UBC Theses and Dissertations

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UBC Theses and Dissertations

Effect of planned patient teaching and psychological support on the adaptation of the elderly patient… Shannon, Valerie Jane 1977

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THE EFFECT OF PLANNED PATIENT TEACHING AND PSYCHOLOGICAL ON THE ADAPTATION OF THE ELDERLY PATIENT TO THE SURGICAL INSERTION OF A PERMANENT PACEMAKER  by VALERIE JANE SHANNON B.Sc.N., 1970, M c G i l l  A THESIS SUBMITTED LN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in The F a c u l t y o f G r a d u a t e  Studies  School o f Nursing We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e required  standard  The U n i v e r s i t y o f B r i t i s h  Columbia  May, 1977 (c)  V a l e r i e Jane Shannon  SUPPORT  In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced d e g r e e a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r and s t u d y .  I f u r t h e r agree that permission  o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may my Department o r by h i s r e p r e s e n t a t i v e s .  reference  f o r extensive  copying  be g r a n t e d by the Head o f I t i s understood that  p u b l i c a t i o n , i n p a r t o r i n w h o l e , o r the c o p y i n g o f t h i s t h e s i s f o r financial  g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n  permission.  VALERIE JANE SHANNON  School; o f .Nursing The U n i v e r s i t y o f B r i t i s h C o l u m b i a , V a n c o u v e r , Canada V6T 1W5  ii  ABSTRACT  An e x p e r i m e n t a l  study, using a p r e t e s t - p o s t t e s t c o n t r o l  group d e s i g n , was c o n d u c t e d  i n a 570 bed a c u t e c a r e t e a c h i n g h o s p i t a l .  I t s p u r p o s e was t o e v a l u a t e the e f f e c t o f p l a n n e d p a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t on the a b i l i t y o f t h e e l d e r l y p a t i e n t t o a d a p t to the s u r g i c a l i n s e r t i o n o f a permanent c a r d i a c pacemaker.  Nine  s u b j e c t s , who met the s t u d y c r i t e r i a , were r a n d o m l y a s s i g n e d t o e i t h e r t h e e x p e r i m e n t a l o r c o n t r o l group.  Each s u b j e c t was a s k e d i f he would  l i k e t o i n c l u d e a s i g n i f i c a n t o t h e r i n the p r o j e c t . the experimental  The members o f  group (5 p a t i e n t s , 3 s i g n i f i c a n t o t h e r s ) were seen  i n d i v i d u a l l y by t h e n u r s e i n v e s t i g a t o r on o r c l o s e t o t h e t h i r d , f o u r t h and f i f t h p o s t o p e r a t i v e day a t w h i c h t i m e t h e i r q u e s t i o n s were a n s w e r e d , t h e y were g i v e n the o p p o r t u n i t y t o e x p r e s s t h e i r c o n c e r n s and,  they  were shown a 15 m i n u t e s l i d e - t a p e programme a b o u t p a c e m a k e r s .  The  members o f the c o n t r o l group (4 p a t i e n t s , 4 s i g n i f i c a n t o t h e r s ) were p r o v i d e d w i t h t h e u s u a l n u r s i n g c a r e g i v e n by t h e ward n u r s i n g s t a f f . A l l p a t i e n t s r e c e i v e d a b o o k l e t f r o m t h e company s u p p l y i n g t h e i r s p e c i f i c t y p e o f pacemaker. The h y p o t h e s e s 1.  t e s t e d were:  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  increase  t h e knowledge base o f t h e p a t i e n t and h i s s i g n i f i c a n t other.  2.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  decrease  t h e s t a t e and t r a i t a n x i e t y l e v e l s o f the p a t i e n t and his s i g n i f i c a n t 3.  other.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  enable  t h e p a t i e n t and h i s s i g n i f i c a n t o t h e r t o d e m o n s t r a t e pulse 4.  taking.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  maintain  or i n c r e a s e the a c t i v i t y l e v e l o f the p a t i e n t from h i s preoperative  state.  At approximately  two and f o u r weeks a f t e r d i s c h a r g e f r o m t h e  h o s p i t a l , the n u r s e i n v e s t i g a t o r v i s i t e d a l l the p a t i e n t s i n the and t h e i r s i g n i f i c a n t o t h e r s .  study  Knowledge b a s e , a n x i e t y ( s t a t e and  t r a i t ) l e v e l , a c t i v i t y l e v e l and p u l s e t a k i n g a b i l i t y were measured on a l l p a t i e n t s ; w h e r e a s , o n l y knowledge b a s e , p u l s e t a k i n g a b i l i t y and a n x i e t y ( s t a t e and t r a i t ) l e v e l were measured on a l l s i g n i f i c a n t No s i g n i f i c a n t d i f f e r e n c e s were found between the two g r o u p s on of these v a r i a b l e s .  Some m e t h o d o l o g i c a l  i m p l i c a t i o n s o f the f i n d i n g s a r e  p r o b l e m s and c l i n i c a l  discussed.  others. any  iv  TABLE OF CONTENTS Chapter  Page  ABSTRACT  i i  LIST OF TABLES  ix  LIST OF FIGURES  . .  xi  ACKNOWLEDGEMENTS  I.  xii  OVERVIEW OF THE STUDY  1  INTRODUCTION  1  THE PROBLEM  2  Statement Significance  2 .  DESCRIPTION OF THE STUDY . . . . . . . . . . . . . .  3 6  Purpose .  6  Hypotheses  6  Variables  7  R a t i o n a l e f o r t h e C h o i c e o f Dependent Variables .  8  D e f i n i t i o n o f Terms .  10  Assumptions  12  Methodology  12  Limitations  13  SUMMARY  15  v Chapter  II.  Page  LITERATURE REVIEW  16  IMPLANTED CARDIAC PACEMAKERS  ..  16  H i s t o r i c a l Development  16  Types  19  Indications . . . . .  20  Complications  20  .  F o l l o w - U p Care  22  Current Medical Research  22  CONCERNS OF THE SURGICAL PATIENT . . . Fear Time F a c t o r s  24 24  . .  The I l l n e s s KEY EXPERIMENTAL STUDIES ON THE PRE-OPERATIVE PREPARATION OF GENERAL SURGICAL PATIENTS  24 25 26  CONCERNS OF THE PATIENT WITH A PERMANENT PACEMAKER The Kos and C u l b e r t S t u d y .  30 31  THE CONCEPT OF ANXIETY  34  KEY NURSING STUDIES ON ANXIETY REDUCTION  40  INFORMATION SHARING AND PATIENT'S RIGHT TO KNOW PHYSIOLOGICAL AGING AND ITS INFLUENCE ON THE TEACHING-LEARNING PROCESS  46 48  M e t a b o l i c Rate  49  C a r d i a c Output  50  vi Chapter  P a  Lung P e r f o r m a n c e Nerve C o n d u c t i o n  e  50 Velocity  . .  51  .  51  V i s u a l and A u d i t o r y Changes C e l l u l a r Changes i n t h e B r a i n  52  CULTURAL AGING AND ITS INFLUENCE ON THE TEACHINGLEARNING PROCESS  53  Independence  54  Social Acceptability  54  Adequacy o f P e r s o n a l R e s o u r c e s  55  A b i l i t y t o Cope w i t h S e l f Change  .  H a v i n g S i g n i f i c a n t Goals o r Meaning i n L a t e r Life A b i l i t y t o Cope w i t h E x t e r n a l T h r e a t s o r L o s s e s  III.  9  55 56  . .  56  PSYCHOLOGIC AGING AND ITS INFLUENCE ON THE TEACHINGLEARNING PROCESS  57  FACILITATING LEARNING AMONG THE ELDERLY . . . . . . . .  59  Motivation  59  Methods  60  Audiovisual Aids  61  I n d i v i d u a l Teaching and C o u n s e l l i n g  66  SUMMARY  69  METHODOLOGY  71  INTRODUCTION  71  THE RESEARCH DESIGN  71  Chapter  Page  THE SETTING  72  THE SAMPLE  74  ETHICAL CONSIDERATIONS  ..  75  THE SLIDE-TAPE PROGRAMME  76  THE PROCEDURE  77  The E x p e r i m e n t a l Group  78  The C o n t r o l Group  80  . .  THE DATA GATHERING TOOLS  81  Knowledge Base Q u e s t i o n n a i r e  82  The A c t i v i t y Check L i s t (ACL)  . . .  S t a t e - T r a i t Anxiety Inventory ( S e l f Evaluation Questionnaire)  83 89  CRITERIA USED TO DETERMINE PULSE TAKING ABILITY  IV.  . .  95  DATA MANAGEMENT  95  SUMMARY  96  THE FINDINGS  97  INTRODUCTION THE SAMPLE  97 . :  97  HYPOTHESIS ONE  .  100  HYPOTHESIS TWO  . .  105  HYPOTHESIS THREE  112  HYPOTHESIS FOUR  114  viii Chapter  V.  Page INCIDENCE OF COMPLICATIONS  1.20  LENGTH OF HOSPITAL STAY  121  SUMMARY  121  SUMMARY, CONCLUSIONS AND IMPLICATIONS . SUMMARY  . .•  CONCLUSIONS  122 122  .  124  IMPLICATIONS  127  BIBLIOGRAPHY  129  Books  129  Articles  .  132  Unpublished Manuscripts  136  Government P u b l i c a t i o n s . . . . . . .  137  APPENDIX A - CONSENT FORM - GROUP 1  138  GROUP 2  139  APPENDIX B - S C R I P T AND STORYBOARD FOR THE SLIDE-TAPE PROGRAM -.PART 1  142  Part 2  149  APPENDIX C - ACTIVITY INTERVIEW SCHEDULE  158  APPENDIX D - PATIENT DATA SHEET  165  . . . . .  APPENDIX E - KNOWLEDGE BASE QUESTIONNAIRE  166  APPENDIX F - S T A I . .  171  ix  L I S T OF TABLES Table  Page  1.  P o t e n t i a l C o m p l i c a t i o n s o f Permanent Pacemakers . . . .  21  2.  S e n i o r C i t i z e n s ' Response t o A c t i v i t y C h e c k l i s t . . . .  85  3.  N u r s e s ' O p i n i o n o f Pacemaker P a t i e n t ' s A c t i v i t y Capabilities  8 8  4.  Demographic Data - P a t i e n t s  98  5.  R e l a t i o n s h i p Between P a t i e n t and S i g n i f i c a n t Other .  99  6.  Knowledge Base - Two Weeks A f t e r D i s c h a r g e  101  7.  Knowledge Base - F o u r Weeks A f t e r D i s c h a r g e  102  8.  C o r r e l a t i o n C o e f f i c i e n t s Among S e l e c t e d  Dependent  V a r i a b l e s f o r t h e E x p e r i m e n t a l Group 9.  T r a i t A n x i e t y S c o r e s - Two Weeks A f t e r D i s c h a r g e  104 . . .  106  10.  T r a i t A n x i e t y S c o r e s - Four Weeks A f t e r D i s c h a r g e . . .  107  11.  S t a t e A n x i e t y S c o r e s - Two Weeks A f t e r D i s c h a r g e  ...  108  12.  S t a t e A n x i e t y S c o r e s - Four Weeks A f t e r D i s c h a r g e . . .  109  13.  P u l s e T a k i n g A b i l i t y - Two Weeks A f t e r D i s c h a r g e  113  14.  A c t i v i t y C h e c k l i s t S c o r e s - Two Weeks A f t e r Discharge  15.  . . .  115  A c t i v i t y C h e c k l i s t S c o r e s - Four Weeks A f t e r Discharge  116  X  Table  16.  17.  Page  Reported S a t i s f a c t i o n / D i s s a t i s f a c t i o n With A c t i v i t y Level  117  P a t i e n t ' s D e s c r i p t i o n of T h e i r Morale  118  xi  L I S T OF FIGURES Figure  1.  Page  A Model o f Normal A n x i e t y .  Pathways w h i c h  may i n c r e a s e a n x i e t y a r e shown w i t h  solid  l i n e s ; t h o s e r e d u c i n g a n x i e t y a r e shown with broken l i n e s  38  ACKNOWLEDGEMENTS  To Dave and C h r i s t o p h e r f o r t h e i r unending  encouragement,  To Ruth and J a c k f o r t h e i r wisdom and g u i d a n c e , To S t u a r t and Rose Mary f o r t h e i r many hours o f c r e a t i v e work on t h e s l i d e - t a p e  programme,  And t o t h e p a t i e n t s and s t a f f a t S t . P a u l s H o s p i t a l f o r t h e i r time and s u p p o r t , Thank y o u .  1 CHAPTER I OVERVIEW OF THE STUDY INTRODUCTION  P a t i e n t e d u c a t i o n i s an i n t e g r a l , unique and key f u n c t i o n o f the p r o f e s s i o n a l n u r s e .  K r e u t e r i d e n t i f i e s t e a c h i n g o f s e l f - c a r e and  c o u n s e l l i n g on h e a l t h m a t t e r s as n u r s i n g o p e r a t i o n s e s s e n t i a l t o p r o viding care.'  Henderson i m p l i e s t h a t n u r s i n g i n v o l v e s t e a c h i n g when  she says t h a t n u r s i n g a s s i s t s t h e s i c k o r w e l l t o p e r f o r m h e a l t h a c t i v i t i e s t h e y would do u n a i d e d i f t h e y p o s s e s s e d t h e n e c e s s a r y 2 s t r e n g t h , m o t i v a t i o n and knowledge. Lambertsen c h a r a c t e r i z e s n u r s i n g as an " e d u c a t i v e p r o c e s s " and P e p l a u d e s c r i b e s n u r s i n g as an e d u c a t i v e 3 4 instrument. ' Now t h a t t h e t e a c h i n g component o f t h e n u r s e ' s r o l e has be5 6 come p a r t o f t h e r e p e r t o i r e o f b a s i c p r a c t i c e s k i l l s , ' i t i s i m p o r t a n t V.R. K r e u t e r , "What i s Good N u r s i n g C a r e ? " N u r s i n g O u t l o o k , 5 ( 1 9 5 7 ) , pp. 302-304. 2 V. H e n d e r s o n , "The Nature o f N u r s i n g , " American J o u r n a l o f N u r s i n g , 64 ( A u g u s t , 1964), pp. 62-68. 3 E.C. Lambertsen, " N u r s i n g D e f i n i t i o n and P h i l o s o p h y P r e c e d e Goal Development," Modern H o s p i t a l , 103 (September, 1964), p. 136. H.E. P e p l a u , I n t e r p e r s o n a l R e l a t i o n s i n N u r s i n g (New York: C P . Putman & Sons, 1952]^ 5 B.K. Redman, The P r o c e s s o f P a t i e n t T e a c h i n g i n N u r s i n g , 2nd E d i t i o n ( S t . L o u i s : The C.V. Mosby Co., 1972). g M.L. P o h l , " T e a c h i n g A c t i v i t i e s o f t h e N u r s i n g P r a c t i t i o n e r . N u r s i n g R e s e a r c h , 14 ( W i n t e r , 1965), pp. 4-11. 4  2  to evaluate the e f f e c t that t h i s intervention i s having on the well being of the patient and his s i g n i f i c a n t other.  The focus of t h i s  i n v e s t i g a t i o n i s e l d e r l y patients who have had permanent cardiac pacemakers i n s e r t e d .  The nurse i n v e s t i g a t o r w i l l i n d i v i d u a l l y assess  the educational and emotional needs of these patients and t h e i r s i g n i f i c a n t other and w i l l attempt to meet these needs by employing a nursing intervention that consists of planned patient teaching and psychological support.  The i n v e s t i g a t o r w i l l examine how planned  patient teaching and psychological support during h o s p i t a l i z a t i o n enhance the a d a p t a b i l i t y of the patient and his s i g n i f i c a n t other a f t e r the i n s e r t i o n of a permanent pacemaker.  THE PROBLEM  Statement The general question which t h i s study i s attempting to answer is:  Does patient teaching and psychological support enhance the  a d a p t a b i l i t y of the e l d e r l y person with a permanent pacemaker? S p e c i f i c a l l y ; a f t e r the i n s e r t i o n of a permanent pacemaker, 1.  