, Berlin JA, Lowe RA. Factors affecting decisions to seek treatment for sick children in Kerala in India. Soc. Sci. Med Journal2003; 57: Van der Stuyft PSS, Delgado E, Bocaletti E: Health seeking behaviour for child illness in rural Guatemala. Tropical Medicine and International Health 1996, 1(2): Thuan NT, Lofgren C, Lindholm L, Chuc NT: Choice of healthcare provider following reform in Vietnam. BMC Health Serv Res 2008, 8: Sur D, Manna B, Deb AK, Deen J L, Danovaro- Holliday MC, von Seidlein L. Factors associated with reported diarrhoea episodes and treatmentseeking in an urban slum of Kolkata, India: J Health Popul Nutr. 2004; 22: Taffa N. Chepngeno G. Determinants of health care seeking for childhood illnesses in Nairobi slum. Trop Med Int Health2005;10(3): Schellenberg JA, Victora CG, Mushi A, de Savigny D, Schellenberg D, Mshinda H, Bryce J. Inequities among the very poor: health care for children in rural southern Tanzania. J Bio Soc Sci. 1992; 24:

213 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Septic Shock: Early Goal Directed Management Can Save Lives Sana Hirani 1 Critical Care Nurse, Department of Intensive Care Unit, Aga Khan University School of Nursing and Midwifery, Karachi, Pakistan ABSTRACT Septic shock is a medical emergency associated with substantial mortality and morbidity rate. The transition of this complex syndrome occurs from the invasion of micro organism to severe sepsis and septic shock which results in global tissue hypoxia and circulatory abnormalities. The purpose of this paper is to highlight the current research related to early goal directed management of septic shock and its effects on mortality rate. Five peer reviewed research article and publications were studied from different resources. Information were gathered through intervene the selected interventions on septic shock patients and their findings were compared with those who received standard care instead of early goal directed treatment. Finding of this article revealed three positive treatment options which are early stabilization of airway, early resuscitation of fluids and early antimicrobial therapy. As a result of these interventions, improvement initiated and 17.7 % significant reduction is seen in the morality rate of patients. Authors supported that early treatment prevents organ damage and improves patients overall chances of survival. Hence, early goal directed treatment provides significant benefits and increase overall health status of patients. I recommended that multi disciplinary approach should be use in order to provide holistic care because these approaches address the problem from all dimension and decrease the mortality rate. (211). Keywords: Septic Shock; Hypoxia; Circulatory And Antimicrobial Therapy INTRODUCTION Septic shock is a term that health care provider frequently used during their professional career life. Septic shock is a medical emergency and a serious health problem in which patients are overwhelmed with certain infection (known or suspected) which can be life threading. It is a complex syndrome which is difficult to define diagnosis and treat. The transition of this complex syndrome occurs from the invasion of microorganism to severe sepsis and septic shock which results in global tissue hypoxia and circulatory abnormalities. This is a major health problem which affects millions of people worldwide and the incidence of it is increasing day by day. According to the US research every year 1665,000 cases are reported and still there is no significant improvement in the survival rate (6). However, early goal directed managements are the key priority treatment by which we can manage this problem and increase the overall health status of our patients. The purpose of this paper is to present the current research related to early goal directed management of septic shock which include: early stabilization of airway, early resuscitation and early antimicrobial therapy. The major focus is to initiate the early goal directed therapy by stabilizing the airway and breathing therefore it should be initiated it in the first four hours of the injury which is known as Golden hour. According to Sepsis Campaign (2013), the strategy of early goal directed therapy was evaluated in multicenter trial of 514 patients and it reveals that there is 17.7% significant reduction in mortality rate (1). The benefits of early goal directed therapy in terms of outcome is multifactorial. If treatment is initiated in this few hours then it will increase patient outcome and decreases the mortality rate by 16 % (7).

214 206 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Furthermore, prompt treatment of hypoxia prevent the secondary injury therefore, it is important for a nurse to monitor patient oxygenation, respiratory status for rate,depth and effort thought pulse oximetry throughout the course of illness. In addition, supplement oxygen therapy should be administered via a mask to achieve adequate oxygenation saturation > 95% and if airway compromised than the need of mechanical ventilation should immediately assess in order to improve tissue oxygenation. According to Robson & Newell (2005), patient s airway should always be assessed and managed before anything else because an obstructed airway will kill the patient before a problem (5). Once the goal of oxygenation is achieved, then it is a responsibility to move towards the initial fluid resuscitation for restoration and maintenance of adequate tissue perfusion. Therefore careful and invasive monitoring of blood pressure and pulse are required in this stage. Hypovolumeia is the important factor that contribute to septic shock,therefore initial fluid resuscitation should begin with crystalloid and colloid fluid challenge of ml/kg which is 1 to 2 liter over 30 minute and this can be increase up to 10 liters of fluids in 24 hours. This rapid challenge of fluid would help patient in circulatory support but careful monitoring for the sign of volume overload should be monitored like pulmonary edema, dyspnea in order to prevent from respiratory complication. Robson & Newell (2005) stated that the initial resuscitation of fluid prevents organ damage and improves patient chance of survival (5). In addition, improvement in the patient mental status, hemodynamic status will indicate adequate volume resuscitation has been achieved. Even, after adequate fluid resuscitation challenge if patient does not respond then he may require vasoconstriction drugs such as norepinephrine. According to a systemic review study done by Martin et al 1993, norepinephrine is three time better drug of choice for hemodynamic instability and oxygen transport and for best result it should be started within 6 hours of treatment (7). According to Rivers, Jaehne, Wharry, Brown & Amponsah (2010) in his research he conclude that while comparing the finding between the standard care with early management, there is a no significant short term improvement but in long term patients who received early management therapy of fluid resuscitation, there mortality rate were 30.5% while patient who received only standard treatment their mortality rate were more than 46.5% which shows severe organ dysfunction has occurred and patient is in end stage disease (4). In addition, administration of antimicrobial therapy is another priority management which should initiate within 1 hour of diagnosis of septic shock. Dr Gaieski et al 2010, demonstrate that patient who receive initial antibiotic coverage had low mortality rate, but the level of mortality is also depend on nurses knowledge as it is very important for a nurse to know what antibiotic needs to be given at what time, dose, route and frequency (7). Initial dose of antibiotic should be initiated as quickly as possible. Another element which needs to control is the source of infection. As patient is suffering from multi organ failure many pathogen have already invade in his body, therefore correct antibiotic therapy should be employed for appropriate action. It has been suggested that when the source of infection is unknown, it is important to administered broad spectrum antibiotic which fight against both gram positive as well as gram negative organisms. According to study, it has been concluded that if health care provider didn t select the appropriate antibiotic then mortality rate can even worsen. Kumar et al 2009, in his retrospective review of 5715 patients, he conclude that inappropriate antibiotic coverage result in 20% increase in mortality rate and it also decreases the patient chance of survival due to severe antibiotics side effects and reactions (7). Septic shock is a critical and serious health disease but by early recognition of sepsis and timely intervention of airway, fluids resuscitation and appropriate administration of antibiotics we can increase patient outcome and decrease mortality rate. Moreover, by initiating the early goal directed management we can also decrease the overall hospital stay of patients and gave them short term and long term benefit to their health. In this nurse s clinical competency and in depth critical knowledge plays a significant role as they are the first line provider in term of delivering care to the patient. In addition, I recommended that multi-disciplinary approach should be used in order to provide holistic care to the patients because these approaches address the problem from all dimension and decrease the mortality rate and increase chance of survival. It seems clear that by using early management therapy we can control this disease appropriately and save many human lives.

215 International Journal of Nursing Education. January-March 2015, Vol. 7, No Acknowledgment: Faculties of Aga Khan University Hospital Conflict of Interest: None Source of Funding: No source of funding Ethical Clearance: Not applicable. REFERENCES 1. Dellinger RP,Levy MM,Rhodes A,Annane D,Gerlach H,Opal SM,etal., Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: (41)2, doi: / CCM.0b013e31827e83af; Reinhard KR.The Role of The Acute Care Nurse Practitioner in the Early Identification and Management of Sepsis; Retrieved from 081_Reinhard_Karen.pdf 3. Rivers EP, Jaehne AK, Wharry LE, Brown S, & Amponsah D.Fluid therapy in septic shock. doi: /mcc.0b013e32833be8b3; Rivers E,Nguyen B,Havstad S,Ressler J, Muzzin A,Knoblich B,Peterson E &Tomlanovich M. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. (345)19, ;2001. Retrieved from RSSeriesBrochure/19607%20-%20.htm 5. Robson W & Newell.Assessing, treating and managing patients with sepsis. Nursing Standard, (19) 50, 56-64;2005.Retrieved from archive/article-assessing-treating-andmanaging-patients-with-sepsis 6. Schmidt GA & Mandel J. Evaluation and management of severe sepsis and septic shock in adults.uptodate Retrieved from Tannehill D. Treating Severe Sepsis & Septic Shock in Blood, Disorders & Transfusion. doi: / s4-002;2012.

216 208 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Effectiveness of Informational Booklet on Management of PEPTIC Ulcer Patients Asishbala Mohapatra 1, Maya Patlia 2 1 Research Scholar, SOA University, Hi-tech College of Nursing, Bhubaneswar, Odisha, 2 Principal, Indore College of Nursing, Gendalal Bam Parisar, Raw Pithampur Road, Vill - Dehri, Indore MP ABSTRACT Objective: Peptic ulcer is one among the oldest known gastro - intestinal disorder. It occurs with the greatest frequency in people between 40 to 60 years of age, in both developed and developing countries. The present study was aimed to assess the knowledge of patients on management of peptic ulcer including home management through administration of booklet. Material and method: The study included 60 patients from medicine ward, Hi-Tech medical college & Hospital. Convenient sampling technique was used. Data was collected by using structured questionnaire. Results: Over all patient's knowledge of pre-test, (0) had excellent, 01 (2%) had good, 5(93%) had average, 3(5%) had poor knowledge regarding management of peptic ulcer. The mean standard deviation was 3.4 and mean percentage was Over all patients knowledge of post test, 34 (56.7%) had excellent, 26(43.3%) had good, (0) had average and (0) had poor knowledge level. The mean standard deviation was 7.55 and mean percentage was 83.8 Z-test was significant which shows there is difference in pre test and post test score. Chi-square value was also significant which shows there is association between selected demographic Variables & knowledge. Keywords: Effectiveness, Informational Booklet, Peptic Ulcer Patient INTRODUCTION Peptic ulcer is one among the oldest known gastrointestinal disorder. It occurs with the greatest frequency in people between 40 to 60 years of age. In the past, stress and anxiety were thought to be causes of ulcers, but research has documented that peptic ulcers result from infection with gram negative bacteria H.pylori, which may be acquired through ingestion of food and water. Person to person transmission of the bacteria also occurs through close contact and exposure to emesis. In addition, excessive secretion of Hcl in the stomach, stress, ingestion of milk and caffeinated beverages, smoking and alcohol, chronic use of NSAIDS also precipitate to have peptic ulcer. Familial tendency also may be a significant predisposing factor. People with blood type O are more susceptible. The zo linger Ellison syndrome (ZES) consists of severe peptic ulcer & extreme gastric hyperacidity. OBJECTIVES To assess the knowledge of patients on management of peptic ulcer including home management before administration of the booklet. To develop and validate a booklet on management of peptic ulcer including home management. To evaluate the effectiveness of booklet on management of peptic ulcer patients. To find out the association between the level of knowledge and the selected demographic variables. HY POTHESIS H 1 The teaching programme is effective. H 2 - There is significant association between demographic variables and knowledge.

217 International Journal of Nursing Education. January-March 2015, Vol. 7, No Conceptual Frame Work It is based on Ludwig s general system model for evaluation of the effectiveness of informational booklet on management of peptic ulcer patient. RESEARCH METHODOLOGY Research Design: Pre test, post test design (before and after without control design) Setting of the study: In patient department, medicine ward, Hi-tech medical college and Hospital, Bhubaneswar. Sample and sampling technique: Sample size = 60, purposive sampling technique. Development of self structured questionnaire: It was prepared for collecting personal data and to assess the knowledge of patients regarding management of peptic ulcer. Total no. of items = 35 Scoring system Excellent (>80%) Good (60-79 %) Average (50-59%) Poor <10 (< 50%) ANALYSIS & DISCUSSION Overall patients knowledge of pre- test, (0) had excellent, 01 (2%) had good, 56 (93%) had average, 3(5%) had poor level regarding management of peptic ulcer. The mean standard deviation was 3.4 and mean percentage was Over all patients knowledge of post test, 34 (56.7%) had excellent, 26 (43.3%) had good, (0) had average and (0) had poor level regarding the management of peptic ulcer. The mean standard deviation was 7.55 and mean percentage was As the mean increases, it indicates that the teaching programme was effective. Table No.1 Distribution of subjects according to the grading of Pre-test and Post test knowledge score N=60 Sl No. Level of Pretest Post Test Pre Test Post test Effectiveness Knowledge Frequ ency Percentage Frequ ency Percentage Mean Mean Mean Mean Mean (SD) (F) (%) (F) (%) SD (%) SD (%) SD (%) increase increase 1 Excellent Good Average Poor Total Table No. 2. Area wise analysis and the value of Z-Test N= 60 Area of Knowledge Pre Test Post test Z, Value Level of mean (SD) Mean (SD) Significance Risk factors 1.2 (14.6) 3(32.1) 3 Significant Signs of symptoms 1.1 (15.9) 2.5 (34.7) Significant Management including home management 1.1 (15.9) 2.05 (34.9) Significant There is a mean gain in the means standard deviation. Z Test was calculated to analyze the difference in Pre-test and Post-test knowledge score. It shows the teaching Programme is affective

218 210 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 3: Chi-square value showing association between selected demographic variables and knowledge. N=60 Demographic Variables df Chisquare Value Table Value Remark Age Significant Religion Significant Education Significant Marital Status Significant Habit of Drinking alcohol/ Smoking Significant History of taking spicy food Significant Stress & Strain Significant P value <0.05 Significant P value >0.05 not Significant. Chisquare values shows that there is a significant association between selected demographic variables and knowledge CONCLUSION The study concluded that there was a significant improvement of knowledge which was analyzed by Z-test. Chi square test also indicate that there is significant association between selected demographic variables and knowledge. Nursing Practice The nurse practitioners should attempt to educate the staffs periodically to organize and conduct mass education programme on management of peptic ulcer including home management, using appropriate role play to create awareness among public. RECOMMENDATIONS The study can be replicated in various settings. Acknowledgement: The authors are grateful to the medical superintendent & Nursing superintendent, Hi-Tech medical college and Hospital, and department of clinical research and bioethics for providing administrative permission and support. Conflict of interest: Nil REFERENCES 1. Susan Holmes, (2005). Assessing the quality of the reality on impossible dream? International journal of nursing studies, 42(1) P Maritha Valimaki P(2005). Quality of life, individualized care, and satisfaction with nursing care, journal of advanced nursing, 50(3), P Kenn Sellick (2004), Symptoms, Psychological distress, social support and quality of life among patients newly diagnosed with gastro intestinal cancer nursing, 27(5), Ellen Wai (1999). The impact on quality of life of patients with terminally ill, p The WHO QOL group the world health organisation quality of life assessment : position paper from WHO (1995) Social Science of medicine 41, Zhan L (1993) Quality of life conceptual and measure issues, journal of Advanced Nusring, 17, Brunner and Suddarth (2008), Medical Surgical Nursing Vol.2, 10 th Edition, Philadelplia ; Lippincott William and wilkins, P Source of funding: Nil

219 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Childbirth Education: Preparing Pakistani Mothers for Breastfeeding and Neonatal Care Challenges Zohra Kurji 1, Zahra Shaheen 2, Yasmin Mithani 1 1 Senior Instructor, The Aga Khan University School of Nursing and Midwifery, 2 Chief Operating Officer, Catco Kids. Affiliation: University of London ABSTRACT Purpose: Breastfeeding rates are declining globally and promotion and support of breastfeeding is a priority child-survival intervention. 3,4,11 However, many mothers are ill prepared for breastfeeding and Newborn care. The aim of the study was to explore the differing views and experiences on breastfeeding and newborn care. Design and sampling: A qualitative descriptive exploratory design was used to investigate with Purposive sampling technique by researcher for this study. 17 participants 10 from the not attended and 7 from the attended group recruited for study Findings: Interestingly, in this study, participants who had attended classes did not introduce any pre lactate feed but every mother recommended that the challenges and their management should be discussed in class Moreover; both the groups had no knowledge regarding baby care. Conclusion: Childbirth classes should be promoted with in-depth knowledge on breastfeeding and Newborn care for every first time mothers. Keywords: Pre Lactate Feed, Breastfeeding, Newborn Care, Childbirth Classes INTRODUCTION Breastfeeding rates are declining globally and promotion and support of breastfeeding is a priority child-survival intervention. 3,4,11 The world Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding for the first 6 months, followed by the introduction of suitable complementary foods and continued breastfeeding upto 2 years of age. However, many mothers are ill prepared for breastfeeding as there is insufficient knowledge about the practical process of initiating and maintaining breastfeeding. 3 Lack of awareness and information regarding breastfeeding and care of baby can be major factor in lower rate of breastfeeding and lack of confidence about care of newborn. Therefore, patient education during pregnancy is cornerstone for every first time mother. For above mentioned reasons many countries developed the educational curriculum for pregnant women who is conducted by doctors or midwifes to prepare them for motherhood. 1,2,13 In Pakistan there are very few hospitals conducted theses classes in which breastfeeding and newborn care is the part of curriculum. As per my knowledge, none of study finding published in Pakistan to talk about perception and experience of mothers who attended theses classes. Therefore, the results of this study will help health care professional to understand that information shared about breastfeeding and newborn care which will help to increase rate of exclusive and optimum breastfeeding practices in Pakistan. STUDY OBJECTIVES To evaluate postnatal experience like breastfeeding and baby care in both the groups. This study will also talk about how childbirth education prepares mothers for breastfeeding and newborn care. Literature Review Childbirth Classes and Breastfeeding

220 212 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 One study mentions that 60% of women had poor knowledge regarding breastfeeding, which lead to conscious decision of formula feeding. 3 However, one of the studies found that women who received information during the antenatal period regarding correct positioning and attachment to reduce lactation difficulties were able to exclusively breastfed their babies as they were prepared mentally for it. 3,4 Educating women regarding breastfeeding helps women cope with breastfeeding problems. There are numerous physiological problems such as nipple pain and nipple trauma which, if not managed timely, can result in discontinuation of breastfeeding. These problems can, however, be resolved by providing prior education. 10 In summery childbirth classes help and prepare women regarding breastfeeding management and challenges but a great deal of literature highlights that only breastfeeding knowledge will not help women to opt for exclusive breastfeeding. Study Design METHODOLOGY Qualitative studies allow researchers to explore real life behavior 12 in addition to helping explore the participants experiences. As this study s aim was to To explore the differing views and experiences on breastfeeding and newborn care therefore, a qualitative descriptive exploratory design was used to investigate. Population and Setting The study population was selected from a private hospital of Pakistan where antenatal education is only offered to mothers. Sampling and Sample Size Purposive sampling technique was used by researcher for this study. Based on t inclusion and exclusion criteria 17 participants 10 from the not attended and 7 from the attended group recruited for study. Recruitment of Participants Permission was taken from the study site and from the Ethical Research Committee (ERC) and the Participants were interviewed on their postnatal visits after taking consent for the study. DATA COLLECTION Semi Structured Interviews In this study I used semi structured interviews to allow the give chance to participants time to share their experiences, along with semi structured guide. Pilot testing on postnatal mothers having similar inclusion exclusion criteria conducted by researcher. Data Analysis Thematic analysis was used, and the following steps were followed Record data using digital recorder and at the same time note taking was performed by note taker Code was assigned to each transcription and save them in separate folders Reviewed transcriptions again and again to identify exact words according to the themes, as used by the participants STUDY RESULTS Differing Views of the women on breastfeeding and newborn The main themes which emerged from semi structured interview were Breastfeeding and Newborn Care. These themes were further divided into categories and sub categories. Theme 1: Breast Feeding The category of postnatal phase consists four subcategories, which are Breastfeeding is natural process, pre lactate feed, problems during breastfeeding and the postnatal phase. category 1: Breastfeeding is natural process All non- attending participants shared that nobody had discussed breastfeeding with them during the antenatal period. All of them faced many challenges like cracked nipple, engorgement, issues with sucking and lack of milk. They all shared that although nurses were there to give information and support still it was a difficult and challenging experience for them. As one of the participants highlighted:

221 International Journal of Nursing Education. January-March 2015, Vol. 7, No I had a lot of issues in feeding I was thinking that [breast] feeding is a natural thing and requires no preparation but I faced many challenges I realized that every baby cannot suck I thought that every baby knows how to suck.but now I have learnt that these things need preparation beforehand. (NA 6) The participants who attended childbirth classes have very similar experience out of seven only two mentioned that breastfeeding was discussed in the class in details. They also think that breastfeeding is not natural process it s not only need to discuss in class but ongoing support is very important during pre, intra and postnatal phase. As one of the participants shared: Yes class gives me knowledge on breastfeeding but nurse facilitation and support help me a lot..(a7) Category 2: Pre lacteal feed One out of 10 participants even shared that they had fed their babies pre lacteal feed Ghutti and almost all babies had had formula milk in the first 2 days. Every participants thinks that it is in culture and in religion as well. Like one of the non-attended participant mentioned strongly No one can stop us to give Ghutti, my husband give it as first food to my baby and it is in Islam as well as it is mentioned that our prophet also had Ghutti.(NA5) Out of seven who attended childbirth classes, one participant shared that her child was on complete formula feeding as she had no milk supply. Moreover, none of them had given any pre lacteal feeds as they all had this information from the antenatal class. One participant mentioned that in class instructor mentioned that pre lactal feed can harmful for baby (A1) Category 3: Problems during initiating and maintaining of breastfeeding These participants faced challenges similar the non attending ones in initiating breastfeeding, like breast engorgement, lack of milk, etc, and required professional help, though, few (n=2) reported cracked nipples. Although these participants had prior knowledge, none of the children were on exclusive breastfeeding and every mother shared that since they had no milk for 2-3 days, their babies were started on formula feed by the nursery nurse. Only one participant shared that the nurse brought her baby for breastfeeding on the delivery table. One participant shared: Yes in class they explained me about everything but I had very little milk and nobody in the class talked about that... I gave up. my baby is now on top [formula] milk and this was God s wish that I had no milk Allah ki marzi mujhe doodh nahi hoowa (A4) The attending participants shared that they received information from the class on benefits of feeding, positioning and diet during pregnancy but nothing about breastfeeding challenges and its management. One of the attended participants mentioned that: In CBC they discussed breastfeeding very superficial even they have nor talked about what to do with crack nipples and breast engorgement.i had a lots of issue and as I found this experience very painful I gave up and now my baby on top feed (A3) Theme 2: Care of the New Born. Eight out of ten non-attending participants shared that they had no or very limited knowledge about baby care and they had to approach their pediatricians for even minor issues; as a result, they got frustrated and did not enjoy the postnatal period. Consequently, most of the participants (n= 7) shared that if they did not handle the child properly or if the child cried a lot, they started blaming themselves. Therefore, lack of knowledge about baby care made them frustrated and anxious. As 1 participant shared that: Regarding lack of informational support by elders, one participant shared that In the past, we had elders in our family who guided us on child rearing but time is changing. Now nobody has time and there is lack of awareness of mothers-in- law about changes in practices (NA 4) Similarly, all the attending participants (n=7) also felt that they had not received any information about baby care such as holding the baby, baby bath, changing diapers, or managing babies who cry too much. They too were very concerned about minor ailments like nose blockage, cord care etc and

222 214 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 approached pediatricians for these petty issues. Most of them also shared that they were inexperienced and they did not want to take any risk. One of the participants reported: Initially, I was in stress as I didn t know how to hold the baby. I even didn t know how to change pampers If my baby cried; I also started crying because I felt that I am not understanding the reason that was really frustrating (A 6) DISCUSSION ON FINDINGS Successful breastfeeding not only needs knowledge during pregnancy but it also requires support from family and health professionals. It was also evident from findings that every mother from both the groups faced many challenges related to initiation and maintenance of breastfeeding and they had no awareness about how to manage those challenges although they had support of staff and family. Educating women regarding breastfeeding helps women cope with breastfeeding problems. There are numerous physiological problems such as nipple pain and nipple trauma which if not managed timely, can result in discontinuation of breastfeeding. These problems can however be resolved by providing prior education. 10 In present study no difference was observed in both the groups; both fond that feeding was a very challenging and painful experience. Many researches support that early initiating of breastfeed and postnatal support are equally important to improved exclusive breastfeeding practices. 10, 15 A Randomized Control Trial conducted in a tertiary hospital in Singapore supports this study that antenatal breastfeeding education, combined with postnatal lactation support, significantly the improved rates of exclusive breastfeeding. 5 Interestingly, in this study, participants who had attended classes did not introduce any pre lactate feed and they all were very well aware with positioning but every mother recommended that the challenges and their management should be discussed in class along with special session for working mothers. Ho I, and Holroyd E shared similar findings, that most of the participants felt that educators only talked about the positive features of breastfeeding and did not emphasize the challenges faced during the establishment of feeding. 2 Knowledge about the Care of Babies Data further revealed that both the groups had no knowledge regarding baby care. They were not comfortable in taking care of the baby and were not confident enough to handle minor symptoms like nose block, tummy aches, etc. It was very surprising that although most of the participants received support from their mothers and mothers-in-law they all recommended that classes should discuss about baby care in detail. A study in Turkey revealed that a majority of Turkish women were satisfied with the knowledge and skills they had learnt regarding care of the babies and preparation of parenthood as it prepared them to cope with the postpartum period, baby care, and successful breastfeeding. 8 Results of this study depict that lack of prior information hampered care of the newborn during postnatal period. A study done on Chinese women also supported similar findings, as all women shared that they lacked confidence in baby; they were unable to perform a baby bath, or manage common neonatal problems as there were not discussed in the class. 2 This data was very different from what I had assumed earlier that due to family support system in Pakistan and Turkey, our participants would not have any issue with regard to postnatal care. However, it was interesting to see that although participants received social support from other family members, they were not confident and wanted to learn more about how to handle babies. As per my analysis both the groups had lack of knowledge regarding baby care and this shows how important preparatory classes are for the new parents to make them confident to face challenges. RECOMMENDATIONS AND IMPLICATION This study will support to change in practice by introducing child birth classes which include detail information on breastfeeding management issues and newborn care based on the cultural context, to bring positive outcome on breastfeeding rate. Moreover, New mothers will be ready to face challenges and feel confident regarding care of the newborn. Acknowledgement: I would like to acknowledge everyone who have assisted me in writing this article; including Participants, my tutors, friends, family, and my dear husband and children. This would not have been possible without their unconditional love and support! Conflict of Interest: None

223 International Journal of Nursing Education. January-March 2015, Vol. 7, No Ethical Clearance: Taken Source of Funding: None REFERENCES 1. Walker S D, WHNP,, FNP, Visger J and Rossie D. Contemporary Childbirth Education Models. [on line].journal of Midwifery & Women s Health. 2009, November/December.Volume 54(6). 2. Ho I, and Holroyd E. Chinese women s perceptions of the effectiveness of antenatal education in the preparation for motherhood.[on line].journal of Advanced Nursing.2002;Vol 38(1); Mattar C M, Chong Y S, Chan y S,etal. Simple Antenatal Preparation to Improve Breastfeeding Practice: A Randomized Controlled Trial Obstetrics & Gynecology.2007;Vol. 109(1). 4. Dyson L, McCormick FM, Renfrew M J. Interventions for promoting the initiation of breastfeeding (Review) 1. [On line].the Cochrane Collaboration. 2008;Vol Su L L, Chong Y S, Chan Y H, Chan Y H, Fok D, Tun K T, Rauff M. Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomized controlled trial. [On Line]. BMJ.2007.Avaialble From: full.pdf. [Accessed 26 Dec 2011]. 6. Dhandapany G, Bethou A, Arunagirinathan A, Ananthakrishnan. Antenatal counselling on breastfeeding is it adequate? A descriptive study from Pondicherry, India S.[On line]. International Breastfeeding Journal. 2008;Vol 3(5). 7. Mete S, Yenal K, Okumus H. An Investigation into Breastfeeding Characteristics of Mothers Attending Childbirth Education Classes.[On line]. Asian Nursing Research December. 2010; Vol 4(4). 8. Serçekus P, Mete S.Turkish women s perceptions of antenatal education.[on line]. The Authors. International Nursing Review.2010;Vol 57; Lumley J, Brown S.Attenders and nonattenders at childbirth education classes in Australia: how do they and their births differ?[on line]. Birth Sep. Vol 20(3): Avaialble from: / [Accessed 26 Dec 2011]. 10. Duffy E R, Percival P and Kershaw E. Positive effects of an antenatal group session on postnatal nipple pain, nipple trauma and breast feeding rates. [On line]. Midwifery. 1997; Vol 13; Hofmeyr GJ, Nikodem VC, Wolman WL, Chalmers BE, Kramer T. Companionship to modify the clinical birth environment: Effects on progress and perceptions of labour and breastfeeding. [On Line]. British Journal of Obstetrics and Gynecology.1991;Vol 98; Kuper A, Reeves S, Levinson W.An introduction to reading and appraising qualitative research.bmj 2008; 337:a288 doi: /bmj.a288 (Published 7 August 2008) 13. Lauzon L, Hodnett E D. Antenatal education for self-diagnosis of the onset of active labour at term. [Intervention Review]. [On line].the Cochrane Collaboration and published in The Cochrane Library. 2009; Vol issue Riordan JM, Koehn M.Reliability and validity testing of three breastfeeding assessment tools. [On line]. J Obstet Gynecol Neonatal Nurs. 1997;Vol 26(2); Available from: Premani Z S, Kurji Z, and Mithani Y. To Explore the Experiences of Women on Reasons in Initiating and Maintaining Breastfeeding in Urban Area of Karachi, Pakistan: An Exploratory Study.[on Line]. ISRN Pediatrics.Volume 2011 (2011).Available From: journals/pediatrics/2011/514323/ref//. [Accessed on ]. 16. Judith Lumley and Stephanie. Attenders and Nonattenders at Childbirth Education Classes in Australia: How Do They and Their Births Differ?[on line]. Birth Volume 20, Issue 3, pages , September 1993.

224 216 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / A Study to assess the Stress and Coping among Widows Residing in Selected Areas of Udupi District Avita A A Fernandes 1, Suja Karkada 2, Ansuya 3 1 Clinical Instructor, Institute of Nursing Education, Bambolim, Goa, India, 2 Asst. Professor, Community Health Nursing, RAK College of Nursing, RAK Medical and Health Sciences University, UAE, 3 Assistant Professor, Manipal College of Nursing, Manipal, Karnataka, India ABSTRACT Introduction: A women experiences a lot of stress in order to cope with the demands of life as a widow. Low income and lack of social support can lead to suffering for the widow and her dependent children. Objectives: To assess the levels of stress and identify the coping strategies adopted by the widows; find the association between stress levels and selected variables; coping strategies and selected variables; find the relationship between stress level with coping strategies, systolic blood pressure and diastolic blood pressure. Material & Method: Descriptive survey approach was used to conduct a study among 52 widows who had lost their husbands on or before 6 months, were less than or equal to 55 years of age and residing in Katapadi village. Snowball sampling technique was used to collect the data through structured interview method. Results & Discussion: The analysis of data revealed majority 86% of the widows were aged above 40 years, 55.8% were widowed for a period of more than 5 years, 61.5% were receiving widow pension. There was significant association between stress and diastolic blood pressure (χ 2 = 4.661; p =0.043); coping strategies adopted with type of family (χ 2 = 8.125; p =0.009); and widow pension (χ 2 = ; p =0.001); however other variables were independent of stress and coping level. Spearman's correlation coefficient showed positive relationship between stress and coping (ρ=0.386; r=0.005) and between stress with diastolic blood pressure (ρ=0.299; r=0.031). Conclusion: The study was limited as it used purposive sampling method, so generality of the study was limited to the sample. By this study we can conclude that the widows are at risk for developing Hypertension and other stress related disease. Adequate widow pension and family support can enhance the widow's coping. Keywords: Widow, Stress, Coping, Widow-pension INTRODUCTION As a single parent the widow has to face stressors such as demands at home or workplace, uncertainty of the future, lack of control over a situation, brooding over the past and worrying about the future, personal and social problems, financial difficulties, inability to meet basic needs of the family (e.g. food, clothing, health care, etc). 1 According to a report prepared by The Loomba foundation, London, UK, the countries with the highest number of widows in 2010 were : China-43 million, India-42.2 million, United States-13.6 million, Indonesia-9.4 million, Japan-7.4 million, Russia with 7.1 million, Brazil with 5.6 million, Germany with 5.1 million, and Bangladesh and Vietnam with about 4.7 million each. Out of which more than 115 million widows live in devastating poverty. 2

225 International Journal of Nursing Education. January-March 2015, Vol. 7, No The Karnataka state Government, since 1984, is providing assistance to destitute widows in the age group of above 18 years through the destitute widow pensions (DWP). The eligibility criteria are that she should belong to BPL household, the husband is legally dead and the income should not exceed 6,000 per annum. The pension is paid until she remarries or her children start supporting her or her income limit crosses 6000 per annum, or till her death. Currently 400 is being paid as pension per month. 3 This study aims, to gain an insight into the stress experienced by the widow and the adjustments after widowhood, so that awareness can be created among the people to provide supportive measures to help the widows in coping and facilitate this vulnerable group to develop gender equality and empowerment. This study aims, to create awareness among the people regarding the stress experienced by the widows so that supportive measures could be facilitate to help the widow in coping. MATERIAL AND METHOD A descriptive survey design was adopted for the study. The population selected for the study were widows, who had lost their husbands on or before 6 months, were less than or equal to 55 years of age and residing in Katapady, during the data collection period. Snow ball sampling technique was used and a total of 52 widows who fulfilled the selection criteria were included in the present study. Tools: Demographic Proforma, Questionnaire on stress experience in widows and Questionnaires on coping strategies. After content validity by experts the tools were pre-tested and reliability of the tools was confirmed. The Blood Pressure of the widows was recorded by using calibrated syghygnomanometer and stethoscope. Variables: Primary outcome variables were stress and coping. The extraneous variables were age, years of widowhood, type of family, financial support, widow pension, systolic blood pressure, diastolic blood pressure. Limitations: The study used purposive sampling method, so generalization of the study was limited to the sample. MAJOR FINDINGS OF THE STUDY Sample Characteristics Majority of the widows 86.5% were aged above 40 years, 55.8% of the widows had more than 5 years of widowhood, 96.2% were Hindus, 71.2% had education less than standard Xth, 61.5% were living in a nuclear family, 55.8% had one or two children, 61.5% were receiving widow s pension, 94.2% said that they did not acquire any asset from the husband after his death, 65.4% of the widows had Systolic and Diastolic blood pressure more than or equal to 140/90mm of Hg. Stress among widows Majority of the widows 28 (53.8 %) experienced medium level of stress and 24 (46.2 %) experienced low level of stress. There were no samples identified under the category of high level of stress. Coping strategies adopted by the widows The study revealed an equal distribution of widows experiencing high and low coping 26 (50 %). Association between stress levels and variables Chi-square was used to find the correlation between stress and selected variables. Table 1: Association between stress levels and variables (n=52) SINo Item Low Moderate Chi- Degree of p value stress level (20-46) stress level (47-73) square (χ2 χ2) freedom (df) 1 Age More than 40 yearsless than/ equal to 40 years 2 Years of widowhoodless than 5 years years and above 3 Type of family-nuclear familyjoint family 4 Number of children-no children0ne or two childrenmore than two Likelihood hood ratio considered

226 218 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 2: Association between stress levels and variables (n=52) SINo Item Low stress Moderate Chi-square Degree of p value level(20-46) stress level (χ2 χ2) freedom (df) ( 47-73) 5 Widow Pension-Yes-No Depend financially-yes-no Systolic BP(mm of Hg)< 140 e Diastolic BP< 90 ee * * p< 0.05 The data in table No 1 and 2 shows that, there was significant association of stress levels with diastolic blood pressure (χ2= 4.661; p =0.043), however other variables were independent of stress level. By this data we can infer that widows are at risk for developing stress related diseases such as hypertension. Association between level of coping strategies adopted by the widows and variables Chi-square was used to find the correlation between stress and selected variables. Table 3: Association between coping strategies and variables SINo Item Low High Chi- Degree p value coping coping square(χ 2 ) of freedom (df) 1) Age in years > 40 yearsde40 years ) Years of widowhood< 5 yearsee 5 years ) Type of family-nuclear familyjoint family * 4) Number of children-no childrenone or two childrenmore than two 5) Widow Pension-Yes-No * 6) Systolic BP-Less than 140 mm of Hg-More than 140 mm of Hg 7) Diastolic BP-Less than 90 mm of Hg-More than 90 mm of Hg * p< Likelihood hood ratio considered (n=52) The data in table No 3 shows that, there was significant association between levels of coping with type of family (χ2= 8.125; p=0.009), and widow pension (χ2= ; p=0.001) however other variables were independent of coping level. By this data we can infer that coping is better in those widows who are living in joint families and also getting widow pension Relationship between stress with coping, systolic and diastolic blood pressure. Spearman s correlation coefficient was used to find the correlation between stress, coping, and blood pressure. Table 4: Correlation between stress, coping, systolic blood pressure (SBP) and diastolic blood pressure (DBP). (n=52) Variables Stress Coping Stress - ρ=0.386 (r=0.005*) Coping - - SBP ρ=0.218 (r=0.120) ρ=0.081 (r=0.569) DBP ρ=0.299 (r=0.031*) ρ=0.162 (r=0.252) *p<0.05 The data in table No 4 shows that there was significant correlation between stress and coping (ñ=0.386; r=0.005) and stress scores with diastolic blood pressure (ñ=0.299; r=0.031) However other variables

227 International Journal of Nursing Education. January-March 2015, Vol. 7, No were independent of stress and coping level. Thus we can infer that chronic stress can predispose the widow to stress related disease such as hypertension. DISCUSSION The present study findings revealed that majority the widows had medium stress levels 53.8%. This finding is supportive by a study done in Nigeria which revealed majority of the widows as having medium stress level 59.9%. 4 The present study findings revealed that majority of the widows 61.5% were receiving widow pension. This study is supported by a comparative study done on Vrindavan and Varanasi widows by the Guild for Service in Vrindavan which identified 66.25% the widows receiving widow pension were from rehabilitation home, 62.50% from boarding homes, and 35% from the streets. In Varanasi the widows receiving widow pension were 28.57% from rehabilitation home, 35.71% from boarding house, and 35.71% from the streets. The findings of the widows in Varanasi contradict the present study findings. 5 CONCLUSION The following conclusions are drawn on the findings of the present study: 1. Chronic stress can predispose the widow to hypertension and other stress related disease hence the need to screen this vulnerable group for stress related diseases. 2. There is a need to educate the widows on stress management. 3. The widow has to undergo a lot of stress as she takes the role of a single parent especially if it is a girl child who is not married. There is a need for extra financial support through the government/ NGO for this sub-group of widows. 4. In view of the rise in cost of living there is a need to increase the widow pension 5. The widow can be empowered to support herself and her children through self-employment and being a part of self-help groups hence there is a need to provide free training to the widows. 6. Rehabilitation services in the community can be provided such as counselling services, occupational training, self employment schemes, and social support groups, training in stress management techniques and use of effective coping strategies, etc to facilitate the widows in coping. Acknowledgement: The authors are grateful to the Dean, Manipal College of Nursing, Manipal, Department of Community Medicine, KMC, Manipal, MU and panchayat presidents of Katpadi and Kote villages, Uduip for providing administrative permission and support. Conflict of Interest: Nil Source of Funding: Self funding Ethical Clearance: For collecting the data following steps were taken: Obtained administrative permission from Dean, Manipal College of Nursing, Manipal, MU. Obtained permission from panchayat presidents of Katpadi and Kote villages. Obtained permission from University Ethics Committee. Obtained permission from Department of Community Medicine, KMC, Manipal. Informed consent was taken from the participants of the study. REFERENCES 1. Garza ML. How does culture and community support help with coping among Mexican- American single mothers? Arizona, unpublished MSc(N) thesis University of Arizona, USA. 2. GN Bureau. June India s widow population second-largest in the world. Available from : views/think-tanks/indias-widow-populationsecond-largest-world 3. D Rajasekhar, G Sreedhar, Narasimha R, Biradar RR, Manjula SR. The delivery of Social Security Pension Benefits in Karnataka. Available from:

228 220 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 4. Owen M. Widows banding together. People Planet.1995; 4(3):20-2.Available on : Db=Pub Med&Cmd=ShowDetailView&TermTo Search= &ordinalpos=1&itool=Entre zsystem2.pentrez.pubmed.pubmed_results Panel.Pubmed_RVDocSum 5. Latest internationally-funded study on the status of Vrindavan s widows. The Hindu Arts magazine by admin on February 12, / latest-internationally-funded-study-on-thestatus-of-vrindavans-widows/ 6. Black MJ. Hawks JH. Medical and Surgical Nursing Clinical Management for positive outcomes, 7 th edition, Missourie, Elsvier publication 2005.

229 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Perception on Women's Rights among Working and Non Working Women Shiney Easo 1, Shashidara Y N 2, Ansuya 3 1 MSc Nursing, 2 HOD, Dept of Community Health Nursing, 3 Asst. Professor, Dept of Community Health Nursing, Manipal College of Nursing, Manipal University, Manipal, Udupi District, Karnataka ABSTRACT The study was conducted to assess the perception regarding women's rights of working and non working women. The sample includes working and non-working women of Marne village in the age group of yrs. The research approach was quantitative survey approach and the design used was comparative descriptive design.the data were collected by the investigator from 50 working and non working women by house to house survey by administering questionnaire to working and non-working women. Majority of the working women (94%) had good perception and non-working women (50%) have average perception respectively. This demonstrates that working women has better perception on women's rights than non-working women at selected settings. Keywords: Perception, Women's rights INTRODUCTION Women s rights are entitlement and freedoms claimed for women and girls of all ages in many societies. In some places these rights are institutionalized or supported by law, local custom, and behavior, whereas in others they may be ignored or suppressed. It is a matter of grave concern that girl child or women continues to be insecure and vulnerable in the country India. Therefore, the need of the hour is to stress upon other avenues/alternatives that can strengthen the law and can bring about desired social change. One such alternative is by increasing the awareness and changing the perception in the community about women s right, so that the people can identify it as a social problem and further try to counter the abuse. OBJECTIVE Assess the perception regarding women s rights between working and non working women by using perception scale. Setting: Marne village of Udupi Districts of Karnataka. Participants: Working women with minimum qualification of SSLC and non working women between the age group of years. MATERIALS AND METHOD Research approach was quantitativesurvey approach and design used was comparative descriptive design. The data were collected by the investigator from 50 working and non working women by house to house survey in Marne village by administering questionnaire to working and nonworking women. Majority of the working women (94%) had good perception and non-working women (50%) have average perception respectively. FINDINGS The study found that majority of the working women (94%) had good perception and non-working women (50%) have average perception respectively. CONCLUSION The study concluded that working women have good perception than non-working women. What is already known about this topic? Globally and nationally there is an increase in the violence against women. Perception on women s rights varying from person to person, culture, locality, values and belief.

230 222 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 What this paper adds? This study outlines the perception of working and non working women about selected women s rights in selected villages of Udupi, Karnataka, and its association with selected variables which is explored minimum. Back ground A study was conducted by BiswajitG to assess the perception of people regarding the practice of dowry in the rural area of South West Bengal. Six hundred (600), responded were interviewed from overall 22 villages of the selected district areas. The study shows that boys view marriage as an occasion to achieve wealth. The dowry is viewed as the Socio-economic factor which matters relatively more in the middle as well as lower classes of family. The factor that settles the amount of dowry is income of boys, educational qualification, family property, background, influence of family future prospect of Bride-groom, caste, age and profession. Puri S, Bhatia V, Swami HMconducted a study among 373 married females representative of slum populations in the age group of years attending health centre attached to Govt. Medical College, Chandigarh. The aim of the study was to find out the level of their awareness regarding sex determination. Data was collected using a predesigned proforma and the samples were selected by systematic sampling. The study result showed that majority (88.4%) were not aware of sex determination techniques. 65.5% perceived that sex determination is a crime. 16.3% and 11.4% knew about punishment for sex determination & implications of killing of female child, respectively. The study concluded that thoughthere is much development & improvement in literacy status still the dislike for female child and women is groped in the society. Study hypothesis METHOD The following hypotheses were tested at 0.05 level of significance. H 1 : There will be significant difference between perception scores among working and non working women H 2 : There will be significant association between perception and selected variables like education, occupation, and family income per month. Study design and study population Quantitative study adopted a survey approach to assess the knowledge of working and non working women on women s rights. The design used was comparative descriptive design. The study population is working women with a minimum qualification of SSLC and non working women between the age group of years, could read and write in Kannada and English, who resides in the adopted village of MCON, Manipal. The power of the study was fixed at 80% and confidence interval as 95%. The estimated sample size was 47 in each group. The sample taken in each group is 50. Administrative permissions were obtained from Dean, Manipal College of Nursing Manipal and Director of Nursing Education, Manipal University, Manipal, ethical clearance from Institutional Ethics Committee of Kasturba Hospital, Manipal, and written informed consent from the participants of the study Data collection instruments and measurements The following tools were used to collect the data. Tool 1: Demographic Proforma The demographic proforma included items to collect data on the background. There were 13 items. The items included wereage, religion education, occupation, income, type of family, awareness about the women s rights, source of information, marital status, number of children, do you like to know the sex of the child before delivery, given/ got dowry, subjection to any form of domestic violence. The tool was validated by seven experts, translated into Kannada and retranslated to English and pretested among three working and non working women respectively. Tool 2: Perception scale on women s rights Perception scale was developed to assess the perception of working and non-working women on women s rights. The scale consisted of 21 items in which there were 12 positive items and 9 negative items. The response for each item was to be rated by placing a tick mark (ü) in one of the five point likert scale. Response were strongly agree, agree, uncertain, disagree, strongly disagree and were scored as 4, 3,0,2,1 respectively. Reverse scoring was done for negative items. The score obtained were graded as no

231 International Journal of Nursing Education. January-March 2015, Vol. 7, No perception (0), poor perception (1-28), average perception (29-56), and good perception (57-84). Pretesting was done among three working and non working women respectively. Reliability was tested by split-half method among 10 working and nonworking women and r= Pilot study was conducted among 10 working and non working women and no changes were made in the tool or in the design of the study. PROCEDURE The data was collected from 50 working and non working women of Marne village from 15 th January to 14 th February During this period investigator approached the working and non working women and explained the purpose of study, ensured the confidentiality of the information given by the subjects and written consent was taken. The data was collected by the investigator from by house to house survey in Marne village by administering questionnaire to working and non-working women Statistical analysis The data were analyzed using both Descriptive and inferential using Statistical Package for Social Science Version 16 (SPSS 16). Descriptive statistics: Frequency and percentage distribution, mean and standard deviation were used to describe the sample characteristics and the knowledge of working and non working women. Inferential statistics: chi-square was used to find the association between knowledge and selected variables. RESULTS Description of sample characteristics Table 1: Frequency and percentage distribution of samples characteristics n= (50+50) = 100 Sample characteristics Working women Non-working women f % f % Age in years Religion Hindu Christian Education Primary (1-7) High school (8-10) PUC Diploma Graduate Postgraduate Type of occupation Non-working Class IV worker 6 12 Technician 6 12 Clerk 6 12 Teacher Nurse 9 18

232 224 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 1: Frequency and percentage distribution of samples characteristics (Contd.) n= (50+50) = 100 Sample characteristics Working women Non-working women f % f % Type of family Nuclear Joint Family income per month in rupees <3, , >13, Are you aware about the women s rights? Yes No If yes, what is the source of information? Family Relatives Friends Media Marital status Married Unmarried Number of children Do you like to know the sex of the child before delivery? Yes No Have you given/ got dowry? Yes No Do you think you have ever been subjected to any form of domestic violence? Yes 0 0 No Majority of the working women were teachers (46%) and between the age group of years (48%), where as among the non-working women majority were in the age group of years (42%). Majority of working women (92%) were aware about the women s rights and the source of information was media (64%). Majority of the non-working women (86%) are aware about the women s rights and the source of information was media (44%). Majority of working women were Graduates (38%) were as majority of the non-working women has an education of high school (52%). All the working and non working women (100%) reported that they have not been subjected to domestic violence and given/got dowry. All the working women (100%) reported that they don t want to know the sex of the child before delivery. 2% of non working women reported that they want to know the sex of the child before delivery.

233 Perception of working and non-working women on women s rights International Journal of Nursing Education. January-March 2015, Vol. 7, No Table 2: Area wise mean, standard deviation and mean percentage of perception on women s rights among working women and non-working women n= (50+50) =100 Area Maximum Working Non-working scores women women Mean Mean Standard Mean Mean Standard percentage deviation percentage deviation Women s rights Dowry Prohibition Act Pre-natal diagnostic and sex determination Act Domestic Violence Act Overall score Mean percentage score obtained in different areas of perception on women s rights among working and non-working women was much higher among working women which is compared to non-working women. By which we can interpret as working women has good perception and awareness as against nonworking women on women s right Association between level of perception and selected variables among working women Table 3: Association between level of perception and selected variables such as age, education, type of occupation income among working women Sample characteristics Level of perception Chi-square value df P value Average Good Age in years Education High school 2 4 PUC * Diploma 0 17 Graduate 0 19 Postgraduate 1 5 Type of occupation Nurse 0 9 Teacher * technician 0 6 class IV 2 4 clerk 1 5 Family income per month in rupees , >13, (n=50) Chi-square was computed to find the association between knowledge and selected variables. It showed that there is association between perception and selected variables like education and type of

234 226 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 occupation. So the research hypothesis was accepted with regard to these variables. It is inferred that there is an association between perception and selected variables like education and type of occupation among working women. (Table 3) Table 4: Association between level of perception and selected variables such as age, religion, education, occupation and type, income, type of family among non working women Sample characteristics Level of perception Chi-square value df P value Poor Average Good Age in years Education Primary (1-7) High school PUC Income per month in rupees < , >13, (n=50) Chi-square was computed to find the association between knowledge and selected variables. It showed that there is no association between perception and selected variables like age, education, income per month among non-working women. So the null hypothesis was accepted with regard to these variables and research hypothesis was rejected. It is inferred that there is no association between perception and selected variables like age, education and income.(table 4) DISCUSSION Perception on Women s rights Majority of the working women (94%) had good perception and non-working women (50%) have average perception respectively. A study was conducted by Kabir M, Afroze R, Aldeen M in Bangladesh to assess perceptions on the requirement of dowry and the cause behind the requirements of dowry. 75% of the female respondents perceive that it was niom (social norm) and is necessary in their marriage. All the girls said that dowry is a bad practice both for families and society. 22 Adescriptive study conducted to study the perception of rural Rajput community regarding prenatal sex determination tests. Results of the study revealed that 69.5% of the parents were aware of the sex determination tests and considered it right and safe method for having a son. They wanted the practice to be continued in spite of the legal restrictions and legislation against it % said that the practice should be stopped. 3 Association between perception and selected variables The findings of the study showed that there is an association between perception and selected variables like education and type of occupation among working women. The findings of the study showed that there is no association between perception and selected variables like age, education, income per month among non-working women. CONCLUSIONS People who are aware of their right stand the best chance of realizing them. Knowledge of women s rights spread is the first and surest defense against the danger that these rights will be tramled on. Learning about one s own rights builds respect for the right of others, and points the way to more tolerant, peaceful societies. Vast numbers of people arenot aware of their rights as human beings. Many suffer due to the lack of basic knowledge of women s rights. The existing laws help them to defend them and counter abuses.

235 International Journal of Nursing Education. January-March 2015, Vol. 7, No Knowledge of women s rights is essential for the promotion of human rights and for the creation of a climate of public opinion in which gross violation of human rights is unacceptable.. Limitations of the study The study used non probability purposive sampling, so the generalization of the study was limited to sample. RECOMMENDATIONS A study can be conducted based on various laws individually. A study can be conducted with a larger sample at different settings with different categories of workers. Acknowledgement: The study was successfully completed by the help and guidance of Dr. Anice George (Dean, Manipal College of Nursing, Manipal). I am immensely grateful to all the experts who gave their valuable time and suggestions for validating the tools Source of funding: The source of funding was by the researcher alone Conflict of Interest: No conflict of interest, neither in the institution nor fromthe community. REFERENCES 1. Wikipedia, the free encyclopaedia. Available from srights 2. Chaudary A et al. Awareness and Perceptions of School Children about Female Feticide in Urban Ludhiana. Indian Journal of Community Medicine. 2010; 35(2): Dowry thrives in India. Freedom of expression, fairness in articulation 2013 Apr 28:4. 4. Tomlinson C, Tariquzzaman S. Action research on dowry and extreme poverty: Khutamara union, Nilphamari district.bangladesh: UST; Nawal, et al.female foeticide perceptions and practices among women in surat city. National journal of community medicine. 2011; 2(1): State crime records bureau.crime review June Government of Karnataka; Bangalore. Available from files/junecrimereview.pdf. 7. Shalini S, Kariwal P, Kapilasrami M C. A community-based study on awareness and perception on gender discrimination and sex Preference among married women (in reproductive age-group) in a rural of district Bareilly Uttar-Pradesh. National Journal of Community Medicine. 2011; 2 (2):

236 228 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / A Retrospective Study to assess the Delay in Treatment Seeking and Factors Contributing to Delay in Seeking Treatment among the Caregivers of Persons Having First Episode Psychosis N Sujata 1, Sandhya Gupta 2, Mamta Sood 3 1 Lecturer, CON, DMCH, 2 Lecturer, CON, AIIMS, 3 Assistant Professor, Department of Psychiatry, AIIMS ABSTRACT A retrospective, exploratory study on a consecutive sample of 100 caregivers of persons having first episode psychosis was done in OPD, Department of psychiatry, in a selected hospital of Delhi to assess the factors contributing to the delay in seeking treatment of persons having first episode psychosis. Data was collected on tools demographic and select variables, Positive and negative syndrome scale (standardized) and structured questionnaires to assess factors contributing to delay in seeking treatment. The result showed that one fifth of the caregivers (22%) had contact with mental health professionals, Most of them delayed seeking treatment for a long duration (>6 month) for the patients having first episode psychosis and lack of awareness regarding the identification of mental illness was the main factor which contributed to the delay in treatment seeking for first episode psychosis. Implications of the findings of this study are for the professionals in mental health as well as community health services there is a need to provide awareness about early identification of mental disorders and to develop positive attitude towards the treatment of mental disorders and to remove fear of seeking help from professionals in mental health services. Keywords: First Episode Psychosis, Delay in Treatment Seeking, Duration of Untreated Psychosis INTRODUCTION The world health organization (WHO) declared 2001 as the year for mental health in recognition of the burden that mental and brain disorders pose on people and families affected by them. As per the WHO report 2001, although most people encounter person with mental disorder in the families and the neighborhoods, people show tendency to feign ignorance and actively ignore this fact. Number of persons with major mental illnesses will increase substantially in the decade to come. The study on factors associated with course and outcome of schizophrenia has shown that there are a number of factors influencing the course and outcome of schizophrenia which are amenable to intervention such as treatment at early stage, good drug compliance, positive and supportive attitude of key relatives and provision of some kind of regular occupational schedule. The connection between the delay in treatment of first-episode psychosis and poorer outcome is understandable and the process of becoming psychotic creates profound psychological changes, almost always disturbing to the patient. 1 Delay in treatment of the first episode is a major problem and is associated with poor treatment outcome. Recent evidence that treatment delay may compromise the potential for recovery from psychotic disorders has resulted in increased interest in factors that influence help seeking. 2 The initial episode of psychotic disorders can be particularly confusing and traumatic for the person as well as their family. A lack of understanding of psychosis often leads to delays in seeking help. As a result these treatable illnesses are left unrecognized and untreated. Recent studies have brought out existence of notable delay before the start of psychiatric treatment following a first psychotic

237 International Journal of Nursing Education. January-March 2015, Vol. 7, No episode and related disorders. 3 Presently no epidemiological study was found in literature which includes some aspects such as factors associated with delay in seeking treatment in Indian setting. Hence the present study is intended to find out the factors contributing to the delay in seeking treatment of persons having first episode psychosis. So that this baseline data can help to plan educational and interventional strategies for public awareness programmes for Indian scenario. MATERIALS AND METHOD This was a retrospective, exploratory study. Approval to conduct the study was obtained from the institutional ethics committee. The study was conducted in OPD, Department of psychiatry, in a selected hospital of Delhi with the aim to assess the delay in treatment seeking and factors contributing to delay in seeking treatment. A consecutive sampling technique was used. A total of 100 caregivers of persons having first episode psychosis were selected as sample size. Brief information was given about the purpose of the study and consent was taken from subjects before data collection. Data was collected using the following tools. Tool no 1. was socio demographic details and select variables of caregivers, Tool no. 2. was Positive and negative syndrome scale (PANSS) and is a standardized tool and Tool no. 3 was structured questionnaires to assess factors contributing to delay in seeking treatment. Descriptive statistics and inferential statistics were used for analysis of data in SPSS 16 version. RESULT Clinical profiles of patients There were a total of 100 patients and their mean age was years (range=18-43). More than half (61%) were male, 51% of them were unmarried, 90% of patients followed Hindu religion, 69% stayed in urban area, 39% of them studied upto 8 th standard, 41% of them had annual family income < Rs /- and 64% stayed in nuclear families. Socio-demographic characteristics of caregivers The mean age of caregivers was years. Majority (72%) were male, 90 % of them were married, 90% of them followed Hindu religion, 37% of them studied upto 8 th standard. 35% of them had income between Rs /- and 80% were employed. Fifty one percent were unskilled workers, 64 % of them stayed in the nuclear family and 69% of them stayed in urban area. No adequate health care facility was reported by 22% of caregivers. No family history of mental illness was reported by 84% of caregivers. No history of contact with mentally ill patient was reported by 83% of caregivers, 78% of them had no contact with mental health worker and 58% of them used alternative treatment modalities. Duration of untreated psychosis Treatment seeking was delayed by >2-6 months in 34 % of the patients, 32% delayed by >6-12 months, 20 % delayed by >12 months, 14 % delayed by <2 months respectively. Duration of untreated psychosis was categorized into two, short duration ( 6months) and long duration (>6 months) 4, so majority (52%) of the patients were having long duration of untreated psychosis. Fig. 1. Bar diagram showing the distribution of duration of treatment delay in terms of months of patients. (N=100) Factors contributing to delay in treatment seeking Out of 100 caregivers, most (91%) of the caregivers said that they could not recognize the symptom of patient as mental illness, 75% of caregivers thought that symptoms were due to some kind of evil spirit and 63% of them took treatment from faithhealers. Thirty two percent of caregivers said that they delayed treatment seeking due to nonavailability of adequate hospital facilities and also 30% of caregivers thought that the symptoms would disappear naturally. One fifth (20%) of the caregivers said that due to lack of money treatment initiation of the patient was delayed, 21% of caregivers said they took alternative treatment (Ayurveda/ homeopathic). Nineteen percent of caregivers reported that they were scared to go to a psychiatrist to get treatment. Hence, it can be interpreted that the knowledge and stereotype misconceptions regarding the symptoms were the most important factors contributing to the delay in seeking treatment among the caregivers of persons having first episode psychosis.

238 230 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 OTHER FINDINGS There was no significant difference of the mean scores of durations of untreated psychosis in relation to total positive, negative and general psychopathology scores of PANSS as shown in Table no. 1. Fig. 2. Bar diagram showing the factors contributing to delay in seeking treatment (N=100) Table no. 1: Relationship of positive and negative syndrome score with Duration untreated Psychosis (N=100) Positive and negative Duration of untreated Oneway syndrome score(panss) psychosis ANOVA F(p) 2 months >2-6 months >6-12 months 12 months Total score of positive symptoms 19.4± ± ± ± (.092) Total score negative symptoms 19.4± ± ± ± (0.66) Total general psychopathology 43.2± ± ± ± (0.55) (*p=0.05) Hence it can be interpreted that current PANSS scores were not correlated with duration of untreated psychosis as they were under treatment at present. Table no 2 : Relationship of factors contributing to the delay in seeking treatment with Duration of untreated psychosis (N=100) Factors for delay in treatment seeking Duration of untreated psychosismean(sd) t test(p) Short duration Long duration ( 6months) (>6months) Due to non availability of transport facility 1.87± ± Due to non availability of appropriate hospital facility 2.16± ± Far distance of health care facility from home 2.02± ± * No money to seek treatment 2.04± ± Unable to recognize symptoms as an illness. 3.14± ± Thought that symptoms were due to some evil spirit 2.8± ± Took treatment from faith healer 2.7± ± Took alternative treatment (ayurveda/homeopathy) 2.10± ± Thought symptoms will disappear naturally 2.3± ± Fear to get psychiatric treatment 2± ± No time to go to a doctor 2.1± ± Don t want to get label of being a family 1.9± ± member of mentally ill person Hesitant about discussing the symptoms with others 2.04± ± Afraid that people will look at them differently 1.91± ± Fear of not being accepted at the work place 1.9± ± (*p=0.05)

239 International Journal of Nursing Education. January-March 2015, Vol. 7, No The Mean 2.02 ± SD 0.52 of patients had longer duration (>6 months) of untreated psychosis (2.26±0.59) were higher than those who had shorter duration (<6 months) of untreated psychosis in relation to the factor Far distance of health care facility from home. Hence, it can be interpreted that patient who stayed far away from health care facility had longer duration of untreated psychosis as shown in Table no. 2. DISCUSSION Successful treatment requires that persons suffering from the disorder take a sequence of steps in the helpseeking process in time. These steps include experiencing symptoms, evaluating the severity and consequences of the lack of awareness and misconceptions of caregivers regarding the symptoms of illness, assessing whether treatment is required, assessing the feasibility and options for treatment and deciding whether to seek treatment. It is been reported that I wanted to solve the problem on my own and I thought that the problem would get over by itself were the most commonly endorsed barrier to initiate treatment. 5, 6 In the present study it was revealed that caregivers who belonged to urban area took alternative treatments (homeopathic/ayurvedic/ spiritual). Most of the caregivers thought that the symptoms would disappear on their own naturally and also were afraid to seek psychiatric treatment. Caregivers who belonged to urban area delayed initiation of treatment as they were hesitant to discuss about the symptoms with others. The probable reason might be that in India people strongly endorse folk, supernatural, spiritual or mystical beliefs as causes of illness, which have been found to be associated with lower rates of initiation of treatment. They also are less likely to perceive themselves as having mental health problems and are further more likely to fear mental health treatment. Similar results were found in a study done on African- American population. 7 It was also found in the present study that most (90%) of caregivers delayed treatment initiation due to lack of knowledge in identification of symptoms as an illness. Most of them thought symptoms were due to some evil spirit (75%), took treatment from faithhealers (63%) and also reported that they thought symptoms will disappear naturally (30%). Hence, lack of knowledge and stereotype misconceptions regarding the symptoms were the most important factors contributing to the delay in seeking treatment among the caregivers of persons having first episode psychosis. Similar results were found in the previous studies. 8,9 CONCLUSION Research consistently showed that a high proportion of people with prevalent mental disorders being untreated despite their disorders causing substantial distress and impairment and despite effective treatments being available. It is of considerable public health importance to uncover modifiable reasons for this lack of treatment of mental disorders and also recommended to explore the models for providing services of mental health by working with faith healers to educate them about when to give referral to psychiatric services. Acknowledgement: None Conflict of Interest: None Source of Funding: Self Ethical Clearance: Obtained from Institutional Ethical Committee. REFERENCES 1. Kumar N. Developments in mental health scenario: needs to stop exclusion-dare to care. ICMR\ Bulletin Apr;31(4) 2. Compton M T, Ramsay C E, Shim R S, Goulding G S, Gordon T L, Weiss P S, Druss B G, Health Services Determinants of the Duration of Untreated Psychosis Among African-American First-Episode Patients. Psychiatr Serv Nov; 60: McGlashan T H. Duration of untreated psychosis in first episode schizophrenia: marker or determinant of course? Biol Psychiatr. 1999; 46 (7): Sareen J, Jagdeo A, Cox B J, Clara I, Have M T, Belik S L, et al. Perceived Barriers to Mental Health Service Utilization in the United States, Ontario, and the Netherlands, Psychiatr Serv.2009; 60: 1425.