W i l l there be a change in the knowledge base of the patient and his s i g n i f i c a n t other a f t e r r e c e i v i n g teaching and psychological support?  3 2.  W i l l t h e r e be a change i n t h e a n x i e t y l e v e l o f t h e p a t i e n t and h i s s i g n i f i c a n t o t h e r a f t e r r e c e i v i n g t e a c h i n g and psychological  3.  support?  W i l l t h e r e be a change i n a c t i v i t y l e v e l o f t h e p a t i e n t a f t e r r e c e i v i n g t e a c h i n g and p s y c h o l o g i c a l  4.  support?  W i l l t h e p a t i e n t and h i s s i g n i f i c a n t o t h e r be a b l e t o d e m o n s t r a t e p u l s e t a k i n g a f t e r r e c e i v i n g t e a c h i n g and psychological  support?  Significance "The age o f p a t i e n t e d u c a t i o n i s upon us and we a r e n o t ready. These words o f Dr. B a r b a r a today.  Redman r i n g t r u e i n t h e n u r s i n g  profession  T h e r e i s an o v e r w h e l m i n g f e e l i n g o f n o r m l e s s n e s s w i t h  to health c o u n s e l l i n g .  respect  P a t i e n t e d u c a t i o n , i n t h e p a s t , was a  humane a c t f o r w h i c h we were n o t h e l d a c c o u n t a b l e  reasonably  but c u r r e n t l y i t i s  c o n s i d e r e d t o be a f o r m o f t h e r a p y f o r w h i c h p r a c t i c e laws h o l d us responsible.  A c c o r d i n g t o Redman, no one has s y s t e m a t i c a l l y t e s t e d  the amount and k i n d o f p a t i e n t e d u c a t i o n t h a t can be p r o v i d e d as p a r t 2 o f t h e c a r e g i v e n by an a d e q u a t e l y  p r e p a r e d and s u p p o r t e d  A strong b e l i e f i n the value o f health education chronically ill i s frequently expressed—but  staff. f o r the  i s i t a c t e d upon? I t  ^B.K. Redman, " G u i d e l i n e s f o r Q u a l i t y o f Care i n P a t i e n t E d u c a t i o n , " C a n a d i a n Nurse ( F e b r u a r y , 1 9 7 5 ) , p. 19. 2  I b i d . , p. 20.  4  was o n l y t e n y e a r s ago t h a t Canada f i r s t a t t e m p t e d t o a s c e r t a i n the problems o f the aged.  One o f the recommendations  o f the F i n a l  Report  o f t h e S p e c i a l Committee o f the S e n a t e on A g i n g s a i d t h a t t h e r e i s a "need t o d e v e l o p p o s i t i v e and p r e v e n t i v e measures which would e n a b l e o l d e r p e o p l e t o c o n t i n u e t o l i v e h e a l t h y and u s e f u l l i v e s as members o f t h e C a n a d i a n Community."^  The commonest d e s i r e s as e x p r e s s e d by the  e l d e r l y p e o p l e i n t e r v i e w e d f o r t h a t r e p o r t were t o m a i n t a i n a s a t i s f a c t o r y f o o t h o l d i n t h e community, t o m a i n t a i n a s e n s e o f s e l f - w o r t h and t o be as i n d e p e n d e n t as p o s s i b l e .  One o f t h e p r i m a r y g o a l s o f  h e a l t h t e a c h i n g i s t h a t o f i n c r e a s i n g the p e r s o n ' s  independence.  The number o f e l d e r l y p e r s o n s ( i . e . , o v e r 65 y e a r s o f age) has i n c r e a s e d f i v e t i m e s between 1901 and 1961,whereas, t h e whole p o p u l a t i o n o f Canada has i n c r e a s e d o n l y t h r e e t i m e s i n t h a t same time 3 period. The number o f e l d e r l y p e o p l e i n Canada i n 1961 was a p p r o x i 4  m a t e l y 1.5 m i l l i o n . The p r o p o r t i o n o f o l d e r p e o p l e i n t h e p o p u l a t i o n was 7.6 p e r c e n t i n 1961 w i t h a p r o j e c t e d f i g u r e o f n i n e p e r c e n t i n 5 1981.  The p r o p o r t i o n o f p e o p l e o v e r s i x t y - f i v e y e a r s o f age by  province varies considerably but  B r i t i s h Columbia has t h e h i g h e s t  F i n a l R e p o r t o f the S p e c i a l Committee o f t h e S e n a t e on A g i n g (Ottawa: Queen's P r i n t e r and C o n t r o l l e r o f S t a t i o n a r y , 1966), p. VII. 2  I b i d . , pp.  8-15.  3 I b i d . , p. 1. 4  Ibid.  5  Ibid.  5 v a l u e o f 10.2 p e r c e n t . ^  T h i s p r o b a b l y r e f l e c t s the tendency o f o l d e r  p e o p l e t o m i g r a t e here b e c a u s e o f the c l i m a t e .  The e l d e r l y r e p r e s e n t  a s i g n i f i c a n t p e r c e n t a g e o f B r i t i s h C o l u m b i a ' s and Canada's p o p u l a t i o n . They a r e t h e p e o p l e who a r e most l i k e l y t o be a f f e c t e d by c h r o n i c i l l n e s s i n g e n e r a l and h e a r t d i s e a s e i n p a r t i c u l a r .  During  1967,  s l i g h t l y o v e r f i f t y p e r c e n t o f a l l d e a t h s i n Canada were due t o c a r d i o v a s c u l a r d i s e a s e with over t h r e e - q u a r t e r s o f these deaths o c c u r r i n g i n p e o p l e who were a t l e a s t s i x t y - f i v e y e a r s o f age.  The r i s e i n  c o r o n a r y h e a r t d i s e a s e r e f l e c t s , t o a g r e a t e x t e n t , the i n c r e a s i n g p r o p o r t i o n o f o l d e r p e r s o n s i n the p o p u l a t i o n . The number o f e l d e r l y p e o p l e who have permanent pacemakers due t o h e a r t rhythm d i s t u r b a n c e s i s i n c r e a s i n g r a p i d l y .  In the U n i t e d  S t a t e s i n 1970,  1/5000 p e o p l e had a permanent pacemaker (mean a g e = 7 0 ) . 3 t h a t f i g u r e r o s e t o 1/2500. A similar situation exists in  In 1972, 4 Canada.  T h i s s h a r p r i s e i n the number o f p e o p l e w i t h pacemakers can  be a t t r i b u t e d t o an i n c r e a s e i n the f a c i l i t i e s and p e r s o n n e l  capable  o f i n s e r t i n g pacemakers p l u s an e x p a n s i o n o f the c r i t e r i a f o r permanent pacemaker i m p l a n t a t i o n . In summary, t h i s s t u d y i s t i m e l y because i t d e a l s w i t h an o f t e n f o r g o t t e n but e v e r i n c r e a s i n g segment o f the p o p u l a t i o n — t h e ^ F i n a l R e p o r t o f the S p e c i a l Committee o f the Senate on A g i n g (Ottawa: Queen's P r i n t e r and C o n t r o l l e r o f S t a t i o n a r y , 1966), p. 2. 2  V i t a l S t a t i s t i c s - Canada. 1967, Dominion Bureau o f S t a t i s t i c s (Ottawa: The Queen's P r i n t e r , 1969), p. 22. 3 V. P a r s o n n e t , "A S u r v e y o f C a r d i a c P a c i n g i n the U.S. & Canada," C a r d i a c P a c i n g , P r o c e e d i n g s o f the F o u r t h I n t e r n a t i o n a l Symposium on C a r d i a c P a c i n g , T h a l e n , H.J. TH., e d i t o r (The N e t h e r l a n d s : Van Gorcum & Co., 1973), p. 43. 4  I b i d . , p. 44.  6  e l d e r l y ; an i l l n e s s w h i c h e x i s t s i n e p i d e m i c p r o p o r t i o n s on o u r s o c i e t y c a r d i o v a s c u l a r d i s e a s e ; and a p o o r l y r e s e a r c h e d nursing i n t e r v e n t i o n — p a t i e n t  b u t o f t e n used mode o f  education.  DESCRIPTION OF THE STUDY  Purpose The p u r p o s e o f t h i s s t u d y i s : 1.  to evaluate a nursing i n t e r v e n t i o n that consists o f planned p a t i e n t t e a c h i n g and p s y c h o l o g i c a l  2.  t o improve t h e q u a l i t y o f p a t i e n t c a r e as i t r e l a t e s t o patient  3.  support,  education,  t o i n c r e a s e t h e f e e l i n g o f i n d e p e n d e n c e and s e l f - c o n t r o l on the p a r t o f t h e p a t i e n t ,  4.  t o p r o v i d e p a t i e n t s and t h e i r s i g n i f i c a n t o t h e r s w i t h i n formation  related to t h e i r altered health status,  r e g i m e and s u b s e q u e n t l i f e s t y l e .  Hypotheses The h y p o t h e s e s t o be t e s t e d a r e :  medical  7  1.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  increase  the knowledge base o f t h e p a t i e n t a n d h i s s i g n i f i c a n t other. 2.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  decrease  the s t a t e and t r a i t a n x i e t y l e v e l s o f the p a t i e n t and h i s significant 3.  other.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  enable  the p a t i e n t and h i s s i g n i f i c a n t o t h e r to d e m o n s t r a t e pulse taking. 4.  P a t i e n t teaching psychological support w i l l maintain  and  i n c r e a s e the a c t i v i t y l e v e l o f the p a t i e n t f r o m h i s p r e operative state.  Variables The d e p e n d e n t v a r i a b l e i n t h i s s t u d y i s the p a t i e n t ' s a b i l i t y t o a d a p t to the i n s e r t i o n o f a permanent pacemaker as e v i d e n c e d i n c r e a s e d knowledge b a s e , h i s d e c r e a s e d  by h i s  a n x i e t y l e v e l , h i s a b i l i t y to  d e m o n s t r a t e p u l s e t a k i n g and the m a i n t e n a n c e o r i n c r e a s e i n h i s a c t i v i t y as compared w i t h h i s p r e - o p e r a t i v e l e v e l .  The i n d e p e n d e n t v a r i a b l e  i s the n u r s i n g i n t e r v e n t i o n t h a t p r o v i d e s p l a n n e d , and p s y c h o l o g i c a l  support.  patient  teaching  8 R a t i o n a l e f o r t h e C h o i c e o f Dependent V a r i a b l e s The measurement o f change i n knowledge base as an outcome o f p l a n n e d p a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t was chosen as one o f the f o u r dependent v a r i a b l e s because o f i t s obvious the v a r i o u s e l e m e n t s i n t h e c o g n i t i v e domain.  reflection of  The q u e s t i o n n a i r e w h i c h  e v a l u a t e s t h e knowledge base o f t h e s u b j e c t s c o n t a i n s items w h i c h demonstrate r e c a l l o f facts,comprehension,  application, analysis,  s y n t h e s i s and e v a l u a t i o n . ^ I t has been assumed i n t h i s s t u d y t h a t p a t i e n t s u n d e r g o i n g s u r g e r y f o r t h e i m p l a n a t i o n o f a permanent c a r d i a c pacemaker w i l l e x h i b i t some d e g r e e o f a n x i e t y .  Many n u r s e s b e l i e v e t h a t , by p r o v i d i n g  p a t i e n t s and t h e i r f a m i l i e s w i t h i n f o r m a t i o n t h a t i s t a i l o r e d t o meet the p a t i e n t ' s e d u c a t i o n a l n e e d s , a n x i e t y w i l l be r e d u c e d .  Redman  and  3  Skipper  s u p p o r t t h i s n o t i o n by s t r e s s i n g t h a t t h e r e i s a d i r e c t  r e l a t i o n s h i p between h e a l t h t e a c h i n g and a n x i e t y r e d u c t i o n .  Therefore,  a change i n a n x i e t y l e v e l as an outcome o f p l a n n e d p a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t was c o n s i d e r e d an a p p r o p r i a t e  dependent  variable. B.K. Redman, The P r o c e s s o f P a t i e n t T e a c h i n g i n N u r s i n g , 1 s t E d . . ( S t . L o u i s : The C.V. Mosby Co., 1968), pp. 52-53. 2  I b i d . , p. 3.  3  J.K. S k i p p e r . "Communication and t h e H o s p i t a l i z e d P a t i e n t , " S o c i a l I n t e r a c t i o n and P a t i e n t Care, S k i p p e r , J.K., and L e o n a r d , R . C , e d i t o r s ( P h i l a d e l p h i a : J.B. L i p p i n c o t t Co., 1 9 6 5 ) , pp. 61-82.  9 When c o n s i d e r i n g i f l e a r n i n g has o c c u r r e d , the n u r s e e v a l u a t e the degree t o w h i c h the p a t i e n t has mastered skills.  can  psychomotor  In the c a s e o f the p a t i e n t w i t h a permanent pacemaker, the  t a k i n g o f one's p u l s e i s an a p p r o p r i a t e t a s k t h a t e n a b l e s the p a t i e n t o r f a m i l y member t o a s s e s s the p r o p e r f u n c t i o n i n g o f t h i s e l e c t r i c a l device.  The l o w e r i n g i n p u l s e r a t e o v e r time i s a r e l i a b l e i n d i c a t o r  o f impending  battery failure.^  Whether o r not the p a t i e n t o r f a m i l y  member can p e r f o r m t h i s p s y c h o m o t o r s k i l l and i n t e r p r e t the s i g n i f i cance o f the p u l s e r a t e was c o n s i d e r e d t o be a c r i t e r i o n o f the e f f e c t i v e n e s s o f the t e a c h i n g programme and the e m o t i o n a l  support.  Maddox and E i s d o r f e r say t h a t t h e r e i s a p o s i t i v e a s s o c i a t i o n between m a i n t e n a n c e o r e x p a n s i o n o f a c t i v i t y and p e r s o n a l 2 o r h i g h m o r a l e among the e l d e r l y .  adjustment  C l a r k and A n d e r s o n s t u d i e d the  s o u r c e s o f h i g h m o r a l e among the aged and found t h a t the top t h r e e items d e a l t w i t h d i f f e r e n t k i n d s o f a c t i v i t i . e s .  That i s , s i x t y - n i n e  p e r c e n t o f t h e sample i d e n t i f i e d e n t e r t a i n m e n t s and d i v e r s i o n s as a s o u r c e o f h i g h m o r a l e , f i f t y - s e v e n p e r c e n t m e n t i o n e d s o c i a l i z i n g and f i f t y - f o u r percent r e p l i e d that productive a c t i v i t y created high 3  morale.  Kos and C u l b e r t found t h a t a c t i v i t i e s and r e s t r i c t i o n s  g e n e r a t e d the most i n t e r e s t and t h e g r e a t e s t number o f q u e s t i o n s when ^M. Dunst, " C a r d i a c Pacemakers," M e d i c a l C l i n i c s o f N o r t h A m e r i c a , 57 (November, 1973), pp. 1515-1524. 2 G. Maddox and C. E i s d o r f e r , "Some C o r r e l a t e s o f A c t i v i t y and Morale Among the E l d e r l y , " S o c i a l F o r c e s , 40 (1962), pp. 254-260. 3  M. C l a r k and B. A n d e r s o n , C u l t u r e and A g i n g ( S p r i n g f i e l d , I l l i n o i s : C h a r l e s C. Thomas, 1967), p. 211.  10 4 t h e y s t u d i e d a group o f t w e n t y - s i x  p a t i e n t s w i t h permanent pacemakers.  A p e r s o n ' s l e v e l o f a c t i v i t y i n t h i s s t u d y i s seen as an i n d i c a t o r o f h i s p e r c e p t i o n o f h i s s t a t e o f h e a l t h and h i s m o r a l e .  I t i s hoped  t h a t p a t i e n t e d u c a t i o n and p s y c h o l o g i c a l s u p p o r t w i l l be a b l e t o d i s p e l f e a r s r e g a r d i n g e x e r c i s e and h e a r t d i s e a s e and i n f l u e n c e the  subject's  w e l l b e i n g i n g e n e r a l and l e v e l o f a c t i v i t y i n p a r t i c u l a r . D e f i n i t i o n o f Terms Adaptation:  A s t a t e o f b e i n g t h a t r e f l e c t s a change i n knowledge and  understanding;  a change i n t e c h n i c a l s k i l l s and h a b i t s ; and  a change i n a t t i t u d e s and Patient Teaching:  appreciations.  Any a c t i v i t y by w h i c h the n u r s e h e l p s the p a t i e n t  and h i s s i g n i f i c a n t o t h e r to l e a r n and u n d e r s t a n d a s p e c t s o f h e a l t h and Psychological Support:  the  various  illness.  An i n t e r a c t i o n p r o c e s s between the p a t i e n t ,  the s i g n i f i c a n t o t h e r and the n u r s e t h a t aims to p r o v i d e o p p o r t u n i t i e s to express to express concerns,  i n d i v i d u a l i t y , to f e e l  understood,  t o e x p l o r e problems and t o seek  solutions. Anxiety:  A complex, m u l t i d i m e n s i o n a l  behavioural  e v e n t i n f l u e n c e d by  s i t u a t i o n a l , p e r s o n a l i t y and mode o f r e s p o n s e f a c t o r s p l u s ^B. Kos and B. C u l b e r t , " T e a c h i n g P a t i e n t s About Pacemakers," A m e r i c a n J o u r n a l o f N u r s i n g , 21 (March, 1971), p. 526.  11 their interactionsJ  D i s t r e s s , f e a r , t e n s i o n and d i s -  c o m f o r t a r e c o n s i d e r e d t o be synonymous w i t h a n x i e t y i n this  study.  State Anxiety:  A t r a n s i t o r y , emotional  s t a t e o r c o n d i t i o n o f the  human o r g a n i s m c h a r a c t e r i z e d by s u b j e c t i v e ,  consciously  p e r c e i v e d f e e l i n g s o f t e n s i o n and a p p r e h e n s i o n ,  and  heightened  2  autonomic nervous system a c t i v i t y . Trait Anxiety:  A r e l a t i v e l y s t a b l e i n d i v i d u a l d i f f e r e n c e i n the  t e n d e n c y to r e s p o n d t o s i t u a t i o n s p e r c e i v e d as  threatening  3  with elevations in state anxiety i n t e n s i t y . Nursing Intervention: gical Activity Level:  A combination  o f p a t i e n t t e a c h i n g and  psycholo-  support. The number o f a c t i v i t i e s t h a t the p a t i e n t r e p o r t s he  can p e r f o r m as d e t e r m i n e d  by the a c t i v i t y c h e c k l i s t .  (See  Appendix C ) . Knowledge B a s e :  The number o f c o r r e c t r e s p o n s e s  made by the p a t i e n t  and h i s s i g n i f i c a n t o t h e r on a q u e s t i o n n a i r e b a s e d on a s l i d e t a p e programme on permanent pacemakers. (See A p p e n d i x E ) .  Vol. 1  I p a u l M c R e y n o l d s , e d i t o r , Advances i n P s y c h o l o g i c a l A s s e s s m e n t , ( P a l o A l t o , C a l i f o r n i a : S c i e n c e & B e h a v i o u r Books I n c . , 1968). 2  C D . S p i e l b e r g e r , R.L. G o r s u c h and R.E. L u s c h e n e , STAI Manual ( P a l o A l t o , C a l i f o r n i a : C o n s u l t i n g P s y c h o l o g i s t P r e s s , I n c . , 1970), p. 3. 3 I b i d . , p. 3.  12 S i g n i f i c a n t Other:  Any f a m i l y member o r f r i e n d t h a t t h e p a t i e n t l i v e s  w i t h o r d e s c r i b e s as b e i n g i m p o r t a n t o r c l o s e t o him.  Assumptions T h i s s t u d y makes t h e f o l l o w i n g a s s u m p t i o n s : 1.  H a v i n g a permanent pacemaker i n s e r t e d i s an a n x i e t y p r o v o k i n g e v e n t f o r both t h e p a t i e n t a n d h i s s i g n i f i c a n t other.  2.  A n x i e t y can be measured.  3.  Adaptation to s t r e s s o r anxiety i s b a s i c to the continued well being o f the p a t i e n t .  4.  P u l s e t a k i n g i s a s i m p l e and r e l i a b l e means o f d e t e r m i n i n g w h e t h e r o r n o t a pacemaker i s f u n c t i o n i n g e f f e c t i v e l y .  5.  Each p e r s o n has h i s own a c t i v i t y l e v e l based on h i s i n d i v i d ual p a t t e r n o f l i v i n g .  Methodology An e x p e r i m e n t a l s t u d y , u s i n g a p r e t e s t - p o s t t e s t c o n t r o l group d e s i g n , was s e l e c t e d t o s t u d y t h e e f f e c t o f p l a n n e d p a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t on t h e a d a p t a b i l i t y o f t h e e l d e r l y p a t i e n t t o t h e i n s e r t i o n o f a permanent c a r d i a c pacemaker.  The s u b j e c t s i f ;  t h e y met c e r t a i n s e l e c t i o n c r i t e r i a , , > w e r e randomly a s s i g n e d t o e i t h e r  13 the e x p e r i m e n t a l  o r c o n t r o l group.  The members o f the  experimental  groups were seen i n d i v i d u a l l y on o r about the t h i r d , f o u r t h and p o s t o p e r a t i v e day.  fifth  They were e n c o u r a g e d t o e x p r e s s t h e i r f e e l i n g s  and c o n c e r n s and to ask any q u e s t i o n s w h i c h a r o s e i n r e l a t i o n t o t h e i r pacemaker. makers.  They were a l s o shown a s l i d e - t a p e programme a b o u t paceThe members o f the c o n t r o l group r e c e i v e d the u s u a l  nursing  c a r e t h a t was p r o v i d e d by the ward n u r s i n g s t a f f . At approximately  two and f o u r weeks a f t e r the p a t i e n t s were  d i s c h a r g e d , the n u r s e i n v e s t i g a t o r v i s i t e d a l l o f the s u b j e c t s and measured t h e i r knowledge b a s e , a n x i e t y ( s t a t e and t r a i t ) l e v e l pulse taking a b i l i t y . a l s o measured.  The a c t i v i t y l e v e l o f the p a t i e n t s a l o n e  was  The d a t a g a t h e r e d c o n c e r n i n g mean changes i n knowledge  b a s e , a n x i e t y l e v e l and a c t i v i t y l e v e l o v e r time was a n a l y z e d using a o n e - t a i l t t e s t . used to d e t e r m i n e  and  by  A Fisher-Yates Exact P r o b a b i l i t y Test  was  the s i g n i f i c a n c e o f the d i f f e r e n c e i n p u l s e t a k i n g  a b i l i t y between t h e two  groups.  L i mi t a t i o n s B e c a u s e the sample s i z e i s s m a l l and w i l l o n l y i n c l u d e p a t i e n t s f i f t y y e a r s o f age and o v e r , the g e n e r a l i z a b i l i t y o f the r e s u l t s w i l l be r e s t r i c t e d .  A l s o , the nurse i n v e s t i g a t o r w i l l be u s i n g a n u r s i n g  i n t e r v e n t i o n t h a t i m p l i e s t h a t the s u b j e c t s can r e a d and w r i t e E n g l i s h and t h a t t h e y can e x t r a c t i n f o r m a t i o n from a s l i d e - t a p e programme. O b v i o u s l y , a v e r y d i f f e r e n t a p p r o a c h w o u l d be needed f o r the i l l i t e r a t e p e r s o n o r one who does n o t speak E n g l i s h . F a c t o r s c r e a t i n g l i m i t a t i o n s f o r the v a r i a b l e s used i n t h i s s t u d y i n c l u d e the amount o f time the n u r s e i n v e s t i g a t o r spends w i t h the e x p e r i m e n t a l  p a t i e n t s , the l a c k o f c o n t r o l o v e r the number o f  people  14 who i n t e r a c t w i t h t h e p a t i e n t and t h e n a t u r e o f t h e i n t e r a c t i o n s a f t e r the s u r g e r y , t h e t e a c h a b l e moment, a n d , w h e t h e r t h e d e f i n i t i o n o f a d a p t a b i l i t y i n t h i s s t u d y encompasses measures t h a t a r e s u f f i c i e n t l y s e n s i t i v e t o i n d i c a t e change. The p a t i e n t s i n t h i s s t u d y w i l l be p r e t e s t e d w i t h r e s p e c t t o t h e i r knowledge b a s e , a c t i v i t y a n d s t a t e and t r a i t a n x i e t y l e v e l . I t i s p o s s i b l e t h a t t h e p r e t e s t i n g m i g h t enhance t h e i r a d a p t a b l i t y i n the d e s i r e d d i r e c t i o n s i m p l y b e c a u s e i t has f o c u s s e d t h e i r a t t e n t i o n on what t h e i n v e s t i g a t o r w i s h e d t o measure.  Another question  that  a r i s e s i s whether t h e p e r s o n a l i t y o f the i n v e s t i g a t o r a f f e c t s the d e s i r e d outcome o r n o t .  To a s c e r t a i n t h i s , t h e s t u d y would need  to be r e p l i c a t e d u s i n g a d i f f e r e n t i n v e s t i g a t o r . L i m i t a t i o n s a r e p r e s e n t i n t h e d a t a c o l l e c t i n g methods b e c a u s e the n u r s e i n v e s t i g a t o r i s r e l y i n g on s e l f - r e p o r t by p a t i e n t s as a means o f e v a l u a t i n g t h e i r a c t i v i t y l e v e l . w i l l a l s o be t h e p e r s o n who a d m i n i s t e r s  The n u r s e i n v e s t i g a t o r  t h e p o s t t e s t and a l t h o u g h  she w i l l t r y t o be as u n b i a s e d as p o s s i b l e , s h e w i l l be aware o f w h e t h e r t h e p a t i e n t i s a member o f t h e e x p e r i m e n t a 1 o r group.  control  15 SUMMARY  C h a p t e r I has p r o v i d e d an o v e r v i e w o f the s t u d y .  I t has s t a t e d  the p r o b l e m to be i n v e s t i g a t e d and i t s s i g n i f i c a n c e i n t h e n u r s i n g p r o f e s s i o n today.  The p u r p o s e , h y p o t h e s e s , v a r i a b l e s , a s s u m p t i o n s and  d e f i n i t i o n o f terms t h a t p r o v i d e a framework f o r the s t u d y have been outlined. limitations.  The methodology has been b r i e f l y d e s c r i b e d as w e l l as the  16  CHAPTER I I LITERATURE REVIEW  INTRODUCTION  The e l d e r l y p e r s o n w i t h a permanent c a r d i a c pacemaker i s t h e subject o f t h i s c r i t i c a l review o f the l i t e r a t u r e .  The p u r p o s e and  c u r r e n t s t a t u s o f i m p l a n t e d c a r d i a c pacemakers w i l l f i r s t be a s s e s s e d and then t h e c o n c e r n s o f t h o s e who have a pacemaker w i l l be e x p l o r e d . P e r t i n e n t s t u d i e s from t h e n u r s i n g l i t e r a t u r e w i l l be c r i t i q u e d .  The  c o n c e p t o f a n x i e t y as used i n t h i s s t u d y w i l l be examined and a g a i n r e l e v a n t n u r s i n g l i t e r a t u r e on a n x i e t y r e d u c t i o n w i l l be c i t e d .  Health  t e a c h i n g w i l l be a c e n t r a l f o c u s and v a r i o u s elements o f t h e t e a c h i n g l e a r n i n g p r o c e s s w i l l be c o n s i d e r e d as t h e y r e l a t e t o p h y s i o l o g i c a l , c u l t u r a l and p s y c h o l o g i c a l a g i n g .  Means o f f a c i l i t a t i n g l e a r n i n g  w i l l a l s o be p r e s e n t e d .  IMPLANTED CARDIAC PACEMAKERS Historical  Development  G a l v a n i , i n 1791, o b s e r v e d t h a t muscle would r e s p o n d t o e l e c trical stimulationJ  Galvani's d i s c o v e r y heralded the development o f  ^S. Furman, "Fundamentals o f C a r d i a c P a c i n g , " American J o u r n a l , 73 ( 1 9 6 7 ) , p. 261.  Heart  17 The s o p h i s t i c a t e d c a r d i a c pacemakers t h a t a r e used today.  The 1800's  were a v e r y i n a c t i v e p e r i o d a s f a r a s f u r t h e r advancement o f G a l v a n i ' s f i n d i n g were c o n c e r n e d and i t was n o t u n t i l t h e 1930's t h a t Wiggers demonstrated the p h y s i o l o g i c e f f e c t s o f s t i m u l a t i n g the heart i n animals J  Z o l l , i n 1952, d e v e l o p e d  the technique  o f closed  c h e s t s t i m u l a t i o n o f t h e human h e a r t w h i c h p r o v e d t o be l i f e  saving  i n many i n s t a n c e s and began t h e e r a o f t h e w i d e s p r e a d use o f devices that e l e c t r i c a l l y stimulated the heart. s p u r r e d by t h e o c c u r r e n c e  W e i r i c h , i n 1957,  o f s u r g i c a l l y induced a t r i o - v e n t r i c u l a r  d i s s o c i a t i o n , demonstrated the c l i n i c a l f e a s i b i l i t y o f s t i m u l a t i n g the h e a r t w i t h w i r e l e a d s w h i c h e x i t e d t h r o u g h  the chest wall and  connected  The next m a j o r change  t o an e x t e r n a l p u l s e g e n e r a t o r .  t o o c c u r i n pacemaker t e c h n o l o g y was d e m o n s t r a t e d by Furman and R o b i n s o n i n 1958.  They showed t h a t t h e e n d o c a r d i a l s u r f a c e o f t h e  human r i g h t v e n t r i c l e c o u l d be s t i m u l a t e d on a s h o r t term b a s i s by a transvenously  introduced unipolar cardiac catheter.  h i s a s s o c i a t e s i n 1959 d e v e l o p e d  the f i r s t implanted  for pulsed stimulation o f the heart v i a radio  Journal.  ^1%TV'^K"^'2 °F CARDIAC 2 I b i d . , pp. 261-277. 3 I b i d . , p . 261. 4 I b i d . , p . 262. 5  Ibid.  G l e n n and  pacemater system 5 frequencies. The  " ^ " 9 . " American  fart  18 e a r l y u n r e l i a b l e component o f the pacemaker s y s t e m were the e l e c t r o d e s . They have now been improved g r e a t l y and c o u p l e d w i t h s e l f - c o n t a i n e d i m p l a n t e d p u l s e g e n e r a t o r s p o s s e s s i n g the n e c e s s a r y c i r c u i t and c h e m i c a l o r n u c l e a r c e l l s f o r the p r o d u c t i o n o f energy adequate h e a r t f o r many y e a r s .  