240 232 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 5. Regier D A, Narrow W E, Rae D S, Manderscheid R W, Locke B Z, Goodwin F K. The de facto US mental and addictive disorders service system: epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993; 50: Wang P S, Berglund P, Kessler R C. Recent care of common mental disorders in the United States: prevalence and conformance with evidencebased recommendations. J Gen Intern. Med. 2000; 15: Orlena B. Merritt D, Matcheri S. K, Pathways to Care for African Americans With Early Psychosis, psychiatr Ser Jul ; 57: Rogler LH, Cortes DE. Help-seeking pathways: a unifying concept in mental health care. Am J Psychiatry. 1993;150: Golberstein E, Eisenberg D, Gollust S E, Perceived Stigma and Mental Health Care Seeking, Psychiatr Serv.2008 Apr ;59:

241 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Teaching Physical Assessment Skills to International Nursing Students in New Zealand Gillianne Meek Senior Lecturer Pakaro a Ihenga: Faculty of Health, Education and Humanities, Waiariki Institute of Technology, Rotorua, New Zealand ABSTRACT Carrying out a physical assessment and taking a health history from a patient is traditionally seen as a medical role rather than a nursing role in many countries. In New Zealand physical assessment skills are taught routinely as part of the undergraduate bachelor of nursing degree programme. Due to changes made by the Nursing Council of New Zealand in 2012, a group of internationally qualified nurses, predominantly GNM diploma nurses from India, who were then studying in New Zealand, were required to complete a degree level paper in simulated physical assessment. For many students this meant learning a whole new set of skills and overcoming the psychological barrier that this is a medical role. Keywords: Physical Assessment, Health History, New Zealand, Internationally Qualified Nurses INTRODUCTION The International Council of Nurses states that Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles 1. How this definition is interpreted in each individual country can be extremely different. While all nurses have caring as a central feature of their profession, the roles, expectations and level of accountability that is attributed to Registered Nurses (RN) in each country can vary greatly. In New Zealand (NZ) the teaching of physical assessment skills (Inspection, Auscultation, Palpation and Percussion) and the taking of a comprehensive health history, has been taught as part of the undergraduate bachelor of nursing programme since the early 1980s 2, with RNs on graduation being expected to use aspects of physical assessment specific to their area of clinical practice 3. For international nurses who migrate to NZ, this may mean a considerable difference in the skills they need to know and use in their everyday nursing. Over the past 6 years the number of internationally qualified nurses (IQN) who have become registered in NZ is almost equal to the number of NZ nurses who graduate each year (approximately 1230). These figures may appear low, but the total population of the country is approximately 4.4 million people. Registered Nurses from India make up 15% of all international nurses working in NZ 4. It is a legal requirement that nurses, domestic and international working in NZ are registered with the Nursing Council of New Zealand (NCNZ) and have a valid annual practicing certificate. Changes to international nurse registration In 2012, the NCNZ, the regulatory body for the profession, made changes to the eligibility criteria for IQNs wanting to join the nursing register. Nursing education in New Zealand has all been at degree level since the 1990s and the changes made by the NCNZ signified that international nursing qualifications need to be at an equivalent degree level to the qualification being taught in NZ. The consequence of this change has meant that some internationally qualified registered nurses are now no longer eligible to apply for registration in NZ; these nurses include General

242 234 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Nursing and Midwifery (GNM) Diploma holders from India, Proficiency Certificate Level (PCL) holders from Nepal and some other RN qualifications. When this change was introduced, a group of IQNs, many of whom held GNM diplomas were completing a 1 year top up from a diploma to a degree in nursing in NZ. This additional qualification did not provide registration with the NCNZ. Graduates of this programme still had to complete a 6 week competency assessment programme to gain registration and be eligible to practice, however it did give them a NZ degree in nursing. To allow these GNM nurses to eventually become eligible to apply for registration, the NCNZ through extensive negotiations requested the school of nursing at the tertiary institution where the students were studying, to make changes to their curriculum by adding a paper on simulated clinical assessment. Graduated students, who had not yet gained registration, were required to return to the school of nursing to complete an additional simulated clinical assessment paper. Physical assessment papers Academic staff from the school of nursing were required to quickly develop and have approved two new papers. Firstly a simulated assessment paper that would be taught over a whole semester to the students who were still enrolled in the 1 year degree programme (July-November 2012) and secondly a condensed version of the paper that could be taught over a 3 week block course for those students who had graduated. The NCNZ would moderate the content, teaching and assessments. A paper taken from the 3 year undergraduate nursing degree was adapted and upgraded for these students. However the real challenge lay in teaching a whole semester of coursework within a 3 week period and allowing students enough time to process both the new knowledge and practice the unfamiliar physical assessment skills that were being taught. Time was also needed for students to adjust to studying what many of the students felt was not a nursing role. This required a different teaching approach to the paper being offered over a whole semester. Nearly 120 previous students returned to the school of nursing to complete the 3 week course. Approximately 90% of these students were from India, with the remaining students from Nepal and China. The course was offered 6 times between August 2012 and March 2013 with no charge made to students. Students needed to pass three assessment in the block course, firstly students had to write an essay and develop a care plan based on a clinical situation, secondly they had to write up how they would meet the NCNZ nursing competencies for the RN Scope of Practice and thirdly, carry out a physical assessment on a volunteer who was participating as a patient in a simulated clinical situation and then accurately and systematically write up the findings of the physical assessment. Physical assessment and health history Assessment has always been a fundamental aspect of nursing, indeed it is the first stage of the nursing process, followed by planning, implementation and evaluation of the nursing care being provided. Assessment has been defined as a systematic and ongoing process for the collection of patient data and forms the basis for any future nursing interventions 5. However for many of the IQNs who completed this course and in agreement with research by West in , physical assessment is often limited to observations, such as blood pressure, temperature, pulse, respirations and oxygen saturation. Several authors 2,7,8 note that physical assessment and patient history taking traditionally sits firmly with the roles and responsibilities of medical staff with physical assessment a relatively new and extended role for nurses. However nursing is a dynamic and ever evolving profession, where nurses need to be responsive to the needs of their patients and the innovations and advancements being made in healthcare. Nursing care in the hospital setting is becoming increasingly complex and acute, with the increased use of new technology and the introduction of advanced medical and surgical treatments. If nurses have a comprehensive understanding of the skills and knowledge needed to carry out a physical assessment, it provides them with a baseline reference point from which they can use critical thinking and clinical reasoning skills to monitor and consider changes in a patients condition 5. The skills needed to undertake a physical assessment and health history include: interviewing skills, physical assessment skills, critical thinking skills and documentation skills 3. Student concerns Many of the students expressed concern that although they eventually wanted to work in the NZ health system, they were unsure about this move into what they considered the role of a doctor. Many of the

243 International Journal of Nursing Education. January-March 2015, Vol. 7, No students were juniors, who had been qualified as RNs for only 1 year and already felt anxious about their lack of experience. Academic staff reassured the students that there is a significant difference in a nurse carrying out a physical assessment and a doctor. For medical staff the purpose of a physical assessment and health history is to identify a medical diagnosis through reviewing all the underlying causes for the signs and symptoms the patient presents with. While for nurses the assessment creates a point of reference from which to base their nursing care plan. It gives nurses the opportunity to develop a therapeutic nursepatient relationship setting the foundations for holistic nursing care being delivered. For nurses being able to recognise both normal and abnormal physical findings enhances the nurse s self-confidence and may improve patient health outcomes and the patient experience 5. As the students felt confident in their ability to perform routine observation for their patients, academic staff linked physical assessment and history taking as the two processes needing completed before the observations were taken. This would give the nurses a reason why the observations were being taken and a possible explanation as to what the results could be. An example being a patient who explains they have hypertension may well have raised blood pressure when it is taken, likewise a patient who says they have osteoarthritis may have pain and reduced movement in their joints. Course design and content The three week block courses were divided into 50% classroom theory and 50% practical in the simulation hospital ward at the school of nursing. The maximum number of students on each course was 20, so that academic staff had time to work individually and in small groups with students. Each student had access to a copy of a DVD that had been developed and produced by the school of nursing for their undergraduate nursing programme and demonstrated six system specific physical assessments; respiratory, abdominal, cardiac, musculo-skeletal, neurological and eyes and ears. Students would only be examined on the first five. As well as being able to carry out a comprehensive physical assessment, students were required to write up a health history assessment based on a variety of clinical situations and patients. The history taking commenced with asking the patient about their presenting problems, and progressed to their current medical history, past medical history and family medical history. Students were taught a core set of questions and then using critical thinking and reasoning skills, they had to link the presenting problem to system specific questioning. Such as a patient presenting with a cough, as part of the respiratory assessment they would have to ask about a history of asthma, bronchitis, previous chest infections, any environmental factors that may impact on the cough, exposure to smoke etc. Students also has to look for opportunities for health education and health promotion for example if a patient said they were a cigarette smoker, the student would have to give advice about smoking cessation, the same way if a patient said they did not have a healthy diet, the students would have to give advice about nutrition. Students were also taught a range of non-clinical skills, such as remembering to introduce themselves, giving an explanation for what they would be doing, asking for consent for the assessment, ensuring the patients privacy and dignity, hand washing and checking the patient understood what was going on. In NZ students also have to provide culturally appropriate care; this is particularly in respect to nursing Maori patients as Maori are the indigenous people of NZ and have special rights under the Treaty of Waitangi 9. OLDCART For each presenting problem the student used the acronym OLDCART to ask questions about the problem. In this example the student is told they are an RN working in a clinic at a university, when John, a 20 year old student presents to them with abdominal pain. O is for Onset, when did the abdominal pain commence? What were you doing? L is for Location, where on the abdomen is the pain? D is for Duration, how long have you had the pain? C is for Characteristic, what is the pain like? Sharp? Dull? Intermittent? Continuous? A is for Aggravating factors, what makes the pain worse? R is for Relieving factors, what reduces the pain? T is for Treatment, what has John taken or used to reduce the pain? e.g. used a heat-pack. Theoretical teaching included anatomy and physiology, practicing writing up physical assessments, care planning and reviewing the NCNZ competencies for the RN scope of practice. In the ward

244 236 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 environment the two academic staff members took the roles of a nurse and patient and demonstrated physical assessment techniques based on typical scenarios that would be given in the actual exam. Students then practiced in groups of three, with one student acting as the patient, one as the nurse and the third taking notes to critique what was happening. Another technique was to have two students act as the nurse and patient and carry out the assessment in front of the whole class the same way that the academic staff had demonstrated. While students were reluctant to initially volunteer for these roles, they quickly realised this was one way to acquire and improve their assessment skill and confidence as classmates would provide hints and encouragement to the two students taking part. All students had to pay particular attention as they were then required to write up the history and clinical findings. For the final physical assessment exams, the school of nursing recruited several volunteers to take the role of patients. The volunteers were aged between 16 and 55 years of age and fully understood what was expected of them and the sort of questions they would be asked with each volunteer creating a medical history for each situation. This small group of volunteers was used each time, becoming very proficient in their roles. CONCLUSION All students knew how important it was to pass the course, as failure meant that they would not then be eligible to eventually register as an RN in NZ, which was the primary intention for many of them. Academic staff carried out a standard course evaluation process at the end of each course and used the feedback to make improvements and changes to the way the following courses were delivered. Students found it very beneficial to have a mock assessment exam, as this gave them feedback on areas they needed to concentrate on for the actual assessment exam. They also reported that as their confidence in performing physical assessment grew, they really enjoyed taking part as the nurse or patient in front of the whole class. A method academic staff used to assist students who were struggling to do their assessments in a logical and systematic manner, was to have that student act as the patient on multiple occasions, as this helped reinforced the step by step process to them. The physical assessment exam was marked by an academic staff member and a senior clinical nurse representing the NCNZ, which created tension and additional pressure for the students. Students, who failed the physical assessment exam, were allowed a re-sit the following day. This gave time to read the feedback given and to practice their techniques. Four students came back and re-sat the whole course again as they failed on re-sit due to forgetting what to ask next and not working through their assessment in a systematic manner. These students all passed on their second attempt at the course. For many of the students completing this course was a significant achievement, all of them provided feedback that they had learned new skills, techniques and approaches. Their confidence in their abilities had increased and they reported in their course evaluations that teaching by the academic staff had made the study exceptionally interesting. The students embraced the challenges put before them and worked exceptionally methodically and conscientiously to full fill the demanding requirements of the course. The course did not set out to create nurses who were experts in physical assessment, but to give these students the same assessment skills that a NZ new graduate RN would have. Becoming an expert takes time and repeated practice and depending on where the students eventually work, they may end up using only a small proportion of what was covered in this course. The course promoted critical thinking, whereby students used a systematic and logical assessment process to guide their questioning of patients and their physical assessment techniques, the purpose being to eventually create competent RNs able to make sound clinical judgements for improved patient outcomes. Acknowledgement: I would like to acknowledge my dear and respected colleagues who helped with the development of the two simulated assessment papers and also co-taught these papers. Ethical Clearance: Not required as no participants recruited. Conflict of Interest: Nil Sources of Funding: Nil REFERENCES 1. International Council of Nurses, Definition of Nursing last updated on 12 th April Retrieved from icn-definition-of-nursing/ 2. Schroyen, B., George, N., Hylton, J., & Scobie, N. (2005, November). Encouraging nurses physical

245 International Journal of Nursing Education. January-March 2015, Vol. 7, No assessment skills. Kai Tiaki Nursing New Zealand, Milligan, K., & Neville, S. (2003). The contextualisation of health assessment. Nursing Praxis in New Zealand. 19 (1), O Connor, T., & Stodart, K. (2013). NZ relies heavily on migrant nurses. Kai Tiaki Nursing New Zealand, 19 (7), Fennessey, A., & Wittmann-Price, R.A. (2011). Physical assessment: A continuing need for clarification. Nursing Forum, 46 (1), West, S.L. (2005). Physical assessment: whose role is it anyway?. Nursing in Critical Care, 11 (4), Koc, Z., & Saglam, Z. (2012). Determination of physical assessment skills used by nurses in Turkey. HealthMED, 6 (3), Thornbory, G. (2013). Taking a history and making a functional assessment. Occupational Health, 65 (3), Ramsden, I., & Spoonley, P. (1994). The cultural safety debate in nursing education in Aotearoa. New Zealand Annual Review of Education, 3,

246 238 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / A Study to assess the effectiveness of STP Regarding Knowledge on Nosocomial Infections in Newborns among the Staff Nurses Working at NICUS in Selected Hospitals at Tumkur District Kiran Patil Registered Pediatric Nurse, Sridevi College of Nursing, Tamkur, affiliated to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka, India ABSTRACT Neonatal is very critical period. Prevention of nosocomial infections in newborns is an art and requires various skills and knowledge. Nurses has key role in infection prevention. This study assess nurses' knowledge regarding nosocomial infection in newborn by using structured knowledge questionnaire and reassess the effectiveness of teaching program on infection control. The study found that mean post knowledge scores(22.84) of nurses were significantly higher than the mean pre -test knowledge scores(13.88).the level of knowledge were significantly higher among the staff with higher qualification, received training/special education and along with increased year of experiences. This study highlights that in order to increaseknowledge repeated reinforcement and motivation is essential to improve their knowledge and practice. Keywords: Nosocomial Infections, Staff Nurses, Knowledge, Assessment, S T P Structured Teaching Program Me. NICU Neonatal Intensive Care Unit INTRODUCTION No stronger condemnation of any hospital or ward could be pronounced than the single fact that zymotic (infectious) diseases has originated in it. -Florence Nightingale. Each year, about 4 million newborns die before they are 4 weeks old 98% of these deaths occur in developing countries. More than half of infant mortality rates are highest in Sub- Saharan, Africa and Asia. 1 India carries the highest single share of neonatal deaths in the world- around 30% of the worldwide total; the neonatal death continues to remain unacceptably high. 2 Healthcare associated infections (nosocomial) are responsible for significant morbidity and late mortality among neonatal intensive care patients 3. Effective strategies to prevent nosocomial infection must include continuous monitoring and surveillance of infection rates and distribution of pathogens, staffing and emphasis on staff accountability for incidence of nosocomial infections. Hand washing compliance, minimizing central venous catheter use and contamination and prudent use of antimicrobial agents. Nurses play a significant role in the development of evidence based guidelines for infection control in the Neonatal Intensive Care Unit (NICU). 4 OBJECTIVES To assess the existing knowledge of staff nurses regarding the nosocomial infections in the newborns. To administer planned teaching programme on nosocomial infections in newborns. To assess the effectiveness of planned teaching

247 International Journal of Nursing Education. January-March 2015, Vol. 7, No programme on nosocomial infection in newborns among staff nurses by comparing pre and posttest knowledge To find out the association between selected demographic variables with knowledge of staff nurses MATERIAL AND METHOD Tool was prepared on the basis of the objectives of the study. A structured knowledge questionnaire was selected to assess the knowledge of nurses. 5 It had 2 sections. Section A Questionnaire focused on Personal Data. And Section B Questionnaire was focused on General information, Causes and mode of transmission, Diagnosis and management and prevention and control The research design of the study was preexperimental design. The subjects selected for the study were staff nurses working in selected NICU units of government District Hospital and Sridevi Hospital Tumkur. The study participants were selected by simple random sampling. The conceptual framework selected for the study was based on IMOGENE M. KING s ATTAINMENT MODEL. 6 Data was collected from selected staff nurses for a period of 4 weeks after conducting the Pilot study. FINDINGS The collected data was analyzed by using descriptive and inferential statistics. 7 The study findings revealed that the Pre-test level of knowledge of nurses regarding Nosocomial infection was inadequate (46.27%) where as the Post test level of knowledge of mothers was adequate (76.13%). The mean Post-test knowledge score (X 2 = 22.84) was significantly higher than the mean Pre-test knowledge score (X 1 = 13.88). The SD of Post test knowledge score (SD=3.81) was significantly lower than the SD of the Pre-test knowledge score (SD= 4088). The computed paired t value (t= 31.59, P,0.001) is greater than the table value. It represents that the structured Teaching Programme has been effective in increasing the knowledge of staff nurses regarding nosocomial infections in newborns. The chi-square test value reveals that there was a significant association found between knowledge and age (6.34), Qualification (9.06), Special Education programme (7.45), current working area (4.5), and experience in years (8.26) whereas no significant association was found between knowledge and gender (0.12). INTERPRETATION AND CONCLUSION The findings showed that only 4(8%) subjects had adequate knowledge in the pre test on Nosocomial infection among newborns. The mean Post-test percentage scores and the modified gain scores in all control and minimum in the area of causes and mode of transmission. Knowledge regarding Nosocomial infections in newborns was poor among the staff nurses working at the selected NICUs at Tumkur. Although they have gained knowledge particularly in the area of causes and mode of transmission. The t test was computed between pre-test and Post test knowledge scores which indicates there is gain in the knowledge. Hence, it was concluded that structured Teaching Programme was effective method to improve the knowledge among mothers. RECOMMENDATIONS Based on the findings of the study the following recommendations are made A similar study may be replicated in another setting. A similar study may be replicated with a control group. Comparative study can be done between staff nurses and students nurses A similar study may be replicated on a large sample for wider generalization. An exploratory study can be done to assess the nosocomial infections encountered by the mothers of neonates. A descriptive study can be conducted to find out the nature of problems related to Nosocomial infections in newborns. CONCLUSION The extended and expanded roles of professional nurses emphasize more about the preventive and promotive aspects of health Nurse as competent

248 240 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 professionals have responsibility to promote health information and practice among health professionals in the hospitals. So the provisions of information to the health care providers working in specialized units have an influence on knowledge regarding preventive of nosocomial infections. Acknowledgement: I owe my deepest gratitude to Prof. Mr. Ramu K Principal, shridevi College of Nursing, Tumkur, for his continuous support, encouragement and expert guidance in successful completion of this study. I am equally grateful to Prof. Mrs. Geetha K, HOD and Professor, Pediatric Department for her Valuable suggestions and guidance in conducting the study. Conflict of Interest Statement: There is no conflict of interest exist in this study. This study was conducted in partial fulfillment of the requirement for the post graduate degree of Master of Science in nursing in pediatric nursing under the guidance of Prof. Geetha. K HOD, Pediatric Nursing, Shridevi College of Nursing, Tumkur. Source of Funding: Self Ethical clearance: The investigator obtained the ethical clearance from the hospital Research and ethical committee prior to the study. The full information was provided to Participant regarding the study and confidential. After that the consent was obtained from the participants about their willingness to undergo the study. REFERENCES 1. Payman Salamati,et al., Neonatal nosocomial infections in Bahrami Children Hospital. Indian J Pediat 2006; 73(3); Dorothy R Marlow. Text book of Pediatric Nursing. 6 th Edition. Philadelphia, Harcourt Publication.p386, Rudnicki J, et al., Nosocomial infections in a neonatology department. Ginekol pol.2003 october; 74(10): Von Dolonger. et al., Effect of neonatal intensive care unit environment on the incidence of hospital acquired in neonates. J Hosp infect.2007 Apr; 65(4): Joan Newby. Nosocomial infection in neonates. Inevitable or preventable. Journal and perinatal and neonatal nursing ; volume 22 : Kothari CR. Research Methodology: methods and Technique. New Delhi: new Age International (p) Ltd Publishers:2005.

249 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Socrates: Making us Think Mark R Adelung 1, Virginia M Fitzsimons 2 1 MSN, PhD(c), 2 Professor and Executive Director Union, NJ, Kean University, School of Nursing ABSTRACT Critical thinking is imperative for nursing. It is utilized in all aspects of our practice. The Socratic Method demonstrates the foundations of critical thinking. We can use this to evaluate and foster the critical thinking abilities in student nurses and practicing nurses. It teaches individuals how to think, not what to think. This article discusses Socrates and his theory of knowledge and how it relates to nursing and the development of critical thinking skills to provide the best, most effective care for our patients. Keywords: Philosophy, Nursing, Knowledge, Critical Thinking INTRODUCTION Where did the idea of critical thinking come from? Critical thinking dates back to any early society that identified the necessity to work through complex situations that required information and reasoning within multiple viewpoints. 2 As nurses, we utilize our critical thinking abilities in all aspects of our practice. This article will discuss the historical examples of Socrates and critical thinking as it relates to nursing education and practice. What is critical thinking? There are many definitions of critical thinking. The American Philosophical Association states The ideal critical thinker is inquisitive, open-minded, flexible, fair-minded, well-informed, persistent in seeking the truth, wise in judgments and decision-making, logical, and honest with facing personal biases. The critical thinker uses sound reasoning and is willing to consider valid alternatives. 8 In nursing, critical thinking allows the nurse to reason and make judgments about clients. It is utilized in carrying out assessments, planning care, intervening with clients and families, and evaluating the effectiveness of our interventions. 4 As nurses, we utilize evidence-based practice for judging our nursing interventions every day. Critical thinking is linked to evidence-based practice. 8 Jones in Potter & Perry states, the ability to think critically through the application of knowledge and experience, problem solving, and decision making is central to professional nursing practice. 1 Socrates and his philosophy of knowledge Socrates lived from B.C. He presides over Western philosophy both in terms of his character and his philosophical conversations. He never wrote anything down and his dialogues were written up by his pupil followers. Topics of interest included human affairs, justice, the soul, and knowledge. 3 This article focuses on his philosophy of knowledge. Socrates helped people identify the inconsistencies and assumptions in their thoughts and reasoning by skilled questioning to investigate deeper understanding and knowledge. He stressed the standards of thinking clearly and consistently as well as the power of constructing organized and directed questions to facilitate critical thought. 2 Socrates said, I cannot teach anybody anything. I can only make them think. The Meno is an example of how he demonstrated his theory of knowledge by recollection. Socrates concluded that we do not learn anything we remember what we already know; all the knowledge of forms, or universals, is already in our minds. Our sense experience only has an incidental effect of jarring our memory, and bringing to our attention information that is within us, but of which we have not yet become aware. 6 The Meno discusses a slave boy who has

250 242 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 never been taught any mathematics throughout his life and was asked to solve a mathematical problem. As the slave boy attempted to figure out the answer, Socrates never indicated the correct answer, but only criticized what the boy said, leading the boy to discover the correct answer on his own. 6 This teaching tactic, Socratic teaching, focuses on giving students questions, not answers. 5 The Socratic Method of investigative inquiry demonstrates the foundations of critical thinking by asking who, what, when, why, define, clarify, describe, relate, explain, justify and what if. 1 Betts quoted Johnson and Weber as stating, Socrates knew that the identification, clarification and understanding of the origin, nature, direction and boundaries of one s thoughts and opinions would increase the truthfulness, reliability and validity of, and accountability of one s thoughts and opinions. 1 SOCRATIC PROCESS Socrates believed a barrier to high quality thought was that often people could not rationally justify their confident claims to knowledge, and such inconsistencies often led to the tendency to compromise ethical and virtuous values. His questioning technique guided students beyond speculation and belief to understanding and knowledge. The Socratic attitude is an essential part of an intellectual tradition based on the assumption that honest inquiry can lead to substantive understanding. 2 There are three important characteristics to the modern Socratic process as argued by scholar Thomas Warren. First, thinking is inherently sociable. The sociability of thinking sets the stage for the dialogical nature of the Socratic Method where individuals not only agree to cooperatively address a problem, but are challenged to confront the socio-centric obstacles to quality thinking. Individuals become more aware of their limits of knowledge and claims to truth. 2 Second, one should not claim knowledge. The Socratic Method challenges individuals to question their claims to knowledge and understanding and to critically reflect on their assumptions. 2 Thirdly, substantive knowledge cannot be passively received or taught. Individuals must do the intellectual work required to bring knowledge into their mind in such a way that its logic can be explained and its applicability can be exemplified and illustrated. 2 Critical thinking in practice In professional education, especially medical education, problem-based learning is frequently used as an educational method, and its thinking structure and philosophical background could be from the educational ideas of Socrates. 7 Nurses use complex critical-thinking processes such as problem solving, decision making and clinical reasoning in their practice. Since nurses care for a plethora of different patients with multiple concerns, a patient s response to therapy is not always apparent. 8 It is imperative that we know why we are doing a certain procedure, intervention or administering a particular medication. If we are not aware of why we are doing something we are unable to evaluate the effectiveness of our intervention. We can cause harm to our patients if we don t know the possible effects of a particular procedure or medication. It is important to critique our nursing interventions, weigh the consequences of varied decisions possible, and consider multiple perspectives to care. 4 Reasoning and reflection are required for the nurse to decide what interventions to use, determine whether they worked, and, if not, figure out why. 8 We need to be able to confidently and rationally justify our claim to that knowledge in which we are actively involved in. The ability to deliver safe, effective and quality nursing care to patients is contingent on the nurse having the necessary knowledge upon which to base decision-making. 9 It is imperative that nurses and nursing students are taught how to think instead of what to think. If you teach nurses to think for themselves, they will have the tools to meet the increasing demands of a lifetime of nursing practice and education. 9 CONCLUSION Critical thinking is not developed in just one class or one clinical experience, but it is a skill developed over time through various experiences. 4 The Socratic Method is just one way to evaluate and enhance those skills. Questions need to be open-ended and have multiple possibilities that encourage individuals to express and defend different views. The Socratic Method is increasing individuals understanding of difficult concepts. 4 Critical thinking is an essential skill for nurses to have and what we have learned from Socrates about Socratic questioning is an important

251 International Journal of Nursing Education. January-March 2015, Vol. 7, No tool to use to evaluate and develop critical thinking skills in nursing students and practicing nurses. Change is always constant. As nurses we need to use our critical thinking skills to constantly adapt to that change. Acknowledgement- nil Ethical Clearance: No experiments were performed on human or animal subjects. Source of funding: Self Conflict of interest: Nil REFERENCES 1. Betts, K. (2013). Defining critical thinking in nursing practice. Retrieved from 2. Hale, E. (2011). Tracing the intellectual tradition of critical thought. Rotman Magazine, Moseley, A. (2008). A to Z of Philosophy. London: Continuum International. 4. Oermann, M. H. (1997). Evaluating critical thinking in clinical practice. Nurse Educator, 22(5), Paul, R., & Elder, L. (1997). Socratic Teaching. Retrieved from 6. Popkin, R. H., & Stroll, A. (1993). Philosophy made simple (2nd ed.). New York, New York: Three Rivers Press. 7. SY, W. (2008). Socrates, problem-based learning and critical thinking a philosophic point of view. The Kaohsiung Journal of Medical Sciences, 24, S Wilkinson, J. M., & Treas, L. S. (2011). Fundamentals of nursing (2nd ed.). Philadelphia, PA: F.A. Davis Company. 9. Yildirim, B., Ozkahraman, S., & Karabudak, S. S. (2011). The critical thinking teaching methods in nursing students. International Journal of Business and Social Science, 2,

252 244 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Prevention of Endotracheal Suctioning-Related Complications: A Comparison Between Manual and Ventilator Hyperinflation/Hyperoxygenation Amina Hemida Salem Lecturer of Critical Care and Emergency Nursing, Department of Critical Care & Emergency Nursing, Faculty of Nursing, University of Alexandria, Egypt ABSTRACT Patients dependent on mechanical ventilation often need to have mucus suctioned from their airways. Endotracheal suction (ETS) is a procedure which aims to keep airways patent by mechanically removing accumulated pulmonary secretions in critically ill patients with artificial airways. Despite being a necessary procedure, it can lead to serious complications. (1-2) the most common complication associated with the endotracheal suctioning procedure is hypoxemia leading to hemodynamic alterations. Hypoxemia is resulting from either disconnection from the ventilator or the removal of respiratory gases with application of negative pressure. (3-5) Consequently, the majority of ETS researches have focused on techniques to minimize suction - induced hypoxemia and hemodynamic alterations. Hyperinflation/Hyperoxygenation is a technique used by a nurse and/or physiotherapist to mimic a cough so that airway secretions are mobilized toward the larger airways, where they can easily be removed; reinflate areas of pulmonary collapse and improve oxygenation. Hyperinflation/ Hyperoxygenation may be delivered by the ventilator or manually by manual resuscitation bag. (MRB (6) But, it is uncertain which method is better; should we use the ventilator or the manual resuscitation bag to hyperinflate/hyperoxygenate the patient before, during and after the suctioning procedure. Aim: This study was aimed to compare between the effects of manual hyperinflation/ hyperoxygenation (MHI) and ventilator hyperinflation (VHI) on blood gas and hemodynamic parameters. Method: A prospective, randomized crossover study of thirty patients, who were intubated, ventilated and hemodyamically stable and met the inclusion criteria was used. Suctioning was performed only when the researcher identified a clinical need for ETS. Hyperinflation/hyperoxygenation technique (manual or ventilator) was determined randomly. The other technique was used at least 2 hours after the first intervention when the patient again required suctioning. Hemodynamic parameters and blood gases were obtained before the procedure (baseline) and 30 seconds, 60 seconds and 120 seconds after suctioning. The variables of hemodynamic and ABG variables were analyzed by use of an analysis of variance (ANOVA) for repeated measures. Statistical significance was set at p < Results: There was no significant difference in hemodynamic and ABG variables between either techniques of treatment. Conclusion: Although both methods produced non-statistically significant differences in relation to hemodynamic and ABGs parameters, MRB produced higher changes in MAP, HR, RR and DBP, which may have a deleterious effects on critically ill patients. Moreover, MV produced higher improvement in ABGs than MRB. Therefore, mechanical ventilator is superior to MRB in delivering hyperinflation/hyperoxygenation. Keywords: Nursing Care; Critically Ill Patients; Endotracheal Suctioning; Manual Hyperinflation; Ventilator Hyperventilation; Arterial Blood Gases and Hemodynamic Parameters

253 International Journal of Nursing Education. January-March 2015, Vol. 7, No INTRODUCTION Critically ill patients in intensive care may require intubation and mechanical ventilation. Endotracheal and tracheostomy tubes bypass the body s natural humidification, filtering and warming system resulting in the need for these to be provided artificially. These systems may not always be sufficient and as a result patients may develop tenacious secretions which are difficult to clear. Intubation also inhibits the normal cough mechanism. This is compounded further by the use of sedation to tolerate intubation and mechanical ventilation, thereby reducing a patient s ability to (3, 7) cough and clear secretions. Endotracheal suctioning (ETS) is one of the most common procedures performed in patients with artificial airways. It is a component of bronchial hygiene therapy and mechanical ventilation that involves the mechanical aspiration of pulmonary secretions from a patient s artificial airway to prevent its obstruction. Despite being a necessary procedure, it can lead to complications, such as lesions in the tracheal mucosa, pain, discomfort, infection, alterations of the hemodynamic parameters and of the arterial gases, bronchoconstriction, atelectasis, increase in intra-cranial pressure, and alterations in cerebral blood flow, among others. (1-2) Atelectasis leading to hypoxemia and hemodynamic alterations are the most common reported complications of the ETS. (3-5) Patient safety has been broadly conceptualized as the prevention of patient harm or potential harm. In relation to this goal of harm prevention, many studies a have been performed in order to establish recommendations & guileless for safer ETS practices. One of these recommendations is to use hyperinflation/hyperoxygenation technique. (1, 8-12) The effects of hyperinflation are usually studied with hyperoxygenation. Hyperinflation is performed by inflation the patient s lungs, manually with a ventilation bag (bagging), or via the mechanical ventilator. A volume of 1.5Í baseline tidal volume is the most common for hyperinflation prior suctioning. Hyperoxygenation is performed by increasing the intake of oxygen immediately prior to suctioning, during and when appropriate, after suctioning. Hyperinflation/hyperoxygenation technique is assumed to improve the patient s oxygenation capacity by recruiting pulmonary volume, losing secretions and preventing of hemodynamic alterations induced by hypoxemia. (10,11,13) Hyperinflation/ hyperoxygenation may be delivered by the ventilator or manually, by use of a manual resuscitation bag, depending upon the respiratory and cardiovascular status of the patient. It is uncertain which method used to deliver hyperinflation/hyperoxygenation breaths would produce improvements in oxygenation, and prevent the suctioning induced complications. The aim of this study was to compare between the effectiveness of MHI and VHI in terms of improving blood gas values (ph, PaO2, PaCO2 & SaO2), and preventing the hemodynamic alterations in stable intubated and ventilated patients. MATERIAL AND METHOD This study was conducted over the course of 3 months, from June to September 2010, in the Intensive Care Units (ICUs) of the Main University Hospital in Alexandria. Permission to conduct the research was obtained from the authority figures in the hospital & in the intensive care units. After having the study explained, a verbal consent was obtained from the patient or the relative. Tool was develop by the researcher and was checked for content validity by five professors from critical care nursing and critical care medicine. A pilot study was conducted on five patients order to test the clarity, validity and applicability of the tool. A randomized, controlled crossover study design was used. Thirty patients who met the inclusion criteria were studied. Patients were included if they were would normally receive hyperinflation/ hyperoxygenation as a part of their physiotherapy treatment. Patients were excluded from the trial if they: Required a fraction of inspired oxygen (FiO2) e 0.6, Had a PEEP e 10 cm H2O, Had pulmonary pathology where lung hyperinflation/hyperoxygenation was contraindicated (for example, adult respiratory distress syndrome, exacerbation of chronic obstructive pulmonary disease), Had an unstable cardiovascular condition as defined by a mean arterial pressure (MAP) d 75 mmhg, a heart rate >130 and Had an arterial oxygen saturation (SaO2) d 90%. Patients were withdrawn from the study if they suffered cardiovascular compromise during the treatment, as defined by the above variables. All suctioning interventions were performed when the researcher identified a clinical need for ETS. The technique used for the first suction intervention (manual or ventilator) was determined randomly. The other technique was used at least 2 hours after the first intervention when