t o s t i m u l a t e the  I n i t i a l l y , a l l p u l s e g e n e r a t o r s were o f the  f i x e d r a t e mode but l a t e r a pacemaker model was d e v e l o p e d which c o u l d sense the p e r s o n ' s i n t r i n s i c h e a r t r a t e and would f i r e o n l y i f the p e r s o n ' s own h e a r t r a t e f e l l below the r a t e a t which t h i s "demand" pacemaker was s e t .  Nathan and h i s a s s o c i a t e s , i n 1963, p r o d u c e d a  pacemaker which s t i m u l a t e d the v e n t r i c l e i n r e s p o n s e t o a t r i a l s y s t o l e , w i t h a c a r d i a c r a t e s e n s i t i v e t o t h o s e p h y s i o l o g i c (and sometimes pathologic)  s t i m u l i which c o n t r o l t h e  atrial  rateJ  In summary, c a r d i a c pacemaker t e c h n o l o g y has f l o u r i s h e d i n the p a s t twenty y e a r s .  The components o f the pacemaker s y s t e m ( p u l s e  g e n e r a t o r , l e a d , e l e c t r o d e s ) have undergone many s o p h i s t i c a t e d changes i n o r d e r t o e n s u r e the s a f e t y , c o m f o r t and h e a l t h o f t h e w e a r e r . T h e p r e s e n t approach o f c h o i c e i s the t r a n s v e n o u s p o s i t i o n i n g o f a b i p o l a r c a t h e t e r s o t h a t the t i p o f the c a t h e t e r i s embedded i n the r i g h t ventricular wall.  The p u l s e g e n e r a t o r i s then i m p l a n t e d  i n the c h e s t w a l l under the r i g h t o r l e f t c l a v i c l e . approaches  subcutaneously  There are other  but t h i s i s the one most commonly u s e d .  ^S. Furman, "Fundamentals o f C a r d i a c P a c i n g , " American J o u r n a l , 73 ( 1 9 6 7 ) , p. 262. 2  Heart  V. P a r s o n n e t , "A Summary o f C a r d i a c P a c i n g i n the U.S. and Canada," C a r d i a c P a c i n g , P r o c e e d i n g s o f the F o u r t h I n t e r n a t i o n a l Symposium on C a r d i a c P a c i n g , T h a l e n , H.J. TH, e d i t o r (The N e t h e r l a n d s : Van Gorcum & Co., 1973), p . 43.  19 TyP  e s  T h e r e a r e two b a s i c t y p e s o f p a c e m a k e r s : 1.  P a r a s y s t o l i c ( a l s o known as c o m p e t i t i v e , a s y n c h r o n o u s ,  fixed  rate), 2.  N o n p a r a s y s t o l i c ( a l s o known as n o n c o m p e t i t i v e ,  synchronous  demand). P a r a s y s t o l i c pacemakers a r e t h e o l d e s t type and s t i m u l a t e t h e h e a r t a t a f i x e d r a t e i n d e p e n d e n t o f t h e h e a r t ' s own e l e c t r i c a l  activity.  The main problem w i t h t h i s type o f pacemaker i s t h a t i t can g i v e r i s e to c o m p e t i t i o n w i t h t h e p e r s o n ' s i n t r i n s i c h e a r t r a t e and i n c r e a s e t h e l i k e l i h o o d t h a t a pacemaker s p i k e c o u l d f i r e i n t h e v u l n e r a b l e phase o f t h e h e a r t c y c l e and p o t e n t i a l l y i n d u c e v e n t r i c u l a r f i b r i l l a t i o n . N o n p a r a s y s t o l i c pacemakers a r e c o n t r o l l e d by t h e i n t r i n s i c e l e c t r i c a l a c t i v i t y o f the heart.  Two g e n e r a l s u b t y p e s a r e t h e v e n t r i c -  u l a r i n h i b i t e d demand pacemaker and t h e v e n t r i c u l a r t r i g g e r e d demand pacemaker.  The f o r m e r i s c o n s t r u c t e d so t h a t i t s ' pacemaker a c t i v i t y  i s s u p p r e s s e d by an e l e c t r i c a l s i g n a l from t h e h e a r t .  The l a t t e r  e m i t s an i m p u l s e i n t o t h e a b s o l u t e r e f r a c t o r y p e r i o d o f each QRS complex i t senses.  In t h e absence, o f a s i g n a l from t h e h e a r t , t h e u n i t r e -  v e r t s t o i t s own a u t o m a t i c r a t e and p a c e s .  N o n p a r a s y s t o l i c pacemakers  o f t h e v e n t r i c u l a r i n h i b i t e d subtype a r e most commonly used.  America,  "M. Dunst, " C a r d i a c Pacemakers," M e d i c a l C l i n i c s o f N o r t h 57 (1973), p. 1517.  20 Indications About f i v e y e a r s ago, the main i n d i c a t i o n f o r a permanent c a r d i a c pacemaker was f i x e d , s y m p t o m a t i c complete  heart b l o c k J  Nowadays, o v e r  o n e - h a l f o f the p a t i e n t s w i t h permanent pacemakers have them i n s e r t e d f o r sinus a r r e s t , h e a r t block secondary to d i g i t a l i s therapy, symptomatic second degree h e a r t b l o c k , b r a d y c a r d i a - t a c h y c a r d i a syndrome, and  suspected  b l o c k a s s o c i a t e d w i t h r i g h t bundle b r a n c h b l o c k and l e f t a n t e r i o r 2 hemiblock.  Complications C o m p l i c a t i o n s a r i s i n g from permanent pacemaker i n s e r t i o n can be e x p e c t e d to o c c u r l e s s than f i v e p e r c e n t o f the time i n Canada and 3  the U n i t e d S t a t e s .  B a t t e r y d e p l e t i o n i s the commonest c a u s e o f pace4  maker m a l f u n c t i o n . 5 by Dunst  The f o l l o w i n g t a b l e e x t r a p o l a t e d f r o m an a r t i c l e  summarizes the p o t e n t i a l c o m p l i c a t i o n s a r i s i n g from the v a r i o u s  components o f the pacemaker  system.  M. D u n s t , " C a r d i a c Pacemakers" M e d i c a l C l i n i c s o f N o r t h A m e r i c a , 57 (November, 1973), p. 1518. 2 V. P a r s o n n e t , "A S u r v e y o f C a r d i a c P a c i n g i n t h e U.S. and Canada," C a r d i a c P a c i n g , P r o c e e d i n g s o f the F o u r t h I n t e r n a t i o n a l Symposium on C a r d i a c P a c i n g , T h a l e n , H.J. TH., e d i t o r (The N e t h e r l a n d s : Van Gorcum and Co., B.V., 1973), p. 43. 3  R e p o r t o f the I n t e r - S o c i e t y Commission f o r H e a r t D i s e a s e R e s o u r c e s , I m p l a n t a b l e C a r d i a c Pacemakers , C i r c u l a t i o n , 50 ( O c t o b e r , 1974), A 21-A 35. 4 M. D u n s t , op. c i t . , p. 5  I b i d . , pp. 1521-1522.  1521.  2:]  TABLE 1 P o t e n t i a l C o m p l i c a t i o n s o f Permanent Pacemakers  Component o f t h e Pacemaker System Pulse  generator  Potential Complication battery failure defective pulse  generator  internal short circuiting  Leads and e l e c t r o d e s  improper connection o f leads to pulse generator lead fractures lead  displacements  myocardial p e r f o r a t i o n  Myocardial f a c t o r s  increased threshold of heart muscle to l o c a l e l e c t r i c a l stimulation increased e l e c t r i c a l resistance  Other  wound i n f e c t i o n c o m p e t i t i o n between t h e pacemaker and t h e h e a r t ' s own rhythm i n t e r f e r e n c e from e l e c t r o m a g n e t i c sources  22 Follow-Up Care Long term f o l l o w - u p o f p e o p l e w i t h permanent pacemakers i s mandatory.  D i f f e r e n t pacemaker models have d i f f e r e n t p r o j e c t e d  b a t t e r y l i f e spans and t h e r e f o r e a l l p a t i e n t s must have t h e i r pacemaker units assessed Approximately  r e g u l a r l y to d i a g n o s i s impending b a t t e r y f a i l u r e . s i x months b e f o r e the a n t i c i p a t e d e n d - o f - l i f e o f the  b a t t e r y , the p a t i e n t should r e c e i v e c l o s e r s u r v e i l l a n c e .  The  commonest  methods o f d e t e c t i n g impending b a t t e r y f a i l u r e a r e : 1.  ECG  recording,  2.  E l e c t r o n i c waveform a n a l y s i s , and  3.  Transtelephone  monitoring.^  D e c l i n i n g r a t e has been a l m o s t u n i f o r m l y a c c e p t e d as e v i d e n c e 2 end-of-1ife. Current Medical Medical  Research r e s e a r c h on c a r d i a c pacemakers has f r o m t h e  p r o v i d e d v e r y good q u a l i t y c o n t r o l . saved w i t h . t h e  of battery  beginning  Many l i v e s have been l e n g t h e n e d  use o f a permanent c a r d i a c pacemaker.  or  Survival rates  o f p a t i e n t s w i t h permanent pacemakers show t h a t a t one y e a r ,  eighty-three  'Report o f the I n t e r - S o c i e t y Commission o f H e a r t D i s e a s e R e s o u r c e s I m p l a n t a b l e C a r d i a c Pacemakers, C i r c u 1 a t i o n , 50 ( O c t o b e r , 1974), A 2 1 A 3 5 . Ibid. 3 L.S. D r e i f u s and D. Cohen, " I m p l a n t e d Pacemakers - M e d i c o l e g a l I m p l i c a t i o n s , " A m e r i c a n J o u r n a l o f C a r d i o l o g y , 36 (August, 1975), p. 266. 2  23 p e r c e n t o f t h e p a t i e n t s a r e s t i l l a l i v e ; a t two y e a r s ,  seventy-seven  percent are s t i l l a l i v e ; a t three years, seventy percent a r e s t i l l and, a t s i x y e a r s , f o r t y - f o u r p e r c e n t a r e s t i l l  alive  alive.'  Dunst has o u t l i n e d t h e c u r r e n t d i r e c t i o n s t h a t a r e b e i n g i n pacemaker r e s e a r c h . 1.  taken  They a r e :  o p e r a t i v e a p p r o a c h e s o t h e r than t h o r a c o t o m y t o a c h i e v e more s t a b l e e l e c t r o d e p o s i t i o n i n g ,  2.  improved e l e c t r o d e s ,  3.  b e t t e r power s o u r c e s  (longer lasting, l i g h t e r , smaller),  and 4.  better understanding heart  mtersurface.  Pacemaker t e c h n o l o g y  o f the physiology o f the e l e c t r o d e 2  has made s t r i k i n g advances based on sound r e s e a r c h  and a s y s t e m a t i c e f f o r t t o implement t h e s e f i n d i n g s i n t h e c l i n i c a l field.  The s a f e t y and s e c u r i t y o f t h e person w e a r i n g t h e pacemaking  d e v i c e has been t h e g u i d i n g p r i n c i p l e f o r t h o s e i n v o l v e d i n b a s i c  medical  research.  V"Pacemaker P e o p l e " ( E d i t o r i a l ) , C a n a d i a n M e d i c a l J o u r n a l , 111 (December 21, 1974), p. 1298. 2  Association  M. Dunst, " C a r d i a c Pacemakers," M e d i c a l C l i n i c s o f N o r t h A m e r i c a , 57 (November, 1973), p. 1524.  24 CONCERNS OF THE SURGICAL PATIENT  Many d e s c r i p t i v e s t u d i e s a r e a v a i l a b l e on t h e p r e - and p o s t o p e r a t i v e concerns o f the general s u r g i c a l p a t i e n t .  B r i e f l y summarized,  t h e s e c o n c e r n s c a n be p l a c e d i n t h e f o l l o w i n g b r o a d c a t e g o r i e s . Fear F e a r o f p a i n and d i s c o m f o r t , f e a r o f t h e unknown and f e a r o f a l t e r e d body image a r e m e n t i o n e d by C a r n e v a l i as b e i n g t h o s e i s s u e s most commonly e x p r e s s e d by p a t i e n t s as t h e y a w a i t e d  surgeryJ  Fear o f the  d i a g n o s i s i t s e l f i s a n o t h e r p o s s i b l e s o u r c e o f a n x i e t y w h i c h sometimes i s m a n i f e s t e d by t h e r e l u c t a n c e o f t h e p a t i e n t t o even ask q u e s t i o n s .  Time F a c t o r s Many p r e - o p e r a t i v e p a t i e n t s a r e c o n c e r n e d factors associated with surgery.  a b o u t t h e time  T h e i r q u e s t i o n s r e v o l v e around i s s u e s  such as when t h e o p e r a t i o n w i l l be p e r f o r m e d , how l o n g i t w i l l 3 4 and when t h e p e r s o n s h o u l d e x p e c t t o r e t u r n home. '  take  D.I. C a r n e v a l i , " P r e o p e r a t i v e A n x i e t y , " A m e r i c a n J o u r n a l o f N u r s i n g , 66 ( J u l y , 1966), pp. 1536-1538. 2  R.E. A l t , " P a t i e n t E d u c a t i o n Program Answers Many Unanswered Q u e s t i o n s , " H o s p i t a l s , 40 (November 16, 1 9 6 6 ) , pp. 76-78. 3 J.R. C a s s i d y and J . A l t r o c c h i , " P a t i e n t ' s C o n c e r n s About S u r g e r y , " N u r s i n g R e s e a r c h , 9 ( F a l l , 1960), pp. 219-221. 4 J.S. Dodge, " F a c t o r s R e l a t e d t o P a t i e n t ' s P e r c e n t i o n s o f T h e i r C o g n i t i v e Needs," N u r s i n g R e s e a r c h , 18 (November - December, 1969), pp. 502-513.  25 The  Illness A t h i r d c a t e g o r y o f commonly e x p r e s s e d c o n c e r n s a r e t h o s e r e -  l a t e d t o the i l l n e s s i t s e l f .  Many p e o p l e wanted more i n f o r m a t i o n about  12 3 4 t h e i r d i a g n o s i s ' ' and the cause o f t h e i r p r e s e n t i l l n e s s . Over oneh a l f o f the p a t i e n t s i n one s t u d y wanted more i n f o r m a t i o n about c o m p l i c a t i o n s o f t h e i r p r e s e n t i l l n e s s i f t h e y d i d n o t c a r e f o r t h e m s e l v e s and 5 more knowledge a b o u t p r e v e n t i t i v e measures.  In terms o f the t y p e o f  i n f o r m a t i o n r e q u e s t e d , perhaps the most n e g l e c t e d a r e a from the p a t i e n t ' s p o i n t o f view i s t h a t o f the e f f e c t o f the i l l n e s s on the f u t u r e l i f e s t y l e o f the p e r s o n i n g e n e r a l and h i s a c t i v i t y l e v e l i n p a r t i c u l a r ^ ' ^ ' ^ ' ^ ^ J . S . Dodge, " F a c t o r s R e l a t e d t o P a t i e n t ' s P e r c e n t i o n s o f T h e i r Needs," N u r s i n g Research,18 (November - December, 1969), p. 508. 2 R.E. A l t . , op. c i t . , p. 77. 3 J.R. C a s s i d y and J . A l t r o c c h i , op. c i t . , p. 220. 4 J.S. Dodge, op. c i t . , p. 508. 5 N.J. Pender, " P a t i e n t I d e n t i f i c a t i o n o f H e a l t h I n f o r m a t i o n R e c e i v e d D u r i n g H o s p i t a l i z a t i o n , " N u r s i n g R e s e a r c h , 23 (May - J u n e , 1974), pp. 262-267. I b i d . , p. 265. 6  ^R.E. A l t , " P a t i e n t E d u c a t i o n Program Answers Many Unanswered Q u e s t i o n s , " H o s p i t a l s , 40 (November 16, 1966), pp. 76-78. Q  J.S. Dodge, " F a c t o r s R e l a t e d t o P a t i e n t ' s P e r c e p t i o n s o f T h e i r C o g n i t i v e Needs," N u r s i n g R e s e a r c h , 18 (November - December, 1969), pp. 502-513. o  N.A. 0'Leary,"An Assessment o f P a t i e n t ' s A c t i v i t y , Knowledge and A n x i e t y A f t e r P r o s t h e t i c A o r t i c V a l v e Replacement." U n p u b l i s h e d M a s t e r ' s T h e s i s , U n i v e r s i t y o f T o r o n t o , 1974, p. 50.  