254 246 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 patient again required suctioning. Hemodynamic parameters (heart rate, systolic blood pressure, diastolic blood pressure, mean arterial blood pressure and respiratory rate) and blood gas parameters (ph, PaO 2, PaCO 2 & SaO 2 ) were returned to baseline values prior to beginning the second suctioning intervention. Prior to beginning each suctioning intervention, information on the following variables was obtained: ETT size, ventilator flow rate, tidal volume, positive end expiratory pressure (PEEP) & FiO 2. Regardless of ETT size, all patients were suctioned with a 14F suction catheter, with the suction pressure gauge set at 120 mmhg. Two members of the research team performed all suctioning procedures. Three breaths, at 5-sccond intervals, were given before and after each of two catheter passes. Suction was applied continuously for 10 seconds or less, as the catheter was removed. Normal saline was not used during the suctioning intervention. Manual Intervention Manual hyperinflation/hyperoxygenation breaths were delivered using a MRB with reservoir of 1800 ml. MRB with reservoir was connected to wall oxygen inflow of 15 L per minute and was used to deliver manual breaths was used to deliver manual breaths. The patient was disconnected from the ventilator, attached to the MRB, a two handed technique was used to compress the bag. The same person performed the techniques during the study, limiting the variability that can occur with different hand sizes, hand strength or gender. Three breaths were given at 5-second intervals before and after each of two catheter passes. Ventilator Intervention The 100% oxygen-suction mode was activated on the patient s ventilator, and time allowed ensuring 100% Fio 2 delivery to the patient (a tidal volume 1.5 time of baseline tidal volume). Three ventilator breaths of 100% oxygen at the venti-lated tidal volume were given using the manual inspiration button at 5-second intervals, before and after each of two passes of the suction catheter. Patients were not removed from the ventilator for suctioning but were suctioned through the ventilator circuit-ett port. During the suctioning event, Peak Inspiratory Pressure (PIP) was recorded from the ventilator airway pressure gauge with each ventilator breath. RESULTS Table1: Patients Demographics and Characteristics Item (n=30) % Age Group (in years) % % % > % Gender Male 18 60% Female 12 40% Diagnosis Respiratory Disorders 6 20% Metabolic Disorders 3 10% Neurological Disorders 3 10% Cardiac Disorders % Post operative % Trauma 9 30% Ventilator Settings Mode 6 20% CMV SIMV 24 80% FiO % Tidal Volume % PEEP5 less than % CMV= Continuous Mandatory Ventilation, SIMV= Synchronized Mandatory Ventilation, FiO2= Fraction of Inspired Oxygen, PEEP= Positive End Expiratory Pressure Table 1 shows patients demographics and characteristics, It can be observed that, a total of 30 patients were included in the study. Nearly half of the study sample (43%) was above 60 years and more than half of the sample (60%) was males. Regarding the patients diagnoses, more than half of the patients (56.67%) were surgical cases (30% trauma, 26.67% post operative). Respiratory disorders came in second ranking for 20% (10% pleural effusion, 6.67% pneumonia, 3.33% respiratory failure). Metabolic disorders account for 10% of the study sample. Neurological disorders account for another 10% including two cases of stroke (6.67%), and one case of intracranial hemorrhage (3.33%). The remaining 3.33% are cardiac disorders. Regarding the modes of the

255 International Journal of Nursing Education. January-March 2015, Vol. 7, No ventilator, it was found that, more than half of the sample (80%) was set to SIMV. While the least observed mode was continuous mandatory ventilation (20%). It was also observed that, the ordered fraction of inspired oxygen (FiO 2 ) ranges from 30% to 60%. Moreover, it can be also observed that, all the study sample received PEEP between 5mmHg and less than 10 mmhg. Table (2). Mean and SD of Hemodynamic Changes in Relation to the Method of Hyperinflation/Hyperoxygenation Variable Time Hemodynamic Parameters HR (b/m) SBP (mmhg) DBP (mmhg) MAP (mmhg) RR Mean±SD P- value Mean±SD P- Value Mean±SD P- Value Mean±SD P- Value Mean±SD P- Value Methods of Hyperoxygenation MRB Baseline 91.6 ± ± ± ± ± At 30 sec ± ± ± ± ± 5.4 At 60sec ± ± ± ± ± 5.9 At 120 sec ± ± ± ± ± 6.0 MV Baseline 90.9 ± ± ± ± ± 5.1 At 30 sec ± ± ± ± ± 5.4 At 60sec ± ± ± ± ± 5.6 At 120 sec ± ± ± ± ± 5.2 Table 2 illustrates the hemodynamic changes (Heart rate HR, Systolic blood pressure SBP, Diastolic blood pressure DBP, Mean arterial pressure MAP, and respiratory rate RR) in relation to the method of hyperinflation/hyperoxygenation. The findings revealed that no significant differences were found between the methods of hyperoxygenation when it comes the hemodynamic parameters. For heart rate (P value = when comparing the two methods) and (P value = over time). For systolic blood pressure, (P value = when comparing the two methods) and (P value = over time). For diastolic blood pressure (P value = when comparing the two methods) and (P value = over time). For mean arterial pressure, (P value = when comparing the two methods) and (P value = over time). For respiratory rate, (P value = when comparing the two methods) and (P value = overtime). Table 3 demonstrates the arterial blood gases changes (Partial pressure of oxygen PaO 2, Partial pressure of carbon dioxide PaCO 2, ph, and oxygen saturation of arterial blood SaO 2 ) in relation to the method of hyperoxygenation. Based on the findings of the study, it can be found that, there were no significant differences between the two methods in relation to blood gases changes. The mean Partial Pressure of Oxygen reached maximum after 2 min. of the procedure from the baseline value in both ventilator and MRB group and it finally reached to baseline at 6 min. However, this improvement is not statistically significant (P value = over time). Moreover, no difference was found in the improvement between the methods (P value = 0.793). For PaCO 2, (P value = when comparing the two methods) and (P value = overtime). For ph, (P value = when comparing the two methods) and (P value = over time). And for SaO 2, (P value = when comparing the two methods) and (P value = over time). Table (3): The Mean & SD of Arterial Blood Gases Changes in Relation to the Method of Hyperinflation/ Hyperoxygenation Variable Time Arterial Blood Gases Parameters Methods of Hyperoxygenation PaO 2 (mmhg) PaCO 2 (mmhg) ph SaO 2 (%) Mean±SD P- value Mean±SD P- Value Mean±SD P- Value Mean±SD P- Value MRB Baseline ± ± ± ± At 30 sec ± ± ± ± 6.6 At 60sec ± ± ± ± 5.9 At 120 sec ± ± ± ± 5.7 MV Baseline ± ± ± ± 7.1 At 30 sec ± ± ± ± 7.1 At 60sec ± ± ± ± 7.6 At 120 sec ± ± ± ± 6.3

256 248 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 DISCUSSION The care of the mechanically ventilated patient is at the core of a nurse s clinical practice in the Intensive Care Unit (ICU). Endotracheal suctioning in itself however is potentially hazardous to the patient and should be performed with care. For this procedure, it is important that the nurse has knowledge based on valid scientific evidences concerning endotracheal suction aspects related to it. One of these aspects is using of hyperinflation/hyperoxygenation technique. Hyperinflation/hyperoxygenation can be delivered manually, by MRB, or mechanically, by mechanical ventilator. Should we use the ventilator or the manual resuscitation bag to deliver oxygen enriched breaths of air to the patient before and after suctioning? In order to answer the previous question, this study was conducted. The finding of the current study revealed that, there was no significant difference in hemodynamic and blood gas parameters between either techniques (MRB & MV). Although the difference was not significant, MRB produced a greater increase in MAP, HR, DBP and RR than ventilator (p = 0.808, 0.808, 0.902, 0.476) and the ventilator produced more improvement in ABGs (PaO2 and PCO2, SaO2 & ph) compared to the MRB (p = 0.793, 0.306). Moreover, both methods (MV or MRB) were prevented the post-suctioning hypoxemia. The greater increase in MAP, HR, DBP and RR observed in this study may be attributed to emerge changes in intrathoracic pressure, effect on long stretch receptors, and incidence of coughing with suctioning. Multiple studies results have been congruent with the result of the current study and almost of them concluded that, although manual hyperinflation/ hyperoxygenation has been shown to be an effective technique in the management of intubated patients it has several limitations. (14,15) Some of these studies, the studies that were conducted by Baun, Demers and Carrol. They studied the effect of hyperinflation/ hyperoxygenation technique using the two methods (MV versus MRB) and they reported that, hemodynamic parameters including heart rate, systolic blood pressure, and diastolic blood pressure were significantly higher with MRB than MV. They attributed the hemodynamic changes to arterial oxygen desaturation, which reduces the oxygen supply to cardiac muscle, thereby increasing cardiac (16, 17,18) irritability. On the similar vein, Goodnough has examined the effects of hyperinflation/hyperoxygenation on PaO 2 and hemodynamic after ETS using of MRB versus ventilator. The results have showed that both methods (MRB & MV) have prevented a significant decrease in PaO 2 and hemodynamic changes after ETS. The researcher recommended that, on the practical base, MV is superior to MRB in prevention of deterioration in PaO 2. Investigator has also found hemodynamic changes associated with MV to be less than those associated with MRB. (19) Similarly, Lucke carried out a study on 17 general ICU patients, and evaluated the effectiveness of two methods of pre-oxygenation: the use of 100% oxygen via the ventilator sigh mode or the MRB on the arterial blood gases, SpO 2 & PIP. The results illustrated a significantly greater rise in PaO 2 and SaO 2 for those pre-oxygenated by the ventilatory sigh mode and the author concluded that this method of pre-oxygenation was more effective than the MRB in controlling hypoxemia in critically ill patients. (20) In addition, Preusser et al. studied which method of preoxygenation, MRB versus MV, produced least change in arterial blood gases and prevented postsuctioning hypoxemia. They reported that, there was no significant difference in the partial pressure of arterial oxygen (PaO 2 ) between MRB & MV. They also reported that MRB increased peak airway pressure nearly as twice as high as the ventilator and they attributed the changes that occurred with using of MRB may be due to the fact that the person delivering hyperoxygenation breath has less control over the rate of infusion of air when using the MRB as compared with the ventilator. Although there was no significant differences between both methods. Researchers have described MV as the superior method. (21) Stone critically evaluated the literature available on the various methods employed by researchers and concluded that hyperoxygenation/hyperinflation breaths at 100% O 2 delivered by the ventilator resulted in increased PaO 2 levels which is either superior or equal to the MRB in preventing suction-induced hypoxemia. (22) Grap et al. also recommended the use of the ventilator to hyperoxygenate/hyperinflate due to the inconsistency associated with using the MRB. They found that even when used by an experienced individual, the MRB only delivered 84% of the standard tidal volume required, and oxygen delivery was significantly less than 100%. (23)

257 International Journal of Nursing Education. January-March 2015, Vol. 7, No In another study that was conducted by Paratz and Lipmann. They investigated the reasons behind elevation in MAP, HR and DBP with the manual hyperinflation rather than mechanical hyperinflation. They concluded that, the increase in systemic vascular resistant index and plasma norepinephrine after MHI strongly suggest sympathetic compensation caused vasoconstriction. Decreases in venous return and cardiac output caused by positive pressure are usually offset by compensatory mechanism (vasoconstriction) modulated by sympathetic system. (24) In addition, Dam et al. reported some major limitations to the use of hyperinflation via the MRB, as it may lead to respiratory damage due to variable tidal volumes and airway pressures, barotrauma, and alterations in mean arterial pressure and cardiac output. (25) In another study, Savian et al aimed to compare the effectiveness of manual and ventilator hyperinflation techniques in improving pulmonary mechanics, gas exchange, and secretion clearance in intensive care patients mechanically ventilated. They found that, no significant difference was observed between techniques (MV & MRB) in the hemodynamic or metabolic parameters. The findings of these studies have suggested that in general intensive care patients, ventilator hyperinflation might be used to substitute for manual hyperinflation in patients ventilated on PEEP equal to or lower than 10 cmh O. (26) Conclusions & Recommendations CONCLUSIONS - Based on the findings of the current study, it can be concluded that, both methods produced nonstatistically significant differences in relation to hemodynamic and ABGs parameters, MRB produced higher changes in MAP, HR, RR and DBP and MV produced higher improvement in ABGs than MRB. Therefore, mechanical ventilator is superior to MRB in delivering hyperinflation/ hyperoxygenation. - Some limitations were observed by researchers during the use of the MRB, include: Disconnection of the patient from the ventilator resulting in loss of PEEP. Poor control of airway pressure. Poor control of flow and the fraction of inspired oxygen. RECOMMENDATIONS Because MRB produced higher changes in MAP, HR, RR and DBP which may have deleterious effects on critically ill patients and because the MV produced higher improvement in ABGs than MRB, therefore, mechanical ventilator is superior to MRB in delivering hyperinflation/hyperoxygenation before, during and after the tracheal suctioning. In MV, the tidal volume, respiratory rate, oxygen concentration and peak pressure are electronically controlled by the microprocessor of the mechanical ventilator and can be accurately illustrated on the monitor of the ventilator, so that, limitations associated with using of MRB could be prevented. In case that the MRB is indicated, the following recommendations should be followed Two hands technique should be used to ensure adequate tidal volume is delivered. Manufacturer design of the MRB should be revised before usage because FiO 2 delivery is known to be significantly affected by reservoir style and manufacturer design. Education of therapists to improve reliability and potential effectiveness of the technique. Inclusion of a manometer in the circuit. Enable the critical care nurse to evaluate the effectiveness of the suctioning and hyperinflation/ hyperoxygenation attempts and identify any unexpected effects of these attempts. ACKNOWLEDGEMENT This research paper is made possible through the help and support from everyone, including: family, friends, and in essence, all sentient beings. Especially, please allow me to dedicate my acknowledgment of gratitude toward the following significant advisors and contributors: First and foremost, I would like to thank Dr. Ahmed Ajlan for his most support and helping during the data collection. He kindly read my paper and

258 250 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 offered invaluable detailed advices on clinical aspects, organization, and the theme of the paper. Second, I would like to thank my sister who helped me much during the phase of the data collection because she works in the same carrier and all nurses work in the ICUs as well. Finally, I sincerely thank to my family, and friends, who provide the advice and financial support. The product of this research paper would not be possible without all of them. Publication Disclosure Statement for Conflicts of Interest The author of this publication has not received any research funding support from anybody. Because the purpose for conduction of this research is required for the author s promotion, so all the funding requirements (equipment, editing, materials and publication) were the responsibility of the author. The author also conducts research in areas of interest similar to the business interests of [Nursing]. REFERENCES 1. American Association of Respiratory Care - AARC. AARC clinical practice guideline: endotracheal suctioning of mechanically ventilated patients with artificial airways. Respir Care. 2010; 55(6): Pedersen CM, Rosendahl-Nielsen M, Hjermind J, Egerod I. Endotracheal Suctioning of the Adult Intubated Patient. What Is the Evidence? Intensive Crit Care Nurs. 2009; 25(1): Guglielminotti J. Desmonts J.M.and Dureuil B. Effects of Tracheal Suctioning on Respiratory Resistances in Mechanically Ventilated Patients. Chest/113/5/May, Berney S, Denehy L. A comparison of the Effects of Manual and Ventilator Hyperinflation on Static Lung Compliance and Sputum Production in Intubated and Ventilated Intensive Care Patients. Physiotherapy Res Int 2002; 7: Jones A. Physiotherapy in Intensive Care. In: Intensive Care Manual, 4th ed. Oxford: Butterworth Heinemann, (1997): Berney S. A comparison of the Effects of Manual and Ventilator Hyperinflation on Static Lung Compliance and Sputum Production in Intubated and Ventilated Intensive Care Patients. Physiotherapy Research International 2002; 7(2) Almgren B., Wickerts C.J., Heinonen E. and Marieann. Side Effects of Endotracheal Suction in Pressure- and Volume-Controlled Ventilation. Chest 2004; 125: Council of the European Union (CEU). European Council recommendations on patient safety, including the provision and control of healthcare associated infections. Official Journal of the European Union, Brussels. Available at: health/patient_safety/docs/ council_ World Health Organization (WHO) (2010) A brief Synopsis of Patient Safety. Available at: data/assets/pdf_file/ 0015/ /E Caramez M. P. The Impact of Endotracheal Suctioning on Gas Exchange and Hemodynamics during Lung-Protective Ventilation in Acute Respiratory Distress Syndrome. Respiratory Care. May 2006 Vol 51 No Bronwyn A. et al. Nursing Care of the Mechanically Ventilated Patient: What Does the Evidence Say? Intensive and Critical Care Nursing (2007) 23, Day T. et al. Suctioning: A review of Current Research Recommendations. Intensive and Critical Care Nursing (2002) Pedersen CM. endotracheal suctioning of the adult intubated patient what is the evidence? Intensive and critical care nursing (2009) 25, Ciesla N. Chest physical therapy for patients in the intensive care unit. Physical Therapy 1996; 76: Clarke R, Kelly B, Convery P, Fee J. Ventilatory Characteristics in Mechanically Ventilated Patients during Manual Hyperinflation for Chest Physiotherapy. Anesthesia 1999; 54: Baun M. Physiological Determinants of A Clinically Successful Method of Endotracheal Suction. Western Journal of Nursing Research 1984; 6 (2): Demers B. The Impact of Technology on the Risks Associated with Endotracheal Suctioning and Airway Management: The Changes a Decade Has Wrought. Respiratory Care 1989; 34 (5): Carroll P. Safe Suctioning. Registered Nurse 1994; 57 (5):

259 International Journal of Nursing Education. January-March 2015, Vol. 7, No Goodnough SK. The Effects of Oxygen and Hyperinflation on Arterial Oxygen Tension after Endotracheal Suctioning. Heart and Lung 1985; 14 (1): Luke A. Effect of Manual Hyperinflation on Hemodynamics. Physiotherapy Research International 2003; 8 (3) Preusser BA, Stone KS, Gonyon DS, Winningham ML, Groch KF, Karl JE. Effect of Two Methods of Preoxygenation on Mean Arterial Pressure, Cardiac Output, Peak Airway Pressure, and Postsuctioning Hypoxemia. Heart Lung 1988; 17: Stone KS, Bell SD, Preusser BA. The Effect of Repeated Endotracheal Suctioning on Arterial Blood Pressure. Applied Nursing Research 1991a; 4 (4): Grap MJ, Glass CA, Corley M, Creek more S, Mellot K, Howard C. Effect of Level of Lung Injury on HR, MAP, and SaO 2 Changes During Suctioning. Intensive Crit Care Nurs 1994; 10 (3): Paratz J, Lipman J. Manual Hyperinflation Causes Norepinephrine Release. Heart & Lung 2006 Jul- Aug; 35 (4): Dam V, Wild MC, Baun MM. Effect of Oxygen Insufflation during Endotracheal Suctioning on Arterial Pressure and Oxygenation in Coronary Artery Bypass Patients. Am J Crit 1994; 3 (2): Savian C, Paratz J, Davies A. Comparison of the Effectiveness of Manual and Ventilator Hyperinflation at Different Levels of Positive End Expiratory Pressure in Artificially Ventilated and Intubated Intensive Care Patients. 2006, Heart and Lung 35:

260 252 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / Effect of Oral Cooling on Bolus 5-FUFA Induced Mucositis in Cancer Patients Sharma Preksha 1, Vatsa Manju 2, Sharma Atul 3 1 Lecturer, University College of Nursing, Faridkot, Punjab, 2 Principal, College of Nursing, 3 Professor, Dept of Oncology, AIIMS, New Delhi ABSTRACT Background: Chemotherapy-induced mucositis affects over one third of patients receiving standard dose chemotherapy which may result in pain, dysphagia and risk of infection. Aims: To evaluate the effect of oral cooling using ice-rolls on chemotherapy-induced mucositis in patients administered bolus 5-FUFA. Setting and Design: Study was conducted in BRAIRCH, AIIMS, New Delhi with Randomized controlled trial design. Method: Fifty three cancer patients receiving 5-FUFA, weekly (31) and daily (22) were randomized into control and experimental groups. Twenty seven patients in experimental group were given icerolls for sucking during the chemotherapy-administration. Assessment of mucositis was done using WHO Oral Toxicity Scale and Patient-judged Mucositis Grading. Statistical analysis: Descriptive statistics, independent sample t-test, chi-square and Fisher's exact tests were used. Results: Incidence of mucositis significantly reduced in experimental group at week one (p= 0.001*), week two (p=0.014*) and week three (p=0.050*). In experimental group, none of patient developed moderate to high grade mucositis whereas in control group 5, 4 and 4 patients developed it at week one, two and three respectively. Patients receiving oral cooling had significantly (p= 0.018*) delayed onset (10.28±3.8 days) in comparison to control group (6.1±3.5 days). Duration of mucositis also reduced significantly (p=0.014*) in oral cooling group (6.1± 4.1days) as compared to control group (12.5± 5.9 days). Conclusions: Oral cooling reduced the incidence and duration whereas increased the day of onset of chemotherapy-induced mucositis. These findings strongly recommend the need for routine oral cooling during bolus 5-FUFA administration. Keywords: 5-FUFA, Oral Cooling, Ice-Roll, Chemotherapy, Mucositis, Cancer INTRODUCTION Over 20 million people are living with cancer in the world today. Worldwide12.7 million new cancer cases and 7.6 million cancer deaths occurred in Corresponding author: Preksha Sharma Lecturer University College of Nursing, BFUHS, Faridkot, Punja prekshamaheshwari@gmail.com Phone no: , Among cancer treatment modalities, chemotherapy is becoming increasingly popular and more effective but unfortunately substantial side-effects often accompany the benefits of chemotherapy. 2 Among oral side effects of cancer chemotherapy, mucositis is frequently encountered complication, described as an inflammatory and ulcerative reaction in the oral cavity. 3, Such mucosal toxicity can cause major symptoms and is a dose-limiting toxicity of 5-FU. 4 The prevention, management, and care of mucositis are considered to be most important functions of nurses as patients receiving chemotherapy are immuno-

261 International Journal of Nursing Education. January-March 2015, Vol. 7, No suppressed and tend to get infections easily. Oralcooling applied during chemotherapy suppose to cause local vasoconstriction and decreased blood flow in oral mucosa which reduces the amount of drug distributed to cells, thus reduces the incidence of mucositis. 5 In view of paucity of data regarding preventive efforts for the chemotherapy-induced oral mucositis in Indian cancer patients receiving chemotherapy, this study aimed to (1) assess the incidence and severity of chemotherapy-induced mucositis in cancer patients receiving bolus 5-FUFA and (2) assess the effect of oral cooling using ice rolls in preventing and decreasing the severity of oral mucositis among patients receiving bolus 5-FUFA. METHOD This randomized control trial was conducted in the out patient chemotherapy department of a tertiary care teaching hospital in New Delhi. Purposive sampling was used to include fifty three adult (over 18 years of age) subjects who were (1) Willing to participate (2) diagnosed with cancer of gastrointestinal tract and (3) receiving weekly (n=31) or daily bolus 5-FUFA for 3, 4 or 5 days (n=22). Patients who (1) had mucositis, (2) had received chemotherapeutic agents other than bolus 5-FUFA within last one month, (3) Were receiving whole body irradiation, (4) had Head & neck cancer and receiving radiation to the part, (5) were too sick to co-operate in oral cooling intervention (6) Had known history of allergy to cold exposure; and (7) were known case of asthma, were excluded from the study. Screening sheet was prepared to identify the subjects according to inclusion and exclusion criteria and subjects who fulfilled the inclusion criteria were randomly assigned to control (n=26) and experimental group (n=27). Subjects in control group received only standard care whereas experimental group received oral cooling in addition. Ethical clearance was obtained from ethics committee of AIIMS, New Delhi. Prior permission was taken to collect data. Intervention for oral cooling Oral cooling was done by putting ice-rolls in and out of oral cavity by patients to keep the oral mucosa cool around chemotherapy administration for a total of 30 ± 5 minute duration (10 minutes before, 5 minutes during and 15 minutes after bolus push of 5-FUFA). It maintained oral vasoconstriction during half-life of bolus 5-FU i.e. 10 min. In experimental group intervention of oral cooling was repeated for three consecutive cycles of chemotherapy one week apart for the patients receiving weekly 5-FUFA, whereas for patients receiving daily 5-FUFA regimen, intervention was repeated daily for 3-5 days during the chemotherapy administration. Assessment of mucositis was done every week for three weeks as per 5-FUFA regimen administered. Tools and techniques Five tools were used in the study 1. Subject data sheet: It contained two parts (a) Socio demographic data sheet, (b) Clinical profile sheet, 2. World Health Organization (WHO) Oral Toxicity Scale 6 : This scale grades the mucositis from 0 to 4, where 0 means no mucositis and 1 to 4 grades indicate increasing severity of mucositis. It took 7-10 min per patient for assessment. 3. Sheet for recording the observations during oral cooling: This sheet included the observations made during oral cooling (i.e. duration of oral cooling and number of ice-rolls consumed) 4. Patient-judged Mucositis Grading: 7 This tool grades mucositis from 0 to 4, with grade one standing for least severe and 4 standing for most severe mucositis. A patient-judged Mucositis Grading sheet was provided to the patients for daily recording of mucositis either by patients themselves or their attendants. 5. Observation sheet: It is used to record chemotherapy related other side effects as reported by patients. All the tools were tried out. Content Validity of all the tools was established by experts. Reliability of all tools was found to be acceptable. A competency certificate was taken for assessment of mucositis using WHO Oral Toxicity Scale. Translation of Patientjudged Mucositis Grading was done in Hindi and back-translated tool was found compatible with original tool. RESULTS As shown in table1, control and experimental group were found comparable at baseline with regards to socio-demographic characteristics (p>0.05). Similarly it was noted that both the groups were similar at baseline in relation to clinical characteristics (table 2).

262 254 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 1: Socio-demographic distribution of subjects in control and experimental groups Variable Control Experimental p-value group (N=26) Group (N=27) Age Range p=0.751 Mean 45.73± ±12.07 Gender Male 17 (31.1%) 12 (22.6%) p=0.105 Female 9 (17%) 15 (28.3%) Marital status Married 20 (37.7%) 21 (39.6%) p=0.591 Unmarried/Widowed/other 6 (11.3%) 6(11.3%) Religion Hindu 20 (37.7%) 22 (41.5%) p=0.472 Others 6 (11.3%) 5 (9.4%) Educational Status Illiterate 6 (11.3%) 7 (13.2%) p=0.433 Upto 10 th 13 (24.5%) 9 (17%) Above 10 th 7 (13.2%) 11 (20.8%) Current Occupational Status Employed 7 (13.2%) 12 (22.6%) p=0.228 Unemployed for health reason 16 (30.2%) 15 (28.3%) Unemployed for Other reasons 3 (5.7%) 0 (0%) Monthly per capita < (24.5%) 18 (34%) p=0.366 family income (Rs./-) (18.9%) 8 (15.1%) > (5.7%) 1 (1.9%) Table 2: Distribution of clinical characteristics of subjects in control and experimental groups Clinical characteristics C (N=26) E (N=27) p-value Drug regimen Weekly 5-FUFA n=31(51.67%) 15 (57.69%) 16 (59.26%) p=0.908 Daily 5-FUFA n=22 (36.67%) 11(42.31%) 11 (40.74%) Undergone Surgery Yes 25 (47.2%) 22 (41.5%) p=0.104 No 1 (1.9%) 5 (9.4%) Undergone Radiation therapy Yes 7 (13.2%) 8 (15.1%) p=0.827 No 19 (35.8%) 19 (35.8%) Concurrent radiation therapy Yes 3 (5.7%) 4 (7.5%) p=.522 No 23 (43.4%) 23 (43.4%) History of mucositis Rarely 8 (15.1%) 10 (18.9%) p=0.424 Occasionally 18 (34%) 17 (32.1%) Artificial Dentures Absent 23 (43.4%) 23 (43.4%) p=.522 Present 3 (5.7%) 4 (7.5%) Oral hygiene Brushing < once a day 1 (1.9%) 1 (1.9%) p=0.229 Brushing Once a day 20 (37.7%) 15(28.3%) Brushing Twice a day 5 (9.4%) 11 (20.8%) Compliance to standard care Irregular 23 (43.4%) 24(45.3%) p=0.647 Strict 3 (5.7%) 3 (5.7%) N=53 (N=53) Figure 1 shows the incidence of 5-FUFA-Induced Mucositis in 26 patients of control group. When assessed by researcher using WHO oral toxicity scale, oral-mucositis was found in 9(30%) patients at week 1, 11(42.3%) patients at week 2 and 6(23.1%) patients at week 3, among combined 5-FUFA regime. Thus it can be interpreted that chemotherapy induced mucositis is very high among patient.

263 International Journal of Nursing Education. January-March 2015, Vol. 7, No Similarly significant reduction (p= 0.004*) in incidence of oral-mucositis was noted in experimental group when reported by patients during three weeks of study period using Patient-judged Mucositis Grading (Figure 3). Figure 2 shows the comparative incidence of 5- FUFA-induced oral-mucositis in 53 patients of control and experimental group as assessed by researcher using WHO oral toxicity scale and it was found that incidence of oral mucositis significantly low in experimental group at week 1 (p=0.001*), week 2 (p=0.014*), and week 3 (p=0.050*) as compare to control group. So it can be interpreted that intervention of oral cooling was found effective in preventing 5-FUFAinduced oral-mucositis. Fig. 2. Comparative incidence of 5-FUFA-induced oral-mucositis in control and experimental group as assessed by WHO oraltoxicity scale When severity of oral mucositis was compared, oral cooling seemed to reduce the severity of 5-FU-induced mucositis. As descriptive statistics shows, only mild mucositis was reported in experimental group whereas moderate and severe mucositis were reported in control group (Table 3). So there was an apparent reduction in severity of oral mucositis, though it could not be proved statistically in paucity of observation and inferential statistics were not applied. Table 3: Comparative severity of 5-FU-induced mucositis in control and experimental groups Mucositis Severity of mucositis Severity of mucositis assessed by Oral Toxicity scale assessed by patient judged mucositis grading WEEK I WEEK II WEEK III Over 3 weeks duration C (n= 26) E (n=27) C (n= 26) E (n=27) C (n= 26) E (n=27) C (n= 26) E (n=27) None Mild (35.71%) 4 (100 %) Moderate (35.71%) 0 Severe (28.57%) 0 N=53

264 256 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Moreover in experimental group, significant delay in mean onset of oral-mucositis was noted as compared to control group. Similarly, mean duration of mucositis was significantly less in experimental group in comparison to control group. (Table 4). Table 4: Comparison of patient-judged mucositis characteristics in control & experimental group N=25 Mucositis criteria Control group Experimental p-value Onset (No. of Days) Range 2-13 th day 9-18 th day p=0.02* Mean ± SD 6.9± ±4.03 Mucositis resolved(no. of days) Range 8-21 th days th Mean±SD 17.3± ±2.7 p=0.881 Duration (No. of Days) Range 4-18 days 0-8 days p=0.014* Mean±SD 10.7± ± 2.0 pd 0.05* Oral- cooling was accepted and tolerated well by all the patients (Table 5). Intervention of oral-cooling was applied total eighty eight times to the twenty seven patients of experimental group and patients readiness and cooperation was noted at all 88 times of intervention. Intervention need note to stop any time and completed successfully by patients every time without any complaint. Table 5: Acceptability and tolerance of patients for Oral-cooling Observation=88 Acceptability and tolerance criteria Acceptability N (%) Readiness 88 (100%) Co-operation 88 (100%) Completion 88 (100%) Complaints 0 (0%) Positive comments 44(50%) Interested for future participation 88(100%) Suggestions given 5 (5.7%) DISCUSSION In the present study, for weekly 5-FUFA regimen, incidence of mucositis was found to be 45.45%, 54.55%, and 36.36% at week one, two and three respectively. This finding is consistent with Baydar 8 who found 38.9% incidence of mucositis in patients receiving 5- FUFA combination. In present study, for Daily 5-FUFA regimen, incidence of mucositis was found to be 26.67%, 33.33% and 13.33% at week one, two and three respectively, whereas Jensen 9 found incidence of mucositis to be 17% in adjuvant bolus 5-FUFA. Present study has found that in daily 5-FUFA regimen, 9.09 % % patients suffered from severe mucositis along 3 weeks period whereas in weekly 5- FUFA regimen, none of the patients developed severe mucositis. Wang 10 also found 8.5% incidence of severe mucositis in daily 5-FUFA and none of patients with severe mucositis was found in weekly 5-FUFA. Present study reports that the incidence of chemotherapy-induced mucositis significantly reduced in patients undergoing oral cooling during 5- FUFA. This is consistence with previous studies where oral cooling effectively reduced the incidence of 5-FUinduced mucositis. 8,11 This might be related to the local vaso-constrictive effect of oral cooling during the peak serum level of 5-FUFA.This effect support the hypothesis proposed by Mahood 7 who reported that oral cooling during short half life of daily 5-FU administration significantly prevented occurrence of patient and physician-judged mucositis. Similarly in the present study, patient-judged mucositis was also found to be significantly reduced

265 International Journal of Nursing Education. January-March 2015, Vol. 7, No in patients receiving oral cooling during 5-FU administration. Present study reported decreased duration and delayed onset of mucositis in oral cooling group. Decreased duration of chemotherapy-induced mucositis with oral cooling was also seen in a study conducted by Dose. 12 In the present study oral cooling appeared to be effective in reducing severity of 5-FUFA- induced mucositis in terms of descriptive statistics, but in paucity of observations conclusions could not be drawn. This is inconsistence with the previous studies that have reported the effectiveness of oral-cooling in decreasing the severity of chemotherapy-induced mucositis. 11,12 This needs to be tested further with more number of subjects in particular drug category to draw the conclusions. In the present study, oral cooling using ice-rolls was found 100% acceptable and tolerable to the patients. Previous studies also supported the oral-cooling as an acceptable and effective preventive option for chemotherapy-induced mucositis. 7,8,11,12 In the present study, oral cooling significantly prevented the mucositis irrespective of compliance to mouth washes prescribed as part of standard care. Further compliance to oral cooling was better as compared to standard care, possibly because oral cooling involved direct observation and required only one point intervention (during chemotherapy) whereas standard care required more frequent interventions by patients. Therefore the practice of prescribing commercial mouth washes needs to be tested in terms of its benefit over oral-cooling intervention. CONCLUSION Oral cooling significantly reduced the incidence of 5-FUFA-induced mucositis and resulted in apparent reduction of severity of 5-FU-induced mucositis. Oral cooling significantly decreased the onset and duration of chemotherapy induced mucositis. Oral cooling was found to be an acceptable, readily available, and safe procedure under continuous monitoring and moreover it did not cause any significant increase in chemotherapy related other side-effects. Implications and recommendations Findings of study have clinical implication in identification of high-risk patients for chemotherapyinduced mucositis (i.e. Those getting 5-FU) and providing oral cooling for the prevention of chemotherapy-induced mucositis. Study emphasis the need to develop the oral-cooling protocols and incorporate those in formal training programs of nursing education. In-service education programs also need to be conducted to make oncology nurses aware about oral cooling and chemotherapy-induced mucositis. Nurses should be given training and certification for Assessment of oral mucositis using various Oral Mucositis Assessment tools. Educational material on assessment and prevention strategies of chemotherapy-induced mucositis should be prepared and displayed for patients, their family members and health personnel. Study recommends several important directions for future studies. Future trials can be done with large sample size in each category of 5-FU (daily and weekly 5-FU). Patients preference may differ for various forms of oral-cooling, so other forms of oral-cooling (flavored, chilled fluid gargle, portable ice-trays) can be tested for their effectiveness. Portable Ice-containers may prove a solution to the patients concern about the time required for completion of intervention. Oral cooling can be tested for its mucositis preventive effect in wide range of cytotoxic drugs. Effectiveness of oral cooling can be tested with and without mouth washes that are generally prescribed as a part of standard care. Limitations Despite the conscious efforts study had some limitations such as insufficient sample size to draw the conclusion about hypotheses regarding severity of mucositis. Sample was also considered small for further subgroup analysis. Conflicts of Interest: None Financial Support: By Self Acknowledgement: None REFERENCES 1. Jacques Ferlay, Hai-Rim Shin1, Freddie Bray1, David Forman1, Colin Mathers and Donald Maxwell Parkin, Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008, Int. J. Cancer 2010;127, (2010) VC 2010 UICC 2. Woztaszek C, Management of chemotherapyinduced stomatitis, Clinical Journal of Oncology Nursing 2000; 4:

266 258 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 3. Volpato LE, Silva TC, Oliveira TM, Sakai VT, Machado MA. Radiation therapy and chemotherapy-induced oral mucositis. Rev Bras Otorrinolaringol (Engl Ed) Jul- Aug;73(4): Poon MA, O Connell MJ, Moertel CG, et al: Biochemical modulation of fluorouracil: Evidence of significant improvement of survival and quality of life in patients with advanced colorectal carcinoma. J Clin Oncol 1989;7: Herrstedt J, prevention & management of patient with cancer. International journal of antimicrobial agents. 2000; 16: World Health Organization. Handbook for reporting results of cancer treatment. Geneva, Switzerland: World Health Organization; 1979: Mahood DJ, Dose AM, Loprinzi CL, Veeder MH, Athmann LM, Therneau TM, Sorensen JM, Gainey DK, Mailliard JA, Gusa NL, et al. Inhibition of fluorouracil-induced stomatitis by oral cryotherapy. : J Clin Oncol 1991;9(3): Baydar M, Dikilitas M, Sevinc A, Aydogdu I. Prevention of oral mucositis due to 5-fluorouracil treatment with oral cryotherapy. J Natl Med Assoc 2005;97(8): Jensen SA, Vilmar A, Sørensen JB. Adjuvant chemotherapy in elderly patients (>or=75 yr) completely resected for colon cancer stage III compared to younger patients: toxicity and prognosis.med Oncol. 2006;23(4): Wang WS et al. Randomized trial comparing weekly bolus 5-fluorouracil plus leucovorin versus monthly 5-day 5-fluorouracil plus leucovorin in metastatic colorectal cancer. Hepatogastroenterology. 2000;47(36): Mori T, Yamazaki R, Aisa Y, Nakazato T, Kudo M, Yashima T, Kondo S, Ikeda Y, Okamoto S. Brief oral cryotherapy for the prevention of highdose melphalan-induced stomatitis in allogeneic hematopoietic stem cell transplant recipients. Support Care Cancer Apr;14(4): Dose M, Chemo- related stomatitis on ice. American Journal of Nursing 1992; 92: 14.

267 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Quantitative Intervention and Evaluative Study on Hiv/ Aids Awreness among Adolescent School Children Girija M Principal, Santhy College of Nursing, Calicut, Kerala ABSTRACT The study summarized here is an intervention and evaluative quantitative research on "Effectiveness of the planned teaching program [STP & SIM] in prevention of Risk taking behavior on HIV/AIDS and to evaluate the best suitable method of intervention program among adolescent in selected higher secondary school. The population of the study was the adolescent those who are year's age. Convenient quota sampling technique was used to select 400 samples for the experimental group and 400 samples for the control group. The quantitative research approach was adopted to conduct this study based on pretest and posttest designing. Data collection tools used wear self instructional module, structured teaching program (SIM&STP) and the questionnaire to assess the knowledge, attitude and the knowledge on practice on awareness of HIV/AIDS and the risk taking behavior among the risky adolescent group. Data were analyzed by using descriptive and inferential statistics. The post test experimental group findings shows that statistically significant (p<0.005) increased in knowledge, attitude, and the knowledge on practice on awareness of HIV/AIDS and the risk taking behavior among the risky adolescent group. The investigators study proved, like Global health org, (2009),the most appropriate specific selected group intervention was the Structured teaching program [STP].The STP was better than SIM by the level of significant difference of Pre test and Post test on each method. It was confirmed by t = 60.3p = level of significance. Keywords: STP, SIM,HIV, AIDS, Awarenes, Adolescent INTRODUCTION Many adolescent engage in sexual intercourse with multiple partners without using condoms. Thus they engage in sexual behaviors place them at risk of sexually experienced people 3. Adolescent especially among 15 to 19 years have some of the highest reported rates of STD. According to HIV/AIDS estimation (2007), [UNAIDS/WHO] revealed that people living with HIV/AIDS: 33.0 million. Adults: 30.8 million. Women: 15.5 million. Children: 2.0 million. Newly infected cases: 2.7 million. Children newly infected: 0.37 million. AIDS death: 2.0 million. Child AIDS death: 0.27 million. Young group (under 25 years) account for half of all new HIV worldwide. The number of people living with HIV has risen from 8 million in 1990 to 33 million today, and still growing around 67% living with HIV are in sub Saharan Africa 15 It is important to assess the knowledge, attitude and the knowledge on practice will help the future building nations of adolescent school children regarding HIV / AIDS. OBJECTIVES 1. To assess the knowledge, attitude, and the knowledge on practice among the adolescents on risk taking behavior of HIV/AIDS. 2. To develop and administer an effective educational module SIM for preparing need based curriculum and education methods on sexually risk taking behaviors in prevention of HIV/AIDS among adolescent. 3. To develop and administer an effective educational module STP for preparing need based curriculum and education methods on sexually risk taking

268 260 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 behaviors in prevention of HIV/AIDS among adolescent. 4. To evaluate the effectiveness of the intervention of Planned Teaching (STP&SIM) programs. 5. To determine the statistical correlationship between the knowledge, attitude, and the knowledge on practice among the adolescent on risk taking behavior of HIV/AIDS with the selected demographic variables. 6. To compare and develop the most effective method of intervention for the selected age group of the participants. H 1. H 2. H 3. H 4. HYPOTHESES The mean post test knowledge, attitude, and the knowledge on practice score related to HIV / AIDS among the adolescent will be significantly higher than the mean pretest score at 0.05 level of significant after the intervention program (SIM and STP). There is a significant association between knowledge, attitude, and the knowledge on practice of the adolescents regarding HIV / AIDS and the sexually risk taking behavior. There is a significant relationship between, knowledge, attitude and knowledge on practice of the adolescents risk taking behavior and their selected demographic variables. The Self Instructional Module teaching method because of privacy significantly increases the level of knowledge, attitude and knowledge on practice related to HIV / AIDS among the adolescent school children, than the Structured H 5. Teaching Program. An effective need based curriculum and intervention program on avoiding sexually risk taking behavior of the adolescent will significantly reduce the infection and the spread of HIV/AIDS among the most vulnerable adolescent population. CONCEPTUAL FRAME WORK The investigator adopted W.J.KENNEY S open systems model. The input, throughput, output and the feed back. A) Input: -Refers for the survival of all system, varying types and amount of matters, energy and information enters in to the systems through its boundary. B) Throughput: - Refers to the processing of matter, energy and information; C) Output:-Refers after processing input,the system return output(matter,energy and information) to the environment in an altered state. D) Feed back: - Refers to the environmental responses to the systems output. The system uses adjustment, correction and accommodation to the interaction with the environment. MATERIAL AND METHOD Quantitative Pre test and Post test design was framed to be more suitable to bring appropriate post test score, which ultimately paves way for the foundation of the curriculum planning for the adolescent school children by the school health nurses as well as other health approachers of any kind. Sampling Technique And Sample Size [800] The target population of this study was years age group from Selected higher secondary school. Convenient & Quota Sampling Experimental Group Control Group Total Sample Size 800 Sample Group (I)- 400 Sample Group(II) ( 200 from Urban 200 from Sub urban ) (200 from urban 200 from Sub Urban ) Variables (Maximum INTERVENTION GROUP Homogeneity maintained ) 200 (Age yrs) B& taken but not manipulated STP SIM STP SIM

269 International Journal of Nursing Education. January-March 2015, Vol. 7, No RESEARCH TOOL Part I - Demographic characteristics of adolescent school children Questionnaire. Part II - Knowledge aspect of the Questionnaire. Part III - Attitude Questionnaire consists of Likert type of 5-point items Scale (Strongly Agree, Agree, uncertain, Disagree, & Strongly Disagree). Part IV - Knowledge on Practice aspect of the questionnaire. Part V - Intervention given were [a] Structured Teaching Program (STP) (i.e. Health education on adolescent Prevention of risk taking behavior on HIV /AIDS). [b] Self Instruction Module (SIM) (i.e. a learning package on Prevention of adolescent risk taking behavior on HIV/AIDS). SCORING PROCEDURE 1 mark for every correct answer 0 (zero) for every wrong answer. The resulting score represent as Adequate Knowledge %. Moderately adequate 51-70%, inadequate 0-50%. Validity TESTING OF THE TOOLS Content, construct and criteria of the tool were evaluated by the nine experts in the field based on which the tool was modified and refined. Reliability Knowledge part questionnaire determined by test retest method. The reliability was The reliability of the attitude Likert Scale was determined by the inter ratter method. The reliability was 0.8. DATA COLLECTION During the data collection period on the first day, the prepared questionnaire issued to all the 800 Participants those who met the inclusion criteria. 200 boys and 200 girls totally 400 participants in experimental group underwent planned teaching program (STP &SIM) and their post test was done with the administration of same questionnaire. The remaining 200 boys girls participants of control group pre test and the post test evaluation was done with out any kind of intervention as manipulation. Descriptive and inferential statistics used for analysis. MAJOR FINDINGS The investigator worked on the important areas and achieved the expected selected objectives. 1. Assessed the knowledge, attitude and the knowledge on practice among the adolescents on risk taking behavior of HIV/AIDS. 2. Developed and administered an effective module (SIM & STP) for preparing need based curriculum and education methods on sexually risk taking behaviors and prevention of HIV/AIDS among adolescents. 3. Evaluated the effectiveness of the intervention of Planned teaching (STP & SIM) program. 4. Determined the relationship between the knowledge, attitude and the knowledge on practice among the adolescents on risk taking behavior of HIV/AIDS with the selected demographic variables. 5. Selected the STP as the most effective method of intervention for the selected age group of the participants. The commonest adolescent sexual risk taking behavior includes sex for drugs, less protected sex, Homo sex, I.V. drug users, sex with high risk group and sharing needles 2. Table 1: Demographic Profile level of significance Age Group Sex Educational Status χ2=6.32 p=0.10 χ 2 =0.00 p=1.00 χ2=2.40 p=0.12 Type of school χ2=0.00 p= 1.00 Medium of teaching Place of school χ2=0.00, p=1.00 χ2= 0.00, p=1.00 Health education programe χ2=0.63, P= Table 2: Socio Economic Status level of significance Head of The Family Bread Winner Monthly Income χ2 =0.37 p=0.95. χ2 =0.58 p=0.97 χ2 =3.88p=0.27 TABLE 3: FAMILY BACKGROUND level of significance Residential Location House Order of sibling Number of sibling Type of family χ2 =0.99p=0.61 χ2 =0.66 p=0.41 χ2 =3.53 p=0.31 χ2=2.08 p=0.35 χ2=3.08 p=0.

270 262 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table- 4: Hiv-aids Particulars level of significance No. of death in the family Death Due To HIV Contact Opportunity χ2=0.40 p=0.82 χ2=0.47 p=0.79 χ2=3.53 p=0.31 APAC Services Available AIDS awareness centre available Z=0.73 P=0.46 Reachable distance Z=1.88 P= Association between demographic profile and the (SIM and STP) intervention Association between demographic profile and the post test level of the SIM and STP in the study group reveals that there was association at the level of significant p= The control group showed no significant difference. The demographic variables depicts no statistically significant difference between the study group and the control group. According to DeniseF, Polit, (2007),The Homogeneity of the participant unit was maintained to get the most accurate out come of the study. It was confirmed by using the Pearson chi square test at 0.05 levels. 1. Correlation between knowledge, attitude, and knowledge on practice a) Correlation scored between the post test knowledge and attitude positively in the study group compared to the control group. This was evidenced as r=0.56 p=0.01. b) Correlation between the post test knowledge on practice knowledge scored positively in the study group than in the control group as evidenced as r=0.54 p=0.01. pretest and the posttest knowledge score, (i.e.) t= P= level of significance with intervention in study group. Where as the un interventioned control group t = 1.68 p = 0.10 not significant. Thus the post test level of knowledge gained was higher in the study group than control group as evidence by χ2 = p = c) Correlation between the posttest attitude and practice knowledge scored positively in the study group compared to the control group as evidenced as r=0.51 p= Association between the demographic profile and the knowledge, attitude and knowledge on Practice a) Association between demographic profile and the post test level of knowledge in the study group at the level of significant p= The control group showed no significant differences. b) Association between demographic profile and the post test level of attitude in the study group at the level of significant p= The control group showed no significant differences. c) Association between demographic profile and the post test level of the practice knowledge in the study group at the level of significant p= The control group showed no significant differences. pre test and the post test attitude score, t = 90.42, p = level of significance in the study group. Where as the control group t = 1.37 p = 0.18 not significant. Thus the post test level of attitude changed positive considerably in the study group than the control group. It was evidenced as χ2 = p = level of significance.

271 International Journal of Nursing Education. January-March 2015, Vol. 7, No More evaluative study can be conducted on behavior of adolescent outside the schools will be valuable to bring effective curriculum in cutting transmission and prevention of HIV/AIDS among adolescents. Nursing Implications Sex and HIV education program should focus on, pre test and post test knowledge on practice score, t = , p = 0.001level of significance in the study group where as the control group t = 1.72 p=.11 not significant. Thus the post test level of knowledge on practice considerably increased in study group than control Group. It was evidenced as χ2 =350.9 p =0.001 level of significance. School age male students, specially should have adequately addressed about the risk of unprotected sex with male homo sex. Specific Education Program for female students about threat of unprotected hetero sex with I.V. drug users, and the exchange of sex for drugs. Conducting various Program addressing drug use and needle sharing. Wider coverage on Adolescent abstinence program to protect STD, and HIV/ AIDS. Nurses should focus on realizing that not all sex & AIDS education program designed for adolescents are effective. effectiveness of the two intervention program confirmed by t = 60.3 p = level of significance proved that structure teaching program [STP] study group students gained 9.7% (49.1% %) more knowledge on HIV/Sex education program than the Self instruction module [SIM]. So the investigator study says that structure teaching program [STP] was comfortable with privacy to discuss stigma related problems on sex behaviors compared to Self instruction module [SIM] RECOMMENDATIONS Promising Adolescent clinic program and comprehensive community wide adolescent campaigns be replicated, and evaluated periodically. Additional program that focus upon high risk youth should be implemented and evaluated periodically. More studies need to be conducted on common specific risky characters and use of condom by adolescent. Excellent carefully prepared curriculum based sex and HIV education program with identifiable characteristics delays the on set of intercourse (or) reduce frequency of intercourse (or) reduce number of sex partners (or) increase the use of condoms. Effective curricula will have significant positive behavior outcome. Curriculum should be designed with Behavioral goals, different teaching methods, and materials appropriate to age, sexual experience, and cultural group of the students. Adequate Curriculum duration sufficient enough to cover more materials/more concerns, and more quickly in small groups with emphasis on avoiding the sexually risk taking behavior. School health Nurses should focus on Variety of teaching methods to involve participation, and have them personalize the information. Carefully provide basic accurate information about the risk of unprotected sex and method of avoiding, like illegal body touch, signals, body languages and expressions. Include all activities that address social pressure on various sex behaviors by role play.

272 264 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Training and providing modeling, practice of communication negotiation and refusal skills. The Nurse educator must select teachers or peers who believes the importance of program be implemented to the training of individuals at risk. CONCLUSION Adolescent age group lot of physical and physiological change occurs. Being explorative in nature, they enter in to as well initiate unprotected sex. Ultimately they become victim of sexually transmitted diseases. The findings suggested that of Anand, Shiraishic, (2009), the combination intervention with appropriate age group, and content covered appropriate curriculum exposed group gained excellent benefit than the unexposed group. An expansion of prevention efforts is imperative to reduce HIV infection. The younger populations lack the power / means to protect them. According to Kaiser Family Foundation, (2007), educating about the disease and prevention methods will help to raise awareness of and reduce at-risk behavior, gender- based violence, stigma and discrimination. Studies have demonstrated that sex and HIV program do not significantly increase sexual activity as many people have feared but delays the onset of intercourse and reduce number of sexual partners and increase the condom use. Conflict of Interest: No conflict of interest in the manuscript. Source of funding-self. Ethical Clearance: Consent taken from The college board of ethics, The school authority, The participants and their parents. Acknowledgement: I would like to extend my heart felt gratitude to all the contributors to bring this manuscript successfully. REFERENCES 1. Centers for Disease Control. HIV instruction and selected HIV RISK behaviours among high school students_united states, MMWR 1992:41: Denise F Polit., Bernadette P Hungler. (2007).Nursing Research Principles and method. (7 th ed.). Lippin Cott. 3. Donna L Wong. (2001).Essential of Pediatric Nursing (6 th ed.). St Louis: Mosby Publishers 4. Park.(2009).AText Book of Preventive and Social Medicine.(18 th ed.). Indore:Bhanarsidoss Publications. 5. Philip A Pizzo.,Catherine M Wilfert.(2006). Pediatrics AIDS the challenge of HIV infection in infants, children, and Adolescents.(3 rd ed.). Williams and Wilkins, A Waverly Company. 6. UNAIDS 2009 AIDS Epidemic Update. Geneva: UNAIDS; WHO, UNAIDS, and UNICEF. Towards Universal Accesss UNAIDS, What Countries Need: Investments Need for 2010 targets, 2009.

273 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No A Descriptive Study to assess the Prevalence of Alcohol use in Selected Community Area of Punjab Satinder Paul Kaur 1, Kanwaljit Gill 2 MSN Registered Mental Health Nurse, Centre for Addiction and Mental Health, Toronto, Canada, 2 Principal and Professor, Shahid Kartar Singh Sarabha College of Nursing, Sarabha, Ludhiana, Punjab, India ABSTRACT Although various epidemiological studies have been conducted in specific regions of India, the findings could not be generalized for the entire population, considering the marked variations in ethnic and cultural beliefs across the nation.1 Aim: The aim of the present study was to ascertain the magnitude of problem of alcohol use and the levels of drinking among alcohol users in district Sangrur. Data: A population based cross-sectional survey was conducted using multistage probability sampling technique to collect data from 1000 males aged between 26-55years in five different regions of the district. Interview schedule of Alcohol Use Disorder Identification Test developed by WHO was used to assess alcohol use and levels of drinking. Results: An overall current prevalence of alcohol use 68.9% and rest 31.1% were current abstainers. Majority had hazardous drinking (19%) and harmful drinking level (18.8%), low risk drinking was exhibited by 16.2% and possible alcohol dependence detected in 14.9%. Conclusions: The study found a high prevalence of alcohol use in Sangrur district and emphasizes the need for more rigorous research in the area of alcohol use and drinking patterns across India. Keywords: Current Prevalence, Low Risk Drinking, Hazardous Drinking, Harmful Drinking, Alcohol use Disorder Identification Test(AUDIT), Multistage Probability Sampling INTRODUCTION Alcoholism is a broad term for problems with alcohol, and is generally used to mean compulsive and uncontrolled consumption of alcoholic beverages, usually to the detriment of the drinker s health, personal relationships, and social standing. People suffering from alcoholism are often called alcoholics. Worldwide consumption of alcohol 2 is equal to 6.2 litres of pure alcohol consumed per person aged 15 years or older, which translates into 13.5 grams of pure alcohol per day. In 2011, the per capita consumption of alcohol measured in India was about 2.6 Liters of pure alcohol in 2006 and has been increasing markedly since then 3. India is the dominant producer of alcohol in the South- East Asia region (65 per cent) and contributes to about 7% of the total alcohol beverage imports into the region. More than two thirds of the total beverage alcohol consumption within the region is in India. 4 Age of initiating consumption has declined from 30 to 19 years, 2.7 lakh people die due to use and abuse of alcohol every year, domestic Violence is on the increase Family abuse cases are registered every year, revenue due to alcohol sale is - Rs.25,000 crores in some states of India. About 80% of alcohol consumption is in form of hard liquor. 5 Alcoholism is a progressive fatal disease characterized by excessive and compulsive consumption of alcoholic beverages and physiological

274 266 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 and psychological dependence on alcohol. Some of the harm associated with alcohol use is caused by acute intoxication and some by regular consumption of alcohol over a long period. Alcohol consumption can have an impact not only on the incidence of diseases, injuries and other health conditions, but also on the course of disorders and their outcomes in individuals. A research in India related alcohol to malignant neoplasms of mouth and oropharynx, oesophageal, liver, breast cancer, Unipolar depressive, Epilepsy, Alcohol use: Dependence and harmful use, Diabetes mellitus, Ischaemic heart disease, Haemorrhagic stroke, Ischaemic stroke, Cirrhosis of the liver, Motor vehicle accidents, Drowning, Fall, Poisoning, Selfinflicted, Homicide 6. In 2012, about 3.3 million deaths or 5.9% of all global deaths, 139 million DALYs (disability-adjusted life years) or 5.1% of the global burden of disease and injury, were attributable to alcohol consumption 7. The prevalence of alcohol use disorders was estimated at 1.7 percent globally and overall there is a causal relationship between alcohol consumption and more than 60 types of disease and injury. 8 Data revealed that maximum number of alcohol-related deaths in 2012 occurred in Maharashtra (1514) and Punjab (273) was ranked fifth. 9 Alcoholics scored high on state and trait anxiety, depression, mania scale, paranoia scale, schizophrenia scale, psychopathic deviance, neuroticism, extroversion, low esteem and the Presumptive Stressful Life Events scale. 10 Alcohol use is a major cause for family disruption and marital disharmony in Indian society. Several psychosocial problems, cognitive disabilities, behavioral problems and scholastic disadvantages have been observed among children of alcoholics. 11 NEED OF THE STUDY India is a diverse nation with cultural variations among ethnic, religious and linguistic groups and there are major differences between the urban and rural areas. In the total spectrum of alcohol consumption in the country, only about 50% is documented and the rest is undocumented. 11 One cannot accurately characterize the drinking patterns of all Indian ethnic and cultural groups based on the findings from just one of these groups. 12 As, Indian Government has confirmed its commitment to develop a new national Alcohol Policy, more and in depth research is needed related to actual magnitude of alcohol problem and proved effective interventions to guide a rational, scientific and evidence based National alcohol policy. Population based alcohol surveys are an important method of collecting alcohol consumption data which are also specific to socio-demographic groups within populations. They can be used to gather data on drinking patterns, quantity intake and also document acute adverse consequences. 13 With screening and simple advice, people who are not dependent on alcohol may stop or reduce their alcohol consumption with appropriate assistance. Information about the amount and frequency of alcohol consumption may alert clinicians to the need to advise patients whose alcohol consumption might adversely affect their use of medications and their treatment. It provides an opportunity to educate patients about low-risk consumption and the risks of excessive alcohol use. 14 Working and interacting with patients and more importantly their families in community settings, the researcher realized the need to screen out the alcohol users in general population. STATEMENT OF PROBLEM A descriptive study to assess the prevalence of alcohol use in selected community areas of Punjab. OBJECTIVES 1. To assess the prevalence of current alcohol use in a selected community. 2. To ascertain the level of drinking in alcohol users. 3. To find out relationship of sociodemographic variables with alcohol use. MATERIAL AND METHOD This was a cross sectional exploratory study aimed to assess the current prevalence of alcohol use in general population. The conceptual framework of the present study is based on Sister Callista Roy s adaptation model. 15 A survey was carried out to collect data from different regions of the district i.e. Northern, Southern, Eastern, Western and Central. Sangrur

275 International Journal of Nursing Education. January-March 2015, Vol. 7, No district has a population of 16,54,408. The data collection was carried out from September - October 2011 using standardized Alcohol Use Disorder Identification Test (AUDIT) developed by World Health Organisation. Sampling: Multi-stage probability sampling design was used with sample size With consideration of geographic dispersion, five independent sampling regions were drawn using simple random sampling from five regions of Sangrur Distt. Five blocks were selected to include rural area and urban area using simple random sampling out of five regions. These were stratified with probability proportional to the size and was considered as Primary sampling units. Number of villages in each block and wards in each municipality were listed with their population. Secondary sampling units ie villages (rural) and wards (urban) were selected by simple random sampling. Every other household was selected by systematic random sampling and basic sampling units i.e. individuals were selected out of selected households. In households with more than one alcohol user, one subject was selected with simple random sampling by lottery method. Inclusion criteria 1) Males 2) Aged between 26 to 55 years 3) Those willing to participate 4) Individuals staying for minimum six months in the district 5) Subjects speaking Punjabi, Hindi and English. Exclusion criteria 1) Females 2) Blind, deaf and cognitive impairments 3) Mentally retarded 4) Persons admitted in hospitals or other health care settings Assessment: Those willing to participate were explained the purpose of the study and verbal consent was obtained. The written information sheet was given before interviewing the subjects and included explanation that as alcohol can interact with many medicines, so it is important to know their alcohol use pattern in detail and the size of standard drink was explained. The subjects were asked questions from AUDIT to screen the alcohol use. In case of locked houses, maximum three visits were made to contact them and after that immediately neighboring house was taken in numerical order. Sociodemographic variables: Information about sociodemographic variables of subjects was collected using a structured interview schedule. It includes age, education, family income, occupation, marital status, religion, type of family, type of residence, family history of alcoholism and family size.(table I) Alcohol use prevalence and patterns of drinking: Interview schedule of Alcohol Use Disorder Identification Test (AUDIT) was used. It was translated into Punjabi with back translation strategy by two independent language experts. Any individual with history of alcohol use in the 12 months prior to the date of survey was considered as an alcohol user (Table II) for the purpose of this study 16. Drinking patterns were classified as low risk, hazardous, harmful drinking and possible alcohol dependence based on data collected by direct interviews with the selected respondents (Table III). Table I: Sample Characteristics N = 1000 Characteristic Frequency Percentage Age (in Years) (i) (ii) (iii) Education (i) Illetrate (ii) Below matric (iii) Matric & above (iv) Graduate & above Family Income (Monthly in Rs.) (i) Below 10,000/ (ii) 10,001/- to 20,000/ (iii) 20,001/- to 30,000/ (iv) 30,001/- and above 90 9 Occupation (i) Unemployed (ii) Skilled workers (iii) Laborer/ Agriculture (iv) Business

276 268 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table I: Sample Characteristics (Contd.) N = 1000 Characteristic Frequency Percentage Marital status (i) Unmarried 80 8 (ii) Married (iii) Divorced/ separated (iv) Widower Religion (i) Hindu (ii) Sikh (iii) Muslim (iv) Others Type of Family (i) Nuclear (ii) Joint Type of residence (i) Urban (ii) Rural Family history of alcoholism (i) Yes (ii) No Family size (i) 3 or less (ii) (iii) More than Table II: Prevalence Of Alcohol Use N = 1000 Prevalence N Percentage Current Alcohol Users Current Abstainers Maximum Score- 40 Minimum score-0 Table III: Categorization of Alcohol users as Per Level of Drinking N = 1000 Level of Alcohol Use Audit Score N Percentage Current Abstinence Low Risk Drinking Hazardous Drinking Harmful Drinking Possible Alcohol Dependence Maximum Score- 40 Minimum score-0 AUDIT Alcohol Use Disorder identification Test FINDINGS An overall current prevalence of alcohol use 68.9% and rest 31.1% were not using alcohol. Majority (19%) had hazardous drinking level, almost equal in harmful drinking level (18.8%), low risk drinking exhibited by 16.2% and possible alcohol dependence detected in14.9% and remaining 31.1% had no alcohol use. Majority of the alcohol users belonged to age group 36-45years (51%), had education level below matric(47.9%) and had family income between Rs. 10,001-20,000/- (41.3%). Most of them belonged to labour/agriculture occupation (63.1%), were married (83.8%), belonged to Sikh religion (76.2%), 67.4% out of total alcohol users lived in nuclear family, 53.8% were from rural area, 79.2% had positive family history for alcohol use, 46.8% lived in a family with 4-6 members. Alcohol use was shown to be significantly related to education level at statistical level p<0.05 with highest mean alcohol use score (12.05) among graduate and above subjects. Subjects living in joint family also had higher mean score (10.78) as compared to those in nuclear family (10.04) and the relationship between alcohol use and type of family was statistically significant at p<0.001 level. DISCUSSION The prevalence of alcohol use in Sangrur district is higher than the findings of the study conducted by John et al 17 in 2009 in rural population in Southern India and study by Prakash et al 18 in Western India. A study conducted by Negi et al 19 found the prevalence rate of alcohol consumption 42.2% in rural and 55.5% in urban area of Dehradun (North India). The possible explanations of variations in the prevalence rates of alcohol use in different parts of the country could be attributed to cultural and social patterns of drinking in various communities. 20 The results of other studies related to levels and pattern of drinking show similar findings. 21 Nagender et al 22 found a prevalence of hazardous drinking and alcohol dependence in the study population to be 2.8% and 0.6% respectively. Higher mean alcohol use scores were observed in education level of graduate & above which was quite surprising and in subjects living in joint families which is contrary to the results of certain other studies. 18,23 One reason for the unexpected

277 International Journal of Nursing Education. January-March 2015, Vol. 7, No findings about high alcohol use in more educated group could be underreporting and underestimation of drinking amount in less educated subjects. Limitations: The research was limited in the estimation of prevalence of alcohol use as it did not include persons admitted in de-addiction centers or hospitals for alcohol related reasons. Since interview version of the tools were used, the social desirability bias cannot be excluded. Investigator had to exclude females because of their anticipated low representation in sample considering alcohol being a taboo for women in the area. The age group was limited to years, since the identification tools and effective interventions for alcohol use in younger and older age groups vary significantly from each other. 24 Nursing Implications: 1) The nurses working at all levels of health care will be able to inculcate the alcohol screening in their initial client assessment. 2) The proven usefulness of alcohol screening will lay foundation for need based health programs and the nurses will be able to advocate for comprehensive evidence based national alcohol policy. 3) The nurse educators should be vigilant about the alcohol abuse issues among students and emphasize the importance of alcohol use assessment. CONCLUSION The study found a high prevalence of alcohol use in Sangrur district and emphasizes the need for more rigorous research in the area of alcohol use and drinking patterns across India. Conflict of Interest: All authors declare that they have no conflict of interest. Source of Funding: Self Ethical Considerations: Ethical clearance was obtained from research ethical committee. Formal permission was obtained from Civil Surgeon and local leaders of Sangrur district for date collection. Verbal consent of the participants was obtained. Acknowledgement: The author wants to thank Dr. Sony for entry and analysis of data, Civil Surgeon and local leaders for providing permission for data collection. REFERENCES 1. Bennett LA, Campillo C, Chandrashekar CR, Gureje O. Alcoholic beverage consumption in India, Mexico and Nigeria: A cross-cultural comparison. Alcohol Health Res World. 1998;22: World Health Organization. Global status report on alcohol and health. Geneva global_alcohol_report/en/, accessed 30 Sep World Health Organization. Global status report on alcohol and health. Geneva global_alcohol_report/en/, accessed 30 Sep Indian Alcohol Policy Alliance and Ministry of Health and Family Welfare. Indian Alcohol Atlas. New Delhi IAS/What-we-do/Publication-archive/The- Globe/Issue /Indian-Alcohol-Atlas.aspx, accessed on 25 Aug Indian Alcohol Policy Alliance. India and Alcohol. New Delhi apapaonline.org/apapanetwork/meeting_ Reports/files/GAPA_Auckland_Dec05/ IAPA_Dr_Arulrhaj.pdf, accessed on 26 Aug, Das SK, Balakrishnan V, Vasudevan D. Alcohol: Its health and social impact in India. The National Medical Journal of India. 2006; 19: World Health Organization. Global status report on alcohol and health. Geneva global_alcohol_report/en/, accessed 30 Sep World Health Organization. The World Health Report Reducing Risks, Promoting Healthy Life. Geneva, Alcohol-related deaths on the rise!. Zee Research Group. New Delhi. September 11, Chaudhury S, Das SK, Ukil B. Psychological assessment of alcoholism in males. Indian J Psychiatry Apr-Jun; 48(2): Gururaj G, Pratima M, Girish N & Benegal V. Alcohol related harm: Implications for public health and policy in India, Publication No. 73, NIMHANS, India Edayaranmula J. Alcohol Policy And Challenges In India indiaalcoholpolicy/3, accessed on Aug 20, 2014.