26 These f i n d i n g s d e m o n s t r a t e t h a t i n p r e p a r i n g p a t i e n t s f o r surgery perhaps the nurse i s spending  t o o much time d i s c u s s i n g  concrete,  p r e s e n t o r i e n t e d , p r o c e d u r a l , i n - h o s p i t a l i s s u e s w i t h t h e p a t i e n t and i s u n a b l e t o h e a r h i s more a b s t r a c t , f u t u r e o r i e n t e d , o u t - o f - h o s p i t a l concerns.  A l l o f the t o p i c s mentioned are g e n e r a l i z a t i o n s from various  p a t i e n t samples and t h e n u r s e must remember t h a t each p a t i e n t ' s must be a s s e s s e d  concerns  i n d i v i d u a l l y and n o t assumed.  KEY EXPERIMENTAL STUDIES ON THE PRE-OPERATIVE PREPARATION OF GENERAL SURGICAL PATIENTS  Dumas and L e o n a r d i n 1963 d e m o n s t r a t e d t h a t t h e use o f t h e problem s o l v i n g approach i n c a r i n g f o r gynecologic surgery pre-operatively.reduced'the  patients  incidence o f post-operative vomiting J  T h i s s t u d y marked a change i n f o c u s o f n u r s i n g r e s e a r c h f r o m t h a t o f t h e nurse h e r s e l f to the p r a c t i c e o f nursing.  P e r h a p s t h e most s i g n i f i c a n t  c o n t r i b u t i o n was t h a t i t f o s t e r e d t h e b e l i e f t h a t c l i n i c a l l y based e x p e r i m e n t s i n n u r s i n g p r a c t i c e were f e a s i b l e and p r o f i t a b l e . C l i n i c a l n u r s i n g r e s e a r c h c a n be u n d e r t a k e n by any i n q u i s i t i v e , t h o u g h t f u l n u r s e as i s so a p t l y shown by t h e work  of  Healy  in  R.G. Dumas and R.C. L e o n a r d , "The E f f e c t o f N u r s i n g on t h e I n c i d e n c e o f P o s t o p e r a t i v e V o m i t i n g , " N u r s i n g R e s e a r c h , 12 ( W i n t e r , 1963), pp. 12-15.  27 1968.  She found t h a t by i n s t r u c t i n g s u r g i c a l p a t i e n t s i n deep b r e a t h i n g ,  c o u g h i n g and t u r n i n g t h a t t h e y had fewer p o s t o p e r a t i v e compl i c a t i o n s and remained i n the h o s p i t a l f o r a s h o r t e r p e r i o d o f time than group o f s u r g i c a l p a t i e n t s who tion.^  d i d not r e c e i v e the pre-ropera.t'ive i n s t r u c -  The i n t e r n a l v a l i d i t y o f H e a l y ' s  s t u d y can be  questioned  b e c a u s e o f the l a c k o f c o n t r o l o v e r v a r i a b l e s such as age, t y p e o f s u r g e r y , t i m i n g o f the p r e - o p e r a t i v e p l a n n e d f a c t t h a t her e x p e r i m e n t a l  another  diagnosis,  i n s t r u c t i o n and  the  and c o n t r o l group p a t i e n t s were not i n t h e  h o s p i t a l d u r i n g the same time p e r i o d .  But, Healy's study d i d s t i m u l a t e  f u r t h e r s t u d i e s i n p r e - o p e r a t i v e t e a c h i n g o f a much more s o p h i s t i c a t e d n a t u r e and she made an e x c e l l e n t c a s e f o r t h e need f o r n u r s e s to s e t a s i d e a c e r t a i n amount o f time f o r p r e - o p e r a t i v e i n s t r u c t i o n . In 1971,  Lindeman and Van Aernam c o n d u c t e d a s i m i l a r s t u d y ,  using a pre-experimental y e a r s o f age a d m i t t e d  d e s i g n , on a l l s u r g i c a l p a t i e n t s o v e r  f o r e l e c t i v e s u r g e r y ( o t h e r than EENT).  fifteen They  found t h a t s t r u c t u r e d , p r e - o p e r a t i v e t e a c h i n g to the i n d i v i d u a l p a t i e n t improved the a b i l i t y o f t h a t p a t i e n t to deep b r e a t h e and cough as r e f l e c t e d by v e n t i l a t o r y f u n c t i o n s t u d i e s , reduced  the mean l e n g t h o f  h o s p i t a l i z a t i o n and had no d i f f e r e n t i a l e f f e c t on the need f o r p o s t 2 operative analgesia. From a r e s e a r c h p o i n t o f view, b e c a u s e t h i s  K.M. H e a l y , "Does P r e o p e r a t i v e I n s t r u c t i o n Make A D i f f e r e n c e ? " A m e r i c a n J o u r n a l o f N u r s i n g , 68 ( J a n u a r y , 1 9 6 8 ) , pp. 62-67. 2 C.A. Lindeman and B. Van Aernam, " N u r s i n g I n t e r v e n t i o n w i t h the P r e s u r g i c a l P a t i e n t - T h e E f f e c t s o f S t r u c t u r e d and U n s t r u c t u r e d P r e o p e r a t i v e T e a c h i n g , " N u r s i n g R e s e a r c h , 20 ( J u l y - A u g u s t , 1 9 7 1 ) , pp. 319-332.  28 s t u d y used a s t a t i c group c o m p a r i s o n ,  one has t o q u e s t i o n the t h r e a t t o  i n t e r n a l v a l i d i t y t h a t i s c r e a t e d by such f a c t o r s as h i s t o r y and maturation.  From a c l i n i c a l p o i n t o f v i e w , Lindeman and Van Aernam's  s t u d y was e x c i t i n g because o f the v e r y f a v o u r a b l e r e a c t i o n i t e l i c i t e d from both the p a t i e n t s and the n u r s i n g s t a f f , b e c a u s e t h e y used a soundo n - s l i d e programme t o d e m o n s t r a t e  a s k i l l , b e c a u s e i t was the ward  n u r s e s who a c t u a l l y c a r r i e d o u t the r e s e a r c h a f t e r an e x t e n s i v e s t a f f d e v e l o p m e n t programme and f i n a l l y because i t d e m o n s t r a t e d p h y s i c i a n s and surgeons  that nurses,  c o u l d work i n a c o l l a b o r a t i v e , c o l l e a g i a l  r e l a t i o n s h i p t o enhance the w e l l b e i n g and r e c o v e r y o f the p a t i e n t . In 1972, Lindeman c o n d u c t e d  a n o t h e r s t u d y on p r e - o p e r a t i v e  i n s t r u c t i o n i n deep b r e a t h i n g , c o u g h i n g and bed e x e r c i s e s b u t t h i s time she was e x a m i n i n g instruction.  the e f f e c t s o f group v e r s u s i n d i v i d u a l methods o f  The s t u d y c o n c l u d e d t h a t group p r e - o p e r a t i v e i n s t r u c t i o n  was as e f f e c t i v e as and more e f f i c i e n t than i n d i v i d u a l i n s t r u c t i o n . ^ T h i s s t u d y employed a p r e t e s t - p o s t t e s t c o n t r o l group d e s i g n and randomly a s s i g n e d members t o the v a r i o u s e x p e r i m e n t a l d e s i g n i s much sounder than the s t a t i c group c o m p a r i s o n  conditions.  Lindeman used  i n her l a s t s t u d y b e c a u s e i t c o n t r o l s f o r h i s t o r y , m a t u r a t i o n s e l e c t i o n and t h e i r i n t e r a c t i o n s .  This  and  I t must be remembered t h a t o n l y one  c o n t e n t a r e a o f p r e - o p e r a t i v e p r e p a r a t i o n ( c o u g h i n g , deep b r e a t h i n g  C.A. Lindeman, " N u r s i n g I n t e r v e n t i o n w i t h the P r e s u r g i c a l P a t i e n t - Phase 11," N u r s i n g R e s e a r c h , 21 ( M a y - J u n e , 1972), pp. 196209.  29 and l e g e x e r c i s e s ) has been s t u d i e d and one c a n n o t g e n e r a l i z e a b o u t t h e e f f e c t i v e n e s s o f group v e r s u s i n d i v i d u a l t e a c h i n g methods f o r o t h e r pre-operative concerns.  A l s o , Lindeman noted t h a t " o l d e r p a t i e n t s were  a b l e t o compensate f o r t h e p h y s i o l o g i c a l e f f e c t s o f a g i n g upon t h e r e s p i r a t o r y f u n c t i o n i f g i v e n t h e o p p o r t u n i t y t o l e a r n and p r a c t i c e appropriate exercises."^  T h i s f i n d i n g has r e l e v a n c e f o r t h e p a t i e n t  population that t h i s t h e s i s i s examining i n that i t points to the f a c t t h a t age i s n o t a b a r r i e r t o new l e a r n i n g .  F i n a l l y , Lindeman d i d  i n c l u d e f a m i l y members i n h e r s t u d y i f t h e y w i s h e d t o be i n v o l v e d i n the p r e - o p e r a t i v e t e a c h i n g s e s s i o n s .  O n l y f o r t y - f i v e o u t o f 351 s u b j e c t s  had f a m i l y members p r e s e n t so t h a t no c o n c l u s i v e r e s u l t s c o u l d be o b t a i n e d as t o t h e i n f l u e n c e o f t h e i r p r e s e n c e .  Perhaps t h e t e a c h i n g  s e s s i o n s were h e l d a t an i n c o n v e n i e n t time f o r f a m i l y members t o be present. S c h m i t t and W o o l d r i d g e i n 1973 c o n d u c t e d an e x p e r i m e n t a l  study  on t h e p s y c h o l o g i c a l p r e p a r a t i o n o f s u r g i c a l p a t i e n t s t h a t d i f f e r e d f r o m t h o s e p r e v i o u s l y done i n t h a t i t f o c u s e d on a n u r s i n g i n t e r v e n t i o n t h a t p r o v i d e d p s y c h o l o g i c a l s u p p o r t and h e a l t h t e a c h i n g i n s m a l l  groups  as w e l l as on a o n e - t o - o n e b a s i s and p a t i e n t s h a v i n g m a j o r and m i n o r surgery.  The r e s u l t s were e v a l u a t e d a c r o s s a broad s p e c t r u m o f v e r b a l ,  s o m a t i c and i n t e r a c t i o n a l v a r i a b l e s .  T h e i r study i n d i c a t e d that  those  C.A. Lindeman, " N u r s i n g I n t e r v e n t i o n w i t h t h e P r e - S u r g i c a l P a t i e n t - Phase 11," N u r s i n g R e s e a r c h , 21 ( M a y - J u n e , 1 9 7 2 ) , p. 209.  30 p a t i e n t s who r e c e i v e d t h e e x p e r i m e n t a l  nursing intervention s l e p t better  the n i g h t b e f o r e s u r g e r y , r e c a l l e d more f a c t s o f a l e s s t h r e a t e n i n g nature about t h e i r experiences  on t h e day o f s u r g e r y and were d i s c h a r g e d  s o o n e r than t h o s e who d i d n o t r e c e i v e t h e e x p e r i m e n t a l vention.^  nursing  inter-  One o f t h e most s i g n i f i c a n t a s p e c t s o f t h i s s t u d y , as t h i s  n u r s e i n v e s t i g a t o r sees i t , i s t h a t S c h m i t t and W o o l d r i d g e d e m o n s t r a t e d t h e a s s o c i a t i o n between p r e - o p e r a t i v e p r e p a r a t i o n and r e d u c e d  anxiety.  CONCERNS OF THE PATIENT WITH A PERMANENT PACEMAKER  Hunn i s one o f t h e few n u r s i n g a u t h o r s who makes s p e c i f i c r e f e r e n c e t o t h e p a t i e n t w i t h a permanent pacemaker. the f o l l o w i n g p a t i e n t  She has i d e n t i f i e d  concerns:  1.  f e a r o f sudden death due t o pacemaker f a i l u r e ,  2.  fear that the heart i s f r a g i l e ,  3.  f e a r t h a t p h y s i c a l e x e r c i s e and e x e r t i o n may the  4.  traumatize  heart,  a n x i e t y a b o u t t h e permanent pacemaker b e c a u s e i t i s viewed as a f o r e i g n o b j e c t upon w h i c h t h e p a t i e n t i s t o t a l l y dependent f o r l i f e ,  5.  t h e c o s m e t i c e f f e c t s o f t h e s u r g e r y , and  F.E. S c h m i t t , and P . J . W o o l d r i d g e , " P s y c h o l o g i c a l P r e p a r a t i o n o f S u r g i c a l P a t i e n t s , " N u r s i n g R e s e a r c h , 22 (March - A p r i l , 1973), pp. 108-116.  31 6.  selecting comfortable  clothingJ  The R e p o r t o f the I n t e r - S o c i e t y Commission  on H e a r t D i s e a s e  R e s o u r c e s f o u n d t h a t p a t i e n t s w i t h permanent pacemakers o f t e n c o m p l a i n e d 2 about t h e l a r g e s i z e o f the pacemaker and i t s h e a v i n e s s . A n o t h e r i s s u e sometimes r a i s e d by c o n c e r n e d p a t i e n t s w i t h permanent pacemakers i s t h a t they wonder what happens t o t h e pacemaker when t h e y d i e .  One p a t i e n t t h o u g h t t h a t t h e pacemaker m i g h t b r i n g him 3  back t o l i f e when he was i n h i s g r a v e . A common m i s c o n c e p t i o n w i t h some p e o p l e w i t h pacemakers i s t h a t t h e y t h i n k t h a t t h e pacemaker w i l l 4 p r e v e n t them from h a v i n g a n o t h e r m y o c a r d i a l i n f a r c t i o n .  These v e r y  r e a l c o n c e r n s o f h a v i n g a permanent pacemaker a r e v e r y i m p o r t a n t f o r t h e n u r s e t o be aware o f . The Kos and C u l b e r t Study No r e s e a r c h has been done on the n u r s i n g i n t e r v e n t i o n s t h a t p o t e n t i a l l y c o u l d meet t h e e d u c a t i o n a l and e m o t i o n a l needs o f t h e p e r s o n  ^V. Hunn, " C a r d i a c Pacemakers," American J o u r n a l o f N u r s i n g , 69 ( A p r i l , 1969), pp. 749-754. 2  R e p o r t o f the I n t e r - S o c i e t y Commission on H e a r t D i s e a s e R e s o u r c e s - I m p l a n t a b l e C a r d i a c Pacemakers, C i r c u l a t i o n , 50 ( O c t o b e r , 1974), p. A-22. 3  T h i s i n c i d e n t was r e p o r t e d t o t h e a u t h o r by Ms. Jean A n d e r s o n , C l i n i c a l I n s t r u c t o r , W i l l o w C h e s t P a v i l l i o n , Vancouver G e n e r a l Hospital. No l i t e r a t u r e has a p p e a r e d w i t h t h i s p r o b l e m s t a t e d b u t t h i s a u t h o r and Dr. Ruth Z i t n i k , i n t h e i r c l i n i c a l e x p e r i e n c e , have encountered t h i s misconception f r e q u e n t l y . 4  32 w i t h a permanent pacemaker.  Kos and C u l b e r t have done the o n l y  on e v a l u a t i n g the t e a c h i n g g i v e n to e l d e r l y p a t i e n t s who permanent p a c e m a k e r s . i m p l a n t e d .  study  have had  T h e i r p u r p o s e was to d e t e r m i n e w h e t h e r  t h e r e would be a d i f f e r e n c e i n knowledge r e l a t e d to pacemaker t h e r a p y and a p p l i c a t i o n o f t h a t knowledge t o d a i l y l i v i n g between a group o f p a t i e n t s who  had p a r t i c i p a t e d i n d i v i d u a l l y i n a p o s t - o p e r a t i v e  program and a s i m i l a r group o f p a t i e n t s who  had n o t p a r t i c i p a t e d .  