278 270 International Journal of Nursing Education. January-March 2015, Vol. 7, No Benegal V, Velayudhan, Jain S. The social cost of alcoholism (Karnataka). NIMHANS Journal 2000;18: Babor TH. John C. Higgins-Biddle. John B. Saunders. Maristela G. Monteiro. The Alcohol Use Disorders Identification Test Guidelines for Use in Primary Care. Second edition. WHO/ MSD/MSB/01.6a. World Health Organization. Department of Mental Health and Substance Dependence John A, Barman A, Bal D, Chandy G, Samuel J, Thokchom M, Joy N, Vijaykumar P, Thapa S, Singh V, Raghava V, Seshadri T, Jacob KS, Balraj V. Hazardous alcohol use in rural southern India:nature, prevalence and risk factors. Natl Med J India May-Jun;22(3): Department of mental health and substance dependence, Non communicable diseases and mental health cluster, World Health Organization. Geneva. International guidelines for monitoring alcohol consumption and related harm John A, Barman A, Bal D, Chandy G, Samuel J, Thokchom M, Joy N, Vijaykumar P, Thapa S, Singh V, Raghava V, Seshadri T, Jacob KS, Balraj V. Hazardous alcohol use in rural southern India: nature, prevalence and risk factors. Natl Med J India May-Jun;22(3): Gupta PC, Saxena S, Pednekar MS and Maulik PK. Alcohol consumption among middle-aged and elderly men:a community study from western India. Alcohol & Alcoholism. 2003; 38 (4): Negi KS, Kandpal SD & Rawat CMS. Prevalence of alcoholism among the males in a rural and urban area of district Dehradun. Indian J. Prev. Soc. Med. 2003;(34): Subir KD, Balakrishnan V, d. M. Vasudevan. Alcohol: Its health and social impact in India. Natl Med J India. 2006;19: Chagas Silva M, Gaunekar G, Patel V, Kukalekar DS, Fernandes J. The prevalence and correlates of hazardous drinking in industrial workers:a study from Goa, India. Alcohol Alcohol Jan- Feb;38(1): Nagendra PL, Mark J, Adrianna M, Bayard R and Jim M. Prevalence and Patterns of Hazardous and Harmful Alcohol Consumption Assessed Using the AUDIT among Bhutanese Refugees in Nepal. Alcohol and Alcoholism. 2013; 48 (3): Sundaram KR, Mohan D, Advani GB, Sharma HK, Bajaj JS. Alcohol abuse in a rural community in India. Part I: Epidemiological study. Drug Alcohol Dependence 1984;14: Patton R, Deluca P, Kaner E, Newbury D, Phillips T and Drummond C. Alcohol Screening and Brief Intervention for Adolescents: The How, What and Where of Reducing Alcohol Consumption and Related Harm Among Young People. Alcohol and Alcoholism. 2013; 0 (0): 1 6. doi: /alcalc/agt165.

279 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Factors Affecting the Utilization of University Health Centre by Undergraduates in Ogbomoso, South-West, Nigeria Florence O Adeyemo Dept. of Nursing, College of Health Sciences, Ladoke Akintola University of Technology, Ogbomoso ABSTRACT This study assessed the factors affecting the utilization of university health centre by undergraduates in Ogbomoso. The objective was to find out the students profile in the study area and to determine the three predictor variables (attitude of health workers, time spent and services rendered) on the dependent variable (utilization of university health centre). A survey design was adopted and the target population was undergraduates in various faculties. Simple random sampling technique was used to select six hundred and fifty students. The instrument for collecting the data required for this study was a self-structured questionnaire. The questionnaire was divided into two sections namely: demographic data and the factors affecting the utilization of university health centre (attitude of health workers, time spent and services rendered). Likert rating scale was used. Validity test: The questionnaire was given to colleagues for peer review. Reliability of the research instrument was done through test-retest method which gave 0.84 reliability co-efficient. The statistics used for data analysis include frequency count and simple percentage, percentages, pictorial description and Pearson product moment correlation analysis. Result: The table shows r-value is: i) Positive but small value for the relationship between attitude of health workers and utilization ii) Positive and moderate value for relationship between time spent in the health centre and utilization iii) Positive and moderate value for relationship between services rendered and health service utilization. In conclusion, this study suggests the need to identify and address the barriers of effective utilization of healthcare services in LAUTECH health centre. This study recommends that the University should introduce National Health Insurance Scheme (NHIS) for effective utilization of healthcare services in LAUTECH health centre. Keywords: Factors, Utilization, University Health Centre, Undergraduates INTRODUCTION People visit health care facilities for various reasons which includes; for diagnosis, curing illnesses, preventing health problems, obtaining health information and increasing quality of life. Health care facilities are places that provide healthcare services which include hospitals, clinics, out-patient care centers and specialized care centre. 1 Sound health is very vital for living a productive life; It is believed that improvement in health will lead to improved life expectancy. 2 Majority of the population of a university

280 272 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 are students, who might fall ill during their course of studies may need medical/surgical treatment in the university health centre. An important determinant of students morbidity and mortality is the access to and use of quality healthcare services. Access to quality health services is crucial to improved rate of students mortality and morbidity. Utilization of health services is related to the availability of drugs, attitude of health care providers, equipment and accessibility. Oyekale & Eluwa stated that the World Health Assembly mandated sound health for all people in the year 2000 because it is necessary for socially and productive life. 2 They further explained that there is persistent low quality and inadequacy of health services in many public health facilities in Nigeria. There are various studies that identified many reasons for utilization of various health care facilities such as perceived health status or health related quality of life, socio-economic status, level of education, accessing general practitioner or specialists services. 3 López-Cevallos opined that factors affecting the utilization of health facilities in Ecuador are political instability, inavailability of physicians and infant mortality. 4 Awoyemi, Obayelu & Opaluwa also identified that level of education, health seeking behaviour, expected competency of the provider, income of the individual, long distance and time spent as factors affecting the utilization of health facilities in rural areas of Kogi state. 5 The university health centre was built to take care of the health of the students as well as the health of all members of staff. This health care has undergone tremendous change over a long period especially during each vice-chancellor s regime. The university health centre provides emergency care, treatment of communicable diseases and others, medical examination, radiotherapy, physiotherapy, laboratory investigation, pharmacy, etc. despite functional limitations. The writer discovered during interview with students, that the students patronized the health centre mainly for medical examination as demanded by the university and emergencies. Factors that could affect the utilization of any health facilities includes the availability of prescribed drugs, general satisfaction of services offered and the providers behaviour. Other factors are availability, quality and cost of services as well as socio-economic structure and personal characteristics of the user 2. All these factors will improve quality of services which will increase the likelihood of the health facility being used. A survey on the utilization of primary health care facilities: lessons from a rural community in southwest Nigeria revealed that among those who were ill in the preceding six months, only Forty-four percent of respondents visited a PHC (primary health care) facility to the for treatment, while others relied on self medication/selftreatment. 6 The need to identify and address barriers to health care utilization was identified in a study on Low utilization of health care services following screening for hypertension in Dar es Salaam (Tanzania). 7 Similarly, this study examines the factors affecting the utilization of the university health centre by undergraduates. It will also help decision makers, health care planners and implementers to provide health services to students. It will also contribute to the available literature on the utilization of health facilities. 8 OBJECTIVES 1. To describe students profile in the study area. 2. To determine the three predictor variables (attitude of health workers, time spent and services rendered) on the dependent variable (utilization of university health center) Research Question 1. What is the profile of respondents in the study area? Statement of Hypothesis 1. There is no significant relationship between the three predictor variables (attitude of health workers, time spent and services rendered) on the dependent variable (utilization of university health center) MATERIALS AND METHOD Research Setting: Ladoke Akintola University of Technology (LAUTECH), Ogbomoso, Oyo State, Nigeria. Study Design: Descriptive survey. It was conducted in February Target population: were undergraduates from various faculties. LAUTECH comprises of the following faculties: Faculty of Basic medical sciences, faculty of Clinical sciences, faculty of Engineering and Technology, faculty of Environmental sciences, faculty of management sciences and faculty of pure & applied sciences. Sampling Technique: Simple random sampling technique was used to select six hundred and fifty students.

281 International Journal of Nursing Education. January-March 2015, Vol. 7, No Instrument: The instrument for collecting the data required for this study is a self-structured questionnaire. The content of the questionnaire are divided into two sections namely: demographic profile and the three predictor variables (attitude of health workers, time spent and services rendered) on the dependent variable utilization of university health center). Likert rating scale was used. The statistics used for data analysis include frequency count and simple percentage, percentages, pictorial description and Pearson product moment correlation analysis. Validity test: The questionnaire was given to colleagues for review. Reliability of the research instrument was done through test-retest method which gave 0.84 reliability co-efficient. Procedure for data collection: The questionnaire was administered and data was collected from respondents within a period of two months. Ethical consideration: Permission was sort from the individual students; also a brief letter of introduction appealing to respondents to participate in the study and informing them about the confidentiality of information was given along with the questionnaires. Research question one RESULTS The first research question states that, what is the profile of respondents in the study area? To answer this research question frequency count and simple percentage was used as presented in table 1 and pie chart was also used to show a pictorial description of respondents profile. Table 1: Profile of respondents Description Frequency Percentage Gender: Male ,4 Female Age: Below 20 years years years 6 1 Ethnic group Yoruba Hausa Igbo 6 1 Others Religion Christianity Islam Others Faculty of respondents PA Sci Mgt Env tal Sci Engin tech Basic Med Sci Agric Sci Respondent class 200 level Key: PA Sci means Pure and applied science Mgt means Management science Env tal sci Means Environmental science Engin tech means engineering and technology Basic Med Sci means Basic Medical Science Agric Sci. means Agricultural Science 300 level level level

282 274 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Result of table 1 shows respondents profile, this was possible using the response of respondents from the questionnaire. The table reveal that male is 273 (43.3%) while 356 representing (56.6%) are females, this is also presented in pie chart. For age, 281 representing (44.7%) were below 20 years, while 324 representing (54.6%) are between the ages of 21 through 29 years and only 6 representing (1.0%) are between 30 years and above. Respondents profile reveals that 590 representing (93.8%) are from Yoruba tribe, 18 representing (2.9%) are from Hausa tribe while only 6 representing (1.0%) are from Igbo tribe, whereas 15 representing (2.4%) are from other ethnic groups. Responses of respondents reveals that there were only three option were participant can be accommodated for their religious life, 460 representing (73.1%) indicated that they were Christians, 151 representing (24%) indicated that they were Islam faithful while the remaining 18 respondents representing (2.9%) follow after other religious group which can either be the African tradition, or any other, the implication is that the region had more Christians than any other religion Respondents response reveals that participants from five faculties participated in the study, a breakdown shows that 99 respondents representing (15.7%) are in Faculty of Agriculture Science, 145 respondents representing (23.1%) are in Faculty of Basic Medical sciences, 75 respondents representing (11.9%) are in faculty of Engineering Technology, 62 respondents representing (9.9%) are in faculty of Environmental Science, 150 respondents representing (23.8%) are in faculty of Management and 98 respondents representing (15.6%) are in faculty of Pure and Applied Science. Responses of respondents reveals that participants spread across 200 level through 500 level. 303 respondent representing (48.2%) are in 200 level, 115 respondents representing (18.3%) are in 300 level, 33 respondents represemning (5.5%) are in their 400 level while 178 respondents representing (28.3%) are in their 500 level. The implication is that the 200 level students seem to be more free than any other level since the higher level seem to be more busy, whereas the 400 level students seem to few because majority were on industrial training which majority do outside the school premises. Hypothesis one There is no significant relationship between the three predictor variables (attitude of health workers, time spent and services rendered) on the dependent variable (utilization of university health center) to answer this research question Pearson product moment statistic was used, this is because the research question investigates the relationship that exist among the three independent variables and one dependent variable. The result is presented in table 2 Table 2: Pearson product moment correlation analysis of attitude of health workers, time spent and services rendered on utilization of LAUTECH health centre Variables N Mean STD r-value p.level Attitude of health workers ** Time spent in the health centre ** Services rendered * Health service utilization ** Correlation is significant at 0.01 level, df = 627. The table shows r-value (0.141**) which is positive but small value for the relationship between attitude of health workers and utilization, (0.560**) which is positive and moderate value for relationship between time spent in the health centre and utilization and (.455*) which is positive and moderate value for relationship between services rendered and health service utilization. It follows then that there exist a positive relationship between the three predictor variables and utilization of health services. The level of significance (.000) for the first and second predictor, (.002) for the third predictor variable which is less than 0.05, indicates that the relationship is significant. Therefore, there exists a significant relationship between the three predictor variables (attitude of health workers, time spent in the health centre and services rendered) on utilization of health services in LAUTECH.

283 International Journal of Nursing Education. January-March 2015, Vol. 7, No DISCUSSION A total number of 629 respondents participated in this study; table 1 shows the profile of respondents. 56.6% of the respondents are female while 43.4% are males. Majority of the subjects falls within the age bracket of years and below 20 years. 93.8% are from Yoruba tribe, 2.9% are from Hausa tribe while only 1.0% is from Igbo tribe, whereas 2.4% are from other ethnic groups. 73.1% are Christians and 24% were Islam faithful while the remaining 2.9% follow after other religious group. The faculties of respondents include pure and applied science 15.6%, Management science, 23.8%, Environmental science 9.9%, Engineering technology 11.9%, Basic Medical Sciences 23.1% and lastly Agric Science, 15.7%. Majority of the respondents are in 200 and 400 Level students. This study finding further confirmed previous studies. The finding reveals that there exist a significant relationship between the predictor variables (attitude of health workers, time spent in the health centre and services rendered) and students utilization of University health centre. Pappa & Niakas stated that perceived health status or health-related quality of life (HRQOL) is a very strong predictor of health service utilization. 3 This study confirms that attitude could be considered as a potent factor or driving force to whatever humans do in their day to day activities. Berhane, Berhane & Fantahun perceived that rigid, judgemental position and stereotype behaviour must be abolished. 8 Similarly the result shows that, time spent in the university health centre have significant relationship with utilization of the university health centre. It can be inferred that since time spent in the health centre have relationship with usage of health facilities, management should review factors that causes delay in the hospital and rectify such factors which may include inadequate manpower, in-coordinate activities and lack of relevant equipment. Therefore to get maximum use of the university health centre, the management of the university health centre, should consider improving time management as to reduce time wastage in health centres when patients are waiting to be attended to or better still increase the number of personnel in health centres that are utilized by students who need urgent attention. 8 Lastly this study revealed that services rendered have a significant relationship with students utilization of University health center. Oyekale & Eluwa opined that improved access to better healthcare services would improve health care utilization. They further explained the importance of National Health Insurance Scheme (NHIS) that is being implemented by the Federal Government as part of health reform to ensure improved quality and equitable distribution of healthcare services and reduce high cost of healthcare services. If the NHIS is introduced in the university health centre, it will enhance the utilization of the university health centres by students. CONCLUSION In conclusion, this data suggest the need to identify and address the barriers of effective utilization of healthcare services in LAUTECH health centre. It also emphasizes the need to implement measures that would improve the healthcare utilization in terms of attitude of health workers, time spent in the health centre and services rendered. In addition, user friendly opening time, reduced waiting time and improved access to better healthcare services are steps necessary to increase the utilization of healthcare services in LAUTECH health centre. RECOMMENDATIONS The students should be exposed to health issues by health workers. Secondly, the University should introduce National Health Insurance Scheme (NHIS) for effective utilization of healthcare services in LAUTECH health centre. Acknowledgement: I express my sincere appreciation to God for his mercy and grace throughout the period of this research. My profound gratitude goes to my husband, my children and my colleagues for their unending support. Conflict of Interest: There is no conflict of interest as regarding to this article. Source of Funding: This research and the article is self sponsored. REFERENCES 1. Healthcare Facilities. Wikipedia, Oyekale AS, Eluwa CG. Utilization of Health- Care and Health Insurance among Rural Households in Irewole Local Government, Osun State. International Journal of Tropical Medicine 2009;4(2):70-75.

284 276 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 3. Awoyemi TT, Obayelu OA, Opaluwa HI. Effect of Distance on Utilization of Health Care Services in Rural Kogi State, Nigeria. Kamla-Raj J Hum Ecol 2011;35(1): Pappa E, Niakas D. Assessment of health care needs and utilization in a mixed public-private system: the case of the Athens area. BMC Health Services Research Journal 2002;6: López-Cevallos DF. Understanding the context of health care utilization in Ecuador: A multilevel analysis. BMC Health Services Research Journal 2010;10: Pascal B, Mashombo M, Jean-Pierre G, Marianna B, Christian L, Fred P. Low utilization of health care services following screening for hypertension in Dar es Salaam (Tanzania): a prospective population-based study. BMC Public Health 2008;8: Sule SS, Ijadunola KT, Onayade AA, Fatusi AO, Soetan RO, Connell FA. Utilization of primary health care facilities: lessons from a rural community in southwest, Nigeria. Niger J Med 2008;17(1): Frehiwot B, Yemane B, Mesganaw F. Adolescents health service utilization pattern and preferences: Consultation for reproductive health problems and mental stress are less likely. Ethiop. J. Health Dev 2005:19(1);29-36.

285 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Randomized Controlled Trial of Simulation - Based Teaching versus Traditional Clinical Instructions in Nursing: A Pilot Study Among Critical Care Nursing Students Amina Hemida Salem Lecturer of Critical Care and Emergency Nursing, Department of Critical Care & Emergency Nursing, Faculty of Nursing, University of Alexandria, Egypt ABSTRACT The use of high-fidelity simulation as a substitute for traditional clinical learning experiences in nursing education has gained acceptance over the past decade. Unfortunately, there is little research evidence that demonstrates how well high-fidelity simulation assists students in acquiring and integrating knowledge, skills, and critical thinking into their knowledge base (Weaver, 2011). (1) Instead, most researches have focused on the confidence students' gain after participating in simulation scenarios. (2-4) Therefore, this study was undertaken to compare between the effects of high fidelity simulation and traditional clinical instructions on nursing students' knowledge and skills acquisition as evidenced by their performance on content-specific examinations as evidenced by their performance on content-specific examinations.. Method: Randomized controlled trial was used to address the aim of this study. Fourth - year nursing students (n=38) were randomly distributed into two groups; experimental group, and control group. Subject domain was selected from the course syllabus and learning outcomes or variables that measured were knowledge and Skills. Results: The Simulator group showed significantly greater success (p < 0:05) in performing the selected procedures (40% vs 15%) when compared to the traditional instruction group. Additionally the simulator trained students had a significant performance advantage in term of the total time required to finish the procedures. Moreover, although, there was no significant difference in knowledge retention between the both groups, the simulation group appeared to retain the most (88.5%) and the traditional group the least (82.9%). Conclusion: this study provides an evidence base that suggesting high fidelity simulation can be used as a viable substitute to traditional clinical instructions in nursing education. Keywords: High Fidelity Simulation, Nursing Education, Traditional Clinical Instruction, Objective Structured Clinical Examination (OSCE) INTRODUCTION Educational preparation of students in the 21st century must be accomplished within a changing educational delivery environment. This educational preparation of health care professionals, such as nurses, may take on an even more challenging role since the health care environment is also changing at a pace that is often difficult to keep up with. The availability of appropriate hospital based clinical sites is diminishing, faculty shortages are projected to increase, and the need for additional nurses is increasing. (5-7) In addition the students that faculty face in the 21st century is more technologically savvy and need educational opportunities that blend traditional pedagogy with technologically advanced pedagogical

286 278 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 principles. One method of technologically advanced pedagogy, high-fidelity simulation, can meet some of these challenges in preparing undergraduate nursing students. (8,9) High - fidelity simulation (HFS) offer students an anatomically correct human substitute that can physiologically respond to nursing interventions. Simulations allow students to observe the sequelae of the care they provide and decisions they make both good and bad, without causing harm to an actual patient. In addition, they have the ability to present a patient s progression from admission through discharge or death more quickly than is seen in a reallife situation, offering students a more complete picture of the nursing care involved for specific disease processes. Finally, Human Patient Simulator (HPS) has the ability to standardize the types of patients and disease processes encountered by students, ensuring that they have similar experiences, something that (10, 11) cannot be guaranteed in the traditional clinical setting. However, simulation has some disadvantages. First, no matter how lifelike an HPS is, it is still not a real human being and has limitations, such as restricted communication with the student. Not being able to experience the full range of interaction with a patient makes the simulation less realistic and more ambiguous than an actual patient encounter. (9) Further, the costs of creating and maintaining a high-fidelity simulation laboratory may be prohibitive to many nursing programs due to the budget constraints they are working under in uncertain economic times. (12,14) Setting MATERIAL AND METHOD The study was conducted at College of Nursing - University of Dammam since the college includes full access to a state-of-the-art simulation laboratory. Research Design A randomized controlled trial of simulation basedteaching versus traditional clinical instructions methods among critical care nursing students was used. Participants In the period between January and March 2013, 39 senior students enrolled in the critical care nursing course were recruited to the study. Variables / Outcomes & Tools Variable/ Outcome Knowledge Skills Outcome Measuring Tool Pre & Post Test Written Examination:Based on the global learning objectives of the subject domain, a written pre & post equivalent test was structured and graded by an expert blinded to the specific instructional plans. The test version comprised 30 multi-choice questions, and was worth 30 points. Objective Structured Clinical Examination (OSCE)Post instructions OSCE was used to evaluate the skills acquisition using clinical performance checklist. Competency checklists were developed and previously reviewed and evaluated for content & face validity. Procedure The study was composed of several phases 1. Preparation phase: - Permission to conduct the study was obtained from the College Board after explanation of the aim and research methodology. - Informed consent was obtained from all students involved after explanation of the purpose, the method, and the duration of the study. Although a form of examination is used during the study, it was not linked to any assessment strategy in the course. Students who fully participated in the study were rewarded with a certificate of attendance to enhance their professional portfolio. - A subject domain from the course syllabus was selected, the airway management module. This module includes a set of clinical procedures included in a scenario about the clinical management of a patient with acute respiratory distress syndrome. These procedures include: Respiratory Assessment, Insertion of Oropharyngeal Airway, Assisting with ETT Intubation, Performing Tracheal Suctioning, Drawing an Arterial Blood, Interpretation Results of Blood Gas.

287 International Journal of Nursing Education. January-March 2015, Vol. 7, No Three hours lecture was prepared to cover the theoretical background of the subject domain. 2. Implementation Phase Following approval of the College Board, the researcher recruited the students during a scheduled class. Students were provided with an explanation of the study prior to implementation, they then attended 3 hours /lecture covering the theoretical background of the selected subject domain. All participants took a multiple choice exam to test their knowledge of the material covered. Then participating students were randomly divided into two groups. Half of the students were allocated to the control group (where conventional teaching method were used to teach the subject domain), whereas the other students were allocated to the experimental group (simulation based method used to teach the subject domain). Each group was again randomly divided in teams of 5 students. Students then completed a two week practicum, after which clinical performance was assessed using objective structured clinical examination (OSCE), students again took a multiple choice exam to assess their knowledge retention. Experimental Group (Simulation Based Group) Using SimMan 3G (High Fidelity Simulator, a computerized replica that simulates a real patient and is drug and hypoxia sensitive), a clinical scenario of patient with acute respiratory distress syndrome was adopted. Students from the experimental group were required to attend 18 hours simulation sessions. While one group was actively participated in the simulation session, the other three groups were acting as observers. All students were equally involved in the initial part of the session. Only one instructor interacted with the patient simulator during any session. During the scenario students were expected to act as qualified nurses caring for the simulated patient. When required students received help from the facilitator who then took the role of either a doctor or a senior nurse. After having taken part in the scenario, students were debriefed using footage from the video tape recording. Control Group (Traditional Instruction) Four groups of Students (5 students in each group) were assigned to 4 instructors in the clinical skill laboratory. Each group spent 18 hours training on the above mentioned procedures related to airway management, each procedure was thoroughly explained by the instructor and then demonstrated and re-demonstrated as many times as deemed necessary (each student was asked to remonstrate each procedure 3 times during the training days). For this purpose the instructors used static manikins and task trainers designed to allow the students to practice the procedure safely until mastering it appropriately. Every attempt was made by the instructors to assist students in acquiring the necessary skills related to airway management. 3. Evaluation Phase - Measurement of knowledge acquisition and retention: All participants were asked to attend posttest written examination. - Measurement of skill acquisition: Objective Structured Clinical Evaluation (OSCE). The two groups were exposed simultaneously to an OSCE. The OSCE was conducted as a summative assessment in order to collect the data required for comparison between the both groups. The instructors making the OSCE stations were blinded to the group to which the students belonged (experimental or control). By comparing the results obtained by each group in the OSCE, it was possible to determine whether or not students from the experimental group had improved their clinical performance competencies by participating in the simulations. Competency checklists were modified and summarized to be appropriate with the time allocate to each OSCE station (10 minutes per station). Statistical Analysis Data was coded, entered, & analyzed using statistical package SPSS version 19. Data was summarized using mean & standard deviation. Comparison between groups was done using independent sample t test. P value < 0.05 was considered statistically significant.

288 280 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 RESULTS Knowledge Retention Table 1. Written Exam Scores Before and After Simulation/Traditional Experiences Simulation Based Traditional Method(n=19) Instruction(n=19) Mean SD Mean SD Pre Post Table (1) shows the results of the pre & post tests. Students took a multiple choice exam to assess their knowledge retention. Based on written examinations on the content taught in the airway management module, students in both groups had statistically significant lower scores on the pre - test (p<.000). After 18 hours period of practicum of simulation and/or traditional instruction experiences, the students retained, on average, 86.3% of the knowledge gained in the didactic portion of the course. The simulation group appeared to retain the most (88.5%) and the traditional group the least (82.9%). However, no significant differences in change of knowledge were found between the groups. Skills / Clinical Performance Table 2. Clinical Performance / OSCE Results in Both Groups Item Traditional Simulation p value Instruction Based Method Success in performing the procedures 3(15%) 8(40%) < 0.05 Total time required to complete the procedures 240±38 159±31 < 0.05 The Simulator group showed significantly greater success in performing the selected procedures (40% vs 15%) when compared to the traditional instruction group. Additionally the simulator trained students had a significant performance advantage in term of the total time required to finish the procedures. (Table 2). DISCUSSION Whether or not to include simulation in an undergraduate nursing curriculum, it requires careful considerations with respect to the financial (purchasing simulators & equipment, maintenance and training of trainees) and physical feasibility, and the possible benefits to students. The findings of this study were encouraging in that they help to develop an evidence base that indicates there was knowledge and clinical performance acquisition benefits to participation in high-fidelity simulations. Although the there was no significant statistical difference in the knowledge retention in both groups, the experimental (simulation) group appeared to retain the most (88.5%) and the traditional group the least (82.9%). In relation to the clinical performance, the experimental group showed statistically significant greater improvement in performing of the selected procedures (40% vs 15%) when compared to the traditional clinical instructions group. Additionally the simulator trained students had a significant performance advantage in term of the total time required to finish the procedures. The same findings support the use of high-fidelity simulation as an engaging pedagogy that should be included in the radical transformation of nursing education were reported by Benner et al in their important work on educating nurses. (15) In addition to the results of the studies that were conducted by McCallum & Seropian et al. They mentioned that, the knowledge and skills gain seen in this study were encouraging, especially to nursing programs that are facing clinical placement challenges or are trying to argue for or justify the large capital investments seen with high-fidelity simulation laboratories. (16, 10, 12) This issue is further emphasized by Streufert et al who advance that simulation design is a significant factor in its inferiority or superiority over other training methods. (17) Furthermore, multiple studies findings, in different nursing specialties, have given positive feedbacks for the integration of HFS as an educational tool in nursing education and provide evidences that

289 International Journal of Nursing Education. January-March 2015, Vol. 7, No HFS can be an effective substitute for traditional (18 23) clinical experiences. Limitations of the study - A short period of lecture that covered the theoretical base of the subject domain. - The study did not explore to what extent simulation should be used as a substitute for traditional clinical instructions. CONCLUSIONS - Nursing education should embrace technologybased learning (HFS) as a tool designed not only to improve instruction, but also to meet the learning needs of the incoming generation of nursing students. - HFS can be used as a viable substitute to traditional clinical instructions in nursing education. Recommendations It is necessary for high fidelity simulation to be fully integrated and funded. It is necessary to train the trainers through the development of a skilled faculty of expert clinical facilitators supported by adjunctive support staff in dedicated simulation suites. Further research is needed to explore to what extent simulation should be used as a substitute for traditional clinical instructions. ACKNOWLEDGEMENT This research paper is made possible through the help and support from everyone, including family, friends, and in essence, all sentient beings. I sincerely thank to the College Board, my colleagues who helped me much during the phase of the data collection and my family. Conflicts of Interest: The author of this publication has not received any research funding support from anybody. Because the purpose for conduction of this research is required for the author s promotion, so all the funding requirements (equipment, editing, materials and publication) were the responsibility of the author. The author also conducts research in areas of interest similar to the business interests of [Nursing]. REFERENCES 1. Weaver, A. High-fidelity patient simulation in nursing education: An integrative review. Nursing Education Perspectives 2011; 32, Adbo, A. et al. Student satisfaction with simulation experiences. Clinical Simulation in Nursing 2006; 2(1), e13-e Bremner, M. et al. The use of human patient simulators: Best practices with novice nursing students. Nurse Educator 2006; 31, Feingold, C. et al. Computerized patient model and simulated clinical experiences: Evaluation with baccalaureate nursing students. Journal of Nursing Education 2004; 43, Kovalsky, A.et al. Integration of patient simulators into the nursing curriculum can enhance a student s ability to perform in the clinical setting. Dean s Notes 2004; 25(5), Schoening, A. et al. Simulated clinical experience: Nursing student s perceptions and the educators role. Nurse Educator.2006; (31)6, American Association of Colleges of Nursing. White paper. Faculty shortages in baccalaureate and graduate nursing programs: Scope of the problem and strategies for expanding the supply. Accessed on March 4, 2008 at: WhitePapers/FacultyShortages.htm 8. Jeffries, P. et al Theoretical frameworks for simulation design. Chapter 3, pp21-33 In: Jeffries, P. (Ed.). Simulation in nursing education. New York, NY: National League of Nursing (2007). 9. O Shea, E. Self-directed learning in nurse education: A review of the literature. Journal of Advanced Nursing 2003; 43(1), pp Seropian, M.A., Brown, K., Gavilanes, J.S., & Driggers, B. Simulation: Not just a manikin. Journal of Nursing Education 2004b; 43, Gates M.G., Parr M. B. & Hughen J. E. Enhancing Nursing Knowledge Using High-Fidelity Simulation. Journal of Nursing Education 2012; Vol. 51, No. 1,. 12. Seropian, M.A., Brown, K., Gavilanes, J.S. An approach to simulation program development. Journal of Nursing Education 2004a; 43, Gates, M. Developing a simulation center for your nursing school. Paper presented at the Technology Integration in Nursing Education and Practice Conference 2008, August; Durham, NC.