With the a i d o f a b o o k l e t e s p e c i a l l y d e s i g n e d  f o r the s t u d y ,  p a t i e n t s and f a m i l y members ( i f they w i s h e d ) were g i v e n a b o u t s i m p l e c a r d i a c p h y s i o l o g y and p a t h o l o g y , p u l s e and m e d i c a t i o n strictions.  teaching  the  information  pacemaker f u n c t i o n i n g ,  t a k i n g , d i e t a r y r e s t r i c t i o n s and a c t i v i t y r e -  T w e n t y - s i x p a t i e n t s , o f both s e x e s , o v e r s i x t y - f i v e y e a r s  o f age p a r t i c i p a t e d i n the s t u d y and d e m o n s t r a t e d t h a t the members  who  r e c e i v e d the i n s t r u c t i o n knew more a b o u t pacemaker f u n c t i o n i n g and r e l a t e d s e l f - c a r e and a p p l i e d t h a t knowledge t o t h e i r l i f e s t y l e s the p a t i e n t s who  d i d n o t r e c e i v e the p l a n n e d ,  than  t e a c h i n g programme.^  The p r e c e d i n g s t u d i e s on the p r e p a r a t i o n o f the s u r g i c a l p a t i e n t i n g e n e r a l and t h e pacemaker p a t i e n t i n p a r t i c u l a r d e m o n s t r a t e the f o l l o w i n g t r e n d s : 1.  t h a t the n u r s i n g i n t e r v e n t i o n i s u s u a l l y c a r r i e d o u t o p e r a t i v e l y w i t h l i t t l e emphasis put on d i s c h a r g e  pre-  planning,  ^B. Kos and P. C u l b e r t , " T e a c h i n g P a t i e n t s About Pacemakers," A m e r i c a n J o u r n a l o f N u r s i n g , 71 (March, 1971), pp. 523-527.  33 2.  t h a t group as w e l l as i n d i v i d u a l t e a c h i n g methods have been u s e d ,  3.  t h a t the f a m i l y i s e x c l u d e d o r i n c l u d e d i n a h a p h a z a r d  4.  t h a t t h e outcome v a r i a b l e s used t o e v a l u a t e the  way,  nursing  i n t e r v e n t i o n a r e l a r g e l y o f a s h o r t term and p h y s i o l o g i c a l n a t u r e ( e . g . p o s t - o p e r a t i v e v o m i t i n g , need f o r a n a l g e s i a ) , 5.  t h a t t h e r e i s an i n c r e a s e d use o f a u d i o - v i s u a l methods to enhance l e a r n i n g , and  6.  t h a t t h e c o n c e p t o f a n x i e t y and a n x i e t y r e d u c t i o n as i t r e l a t e s to the s u r g i c a l p a t i e n t has o n l y been examined peripherally. I t has been d i f f i c u l t t o compare the s t u d i e s on t h e e f f e c t o f  t e a c h i n g the p a t i e n t b e c a u s e , as T a g l i a c o z z o s a y s , " t h e r e i s a s u b s t a n t i a l v a r i a n c e i n t h e s e l e c t i o n o f the d e p e n d e n t v a r i a b l e s , measurement t o o l s , p o p u l a t i o n , programme s t r u c t u r e , r o l e s o f the n u r s e o r n u r s e s and t i m i n g o f the i n t e r v e n t i o n .  the  1  D.M. T a g l i a c o z z o , D.B. L u s k i n , J.C. L a s h o f and K. Ima, "Nurse I n t e r v e n t i o n and P a t i e n t B e h a v i o u r , " A m e r i c a n J o u r n a l o f P u b l i c H e a l t h , 64 ( J u n e , 1 9 7 4 ) , p. 597.  34 THE CONCEPT OF ANXIETY  To v e n t u r e causes a n x i e t y , b u t n o t to v e n t u r e i s to lose oneself. A n x i e t y i s the f e a r o f  nothingness. Kierkegaard"  The dilemma o f a n x i e t y has been an i s s u e among p h i l o s o p h e r s , h i s t o r i a n s , w r i t e r s and e v e r y d a y man  f o r hundreds o f y e a r s .  The  t h e o l o g i a n and p h i l o s o p h e r , K i e r k e g a a r d , i n d e v e l o p i n g h i s c o n c e p t  of  is f r e a d , d i s c u s s e s many o f the s a l i e n t c h a r a c t e r i s t i c s o f a n x i e t y as we c o n c e i v e o f them today.  U n t i l F r e u d , i n the e a r l y t h i r t i e s , began to  w r i t e a b o u t h i s views on the n a t u r e o f a n x i e t y , t h i s c o n c e p t was c o n s i d e r e d t o be a p h i l o s o p h i c a l i s s u e . r e s e a r c h done on a n x i e t y was c o n d u c t e d v a r i o u s animal  s p e c i e s but no humans.  From 1930-1950, most o f the i n laboratory settings using I t was o n l y s i n c e the p u b l i c a t i o n  o f the T a y l o r M a n i f e s t A n x i e t y S c a l e i n 1953, on human a n x i e t y were a b l e to be p e r f o r m e d .  T h a t many more s t u d i e s A n x i e t y i s now  approached  from a more s c i e n t i f i c v i e w p o i n t and t o d a y i s one o f the key b e i n g i n v e s t i g a t e d by b e h a v i o u r a l In o r d e r to u n d e r s t a n d  R. May, 13. 2  notions  scientists.  how the c o n c e p t o f a n x i e t y has  i t i s n e c e s s a r y to b r i e f l y r e v i e w v a r i o u s r e s e a r c h e r ' s  1952), p.  mainly  developed,  definitions.  The Meaning o f A n x i e t y (New Y o r k : Ronald P r e s s  E. L e v i t t , The P s y c h o l o g y B o b b s - M e r r i l l Co., IncI 1967).  o f A n x i e t y ( I n d i a n a p o l i s : The  Co.,  Freud (1936) d e s c r i b e d a n x i e t y as "something f e l t , " t h a t i s , a fundament a l , u n p l e a s a n t a f f e c t i v e s t a t e c h a r a c t e r i z e d by a p p r e h e n s i o n .  1  He  f e l t t h a t a n x i e t y c o u l d be d i s t i n g u i s h e d from o t h e r a f f e c t i v e s t a t e s by the u n i q u e c o m b i n a t i o n  o f phenomenological  and p h y s i o l o g i c a l q u a l i t i e s .  A n x i e t y r e s u l t e d from a d i s c h a r g e o f r e p r e s s e d , u n r e l i e v e d , s o m a t i c and s e x u a l t e n s i o n s . ing,  Mowrer (1950) viewed a n x i e t y as o r i g i n a t -  n o t from a c t s w h i c h t h e i n d i v i d u a l would commit i f he d a r e d , b u t  from a c t s w h i c h he had committed b u t w i s h e d he had n o t .  Sullivan  (1953) h y p o t h e s i z e d t h a t a n x i e t y a r o s e from e x p e r i e n c i n g d i s a p p r o v a l i n i n t e r p e r s o n a l r e l a t i o n s h i p s and May (1950) t h o u g h t t h a t a n x i e t y was p r e c i p i t a t e d by a t h r e a t t o some v a l u e which t h e i n d i v i d u a l h e l d e s s e n t i a l t o h i s e x i s t e n c e as a p e r s o n a l i t y .  4  I t becomes o b v i o u s  from  the above d e f i n i t i o n s o f a n x i e t y t h a t t h e r e i s no one s o u r c e o r t h e o r y o f i t s o r i g i n and t h a t none o f t h e d e f i n i t i o n s m e n t i o n e d s o f a r a l l u d e to t h e m u l t i f a c e t e d n a t u r e o f a n x i e t y .  McReynolds (1961) d e s c r i b e s  a n x i e t y as a complex, b e h a v i o u r a l e v e n t i n f l u e n c e d by s i t u a t i o n a l , p e r s o n a l i t y and mode o f r e s p o n s e  f a c t o r s and t h e i r i n t e r a c t i o n .  Lesse  a l s o uses a broad b i o p s y c h o s o c i a l d e f i n i t i o n o f a n x i e t y much l i k e  1.G. S a r a s o n and C h a r l e s S p i e l b e r g e r , S t r e s s and A n x i e t y , V o l . (New Y o r k : John W i l e y , 1975), p. 130. 2 C. S p i e l b e r g e r , e d i t o r , A n x i e t y and B e h a v i o u r (New Y o r k : Academic P r e s s , 1966), p. 20. 1  3  I b i d . , p. 21.  I b i d . , p. 23. 5 Paul M c R e y n o l d s , "The A s s e s s m e n t o f A n x i e t y : A Survey o f A v a i l a b l e T e c h n i q u e s , " Advances i n P s y c h o l o g i c a l A s s e s s m e n t , V o l . 1, P. M c R e y n o l d s , e d i t o r ( P a l o A l t o , C a l i f o r n i a : S c i e n c e a n d B e h a v i o u r Books, I n c . , 1968), p. 246. 4  36 McReynolds but where they d i f f e r i s i n the a r e a o f the s p e c i f i c compone n t s o f the c o n c e p t o f a n x i e t y .  L e s s e (1970) f i r m l y b e l i e v e s t h a t one  must e v a l u a t e the p r e s e n c e o f a n x i e t y by c o n s i d e r i n g a l l f o u r o f i t s components w h i c h a r e motor, a f f e c t i v e , autonomic and v e r b a l J  Lader  and Marks b e s t sum up the c u r r e n t s t a t u s o f the n o t i o n o f a n x i e t y when t h e y say t h a t " a n x i e t y i s an emotion w i t h p r o t e a n m a n i f e s t a t i o n s  about  2  w h i c h t h e r e i s no a g r e e d c o r p u s o f t h e o r y . " T h i s s t u d y i s f u n d a m e n t a l l y c o n c e r n e d w i t h normal a n x i e t y and the e f f e c t t h a t i t has on the b e h a v i o u r o f p e o p l e who e x p e r i e n c e i t . Normal a n x i e t y i s viewed as n o t d i s p r o p o r t i o n a t e t o the o b j e c t i v e t h r e a t , n o t i n v o l v i n g r e p r e s s i o n o r o t h e r mechanisms o f i n t r a p s y c h i c c o n f l i c t , n o t r e q u i r i n g n e u r o t i c d e f e n s e mechanisms f o r i t s management and i m p l y i n g t h a t i t can be c o n f r o n t e d c o n s t r u c t i v e l y ( i . e . , w i t h an e x p a n s i o n awareness and r e - e d u c a t i o n ) on a l e v e l o f c o n s c i o u s a w a r e n e s s .  of Normal 3  a n x i e t y can a l s o be r e l i e v e d i f the o b j e c t i v e s i t u a t i o n i s a l t e r e d . B a s i c a l l y normal a n x i e t y can be seen as the e x p r e s s i o n o f the c a p a c i t y o f an o r g a n i s m t o r e a c t t o t h r e a t s . C a t t e l l and S h e i e r (1961), u s i n g a m u l t i d i m e n s i o n a l  concept  o f a n x i e t y , were the f i r s t t o a p p l y f a c t o r i a l a n a l y s i s t o the d e v e l o p m e n t 4 o f an a n x i e t y t e s t i n g t o o l . T h e i r I n v e n t o r y f o r P e r s o n a l i t y and S t a n l e y L e s s e , A n x i e t y : I t s Components, Development and Treatment (New Y o r k : Grune and S t r a t t o n , 1970), p. 13. 2 M. L a d e r and I. Marks, C l i n i c a l A n x i e t y (London: W i l l i a m Heinemann M e d i c a l Books L t d . , 1971), p. 157. 3 R o l l o May, The Meaning o f A n x i e t y (New York: Ronald P r e s s Co., 1952), p. 194. 4 R.B. C a t t e l l and I.H. S h e i e r , The Meaning and Measurement o f N e u r o t i c i s m and A n x i e t y (New York: The Ronald P r e s s Co., 1961).  37 A b i l i t y T e s t i n g I n v e n t o r y (IPAT) A n x i e t y S c l a e i s w i d e l y used to measure t r a i t anxiety or anxiety  proneness.  C h a r l e s D. S p i e l b e r g e r and h i s a s s o c i a t e s were t h e f i r s t t o i n t r o d u c e an a n x i e t y m e a s u r i n g d e v i c e w h i c h e v a l u a t e d b o t h t r a i t state anxiety.  and  S p i e l b e r g e r (1972) views a n x i e t y as a t r a n s i t o r y s t a t e ,  a r e l a t i v e l y s t a b l e p e r s o n a l i t y t r a i t and complex c o g n i t i v e - e m o t i o n a l motivational process.  1  Lader and Marks have d e v e l o p e d  a n x i e t y b a s e d on the work o f S p i e l b e r g e r .  a model o f normal  I t i s d e p i c t e d on the  f o l l o w i n g page ( F i g u r e 1 ) . As can be seen on page 38, S p i e l b e r g e r f e e l s t h a t a n x i e t y can be d i v i d e d i n t o t h r e e c o m p o n e n t s - - h e r e d i t y ,  p a s t e x p e r i e n c e , and c u r r e n t  status.  T h e s e components i n t e r a c t t o p r o d u c e a n x i e t y p r o n e n e s s o r " t r a i t "  anxiety.  The i n d i v i d u a l ' s a n x i e t y p r o n e n e s s then i n f l u e n c e s the sequence  o f e v e n t s w h i c h p r o d u c e s o r r e s u l t s from a n x i e t y .  Incoming e x t e r n a l s t i m u l i  (and i n the case o f t h i s s t u d y i t would be i l l n e s s and s u r g e r y ) a r e for t h e i r real o r . p o t e n t i a l danger q u a l i t i e s .  The p e r s o n ' s  screened  cognitive  a p p r a i s a l o f the t h r e a t i s then i n f l u e n c e d by h i s " t r a i t " a n x i e t y .  If  the e x t e r n a l s t i m u l i a r e j u d g e d t o be t h r e a t e n i n g then the c e n t r a l n e r v o u s s y s t e m i s a r o u s e d , a n x i e t y i s f e l t and c o p i n g mechanisms a r e mobilized.  The c e n t r a l n e r v o u s s y s t e m a r o u s a l p r o d u c e s p h y s i o l o g i c a l  changes w h i c h i n t u r n i n c r e a s e a r o u s a l .  Awareness o f t h e p h y s i o l o g i c a l  I.G. S a r a s o n and C D . S p i e l b e r g e r , S t r e s s and A n x i e t y , V o l . 2 (New York: John W i l e y , 1975). 2 M. L a d e r and I. Marks, C l i n i c a l A n x i e t y ( L o n d o n : W i l l i a m Heinemann M e d i c a l Books L t d . , 1971), p. 156.  "TRAIT ANXIETY  GENETIC ENDOWMENT  EXTERNAL STIMULI Social, Man' t a l , Work, e t c .  PAST EXPERIENCE  CURRENT STATUS present thoughts, needs, f e e l i n g s  PHYSIOLOGICAL CHANGES AROUSAL OF C.N.S.  <--H  FEELING OF ANXIETY "STATE ANXIETY"  COPING MECHANISMS] REDUCE ANXIETY REMOVE CAUSES change environment  Figure 1  A Model o f Normal A n x i e t y . Pathways which may i n c r e a s e a n x i e t y a r e shown with s o l i d l i n e s ; t h o s e r e d u c i n g a n x i e t y a r e shown w i t h broken l i n e s  39  changes a l s o a l t e r s t h e c o g n i t i v e a p p r a i s a l o f t h e t h r e a t and t h e p e r s o n i s made aware t h a t he i s a n x i o u s . by c h a n g i n g  The p e r s o n a t t e m p t s  t o cope  the threatening s i t u a t i o n , r e a c t i n g a p p r o p r i a t e l y , r e -  a p p r a i s i n g t h e t h r e a t and m o d i f y i n g h i s p h y s i o l o g i c a l s t a t u s d i r e c t l y by v a r i o u s p s y c h o t h e r a p e u t i c  techniques  (e.g., r e l a t i o n  transcendental meditation, hypnosis).  therapy,  The s u c c e s s o f t h e v a r i o u s  c o p i n g r e s p o n s e s w i l l change t h e way " p a s t e x p e r i e n c e " w i l l be used to meet f u t u r e t h r e a t s .  S p i e l b e r g e r s model o f normal a n x i e t y 1  i s u s e f u l b e c a u s e i t g i v e s t h e c l i n i c i a n n o t o n l y an o v e r a l l framework w i t h w h i c h t o view normal a n x i e t y b u t a l s o i t p r o v i d e s  information  as t o what type o f and where i n t e r v e n t i o n c a n o c c u r . The p r e c e d i n g s e c t i o n has d e a l t w i t h a s e l e c t e d r e v i e w o f the c o n c e p t o f a n x i e t y as i t has d e v e l o p e d o v e r t h e p a s t f i f t y y e a r s . The n o t i o n o f a n x i e t y has changed from b e i n g a p h i l o s o p h i c a l to a s c i e n t i f i c issue.  The c o m p l e x i t y and m u l t i d i m e n s i o n a l i t y o f  a n x i e t y has been r e c o g n i z e d and r e s e a r c h e r s a r e s t r u g g l i n g t o f i n d the a p p r o p r i a t e q u a l i t a t i v e and q u a n t i t a t i v e means o f m e a s u r i n g t h i s concept. powerful  Anxiety i s c e n t r a l to o u r everyday  determinant  o f much o f o u r b e h a v i o u r .  l i f e and i s a . I t i s crucial f o r  p r a c t i t i o n e r s o f n u r s i n g t o have an i n - d e p t h u n d e r s t a n d i n g  o f the  n a t u r e o f a n x i e t y so t h a t i t can be a p p r o p r i a t e l y and e f f e c t i v e l y dealt with.  40 KEY NURSING STUDIES ON ANXIETY REDUCTION  The c o n c e p t o f a n x i e t y and and a n x i e t y r e d u c t i o n have been examined i n the n u r s i n g l i t e r a t u r e i n a v a r i e t y o f c l i n i c a l s e t t i n g s . A n x i e t y and p s y c h o l o g i c a l d i s t r e s s a r e terms t h a t have been used i n t e r c h a n g e a b l y i n the f o l l o w i n g s t u d i e s .  These s t u d i e s w i l l  be  reviewed w i t h the f o l l o w i n g q u e s t i o n s i n mind: 1.  How was a n x i e t y measured?  2.  What n u r s i n g i n t e r v e n t i o n s were used t o reduce  3.  Were t h e s e n u r s i n g i n t e r v e n t i o n s e f f e c t i v e ?  4.  Was  anxiety?  the m e t h o d o l o g y sound?  Dumas and L e o n a r d  (1963) measured a n x i e t y i n d i r e c t l y by a s s e s s -  ing another v a r i a b l e — t h e i n c i d e n c e o f p o s t o p e r a t i v e  vomiting.  They showed t h a t by u s i n g t h e n u r s i n g p r o c e s s t o e n c o u r a g e t h e expression o f concerns  p r e o p e r a t i v e l y t h a t the i n c i d e n c e o f post-  o p e r a t i v e v o m i t i n g was  reduced among g y n e c o l o g i c s u r g e r y p a t i e n t s .  1  They m a i n t a i n t h a t p s y c h i c d i s t r e s s i s a m a j o r c a u s e o f p o s t o p e r a t i v e vomiting.  I f one i s w i l l i n g t o a c c e p t t h a t p r e m i s e ,  r e s u l t s are v a l i d .  then  their  I t must a l s o be noted t h a t t h e y were unable  to  c o n t r o l f o r t h e t y p e o f a n a e s t h e t i c a g e n t used o r t h e t y p e o f s u r g e r y and c e r t a i n l y both o f t h e s e f a c t o r s m i g h t i n f l u e n c e the incidence of post-operative vomiting.  Another feature of t h e i r study  R.G. Dumas and R.C. L e o n a r d , "The E f f e c t o f N u r s i n g on the Incidence of Postoperative Vomiting," N u r s i n g R e s e a r c h , 12 ( W i n t e r , 1963), pp. 12-15. 1  41 which must be q u e s t i o n e d i s t h a t t h e y c o n d u c t e d t h r e e d i f f e r e n t e x p e r i ments a n d when each e x p e r i m e n t ' s r e s u l t s were s t a t i s t i c a l l y  analyzed,  t h e p r o b a b i l i t y t h a t t h e r e s u l t was due t o one o f t h e r a n d o m i z e d  varia-  b l e s r a t h e r than t h e e x p e r i m e n t a l t r e a t m e n t was f o u n d t o be h i g h ( p = .13, p = .19, p = .08) J  Y e t , when t h e y combined t h e r e s u l t s o f t h e  t h r e e e x p e r i m e n t s , (which seems i n a p p r o p r i a t e s i n c e t h e y were d i f f e r e n t ) t h e y o b t a i n e d a r e s u l t which was s i g n i f i c a n t a t t h e .05 l e v e l .  The  changes made i n t h e t h r e e e x p e r i m e n t s i n c l u d e d i n c r e a s i n g t h e l e n g t h o f time t h e i n v e s t i g a t o r spent with t h e experimental p a t i e n t ; having a d i f f e r e n t n u r s e , as opposed t o t h e i n v e s t i g a t o r , a s s e s s t h e p o s t o p e r a t i v e s t a t u s o f t h e p a t i e n t s i n t h e r e c o v e r y room; and a s s e s s i n g the p r e - o p e r a t i v e emotional s t a t e o f the c o n t r o l p a t i e n t s .  This author  f e e l s t h a t t h e s e changes a r e o f a g r e a t enough magnitude t o c o n s i d e r t h a t t h e t h r e e e x p e r i m e n t s were i n f a c t d i f f e r e n t .  T h e r e s u l t s were  i n t h e p r e d i c t e d d i r e c t i o n b u t t h e sample s i z e was t o o s m a l l t o make them s t a t i s t i c a l l y s i g n i f i c a n t .  In s p i t e o f t h e c r i t i c i s m o f t h e  methodology, t h i s study represents a p r e l i m i n a r y e f f o r t t o re-focus n u r s i n g r e s e a r c h t o c l i n i c a l m a t t e r s ; and t h e r e f o r e , i t s r e s u l t s warrant f u r t h e r study. Meyers (1964) c o n d u c t e d an e x p e r i m e n t a l s t u d y t o examine t h e e f f e c t o f d i f f e r e n t t y p e s o f communication to s t r e s s .  One p a t t e r n o f communication  on t h e p a t i e n t ' s r e a c t i o n s was s t r u c t u r e d ; t h a t i s , a  R.G. Dumas and R.C. L e o n a r d , "The E f f e c t o f N u r s i n g on t h e I n c i d e n c e o f P o s t o p e r a t i v e V o m i t i n g , " N u r s i n g R e s e a r c h , 12 ( W i n t e r , 1963), pp. 12-15.  42 simple explanation of the procedure was given.  Another pattern pro-  vided no communication other than informing the patient that t h i s was done r o u t i n e l y .  test  A t h i r d type of communication consisted of the  i n v e s t i g a t o r making i r r e l e v a n t comments about the weather as she performed the procedure.  She found that less tension was created when  the patient was given s p e c i f i c information about a procedure so that he could c o g n i t i v e l y structure the impending s t r e s s f u l e v e n t J nursing intervention used was g i v i n g the patient d i f f e r e n t information about a new procedure.  The  types of  Anxiety or stress was measured by  the p a t i e n t ' s subjective response to what he perceived was about to happen to him, h i s r e c a l l of items of equipment on the procedure tray and his f e e l i n g s during the procedure. p o i n t , several concerns a r i s e .  From a methodological view-  The subjects for t h i s study were not  randomly assigned to each of the three experimental conditions as described above.  Although Meyers maintains that each group had  approximately the same age and sex d i s t r i b u t i o n , there might be another uncontrolled v a r i a b l e present which could have accounted f o r the difference in the responses of the subjects.  Another point to con-  s i d e r i s that the i n v e s t i g a t o r was the one who provided the experimental treatment as well as the one who conducted the post experiment view.  inter-  She was then well aware of which patient received which form of  M.E. Meyers, "The E f f e c t of Types of Communication on P a t i e n t ' s Reaction to S t r e s s , " Nursing Research, 13 ( S p r i n g , 1964), pp. 126-131.  43 communication.  Presumably to minimize  t h i s b i a s , the p o s t  experimental  i n t e r v i e w s were a l s o a t t e n d e d by a n o t h e r r e g i s t e r e d n u r s e t r a i n e d and s u p e r v i s e d by the i n v e s t i g a t o r but i t i s s t i l l u n c l e a r as t o w h e t h e r both o f t h e s e n u r s e s c o n d u c t e d some.  each i n t e r v i e w o r w h e t h e r t h e y e a c h d i d  A p a r t from t h e s e m e t h o d o l o g i c a l  o u t the g r e a t i m p o r t a n c e  i s s u e s , Meyer's s t u d y p o i n t s  o f t r e a t i n g the p a t i e n t as a p e r s o n o f i n t e l l i -  gence whose c o o p e r a t i o n i s b e i n g sought by the n u r s e .  The  communication  a p p r o a c h to p a t i e n t c a r e , as seen i n Meyer's s t u d y , m i n i m i z e s  some o f  the s t r e s s i n h e r e n t i n h o s p i t a l i z a t i o n . N i e l d (1971) c o n d u c t e d  an e x p e r i m e n t a l  s t u d y to measure the  e f f e c t s o f h e a l t h t e a c h i n g on the a n x i e t y l e v e l o f p a t i e n t s w i t h c h r o n i c o b s t r u c t i v e l u n g d i s e a s e a t t e n d i n g an o u t p a t i e n t c l i n i c .  She had  three  groups o f p a t i e n t s — t h o s e who were t a u g h t i n d i v i d u a l l y , t h o s e who  were  t a u g h t i n a group and t h o s e who were g i v e n the r o u t i n e c l i n i c c a r e . No s i g n i f i c a n t d i f f e r e n c e s i n the a n x i e t y l e v e l were found among the three groups.  1  The n u r s i n g i n t e r v e n t i o n was h e a l t h t e a c h i n g which  i n c l u d e d a d e s c r i p t i o n o f the c h e s t c l i n i c programme, the d i s e a s e p r o c e s s , t r e a t m e n t m o d a l i t i e s and h e a l t h f u l l i v i n g p r a c t i c e s . h e a l t h t e a c h i n g u n i t was a d m i n i s t e r e d v i a t w o — t h i r t y m i n u t e s a u d i o - s l i d e programmes o v e r a p e r i o d o f two weeks.  The  This each—  subject's  s t a t e a n x i e t y l e v e l was measured by the A f f e c t A d j e c t i v e Check L i s t  and  the t r a i t a n x i e t y l e v e l was measured by the I n s t i t u t e f o r P e r s o n a l i t y  M.A. N i e l d , "The E f f e c t o f H e a l t h T e a c h i n g on A n x i e t y L e v e l P a t i e n t ' s w i t h C h r o n i c O b s t r u c t i v e Lung D i s e a s e , " N u r s i n g R e s e a r c h , 20 (November - December, 1971), pp. 537-541.  44 and A b i l i t y (IPAT) A n x i e t y S c a l e .  T h i s s t u d y was w e l l d e s i g n e d and  e x e c u t e d and t h e f a c t t h a t s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s were n o t o b t a i n e d does n o t d e t r a c t from i t s v a l u e .  Possible explanations o f the  l a c k o f s i g n i f i c a n c e a r e t h a t l i k e h e a l t h , h e a l t h t e a c h i n g i s a low p r i o r i t y c o n s c i o u s need f o r t h e g e n e r a l p o p u l a t i o n and e s p e c i a l l y f o r t h o s e p a t i e n t s who have n o t been r e c e n t l y d i a g n o s e d o r who a r e i n a s t a b l e phase o f t h e i r d i s e a s e .  A l s o , i n N i e l d ' s s t u d y t h e r e was a v e r y  s h o r t time between c o m p l e t i o n o f t h e h e a l t h t e a c h i n g and measurement o f the c r i t e r i o n .  Perhaps a l o n g e r time was n e c e s s a r y t o i n c o r p o r a t e  and c o n s o l i d a t e t h e i n f o r m a t i o n .  From t h e p o i n t o f view o f t h i s t h e s i s ,  N i e l d ' s f i n d i n g t h a t t h e s u b j e c t s who r e c e i v e d t h e h e a l t h t e a c h i n g on an i n d i v i d u a l b a s i s had t h e l o w e s t mean t r a i t and s t a t e a n x i e t y s c o r e s , s u g g e s t s t h a t t h e r e i s a t r e n d toward t h e p r e f e r e n c e o f i n d i v i d u a l o v e r group i n s t r u c t i o n when t h e goal i s reduced a n x i e t y J Johnson (1972) c o n d u c t e d  a l a b o r a t o r y and c l i n i c a l  experiment  w h i c h showed t h a t a c c u r a t e e x p e c t a t i o n s a b o u t s e n s a t i o n s reduced  dis-  t r e s s i n c o l l e g e s t u d e n t s e x p e r i e n c i n g i s c h e m i c p a i n and p a t i e n t s h a v i n g 2 a g a s t r o s c o p y tube p a s s e d .  Her n u r s i n g i n t e r v e n t i o n c o n s i s t e d o f  t a p e d r e c o r d i n g s o f messages w h i c h d i f f e r e d by h a v i n g t h e c o n t e n t o f one d e s c r i b e d s e n s a t i o n s t h a t c o u l d be e x p e c t e d t o o c c u r and h a v i n g t h e other d e s c r i b e the procedure  per se.  D i s t r e s s o f t h e s u b j e c t s was  ^M.A. N i e l d , "The E f f e c t o f H e a l t h T e a c h i n g on t h e A n x i e t y L e v e l o f P a t i e n t ' s w i t h C h r o n i c O b s t r u c t i v e Lung D i s e a s e , " N u r s i n g R e s e a r c h , 20 (November - December, 1971), pp. 537-541. 2 J.E. Johnson, " E f f e c t s o f S t r u c t u r i n g P a t i e n t ' s Expectations on t h e i r R e a c t i o n s t o T h r e a t e n i n g E v e n t s , " N u r s i n g R e s e a r c h , 21 (NovemberDecember, 1972), pp. 499-503.  45  measured by the amount o f t r a n s q u i l l i z e r needed, the d e g r e e o f t e n s e ness o b s e r v e d i n the hands and arms and the degree o f r e s t l e s s n e s s . J o h n s o n ' s s t u d y i s w e l l done and emphasizes the i m p o r t a n t c o n t r i b u t i o n o f p s y c h o l o g i c a l t h e o r i e s such as c o g n i t i v e d i s s o n a n c e and J a n i s ' theory of s t r e s s to nursing  research.  S c h m i t t and W o o l d r i d g e (1973) showed t h a t p s y c h o l o g i c a l a r a t i o n o f the p r e - s u r g i c a l p a t i e n t would d e c r e a s e t e n s i o n and S c h m i t t met w i t h the e x p e r i m e n t a l  p a t i e n t s i n a group the day  prep-  anxiety.  