290 282 International Journal of Nursing Education. January-March 2015, Vol. 7, No Mcintosh, C., Macario, A., Flanangan, B., & Gaba, D.M. Simulation: What does it really cost. Poster session presented at the SimTecT 2005 Healthcare Symposium, Brisbane, Australia 2005 November. 15. Benner, P., Sutphen, M., Leonard, V., & Day, L. Educating nurses: A call for a radical transformation. San Francisco, CA: Jossey-Bass McCallum, J. The debate in favour of using simulation education in pre-registration adult nursing. Nurse Education Today 2007; 27, Streufert S.et al. Improving medical care: the use of simulation technology. Simulation & Gaming 2001; 32 (2), Butler K.W. Implementation of Active Learning Pedagogy Comparing Low-Fidelity Simulation versus High-Fidelity Simulation in Pediatric Nursing Education. Clinical Simulation in Nursing (2009) 5, e129-e Alinier G. et al. Determining the value of simulation in nurse education: study design and initial results. Nurse Education in Practice (2004) 4, Parker B.C. & Florence M. A critical examination of high-fidelity human patient simulation within the context of nursing pedagogy. Nurse Education Today (2009) 29, Gordon J.A. et al. A Randomized Controlled Trial of Simulation- Based Teaching versus Traditional Instruction in Medicine: A Pilot Study among Clinical Medical Students. Advances in Health Sciences Education (2006) 11: Brown D. et al. The Effect of Simulation Learning on Critical Thinking and Self-confidence When Incorporated Into an Electrocardiogram Nursing Course. Clinical Simulation in Nursing (2009) 5, e45-e Prion S. A Practical Framework for Evaluating the Impact of Clinical Simulation Experiences in Prelicensure Nursing Education. Clinical Simulation in Nursing (2008) 4, e69-e78

291 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Effectiveness of Small-Group Sessions in Enhancing Students' Generic Skills at The Shifa College of Nursing, Islamabad, Pakistan Afshan Saleem Daredia Senior Instructor, Shifa College PF Nursing, Patras Bukhari Road, H-8/4, Islamabad, Pakistan ABSTRACT There is no dearth of evidence of the importance of facilitation for the effectiveness of small-group teaching. However, there is hardly any local literature on the knowledge of untrained facilitators and how they apply this knowledge to develop generic skills in students. Needs identified through this study have provided an insight into the areas requiring formal training that could be useful for developing nursing-faculty development programmes. Keywords: Shifa College of Nursing (SCN), Shifa College of Medicine (SCM), Small-Group Sessions (SGS), Small-Group Facilitators (SGF) INTRODUCTION Small-group learning is an important approach for instruction in health-sciences education. Research has proved that students achieve greater understanding through small-group learning than through any other teaching approach. According to Davis 1 students who learn in small groups retain for longer periods than students who are taught through other instructional modes. This instructional modality facilitates students acquisition of generic skills, like problem solving, communication and interpersonal skills 2. These crucial skills are difficult to acquire in large groups. Small group size provides individual members with the opportunity to participate actively and the change in group dynamics that occurs as a result of an increasing number of participants, and causes the domination of some and continued reservations of shy students 3. According to Gillies, encouraging students to ask questions in small groups is essential if problem solving is to be nurtured 4. Small Group work is a method for generating free communication between the group leader and the members and among all the participants themselves. 5 The effectiveness of small-group teaching depends largely on careful planning and on the quality of the facilitation, which, in turn, depends largely on the proficiency of the facilitators. The term facilitator 6 is used to refer to individual who fulfils a variety of roles in groups; as leader, mediator, content expert and instructor. Facilitation is the process that individuals undertake to help identify issues and to encourage problem solving and decision making in the participants, which makes small-group learning more effective. 7 these individuals should be acceptable to all, neutral and not be in an authoritative position. Facilitation is ineffective if it is directionless, unproductive, unsatisfying and threatening. 8 to avoid these problems, facilitators should have an understanding of how groups work and how smallgroup techniques improve learning and the generic skills of students. According to the cognitivist-orientation theory 9, learners develop critical thinking by sharing their views and experiences. The role of facilitators is important because they provide learners with the opportunity to question and work within teams, which

292 284 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 promotes cognitive processing. In order to be effective, facilitators need to have understanding of the topic, to be involved in all the stages of planning, to understand the purpose of the small group and importantly, to have knowledge of facilitation techniques. 10 According to Dario s social-learning framework theory 9, the locus of learning in the social model is on the interaction between the person, the learning environment and the desired behaviour. Based on this theory, teachers are responsible for guiding students behaviour and for modelling new roles, while providing them with the opportunity to practise these. This highlights the fact that, only if facilitators are trained to conduct small-group sessions (SGS) will students benefit and their learning be enhanced. At Shifa College of Nursing (SCN), students are provided with various opportunities to interact and learn in SGS, particularly when they are on clinical rotations. The facilitators at the SCN do not undergo any structured training for facilitation. This led us to believe that a needs-assessment exercise would help to understand the current proficiency of the smallgroup facilitators (SGF) and identify the need for formal intervention in order to address any deficiencies. The primary aim of this study was to determine whether the facilitators of SGS have the knowledge or expertise required to develop learners generic skills and to evaluate their application of this knowledge. The objectives were to determine The facilitation skills of facilitators through the observation of their SGS. The students perceptions of skills of the facilitators in developing generic skills. To identify the general behavior and awareness of the facilitators regarding generic skills. METHOD This mixed-method study design was approved by the Institutional Review Board of the Shifa College of Nursing (SCN) and the Human Research Ethics Committee of Stellenbosch University. Written informed consent was obtained from the students and facilitators prior to the study. The sample consisted of 13 out of 16 SGF from the BSc Nursing programme who consented to participate. A faculty member from the SCM was identified by the dean to observe all the participating facilitators in action. Each planned SGS was observed by the faculty observer and evaluated using an observation checklist. The students also evaluated each SGS using the observation check-list. Self assessment questionnaire was developed, piloted and validated by the Department of Community Health Sciences of the Shifa College of Medicine in the beginning of This validated instrument comprised 17 items. The facilitator evaluated herself or himself using a selfassessment questionnaire, which was a 15-item instrument developed and piloted in the SCM. At the end of each SGS, the author explained details of the study to students and obtained their written consent. Ambiguous terms in the check-list were clarified. The average time of each SGS was 45 minutes. Altogether 119 students completed the questionnaire and per group there were 8 to 10 students. All duly completed check-lists were collected for data compilation and analysis. Three sources were therefore used for data collection An observation check-list completed by the faculty observer An observation check-list completed by the students attending the SGS A self-assessment questionnaire completed by the participating facilitators FINDINGS The quantitative data were analysed using SPSS Descriptive statistics were then performed. The qualitative data were cleaned and common themes were identified.

293 International Journal of Nursing Education. January-March 2015, Vol. 7, No Table 1: Perceptions of the faculty observer and students about the percentage of facilitators who demonstrated the following activities: Note: * = Significant P Value Activity Faculty Student P Value observer % observer % 1 The facilitator made the students sit in a circle or semi circle The facilitator encouraged thinking inquiry and critical reasoning The facilitator encouraged a safe environment to express ideas without fear of embarrassment. 4 The facilitator demonstrated sensitivity towards and respect < 0.01 * for the students. 5 The facilitator provided balance between information and actively involving the students. 6 All the students participated < 0.01 * 7 The facilitator encouraged the participation of all the students < 0.01 * 8 The facilitator refocused the group when the discussion became unfocused. 9 The facilitator encouraged and valued contributions from quiet students < 0.01 * 10 The facilitator questioned and probed the reasoning process The facilitator encouraged the students to assume leadership < 0.01 * responsibility within the group. 12 The facilitator explained the task to the students The facilitator provided feedback when appropriate The group comprised 6 to 12 students The facilitator provided adequate resource material < 0.01 * 16 Overall effectiveness of the facilitator 0 (moderate) 19.3 (moderate) 53.3 (high) 26.1 (high) 46.7 (very high) 52.1 (very high) 17 Overall value of the session 0 (moderate) 18.5 (moderate) 60 (high) 26.1 (high) 40 (very high) 53.8 (very high) Observations of the facilitator by the students and faculty observer Table 2: Self-assessment of facilitators Q # Items % faculty 1 Facilitators who had previously conducted SGS Facilitators who conducted SGS 1 to 5 times; to 10 times; to 15 times; or 15.4 More than 15 times Facilitators who planned the process of SGS Facilitators who had difficulty in choosing the strategy of learning; 38.5 difficulty in providing pre-reading material; 15.4 difficulty in communicating the intended outcomes before the sessions; or 7.7 Other difficulties Facilitators who did not plan the objectives for developing generic skills 40 7 Facilitators who faced problems in facilitating SGS 38

294 286 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table 2: Self-assessment of facilitators (Contd.) Q # Items % faculty 8 Facilitators who faced the following problems in facilitating SGS: Could not manage the time 15 Students did not come prepared 7.7 Could not engage the students in the content 7.7 Marked the option Other 7.7 Did not attempt the question 60 9 Facilitators who identified their problems through previous feedback; 7.7 identified their problems through ongoing evaluation; 15.4 identified their problems through their own observations; or 23.1 did not attempt the question Facilitators who thought that critical thinking could be developed through How and Why questions; 69 What and How questions; or Why questions only Facilitators who felt that they needed a training workshop on SGS. 92 Facilitators who preferred presentations to training sessions. 7.7 Table 3: Qualitative data for the knowledge and perceptions of the facilitators Note: The responses of the participants have been included in this paper in their original words; however, a few improvements in grammar were made without changing the gist of the responses. Q # Question Themes arising from quotes 10 How can you, as a facilitator, develop interpersonal skills in students? a. Through respect b. Through participation of students c. Through providing comfortable environment d. Through role modelling "Set the rules before starting small group session by encouraging them to respect each other" 11 What should be the characteristics of a small-group facilitator? a. Ability to encourage students to speak b. Knowledgeableness c. Questioning and feedback skills d. Effective communication skills e. Management skills f. Ethicalness and professionalism "Facilitator should ask questions that enhance discussion rather than hinder it" "Facilitator should have feedback skills" 13 What should be the behaviour of a facilitator in small-group sessions? a. Adopt a positive tone b. Be friendly c. Be supportive d. Take a passive role "Facilitator should not negate directly; however, it should be done in a way that students do not feel offended and embarrassed" 15 a What are the strengths of facilitators in small-group facilitation? a. Ability to involve and accommodate students b. Knowledgeableness and active listening c. Management skills d. Encouragement in friendly environment "I question to students from clinical perspective to improve problem solving and critical thinking skills" 15 b What are the weaknesses of facilitators in small-group facilitation? a. Becoming involved in discussions b. Lack of planning and process c. Lack of time management d. Lack of questioning e. Not right temperament I get involved in the discussion and start providing answers to students

295 International Journal of Nursing Education. January-March 2015, Vol. 7, No DISCUSSION The importance of small-group discussions as a learning strategy has been established time and again; the nature of interaction in small groups provides an opportunity for students to become actively involved in the process of learning. Facilitators, however, need to apply strategies like effective questioning, active listening and the reinforcement of individual contributions to promote individual involvement, active participation and critical thinking. 11, 12 Effective facilitators provide a non-threatening environment where the students have no fear of humiliation, where their communication improves and learn the principles of therapeutic communication. According to our findings, almost all the faculty members had received the chance to conduct SGS either at the SCN or at other organisations where the same strategy for teaching was used. The SGF of the SCN undergo no any formal training in facilitation. Majority of our samples were successful in providing the relevant ambience for student learning. Evidence shows that the seating arrangements in the classrooms should be such that they facilitate eye contact and the observation of non-verbal behaviours, thus facilitating discussion. 13 Although there was no significant difference in the students and the faculty observer s perceptions of the appropriateness of the logistics, a few observations has shared about the group layout was inappropriate. Critical facilitation skills, like encouraging the participation of shy students, keeping discussions focused and involving all the group members, were found to be deficient by the faculty observer. The students were found to be active participants in small groups and the majority of the facilitators encouraged the students to participate. A few of the students thought that the facilitators did not explain the tasks to them, possibly because they had different perceptions of explanation. Most of the students of the SCN came from a traditional system of education and were therefore more teacherdependent. Effective facilitation advocates people-centeredness by ensuring collaboration among participants. This empowers individuals and strengthens their ability to plan, reflect and learn from each other. 7 Our needs-assessment exercise showed that a good number of facilitators did not plan their sessions. This important prerequisite that of planning has been reinforced by Steinert, 12 who believes that preparation for small-group teaching, is the key to successful learning. Most of the facilitators realised that they needed to improve their facilitation skills. Although they did demonstrate awareness-questions that explore students learning, that is how and why questions, and that encourage critical thinking skills, they did not demonstrate in their sessions. Though they realised the importance of such exploration, but did not modify their facilitation to apply this knowledge. The facilitators shared that SGF should be ethical, professional, friendly yet respectful, skilled in questioning and in providing feedback and content experts. They realised that it is very important in the local context to encourage every student to participate. Students, especially those who are timid and introvert are nervous about speaking in groups and facilitators therefore need to provide an environment in which they do not feel threatened to speak up. 12 This, as discussed earlier, is a deficiency in untrained facilitators. The majority of the facilitators felt that one of their strengths lay in involving and accommodating each and every student in the discussions; this, however, was not corroborated by the faculty observer or the students. The facilitators thought that their weakness lay in their preparation for the SGS, which was not thorough because of time constraints and work overload. This is a universally identified issue that of a tutor giving a lecture rather than conducting a dialogue or talking too much and discouraging student participation. 12 The students and observer s findings of most of the skills of the facilitators were similar except in encouraging participation, involving students, showing respect, encouraging quiet students and providing resource material, the faculty observer did not agree. The reason for this may be that these technical skills were or could not be judged by the students. CONCLUSION Our results show that formal training of facilitators is required in planning through adequate and appropriate resources, guidance in how to keep

296 288 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 discussions focused and ensuring participation of every member of the group. The facilitators require formal guidance in how to demonstrate sensitivity towards the students and how to apply their knowledge of facilitation of small groups to real-life teaching. Regular and sequential workshops focusing on developing these skills are required. Appropriate methodology should be used to ensure that these skills are internalised and that inform the practice of facilitators. This study has therefore identified crucial gaps in expertise that require special emphasis; faculty development programmes should be customized in accordance with the results of this study in order to make small-group activities achieve a greater level of excellence. Acknowledgement: The author would like to thank Prof Juanita Bezuidenhout, Prof Ben van Heerden and Dr Ayesha Rauf for their support and guidance, Dr Ashraf for observing the SGS and Ms Zahra Ladhani, Dr Mohammad Amin, Dr Mohammad Naseem Ansari, Mr Shomail Sikandar and Mr Faisal Aziz for extending their help wherever it was sought. Conflict of Interest: The author declares that there is no conflict of interest. Source of Funding- self or other source Budget requirement was expected to be minimal for this study. This included stationary, and photocopies of the tools. The total amount spent on this study was 2,000 PKR Ethical Clearance: Permission to carry out the proposed study was obtained from the IRB of Shifa College of Medicine and Health Research Ethics Committee of the Faculty of Health Sciences, Stellenbosch University, South Africa. Informed consent from the participants had obtained before starting need assessment. The data was stored in safe place and anonymity of all participants was maintained. REFERENCES 1. Davis BG. Tools for Teaching. San Francisco, CA: Jossey Bass Inc.; Cannon R, Crosby JR, Hesketh EA. Developing the teaching instinct: Small group learning. Medical Teacher. 2004; 26(1): Jones RW. Education and training: Learning and teaching in small groups: Characteristics, benefits, problems and approaches. Anesthesia and Intensive Care. 2007; 35(4): Gillies RM. Promoting thinking, problem-solving and reasoning during small group discussions. Teachers and Teaching: theory and practice. 2011; 17(1): Walton H. Small group methods in medical teaching. Medical Education. 1997; 31: Kolb JA, Song JH. A model of small group facilitator competencies. Inter Science. 2008; 21(2). 7. Schwarz R. The skilled facilitator approach. In: Cannon R, Crosby JR, Hesketh EA. The Skilled Facilitator: A Comprehensive Resource for Consultants, Facilitators, Managers, Trainers and Coaches. 2nd ed. San Francisco, CA: Jossey-Bass; Jaques D. ABC of learning and teaching in medicine: Teaching small groups. BMJ. 2003: Torre DM, Daley BJ, Sebastian JL, et al. Overview of Current Learning Theories for Medical Educators. The American Journal of Medicine ; 119(10) : Becker A. Facilitating a Small Group Meeting: Principles and Techniques. 11. Edmunds S, Brown G. Effective small group learning. AMEE Guide No ; 32: Steinert Y. Twelve tips for effective small-group teaching in the health professions. Medical Teacher. 1996; 18(3). 13. Soliman I. Teaching Small Groups. University of New England; Teaching and Learning Center; 1999.

297 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Adolescent Suicide: a primary Care Issue Ivreen Robinson Assistant Professor, Lehman College, City University of New York, 250 Bedford Park Blvd., Nursing T3 Building, Bronx, New York, ABSTRACT Death by suicide among adolescents continues to be a worldwide concern. It is estimated that approximately 200, 000 teenagers end their lives annually. Suicide remains the third leading cause of death among adolescents between the ages 13 and 19 and the second leading cause of death among year olds. Suicide attempts occur more frequently during adolescents than at other periods of human development. This stage is a critical period of growth and development. Adjusting to the physical, psychosocial, and spiritual issues, pose tremendous burden on the adolescent who is trying to make meaning of all the changes that are occurring simultaneously. The impact of this problem has become a global public health concern; therefore, preventative measures are urgently needed to prevent self-destructive behaviors. A review of the literature will highlight the current statistics related to adolescent suicide attempt and suicide, associating factors, clinical manifestations, diagnosis and management, and preventative measures. Keywords: Adolescents, Suicidal Ideation, Suicide Attempt, Suicide, Suicide Clusters INTRODUCTION Adolescent suicide is a worldwide dilemma. It is estimated that approximately 200, 000 adolescents end their life each year. 1 The act of suicide is referred to as deadly violence against oneself. 2 A large percentage of adolescence with suicidal behaviors have some form of mental disorders. Research has shown that nearly 50 % of depressed adolescents attempt suicide and 10 % of those with major depression commit suicide within 15 years after being diagnosed. Suicidal behaviors (ideations, attempts, completions) sometimes occur without overt underlying mental illness. A state of hopelessness has been reported to be more predictive of suicide than is depression. Further, suicide often becomes an option when adolescents are faced with major life crisis or overwhelming circumstances without any foreseeable solution. Other factors include: physical changes, Corresponding author: Robinson, Ivreen Assistant Professor Lehman College, City University of New York 250 Bedford Park Blvd., Nursing T3 Building Bronx, New York, Ivreen.robinson@lehman.cuny.edu Phone No.: , parental pressures, peer pressures, concerns with homosexual feelings, easy access to weapons, etc. 1, 3 History of suicidal attempts have been identified as predictors of future attempts. It is estimated that that up to % of adolescents who attempt suicide will repeat the behavior within two years from the first attempt. 4 Most suicide attempts are made during adolescence than at any time in life. Each year the prevalence of suicide attempts among 9 th -12 th grade students in the United States is about 7.8%, compared to 0.5% among adults. Further, girls have a higher rate of attempts than boys. The prevalence of actual suicide deaths among teenagers is 0.006%. It remains the third leading cause of death between ages 13 and 19 and the leading cause of death among 10- to 24-year olds. Further, boys between ages 13 and 19 are more likely to die by suicide than girls, with an estimated 9.4 per 100, 000 in comparison to 2.7 among girls. 4 Adolescents suicides sometimes occur in clusters. It is estimated that approximately 1% to 13 % of adolescence suicide is related to suicide clusters. Some of the sources of contagion are online social networking and Short Message Service (SMS) text messaging. These sources also help to identify potential clusters. Suicide clusters are described as an excessive number

298 290 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 of suicides or attempted suicides occurring more closely together in time and space than would typically be expected in a particular community. Although electronic communication provides a means of interaction among young people, it may also become a source of suicide contagion after a suicide. A multidisciplinary approach is critical to recognize and respond to this problem. 5 Factors associated with suicide attempt Some of the risk factors associated with suicide and suicide attempt include hereditary and environmental factors. The interaction between biologic vulnerability and environmental stress is believed to play a pivotal role in depression that leads to suicide attempt or suicide. Environmental risk factors include abuse or neglect, parental substance abuse, parental and peer pressures, marital problems, low socio-economic status and education level, loss of parent, sibling, or a close friend; exposure to war, whether as refugees, civilians, soldiers. Some children and adolescents are further abused by soldiers and other adults during times of war, sexual oppression, or stress related to adolescent development, or issues of sexuality (homosexuality, bisexual, transgender). Research in the United States has shown that as many as 42 % of homosexual males attempt suicide between the ages 1, 3, 6 of 15 and 19. The highest predictors for suicide during adolescence are sexual abuse and physical abuse if occurred early in life. Adolescents who experience sexual abuse are 3.5 times more likely to commit suicide than those who have not. Secondly, adolescents who endured ruthless physical abuse prior to age seven are two times more likely to commit suicide than those who are not abused. 7, 8 One study found that five hours or more of daily video game or internet use was associated with increased risk of reports of sadness, suicidal ideation, and suicidal planning when compared to no video game or internet use. Further, it was also found that excessive gambling was a predictor of suicidal behaviors. 5,9 In 2004, a statement was released by the Food and Drug Administration (FDA) that the pediatric population placed on anti-depressant medication may have increased of risk of suicidality (suicidal thoughts and ideation). The warning emphasized the need for close monitoring of patients placed on these medications. The FDA gave a list of the drugs that have been approved or not approved in pediatric patients. It encourages prescribers to balance this risk with the results of clinical trials. A black box warning is now mandatory for all antidepressants drugs. A black box warning is the most serious type of warning in prescription drug labeling. 10 1, 12 Table 1: Risk factors for suicide and suicide attempts Depression Bullying in school; cyberbullying Homosexuality in males History of completed suicide in the family History of violence in males (as conduct disorder with aggression) Psychosis with suicidality Severe agitation or irritability History of previous attempt(s) Severe personality disorder (borderline or antisocial) History of sexual or physical abuse Substance abuse disorder Easy access to lethal methods (as firearms, knives, or hanging) Ethical or moral acceptance of suicide as an option for overwhelming distress Severe chaos in one local community or country Non compliance to mental health recommendation Homelessness Chronic illness Exposure to social unrest or wars Academic dysfunction or failure Table 2: Possible consequences of depression 1 Suicide Social Isolation Academic failure Loss of intimate friendship with the same or opposite sex Substance abuse experimentation and disorders Abuse sexual and/or physical Sexual promiscuity (with risk sexually transmitted infection or unwanted pregnancy

299 International Journal of Nursing Education. January-March 2015, Vol. 7, No Table 3: Methods of suicide in year olds 1 Firearms 49% Suffocation (mostly hanging) 38% Poisoning 7% Miscellaneous (running into traffic, motor vehicle accidents, burning, etc) 6% 3, 4, 5, 6 Table 4: Possible warning signs It is sometimes difficult to predict which person will ultimately commit suicide based on risk with risks factors. Some of the possible warning signs are Talking about dying Recent loss Change in personality Change in behavior Change in sleep patterns Change in eating habits Fear of losing control Loss of hope Any mention of dying, disappearing, jumping, shooting oneself, or other types of self-harm. Death, divorce, separation, broken relationship, self-confidence, self-esteem; loss of interest in friends, hobbies, and activities previously enjoyed. Sad, withdrawn, irritable, anxious, tired, indecisive, apathetic, psychotic features consistent with mood disorders, such as paranoid delusions or auditory hallucinations with deprecatory content. Inability to concentrate in school work, self-injurious behavior or suicidal ideation, plan, or intent. Behavior ranges from oppositional defiance to frank conduct disorder; may occur in underlying mood disorder. Depressive disorders vary in severity, intensity, and duration of symptoms. Adjustment disorder accompanied by depressed mood can be acute but severe. Major depression (with or without psychotic features) can be classified as mild, moderate, or severe. A detailed account of depressive disorders can be found in the latest edition of the American Psychiatric Association s Diagnostic and Statistical Manual of mental disorders. Insomnia, often with early morning waking or oversleeping, nightmares. Loss of appetite and weight, overeating. Acting erratically, harming self or others. Hopelessness and helplessness Clinical Manifestations DIAGNOSIS AND ASSESSMENT Adolescents who are depressed usually present with a wide range of symptoms. These include sadness, irritability, anger, poor school performance, or behavioral problems. They sometime demonstrate somatic complaints (e.g., headache, stomachache, and muscle weakness) decreased or increased appetite, fatigue, insomnia, hypersomnia, or disturbed sleepwake cycles. Some adolescents develop psychotic features consistent with their mood symptoms, such as paranoid delusions or auditory hallucinations with deprecatory content. Others develop self-injurious behavior, suicidal ideation, or plan and intent. Behavioral problems range from oppositional defiance to frank conduct disorder, may occur in conjunction with an underlying mood disorder. Depressive disorders vary in severity, intensity, and duration of symptoms. Adjustment disorder accompanied by depressed mood can be acute but severe. Major depression (with or without psychotic features) can be classified as mild, moderate, or severe. 6 It can be difficult diagnosing children and adolescents with depressive disorders because there is a broad difference in the clinical presentation that is generally related to the stage of development. Most adolescents experience sadness when faced with stressful situations. Further, because of all the changes that are taking place concurrently, they are sometimes moody, impulsive, and unpredictable in their behaviors. Close observation can distinguish those with the risk for continued morbidity and impairment of social function from those who become upset briefly due to a stressful situation. The clinical history and mental status examination are critical in the evaluation process. 6 Practitioners who provide health care to adolescents should not limit it to the physiological aspect, but include the following: presence or absence of depression; current level of functioning if consistent with his or her baseline; potential for self-injurious

300 292 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 behavior, suicidal ideation, or attempt. Obtaining a history from the adolescent, parent or guardian; other caregivers, such as counselors, or coaches, is an important part of the evaluation. The cultural background of the family should be taken into consideration because it could be related to the adolescent s behavior. Information obtained should include: changes in mood, sleep, appetite, peer relationship, school performance, or suicidal thoughts. Information about interpersonal interactions should be obtained from those in contact with the adolescent. An understanding of the developmental stage is critical in the assessment of depressive disorders. 6 In the primary care setting, self-report questionnaires can also be used to supplement the clinical history. Some of these include: Children s Depression Inventory (CDI), assesses the severity of depression in pre pubertal school-age children, and the Beck Depression Inventory (BD1); Reynolds Adolescent Depression Scale (RADS-2); and the Mood and Feeling Questionnaire (MFQ) for older adolescents. The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Toolkit also has child and report measures and scoring instructions that can be obtained on the web. 6 MANAGEMENT The management of adolescent psychiatric disorders continues to be a challenge because of the limitations in formal clinical guidelines and insufficient amount of child and adolescent practitioners. Pediatricians and other practitioners must have protocols in place to identify and evaluate psychosocial issues, make prompt consultation, or referral as needed. Supportive counseling, problem-solving discussions, and education of adolescents and their families are needed for those with mild depression. The treatment plan for moderate and severe depression includes either prescribed medication alone or with other interpersonal therapies. The three types of treatment that are authorized are: psychopharmacologic intervention, specifically selective serotonin uptake inhibitors (SSRIs), alone or in combination with psychotherapy, cognitive behavioral therapy (CBT), and interpersonal therapy (IPT). 6 Psychopharmacologic agents The psychotropic medications called the SSRIs have established effectiveness in the treatment of depression in adults, children, and adolescents. Currently, Fluoxetine is the only antidepressant approved in the United States (US) by the Food and Drug administration (FDA) for the treatment children and adolescents. Research studies have found that other medications such as citalopram, paroxetine, and sertaline have demonstrated efficacy. In 2006, the FDA meta-analysis of children and adolescents taking SRIs found an increased risk of suicide in those prescribed medication than the placebo group. Additional investigation revealed that that those who benefit from SSRI treatment outnumbered those who became suicidal during SSRT treatment by a ratio of 14:1. 5 It has been proposed that Fluoxetine be the first of choice in the management depressive symptoms because of the evidence for efficacy and safety. 6 Cognitive behavioral therapy Repeated studies have shown that CBT is one of the best non-pharmacologic interventions in the treatment of depression among children and adolescents. It is based on the conceptual framework that individuals feelings and behaviors are determined by the way they see the world and their place it. Their cognitions (verbal or pictorial) are based on attitudes or postulations develop from previous experiences, which may be fairly accurate or vague. The therapeutic format usually include: psycho education, behavioral modification that involves scheduling of enjoyable activities, cognitive restructuring to reframe distortions and permit more rational thoughts, and learning self-relaxation 6, 11 techniques. Interpersonal therapy The focus of IPT is to address problems in the patient s interpersonal interactions, seeking to change disagreeable and hostile relationships, to ones that are supportive, meaningful, and fulfilling. The primary goal of the therapy is the development of social skills and the assessment and effect of shifting roles within the family or peer groups. The patient is educated to see his or her place within a larger social context. 6

301 International Journal of Nursing Education. January-March 2015, Vol. 7, No Table 5: Tips and actions for emergency nurses, teachers, and family members Tips Recognize signs of physical and sexual abuse in children Be aware of a adolescents expressing hopelessness Observe for extreme mood swings in children and teenagers Adolescent's lack of interest in normal activities Ask about changes in eating or sleeping habits Notice if a child has given away prized possessions Recognize strong rage, impulsivity, or recklessness Observe whether children are taking antidepressants because they are at increased risk for suicide Reassess suicidality at discharge and document Action steps Talk to children about suicide Listen keenly as they respond Lock up firearms and weaponry or remove from home Lock up all prescription and over-the-counter medications Seek professional help if a adolescents seem to be in danger Encourage children to confide in adults with whom they have developed trusted relationships Include symptoms in discharge instruction documentation or on a wallet card as well as contact resources (ministers, hospitals, counselors, support groups, hotlines).12 CONCLUSION The adolescence period is a vulnerable period of one s development. The psychological and physiological changes, and also the environmental pressures create added stress, which renders the individual incapable of coping. The death of adolescents by accidents or natural causes can be a tremendous burden on families, peers, and communities. Further, the effect is even more farreaching when the demise is self-inflicted. It continues to be the third leading cause of death in adolescents between ages 13 and 19 and the second leading cause of death among year olds. The primary step in prevention is to have policies in place that address adolescents concerns before suicide for them become their only option. Ongoing discussions are necessary to assess coping skills and well-being of teenagers. Clinicians, parents, teachers, coaches, and counselors all have important roles in preventing suicide among adolescents. Further, a multi-disciplinary approach is necessary to educate providers in the identification of those behaviors that differ from baseline. Health care providers must be cognizant of the risk for suicide among this vulnerable population and screen for potential tragic but preventable phenomenon. Ethical Clearance: Adolescent Suicide: A primary Care Issue Acknowledgements: Nil REFERENCES Greydanus, D. F. Bacopoulou, F. & Tsalamanios, E. (2009). Suicide in Adolescents: A worlwide tragedy. Keio, Japan Medical Society, 58 (2), Hardt, J. (2008) Childhood adversities and suicide attempts: A retrospective study. Journal of Family Violence, 23(8), Nock, M. K.,Green, G., Hwang, I., McLaughin, K. A., Sampson, Zaslavsky, N.A. & Kessler, R.C. (2013). Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents. Journal of American Medical Association Psychiatry, 70 (3), Miranda, R. & Shaffer, D. (2013). Understanding the suicidal moment in adolescence. Annals of the New York Academy of Sciences, 1304 (2013), Prager, L. M. (2009). Depression and Suicide in children and adolescents. Pediatrics in Review, 30 (6), Beck-Little, R. & Catton, G. (2011). Child and adolescent suicide in the United States: A

302 294 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 population at risk. Journal of Emergency Room Nursing, 37 (6), Miller, A.B., Esposito-Smythers, C. Weismoore, J.T. & Renshaw, K. D. (2013). The relationship between Child maltreatment and adolescent suicidal behavior: A systematic review and critical examination of the literature. Clinical Child Family Psychological Review, 16, Messias, E., Castro, J., Do, A. S., Usman, M. & Peebles, D. (2011). Sadness, suicide, and their association with video game and internet overuse among teens: Results from the youth risk behavior survey 2007and Suicide and Life Threatening Behavior: The Official Journal of the American Association of Suicidology, 41(3), Robertson, L., Skegg, K., Poore, M., Williams, S. & Taylor, B. (2012). An adolescent suicide cluster and the possible role of electronic communication technology. Crises 33 (44), United States Food and Drug Administration (2004). Black Box warning for antidepressants. Science Daily, Retrieved 10/04, from htm 11. Varcarolis, E. M. & Jordan-Halter, M. (2010). Foundations of psychiatric mental health nursing: A clinical approach (6 th ed.). St. Louis, MO: Saunders/Elsevier. 12. Cooper, G.D., Clemens, P. T., & Holt, K. E. (2012). Examining childhood bullying and adolescent suicide: Implications for school nurses. The Journal of School Nursing, 28 (4),

303 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Effectiveness of School Based Teaching Programme (SBTP) for Teachers Regarding 'Prevention of Suicide among Students' in Selected Schools, Mangalore Meril manuel 1, Vineetha Jacob 2 1 Lecturer, Department of Mental Health Nursing, K Pandyarajah Ballal Nursing Institute, Ullal, Mangalore, Karnataka, 2 Assisstant Professor, Department of Mental Health Nursing, Yenepoya Nursing College, Deralakatte, Mangalore ABSTRACT Suicide is a growing health problem in the world. Adolescent students are the most vulnerable group for suicide. The great tragedy about suicide among students is that it takes place despite the suicidal students giving out warning signals. A school based teaching programme (SBTP) on knowledge and attitude of teachers regarding 'prevention of suicide among students' is important to make the teachers aware and which will enable them to prevent suicide among students. The main objective of the study is to determine the effectiveness of school based teaching programme on knowledge and attitude of teachers regarding prevention of suicide among students in selected schools. The conceptual framework adopted for the study was based on the "Modified Imogene King's Goal attainment Theory. An evaluative approach with pre-experimental (one group pre-test post-test) design was adopted for the study in order to determine the effectiveness of school. based teaching programme (SBTP) on knowledge and attitude of teachers regarding 'prevention of suicide among students' in selected schools, Mangalore. The tool used for the study was structured knowledge questionnaire and attitude scale. The study result shows that the difference between the mean posttest and the mean pre-test knowledge scores was found to be statistically significant t =6.11 (t29 =2.05, p<0.05) which shows that the school based teaching programme was effective in gaining the knowledge score of teachers regarding prevention of suicide among students. The difference between the mean post-test and the mean pre-test attitude scores was found to be statistically significant t =4.18 (t29 =2.05, p<0.05) which shows that the school based teaching programme was effective in gaining the attitude score of teachers towards regarding prevention of suicide among students. The results also shows that there was a significant association between pre-test knowledge score and selected demographic variable of previous knowledge regarding prevention of suicide and there was no association between the pre-test knowledge score and other variables like age, gender, religion, marital status, education, and years of teaching experience. Keywords: Suicide, Prevention, Students, Knowledge, Attitude, Teachers INTRODUCTION Suicide is a growing health problem in the world. Adolescents are the most vulnerable group for suicide 1. Worldwide, suicide is the third leading cause of death amongst children aged years. 2 Adolescents are in a stressful developmental period filled with major changes physically as well as mentally 3. They experience various changes in body, thoughts, and feelings such as heightened emotionality, sexual maturity and changes in interests, behavioural patterns, confusion, fear, and uncertainty 4. The great tragedy about adolescent suicide is that it takes place in spite of the student giving out distress signals and warning signs of suicide.5 Adolescent students spend a substantial part of their day in school under the supervision of school personnel 6. It is quite possible to reduce the suicide rate greatly by observing the warning signs and taking

304 296 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 appropriate actions in the school 7. This is possible for teachers if they have adequate knowledge and attitude on the recognition of the warning signs. MATERIAL AND METHOD The data collection tool used for the study was demographic proforma, structured knowledge questionnaire and attitude scale on prevention of suicide among students. Demographic proforma of the participants were age, gender, religion, marital status, education, years of teaching experience and previous knowledge regarding prevention of suicide. Knowledge questionnaire consisted of 20 true or false questions and 10 multiple choice questions on the knowledge regarding prevention of suicide among students. Maximum score was 30.The attitude scale consisted of 10 statements. There were 3 positive statements and 7 negative statements. The positive statements scored as 5, 4, 3, 2, 1 (strongly agree to strongly disagree) and the negative statements scored as 5, 4, 3, 2, 1 (strongly disagree to strongly agree). The maximum score was 50. The reliability coefficient obtained for knowledge questionnaire was 7.98 and for attitude scale is The research design adopted for the present study was pre-experimental one group pre-test post test design. DATA COLLECTION PROCEDURE Formal administrative permission and informed consent from the participants were obtained. Nonprobability convenience sampling technique was used to select the sample. The study sample consisted of 30 teachers from selected high schools of Mangalore. Pretest questionnaire and attitude scale were administered to each teacher. School based teaching programme was conducted for an hour on the same day aided by LCD projector and video (developed by researcher and validated by the experts) to facilitate understanding of the teaching. The lecture commenced with a suicidal note. The teachers actively participated in discussion and clarified their doubts. Post-test was conducted using the same questionnaire and attitude scale on the seventh day. Paired t test was used to analyse the effectiveness of teaching programme on knowledge and attitude on prevention of suicide among students. Association between pre-test knowledge scores and selected demographic variable will be calculated using chi-square test. FINDINGS Table 1: Paired t test showing the significant difference between pre-test and post-test knowledge N=30 Pre-test Post-test Paired t value Mean Mean% SD Mean Mean% SD * t 29 =2.05, p<0.05 * Significant Table 2 : Paired t test showing the significant difference between pre-test and post-test attitude score N=30 Mean Median S.D Paired t value Inference Pre-test Significant Post-test t 29 =2.05, P<0.05 The present study findings revealed that the calculated t value ( t=6.11) computed between mean pre-test and post-test knowledge scores was higher than the table value( t29=2.05) and school based teaching programme was effective in improving the knowledge of high school teachers (Table 1). And the study also revealed that the calculated t value ( t=4.18) computed between mean pre-test and post-test attitude scores was higher than the table value ( t29=2.05) and school based teaching programme was effective in improving the attitude of high school teachers towards prevention of suicide among students(table2).

305 International Journal of Nursing Education. January-March 2015, Vol. 7, No Association between pre-test knowledge score & attitude and selected demographic variables The study result showed that there was a significant association between pre-test knowledge score and demographic variable of previous knowledge regarding prevention of suicide (χ 2 =4.47, p<0.05) whereas there was no significant association was found between pre-test knowledge score and demographic variables like age (χ2=0.117, p>0.05), gender (χ2=0.85, p>0.05), religion (χ2=1.49, p>0.05), marital status (χ2=0.025, p>0.05), education (χ2=4.47, p>0.05), and years of teaching experience (χ2=0.036, p>0.05). And also there was no significant association between pretest attitude score and selected demographic variables such as age (χ2=0.045, p>0.05), religion (χ2=0.391, p>0.05), gender (χ2=0.718, p>0.05), marital status(χ2=2.07, p>0.05),education (χ2=0.170, p>0.05), years of teaching experience (χ2=0.238, p>0.05) and previous knowledge regarding prevention of suicide(χ2=0.06, p>0.05). DISCUSSION Effectiveness of school based teaching programme in improving the knowledge and attitude established in this study is supported by a study conducted in USA to evaluate the Impact of a comprehensive suicide prevention programme on knowledge, attitudes, awareness, and Response to Suicidal Youths for the teachers and students in 8th, 9th, and 10th graders at seven schools. Programme components included an educational lesson, video, skill training and interactive activities delivered during a 3 hour period. The programme was well received and showed statistically significant improvements in teachers and student s knowledge, attitudes, awareness, and response to Suicidal Youths. 8 CONCLUSION The findings of the study can be utilized while educating the community and regarding prevention of suicide. The study results will help the investigator as well as the public to update their knowledge and acquire favourable attitude. Regular teaching programme can be instituted for teachers and other personnel on prevention of suicide among students. The nurses have to carry out further studies regarding identifying the causes, risk factors and warning signs related to suicide and prevention of suicide among students through various awareness programme. The study findings help to motivate and initiate further research related to effectiveness of teaching programme on prevention of suicide in various setting. Acknowledgement: I acknowledge my love and gratitude to all those loving hearts who helped me throughout my endeavor. Conflict of Interest: Nil Source of Funding: Nil Ethical Clearance: Ethical clearance obtained. REFERENCES 1. Singh AR., Singh SA. Towards a suicide free society: identify suicide revention as public health policy; [online] [cited on 2011 Mar 7]. Available from: URL: health association international.org/firearmssui.html. 2. Centres for Disease Control and Prevention. Teenage Suicide Statistics. [online] [Cited 2011 Feb 15]; Available from: URL: Kaplan IH, Sadock JB. Synopsis of psychiatry: behavioural sciences/clinical psychiatry. 9 th ed. Hong Kong: William and Wilkinson Publishers; Gil Z, Tomer L, Gal S. Interaction of child and family psychopathology leading to suicidal behaviour. American Journal of Psychiatry 2010 Aug;31(3): Lakshmi V. Suicide and its prevention: The urgent need in India. Indian Journal of Psychiatry 2012 Jul 8;58(4): Teen suicide. Among Indian children. [online] 2010 Feb 16. Available from: URL: aasrasuicideprevention.blogspot.in/2012/06/ alarming-rise-in-student-suicides2010.html. 7. David MF, Michael TL. Suicide attempts and suicidal ideation among adolescents. Indian Journal of Psychiatry 2011 Dec;34(10): Aseltine RH, DiMartino R. An outcome evaluation of the SOS suicide prevention programme. American Journal of Public Health 2004 Jan;94:

306 298 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1DOI Number: / An Experimental Study to assess the effectiveness of Specific Interventions on Alcohol use in Selected Community Areas of Sangrur, Punjab Satinder Paul Kaur1, Kanwaljit Gill2 1 MSc (N) Psychiatric Mental Health Nursing, Registered Mental Health Nurse, Centre of Addiction and Mental Health, Toronto, Canada, 2 Principal and Professor, Shahid Kartar Singh Sarabha College of Nursing, Sarabha, Ludhiana, Punjab, India ABSTRACT Aim: The aim of the present study was to assess the effectiveness of specific interventions on the alcohol use. Data: A longitudinal experimental study was conducted using cluster random sampling technique to recruit 300 males aged between 26-55years to experimental and control groups. The data was collected from five different regions of the district using interview schedule of Alcohol Use Disorder Identification Test(AUDIT). Specific interventions were given to experimental group at 45th day, 3rd month and 5the month of collecting baseline data. Follow up posttest was conducted after 6 months of pretest. Results: After 6months, there was statistically significant (p<0.001) decrease in alcohol use among alcohol users in experimental group whereas, the control group increased their mean alcohol use which was found statistically significant at p< Conclusions: The specific interventions proved highly effective in reducing the alcohol use in selected community areas. Keywords: Specific Interventions, Alcohol Use, Cluster Random Sampling INTRODUCTION Alcohol has been consumed in India for centuries. The per capita consumption of alcohol by adults in India increased by 106.7% between and Rates of current use of alcohol in different regions of Punjab was found to be 45.9% in Jalandhar & 27.7% in Chandigarh and 28.1% in rural areas of Punjab 2. The pattern of drinking in India has undergone a change from occasional and ritualistic use to being a social event. Today, the common purpose of consuming alcohol is to get drunk 3. The impact of globalization and economic liberalization appears to have influenced a widespread attitudinal shift to greater normalization of alcohol use. A new segment of consumers is forming. Flavored and mild alcoholic products have recently flooded the market and are being advertised with special emphasis on relating alcohol with having good times and youth aiming to recruit non-drinkers. 4 The rising problem of alcohol use poses numerous physical and psychosocial risks to individual and the society. There is a significant association between increasing alcohol consumption and risk of death from cirrhosis, trauma, and cancer. Alcohol-related cancers increase in frequency with increasing consumption. 5 Lifetime alcohol dependence has been found to be positively linked to mood and anxiety disorders, also paranoid, histrionic and antisocial personality disorders 6. Alcohol use is a major cause for family disruption and marital disharmony in Indian society. Psychological distress and psychiatric morbidity in

307 International Journal of Nursing Education. January-March 2015, Vol. 7, No spouses of alcohol dependent men is high, with marital satisfaction being low 7. McDonald et al 8 have found patterns of alcohol drinking to be related to road traffic collisions and resulting injuries. A combination of a population-based approach reducing overall consumption and a high-risk approach targeting high-risk behaviors is essential to reduce the impact of the signature pattern of hazardous alcohol use in the country. Health systems, especially at primary care levels, must be geared to play a greater role in the early detection and prevention of alcohol-related harm through brief, cost effective interventions that have been demonstrated to be useful. 9 Certain research studies have demonstrated that brief interventions can promote significant, lasting reductions in drinking levels in at-risk drinkers who aren t alcohol dependent. 10 Some drinkers who are dependent will accept referral to addiction treatment programs. Even for patients who don t accept a referral, repeated alcohol-focused visits with a health 11, 12 care provider can lead to significant improvement. Mattila P et al 13 evaluated the effectiveness of long term brief intervention in routine general practice and concluded that clinically significant reduction of drinking was found in percent of the subjects. Need f the Study Keeping in view, the multi-dimensional nature and magnitude of alcohol burden and impact on Indian society, it is important to address the growing problem through a collaborative mechanism between health sector, media and government. Rigorous research is needed to accurately capture the magnitude of alcohol problem and research based effective interventions to guide a rational, scientific and evidence based comprehensive National alcohol policy. The basic goal for a client in any substance abuse treatment setting is to reduce the risk of harm from continued use of substances. The greatest degree of harm reduction would obviously result from abstinence, however, the specific goal for each individual client is determined by his consumption pattern, the consequences of his use, and the setting in which the brief intervention is delivered. 14 Efficient and effective intervention could be utilized to help people abstain from alcoholism or at least stick to safe drinking. Nurses are in a unique position to identify and intervene by informing the individuals about likely hazards of alcohol on their health and interaction of alcohol with other medical and psychiatric illnesses and numerous medications. They may also play a crucial role in leading patients with alcohol dependence to enter treatment through referrals. Statement of Problem An experimental study to assess the effectiveness of specific interventions on alcohol use in selected community areas of Punjab. OBJECTIVES 1. To develop specific interventions for alcohol users. 2. To assess the effectiveness of specific interventions on alcohol users. 3. To assess the relationship of alcohol use with selected variables i.e. age, education, family income, occupation, marital status, religion, type of family, type of residence, family history of alcohol use, family size. Delimitations The study is limited to: 1) Males aged between years, 2) Subjects willing to participate, 3) Subjects from the regions selected from the five geographical zones of Sangrur district (northern, southern, eastern, western and central), 4) Subjects staying in district for at least last 6 months. MATERIAL AND METHOD The study was aimed to assess the effectiveness of selected interventions on alcohol users. The conceptual framework of the present study is based on Sister Callista Roy s adaptation model. 15 Quantitative experimental approach has been used to assess the effectiveness of specific interventions for alcohol use with longitudinal measurement of outcomes. Randomized Pretest-Posttest Control group Design was used. Independent variable: Specific interventions Dependent variable: Alcohol use Sociodemographic variables: Age, education, family income, occupation, marital status, religion, type of family, type of residence, family history of alcoholism

308 300 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 and family size. Recruitment criteria Inclusion criteria 1) Alcohol users aged between 26 to 55 years. 2) Alcohol users who were willing to participate. 3) The individuals staying for minimum six months in the district. 4) Subjects speaking Punjabi, Hindi and English. Exclusion criteria The study excluded persons with 1) Past history of any psychiatric illness other than anxiety and depression. 2) Mental retardation. 3) Severe medical complications, blind, deaf and cognitive impairments. 4) De-addiction under medical/alternative therapy. 5) Admitted in hospitals or other health care settings. 6) Alcohol users categorized under zone IV as per AUDIT scores (as specialized medical services are needed for zone IV with possible alcohol dependence). 7) Substance abuse. The study was an extension to a prevalence study to screen alcohol use using Alcohol Use Disorder Identification Test. The data collection was carried out from Oct May Subjects who scored between 1-19 on AUDIT in initial screening process (discussed elsewhere) were asked about their willingness to further participate in the interventional part of the study and to sign a consent form. As per cluster random sampling, the clusters were randomly assigned to experimental or control group. Anticipating a drop-out rate of 5% of the study subjects from both groups, 315 alcohol users were randomly assigned to experimental (155) and control (160) groups. The aim was to recruit a total of 300 patients with alcohol use in experimental (150) and control (150) groups. The remaining subjects dropped out of the study due to various reasons. Specific interventions aimed to manage and reduce alcohol use were developed by the investigator and content validity established with experts opinion and independent translation by two language experts. Specific interventions were specific to the level of drinking of each alcohol user and included simple advice, alcohol education and brief counseling for low risk drinking, hazardous drinking and harmful drinking respectively. The subjects were grouped based on their geographical location to conduct specific intervention sessions on 45th day and after 3 months and 5 months of pretest. Every possible effort was made to follow the subjects who were absent or intoxicated at the time of specific intervention session in next 7 days. Posttest was done after 6 months of pretest for each individual. FINDINGS Baseline comparative analysis (Table I) shows that there was non significant difference in both the groups as per their demographic characteristics at baseline except for family history of alcohol use. Pretest alcohol use mean score of experimental group was significantly higher (13.95) than the posttest alcohol use mean score (8.65) at statistical level p<0.001 (Table II). Pretest alcohol use mean score of control group was significantly lower (14.11) than the posttest alcohol use mean score (15.25) at statistical level p<0.001 (Table III). There was no statistically significant difference (at p<0.05 level) between pretest alcohol use mean score of experimental group (13.95) and control group (14.11). Hence, both groups did not differ with regard to alcohol use at the baseline (Table IV). The mean posttest alcohol use score of experimental group (8.65) was significantly lower as compared to control group (15.25) at statistical level p<0.001 (Table V). Alcohol use was found significantly (at statistical level p<0.05 level) related to positive family history of alcohol use.

309 International Journal of Nursing Education. January-March 2015, Vol. 7, No Table I: Pretest comparison of sample characteristics of control and experiental group N = 300 Characteristic Control gp Experimental gp Total df X 2 n Percentage n Percentage n Percentage W/n W/n W/n W/n W/n W/n Ch gp Co gp Chgp Ex gp Chgp To gp Age (in Years) NS Education Illetrate NS Below matric Matric & above Graduate & above Family Income(Rs) Below 10,000/ NS 10,001/- to 20,000/ ,001/- to 30,000/ ,001/- and above Occupation Unemployed NS Skilled workers Labor/Agriculture Business Marital status Unmarried NS Married Divorced/ separated Widower Religion Hindu NS Sikh Muslim Others Type of Family Nuclear NS Joint Type of residence Urban NS Rural Family history of alcohol use Yes *** No Family size 3 or less NS 6-Apr More than

310 302 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Table II: Comparative pretest & posttest mean score of experimental group according to audit N = 300 Test n MS SD df t p Pretest *** Posttest Minimum Score = 0 *** = significant at level Maximum score = 40 AUDIT- Alcohol use disorder identification test Table III: Comparative pretest & posttest mean score of control group according to audit N = 300 Test n MS SD df t p Pretest *** Posttest Minimum Score = 0 Maximum score = 40 *** = significant at level AUDIT- Alcohol use disorder identification test Table IV: Comparative pretest mean score of experimental & control group according to audit N = 300 Group n MS SD df t p Experimental Group NS Control Group Minimum Score = 0 Maximum score = 40 NS= Non significant at 0.05 level AUDIT- Alcohol use disorder identification test Table V: Comparative posttest mean score of experimental & control group according to audit N = 300 Group n MS SD df t p Experimental Group *** Control Group Minimum Score = 0 Maximum score = 40 *** = significant at level AUDIT- Alcohol use disorder identification test DISCUSSION The main positive result of the study was the statistically significant decrease of the mean alcohol use value in experimental group (p<0.001), together with the increase in control group (p<0.001). It implies that specific interventions proved very effective in reducing alcohol use of experimental group and that alcohol use of control group had increased over time in absence of specific interventions. The mean posttest alcohol use score of experimental group was significantly lower as compared to control group which further confirms the effectiveness of specific interventions in reducing alcohol use. The results were in line with the findings of study by Tomson et al 16 which showed a significant decrease in alcohol use with a brief intervention by a primary health care nurse. Similarly, Bischof et al 17 found a significant decrease in alcohol use by at risk drinkers with stepped care interventions relative to control group over 12 months period. The findings show a statistically significant impact of positive family history of alcohol use on the overall alcohol use which is in line with findings of Meena et al 18 who found a strong relationship between family history of alcoholism and alcohol dependence. The code number of house, full name and address

311 International Journal of Nursing Education. January-March 2015, Vol. 7, No with two contact numbers of were noted down with consent of the subjects for follow up and delivering specific interventions and subjects ensured that their contact address and study scores will be kept strictly confidential and anonymous. STRENGTHS OF STUDY Experimental approach with longitudinal measurements of outcomes was used. The experimental and control group were selected from different regions of district and as per cluster random sampling, clusters (group of individual from a geographical region) were randomly assigned to avoid contamination. The study findings show that randomization successfully created groups equivalent for the purposes of comparison which excludes the threat of selection bias to internal validity of study. The drop out rate of present study was 4.7% which is considered within safe limits to ensure internal validity of a study. Repeated efforts to follow up with both experimental and control groups and constant motivation with the cooperation from local leaders helped the researcher to limit the drop out rate of the study and hence reduce mortality. LIMITATIONS OF STUDY 1) Since interview version of the tool was used, the social desirability bias cannot be excluded. 2) The specific interventions were used in groups, so it is possible that the group effect might have influenced the study results. CONCLUSION The specific interventions were proved highly effective in reducing the alcohol use in selected community areas. Conflict of Interest: All authors declare that they have no conflict of interest. Source of Funding: Self Ethical Considerations: Ethical clearance obtained from institutional ethical committee. Formal permission was obtained from Civil Surgeon and local leaders from Sangrur district. Written consent of the participants was obtained. Acknowledgement: The author wants to thank Dr. Sony for entry and analysis of data, Civil Surgeon and local leaders of Sangrur district for providing permission for data collection. REFERENCES 1. Rajendran SD (ed). Globalization and increasing trend of alcoholism. Community Health Cell, for the Asia Social Forum, 2 7 January 2003, Hyderabad, India Varma VK, Singh A, Singh S, Malhotra AK. Extent and pattern of alcohol use in North India. Indian Journal of Psychiatry. 1980; 22: Mohan D, Chopra A, Ray R, Sethi H. Alcohol consumption in India:A cross sectional study.in:demers A, Room R, Bourgault C (eds). Surveys of drinking patterns & problems in seven developing countries. Geneva:World Health Organization; 2001: Benegal V. India: alcohol and public health. Addiction. India. 2005; 100(8): Andrade J. Gin K. G. Alcohol and the heart. BCMJ June 2009 ;51 (5): Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, Correlates, Disability and Comorbidity of DSM-IV Alcohol Abuse and Dependence in the United States. Arch Gen Psychiatry. 2007;64(7): Kishor M, Pandit LV, Raguram R. Psychiatric morbidity and marital satisfaction among spouses of men with alcohol dependence. Indian Journal of Psychiatry 10/2013; 55(4): Macdonald S, Zhao J, Martin G, Brubacher J, Stockwell T, Arason N, Steinmetz S, Chan H. The impact on alcohol-related collisions of the partial decriminalization of impaired driving in British Columbia, Canada, Accident Analysis and Prevention (2013), org/ / j.aap Benegal, V. A., Shantala, Murthy, P. & Janakiramaiah, N. (2001) Report on Development of a Model District Programme for Prevention of Drug and Alcohol Problems: WHO NIMHANS Project. Deaddiction/lit /Mandya_ distt_who.pdf. Accessed Oct 2, 2014). 10. Willenbring ML, Olson DH. A randomized trial of integrated outpatient treatment for medically ill alcoholic men. Arch Intern Med. 13;159(16): , Lieber CS, Weiss DG, Groszmann R, Paronetto F, Schenker S, for the Veterans Affairs Cooperative Study 391 Group. II. Veterans Affairs cooperative study of polyenylphosphatidylcholine in alcoholic liver

312 304 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 disease. Alcohol Clin Exp Res. 27(11): , Ebirim IC & Morakinyo O M. Prevalence and perceived health effect of alcohol use among male undergraduate students in Owerri, South-East Nigeria: a descriptive cross-sectional study. BMC Public Health 2011; 11: Mattila P, Mustonen H, Ruth K, Hyvarinen H, Pulkkinen H, Alho H, Sillanaukee P, Seppa K. Brief intervention for heavy drinkers in routine general practice: a three year randomized controlled study. Alcohol Alcohol. 2001; 36: Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); John A, Barman A, Bal D, Chandy G, Samuel J, Thokchom M, Joy N, Vijaykumar P, Thapa S, Singh V, Raghava V, Seshadri T, Jacob KS, Balraj V. Hazardous alcohol use in rural southern India:nature, prevalence and risk factors. Natl Med J India May-Jun;22(3): Tomson Y, Romelsjo A, Aberg H. Excessive drnking brief intervention by a primary health care nurse. Scand J Prim Health Care. 1998;16: Bischof G., Grothues J.M., Reinhardt S. et al. Evaluation of a telephone-based stepped care intervention for alcohol-related disorders: randomized controlled trial. Drug and Alcohol Dependence: 2008; 93(3): Meena, Khanna P, Vohra AK, Rajput R. Prevalence and pattern of alcohol and substance abuse in urban areas of Rohtak city. Indian J Psychiatry 2002;44:

313 International Journal of Nursing Education. DOI Number: January-March / , Vol. 7, No Integrated Method is the Best Method of Teaching in Medical Education Prospective on Curriculum Development and its effects on Students' Learning and Performance Rita Rezaee1, Leili Mosalanejad 2 11Assistant Professor,Quality Improvement In Clinical Education Research Center, 2 Assistant Professor, Msc in Medical Education, Shiraz University of Medical Sciences, Shiraz, Iran ABSTRACT Case Based Learning, Group Discussion, Teamwork Learning, Team Work Perception, Knowledge- Skills, Attitude Keywords: Suicide, Prevention, Students, Knowledge, Attitude, Teachers INTRODUCTION Health services is possible when graduates are able to adapt themselves to increasing medical knowledge (1,2). It is also necessary for learners to have suitable ability for dealing with various patients problems in critical situations (3-4). Therefore, it has been recommended to use innovative training methods and improve current methods (5). Although more than 90 percent of students prefer active methods to traditional methods, teachers are more likely to use passive mode (8,9). The use of methods that are based on personal experience, are the most important of appropriate teaching methods (10-11). Corresponding author: Leili Mosalanejad Main Campus, Jahrom University of Medical Sciences Motahare Street Jahrom Iran saedparsa2012@gmail.com, Mosalanejad@jums.ac.ir Phone: Cell Phone: Collaborative study methods in which the emphasis is on student participation which in turn has a considerable impact on improving communication skills - Problem solving and practical knowledge. (12-16). Due to the difficulty of Psychiatry subjects, therefore, this research with the aim of, examine the consequences of this approach on learning and performance indicators. OBJECTIVES - To determine the effect of cased based team learning on students learning and performance - To determine the effect of cased based team learning on students team value( knowledgeattitude- performance & perception ) - To develop team based learning in students learning context Participants MATERIALS AND METHOD All nursing students (n = 40) who take mental health course entered to this study trained from two educational techniques in accordance with the expression of case study and then, Students discussed about the cases in group discussion.

314 306 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 STUDY DESIGN First the teacher express the basic principles of the course topics, then, continued by short case based presentation in the form of research about the therapeutic relationship with patients, communicate with patients and their families and other therapeutic challenge in this field. Later students have a one-week opportunity with a goal of finding the answer to the questions. The expressed questions have no definite answers, however they were correlated with students divergent and productive thinking exploring different aspects of this issues. So after a week, along with selfstudy, the students performed team-work at the beginning of class to answer the survey issue, and after they reached a sound conclusion, the instructor turned the attention to the main points. Groups concluded of 4 ten-individual groups. Also, in order to promote the students learning levels and to ensure their readiness to enter new phase, individual and group assurance test acquired. DATA GATHERING The questionnaire included questions about knowledge-attitude and their skills, also perception of team learning and perception of the team working. Internal validity of the survey questionnaire from all questionnaires (α=0.93), (α= 0. 93), (α=0/82), (α=0.87 ), and (α=0.88) respectively were acquired. Evaluation Students learning through the final examination compared with a group of last year students (traditional teaching method ). These students having received the same questions and the same content. Open ended question has taught to them to investigating satisfaction and impact of education on students. FINDING Of 41 students, 26 were girls and the rest boys. The results in Table 1 shows the effects of intervention on all the components and team learning indicators except to that of knowledge. Table 1: The difference between the indices of teamwork among students before and after intervention Variables state Mean ± SD T Knowledge from team working BeforAfter± (2. 1)24.20(6.97) 1.06 Skills from team working BeforAfter 19.29(2.80)29.43(2.67) 7.54* Attitude from team working BeforAfter 20.60(5.1)35.40(4.70) 11.94* Perception from team learning BeforAfter 25(5.72)28.45(5.05) 5.92* Perception from team working BeforAfter 24.10(5.1)28.92(2.34) 3.43* P=0.29 (not significant ) Knowledge from team working(p=0.001) * *Skills from team working(p=0.001) *Attitude from team working(p=0.001) *Perception from team learing (p= 0.001) *Perception from team learing (p=0.002) Other results of the study on other indicators described in Tables( 2,3&4) reveal the impact of casestudy in group environment on improving the effectiveness of group intervention in parameters such as knowledge - skills and attitude of the team work learning (Raising the percentage of responses in the ranges of much and very much).

315 International Journal of Nursing Education. January-March 2015, Vol. 7, No Table 2: Descriptive indicators of student knowledge from team working Variable Before After Very low moderate high Very Very low moderate high Very low high low high Knowledge possess knowledge of the team s mission, objectives, norms, and resources understand the task and the indicators of what needs to be done; understand the logical order to perform tasks agree on a logical way for dividing tasks; understand how to perform specific tasks know their role in exchanging information, handing off tasks, and other interaction patterns have accurate knowledge and a realistic assessment of the problem to be solved Table 3: Descriptive indicators of students skills from team working Skills Before After be flexible and adapt rapidly to events step in to correct and/ , or strengthen the actions of others exchange complete, timely, and accurate information encourage and build the morale of other team members resolve conflicts with mutual satisfaction express themselves clearly and appropriately to others plan, cooperate, and share in approaches to solving problems see problems or issues in their context and be sensitive to the environment of the situation assess and monitor the performance of the team and its members Table 4: Descriptive indicators of students attitude from team working Attitude a shared vision where there is an agreement on what is the ideal state team cohesion, with a strong sense of the collective we mutual trust and confidence in each other s integrity loyalty, and character trust in the team s collective effectiveness; and a team orientation, where thinking of teams is a natural way to approach issues

316 308 International Journal of Nursing Education. January-March 2015, Vol. 7, No.1 Also other results showed that the impact of this teaching method on improving students team work learning and students team work perception (Raising the percentage of responses in the ranges of much and very much).(table 5,6) Table 5: Descriptive indicators of student perceptions of the components of team work learning Perception of team work learning Very low moderate high Very Very low moderate high Very low high low high TBL helped me prepare for course examinations TBL helped me increase my understanding of the course material The T group discussions allowed me to correct my mistakes and improve understanding of concepts Learning issues helped me to focus on core information I learned useful additional information during the TBL sessions Discussions of the TBL learning issues were useful learning activities The TBL format was helpful in developing my information synthesizing skills Individual readiness assurance tests were useful learning activities Table 6: Descriptive indicators of student perceptions of the team work Perception of team working Before After I have a positive attitude about working with my Most students were attentive during TBL sessions I contributed meaningfully to the TBL discussions The ability to collaborate with my peers is necessary if I am to be successful as a student Solving problems in a group is an effective way to practice what I have learned Perceptions of Teamwork My team worked well together There was mutual respect for other teammates viewpoints during TBL The results of the comparison between the traditional method and the mentioned one showed that this method has a positive impact on the promotion of students learning (Table 7). Table 7: Difference between students learning in traditional group and case based team learning groups Teaching method Mean ±Sd T Traditional (lecturing) ( 2.01) 3.18* Case based team learning ( 1.89) *P=.0003 In another analysis, open ended question was used to written expression of students views about the method. Students stated that this method had made learning fun and enjoyable to them (87%), provided the possibility of deeper learning (45%) and changed learning through being utterly a listener to learning via student s activities (48%). Increasing the role of students in their learning (23%), his, search resources and prepare for class (13%) and non-stereotyped teaching for them (38%). DISCUSSION Our results show that the positive impact of this integrated approach on the acquisition of team value and also students learning and satisfaction.

317 International Journal of Nursing Education. January-March 2015, Vol. 7, No Some evidence also reported the positive impact of this integrated method on the national board examination score (16). It seems that team-based learning provide enjoyable learning, students deep learning as well as improving their self (17). Also, some evidence highlights the impact of student center approaches and the priority of these approach versus conventional methods (18). Other demonstrate the effect of these approach on the students performance (19) and significant impacts on the students retention (20,21). Although some studies have also shown that there is no significant statistical difference in students learning with those of lecturing methods. (22-24). The positive impact of this approach on the acquisition of knowledge and students mastery in the field of communication skills in the second year dental student at Mackenzie study has been approved (25). The success of this approaches are underpinned by effective communication and interactions between students (26-27). The case-based method technique, being a fun for teachers, an appropriate way to create motivation in students and facilitates discussion in small groups ( 28). Using this method has a significant impact on students attitudes towards issues, students roles, educational context, reinforces the leadership and collaboration (27-28). The results of this study showed that this method had made satisfaction and priority to other methods in students. Other study also stated that case study approach was preferred by 84% of students and teachers 89% (29). CONCLUSION Using integrated methods can provide an effective learning in medical education that sticks in students memory and develop team work skills as social indicators that are important factors in professional contexts. Therefore we suggest using these new teaching methods in future for all medical instructors. ACKNOWLEDGEMENT The present article was extracted from leili mosalanejads M.Sc. thesis in medical education with cod number of (7146).it was financially supported by the Research Vice-chancellor of Shiraz University of Medical Sciences, Shiraz, Iran. Hereby, the authors would like to thank all the individuals who helped in carrying out the research. Conflict of Interest: Non Ethical Consideration: All ethical principles in educational research as exploration of method for students, No forced to entry of research and completed questionnaires were consider in this study. Also proposal confirmed by ethical committee. REFERENCES 1. Distler JW. Critical thinking and clinical competence: Result of the implementation of student-centered teaching strategies in an advanced practice nurse curriculum. Nurs Educ Prac 2007; 7 (1): Worrell JA Profetto-McGrath J. Critical thinking as an outcome of context-based learning among post RN students: A literature review. Nurs Educ Today 2007; 27 (5): Ozturk C Muslu GK Dicle A. A comparison of problem-based and traditional education on nursing students critical thinking disposition. Nurs Educ Today 2008; 28 (5): Vahidi R Azemian A Vali Zadeh S. Feasibility of PBL implementation in clinical courses of nursing and midwifery from the viewpoints of faculty members of Tabriz University of Medical Sciences. Journal of Medical Education 2004; 4 (2): [In Persian] 5. Abraham S. Vaginal and speculum examination in medical curricula. Aust NZ Obstet Gynaecol 1995;35(1): Pugh C Youngblood P. Development and validation of assessment measures for a newly developed physical examination simulator. Journal of the American Medical Informatics Association 2002; 9: Seldomridge LA Walsh CM. Measuring critical thinking in graduate education: What do we know? Nurs Educ Today 2006; 31 (3):

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