1  before  s u r g e r y and i n d i v i d u a l l y t h e m o r n i n g o f s u r g e r y and p r o v i d e d them w i t h o r i e n t a t i o n - t y p e i n f o r m a t i o n , h e a l t h t e a c h i n g , knowledge a b o u t the d i s e a s e p r o c e s s and she e n c o u r a g e d the e x p r e s s i o n o f f e e l i n g s .  Verbal  i n d i c a t o r s o f t e n s i o n and a n x i e t y were measured i n t h e s t u d y by a s k i n g the s u b j e c t s w h e t h e r t h e y s l e p t w e l l the n i g h t b e f o r e s u r g e r y , i f they f e l t a n x i o u s the m o r n i n g b e f o r e s u r g e r y and what items o r e v e n t s s u r r o u n d i n g the s u r g e r y t h e y c o u l d r e c a l l .  Physiological variables  such as i n c i d e n c e o f u r i n a r y r e t e n t i o n , i n c i d e n c e o f v o m i t i n g ,  blood  p r e s s u r e and p u l s e were a l s o used to i n d i c a t e the s t r e s s l e v e l s o f the p a t i e n t s .  S c h m i t t and Wool r i d g e ' s s t u d y i s i m p o r t a n t  because  i t d e m o n s t r a t e s n o t o n l y t h a t a n x i e t y can be measured but t h a t many p a r a m e t e r s can be used t o e x p l o r e t h i s c o n c e p t and i t s r e l a t i o n to p a t i e n t c a r e . No s t u d i e s e x i s t a t p r e s e n t w h i c h deal w i t h a n x i e t y r e d u c t i o n i n p a t i e n t s who  have had permanent pacemakers i n s e r t e d .  Most o f the n u r s -  i n g l i t e r a t u r e on a n x i e t y and the p r e - s u r g i c a l p a t i e n t o r c h r o n i c a l l y V.E. S c h m i t t and P.J. W o o l d r i d g e , " P s y c h o l o g i c a l P r e p a r a t i o n o f S u r g i c a l P a t i e n t s , " N u r s i n g R e s e a r c h , 22 ( M a r c h - A p r i l , 1973), pp. 108-116.  46 i l l medical  p a t i e n t has s u g g e s t e d  t h a t a n x i e t y can be a l l a y e d by p r o v i d -  ing health teaching and/or p s y c h o l o g i c a l support.  A n x i e t y has been  measured u s i n g p h y s i o l o g i c a l and v e r b a l i n d i c a t o r s and on s e v e r a l occasions, psychological tests.  The r e s u l t s have g e n e r a l l y been  favourable.  INFORMATION SHARING AND THE PATIENT'S RIGHT TO KNOW  Most p e o p l e want t o know what i s g o i n g on a b o u t them so t h a t 1 2 they can have some d e g r e e o f c o n t r o l o v e r t h e i r s i t u a t i o n .  Patients  s h a r e t h e r i g h t t o know what i s h a p p e n i n g t o them o r what t h e y m i g h t a n t i c i p a t e o c c u r r i n g so t h a t t h e y can p a r t i c i p a t e i n d e c i s i o n s  concern-  3  ing t h e i r well  being.  Gregg m a i n t a i n s  that the patient experiences  reassurance  someone he t r u s t s g i v e s him a u t h e n t i c i n f o r m a t i o n when he needs i t .  when 4  'C.A. Baden, " T e a c h i n g t h e C o r o n a r y P a t i e n t and H i s F a m i l y , " N u r s i n g C l i n i c s o f North A m e r i c a , 7 (September, 1 9 7 2 ) , p. 564. 2  M.A. Neuman, " I d e n t i f y i n g and M e e t i n g P a t i e n t Needs i n t h e S h o r t - S p a n N u r s e - P a t i e n t R e l a t i o n s h i p , " N u r s i n g Forum, 2 (1963), p. 25. 3 L.E. R o z o v s k y , C a n a d i a n H o s p i t a l Law, C a n a d i a n H o s p i t a l A s s o c i a t i o n ( T o r o n t o : Southam M u r r a y , 1974). 4 D. Gregg, " R e a s s u r a n c e , " A m e r i c a n J o u r n a l o f N u r s i n g , 55 (1955), p. 174.  Redman  and S k i p p e r  both s t r e s s t h a t t h e r e i s a d i r e c t r e l a t i o n s h i p  between i n f o r m a t i o n s h a r i n g and r e d u c e d  anxiety.  Redman a l s o emphas-  i z e s t h a t i n s t r u c t i o n s h o u l d h e l p t h e i n d i v i d u a l t o f i n d meaning i n i l l n e s s as w e l l as t o c o n s e r v e 3 disease.  h e a l t h and t o c o n t r o l t h e symptoms o f  As T a g l i a c o z z o s a y s , t h e p a t i e n t ' s r e s p o n s e t o t h i s form o f  nursing i n t e r v e n t i o n i n d i c a t e s less that the p a t i e n t i s complying with the e x p e c t a t i o n s o f a " s i g n i f i c a n t o t h e r " and more t h a t t h e t r e a t m e n t 4  p r o c e s s i s p r o v i d i n g meaningful  ways f o r him t o c o n f r o n t h i s i l l n e s s .  A c c o r d i n g t o Mohammed, t h e w e l l i n f o r m e d p a t i e n t g e n e r a l l y p a r t i c i p a t e s in t e s t s , treatments  and s e l f - c a r e more e f f e c t i v e l y , s a f e l y and 5  comfortably  than t h e p o o r l y i n f o r m e d  patient.  Consumer r i g h t s i n h e a l t h c a r e m a t t e r s a r e a v e r y i s s u e i n today's  society.  important  One such r i g h t t h a t has been d i s c u s s e d a t  l e n g t h i s t h e p a t i e n t ' s r i g h t o f a c c e s s t o t h e i n f o r m a t i o n on h i s medical  record. A t t h e May, 1976 g e n e r a l m e e t i n g o f t h e R e g i s t e r e d B.K. Redman, The P r o c e s s o f P a t i e n t T e a c h i n g i n N u r s i n g , 2nd e d i t i o n ( S t . L o u i s : The C.V. Mosby Co., 1972). 2 J.K. S k i p p e r , "Communication and t h e H o s p i t a l i z e d P a t i e n t , " I n : S o c i a l I n t e r a c t i o n and P a t i e n t C a r e , e d i t e d by J.K. S k i p p e r and R.C. L e o n a r d ( P h i l a d e l p h i a : J . B . L i p p i n c o t t Co., 1965), pp. 61-82. 3 R.K. Redman, o p . c i t . , p. 3. 4  Behaviour," p. 596.  D.M. Tagl i a c o z z o e t a j _ . , "Nurse I n t e r v e n t i o n a n d P a t i e n t A m e r i c a n J o u r n a l o f P u b l i c H e a l t h , 64 ( J u n e , 1964),  5  M.F.B. Mohammed, " P a t i e n t ' s U n d e r s t a n d i n g o f W r i t t e n I n f o r m a t i o n , " N u r s i n g R e s e a r c h , 13 ( S p r i n g , 1964), p. 100.  Health  48 N u r s e s A s s o c i a t i o n o f B r i t i s h C o l u m b i a , a r e s o l u t i o n was p a s s e d s t a t e s n o t o n l y t h a t the RNABC s u p p o r t s  which  i n p r i n c i p l e the f a c t t h a t the  consumer has a r i g h t o f a c c e s s to h i s m e d i c a l  r e c o r d but t h a t a f u l l  e x p l a n a t i o n o f the i n f o r m a t i o n on the m e d i c a l  r e c o r d be g i v e n t o the  consumer i n l a n g u a g e t h a t he can  understand.  1  The above a r t i c l e s and books s u p p o r t the p a t i e n t ' s r i g h t to i n f o r m a t i o n a b o u t h i m s e l f and d e m o n s t r a t e the b e n e f i t s a c c r u e d by p r o viding health  teaching.  PHYSIOLOGICAL AGING AND  ITS INFLUENCE ON  THE  TEACHING-LEARNING PROCESS  The m a j o r i t y o f p a t i e n t s who  have permanent pacemakers im-  p l a n t e d are e l d e r l y ; t h e r e f o r e , i t i s important  to examine the  o f t e a c h i n g and l e a r n i n g as they r e l a t e to t h i s age g r o u p . i n g s e c t i o n s w i l l d i s c u s s p h y s i o l o g i c a l , c u l t u r a l and a g i n g and t h e i r i n f l u e n c e on the t e a c h i n g - l e a r n i n g 2 Shock's model f o r a g i n g  The  concepts follow-  psychological  process.  p r o v i d e s a p h y s i o l o g i c framework f o r  d i s c u s s i n g changes i n the c o g n i t i v e , a f f e c t i v e and p s y c h o m o t o r f u n c t i o n s RNABC News, 8 ( J u l y , 1976), p. 7. 2 N.W. Shock, "The P h y s i o l o g y o f A g i n g , " ( J a n u a r y , 1 9 6 3 ) , p. 101. 1  S c i e n t i f i c American  49 as a p a r t o f a g e n e r a l i z e d c e l l u l a r and s y s t e m d e c l i n e .  Normal  w i l l be examined i n terms o f i t s e f f e c t on the t e a c h i n g - l e a r n i n g  aging process  o f the e l d e r l y p a t i e n t . Shock's a n a l y s i s c o n s i s t s o f the f o l l o w i n g p h y s i o l o g i c a l parameters: Metabolic  Rate Metabolic  r a t e i s an i n d i c a t o r o f e n d o c r i n e  t h y r o i d and p i t u i t a r y f u n c t i o n . p a r a l l e l the p r o c e s s o f a g i n g .  Changes i n m e t a b o l i c  1  approximately  Somewhat r e l a t e d i s a d e c r e a s e d a b i l i t y to cope  w i t h p h y s i c a l and p s y c h o l o g i c a l activity.  r a t e o v e r time  There occurs a s l i g h t d e c l i n e from a  p o s s i b l e 100 p e r c e n t l e v e l a t t h i r t y y e a r s o f age, to 80 p e r c e n t a t 80 - 90.  c a p a b i l i t y and  s t r e s s due p r i m a r i l y to l e s s e n i n g  adrenal  The pace a t w h i c h the body a c t s and r e a c t s i s g e n e r a l l y  slowed i n o l d  age.  Donahue and S t o l l say t h a t o l d e r a d u l t s a n t i c i p a t e d i f f i c u l t i e s i n l e a r n i n g and a p p e a r a n x i o u s when a p p r o a c h i n g a l e a r n i n g t a s k . n u r s e must keep t h i s i n mind when she i s c o n s i d e r i n g t e a c h i n g  The  the  p a t i e n t as the o l d e r p e r s o n w i l l need a l o n g e r time and p e r h a p s more support  in attempting  N.W. Shock, "The 1962), p. 101.  1  (January,  to cope w i t h the l e a r n i n g  2  experience.  Physiology o f Aging," S c i e n t i f i c American  W. Donahue and M.R. S t o l l , " P s y c h o l o g i c A s p e c t s , " I n : The Care o f the G e r i a t r i c P a t i e n t , E.V. Cowdry, e d i t o r , 2nd e d i t i o n ( S t . L o u i s : C.V. Mosby, 1963), p. 43.  50  Cardiac Output Cardiac output i s markedly decreased with e i t h e r r e s t o r e x e r c i s e i n t h e o l d e r person d e s p i t e an i n c r e a s e i n h e a r t r a t e and b l o o d pressure.  T h i s i s p r i m a r i l y due t o s t r u c t u r a l changes w h i c h have  o c c u r r e d i n t h e h e a r t such as t h e i n c r e a s e d l a y i n g down o f p i g m e n t s , s t a r c h e s and f a t s and a r t e r i a l e l o n g a t i o n , f i b r o s i s and c a l c i f i c a t i o n . Decreased  c a r d i a c o u t p u t causes c o n g e s t i v e h e a r t f a i l u r e and may  produce myocardial  ischemia which i n turn manifests i t s e l f i n p a t i e n t s  as l e t h a r g y , weakness, s h o r t n e s s o f b r e a t h and c h e s t p a i n .  I f these  symptoms have newly d e v e l o p e d  probably  and a r e u n c o n t r o l l e d , i t w i l l  be v e r y d i f f i c u l t and even unwise t o c o n s i d e r a f o r m a l , c o m p r e h e n s i v e t e a c h i n g programme.  That i s not to say t h a t the p a t i e n t ' s questions  s h o u l d n o t be answered b u t t h a t h i s p h y s i c a l needs may need t o be g i v e n g r e a t e r p r i o r i t y than h i s e d u c a t i o n a l needs a t t h a t p o i n t i n time.  Lung P e r f o r m a n c e Lung p e r f o r m a n c e i n t h e e l d e r l y i s reduced by l e s s e n e d mechani c a l e f f i c i e n c y , d e c r e a s e d c a p a c i t y f o r oxygen uptake by r e d b l o o d c e l l s and d i s e a s e .  Decreased  oxygenation  o f v i t a l o r g a n s may p r o d u c e  symptoms such as c o n f u s i o n , r e c e n t memory l o s s and d i s o r i e n t a t i o n . I f the p a t i e n t ' s mental s t a t u s i s a l t e r e d as d e s c r i b e d above, t h e t e a c h i n g - l e a r n i n g p r o c e s s would be d r a s t i c a l l y a f f e c t e d .  51 Nerve C o n d u c t i o n V e l o c i t y T h e r e i s a d e c r e a s e o f up to f i f t e e n p e r c e n t i n nerve c o n d u c t i o n v e l o c i t y with aging.  A g e n e r a l l o s s o f speed o f f u n c t i o n i n g r e s u l t s  t h a t i s c e n t r a l i n o r i g i n r a t h e r than the r e s u l t o f changes i n the p e r i p h e r a l ( s e n s o r y and motor) end  organs.  O r g a n i z a t i o n o f b e h a v i o u r becomes p r o g r e s s i v e l y more d i f f i c u l t , a c c u r a c y i s s t r e s s e d o v e r speed and i f a d d i t i o n a l time i s n o t t a k e n t o a c h i e v e the c e n t r a l o r g a n i z a t i o n o f m a t e r i a l , as may happen under the c i r c u m s t a n c e s o f h o s p i t a l i z a t i o n , q u a l i t y as w e l l as q u a n t i t y o f r e s p o n s e may be s e r i o u s l y a f f e c t e d .  V i s u a l and A u d i t o r y Changes A l l s e n s o r y modes a r e l e s s e f f e c t i v e i n o l d age.  Because t h i s  t h e s i s i s c o n c e r n e d w i t h p a t i e n t e d u c a t i o n , o n l y v i s u a l and a u d i t o r y senses w i l l be d i s c u s s e d .  V i s u a l changes i n c l u d e p r e s b y o p i a , r e d u c e d  v i s u a l f i e l d s , i n c r e a s e d t h r e s h o l d f o r l i g h t s t i m u l a t i o n due to d e c r e a s e d p u p i l s i z e , and i n c r e a s e d i n t r a o c u l a r p r e s s u r e .  These changes i n  c o m b i n a t i o n o f t e n r e s u l t i n d i m i n i s h e d a c t i v i t y and enjoyment o f l i f e . When t e a c h i n g the e l d e r l y p a t i e n t whose v i s u a l a c u i t y i s d e c r e a s e d , one must e n s u r e t h a t the e n v i r o n m e n t  and m a t e r i a l s t o be  used a r e g e a r e d t o poor v i s i o n .  F o r example, adequate l i g h t i n g i s 1 2 n e c e s s a r y t o compensate f o r d i m i n i s h e d p u p i l s i z e ' and w r i t t e n V.A. C u l b e r t and B.A. Kos, " A g i n g : C o n s i d e r a t i o n s f o r H e a l t h T e a c h i n g , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , 6 (December,1971(, pp.605-614. 2 V. S t o n e , " G i v e the O l d e r P e r s o n Time," American J o u r n a l o f N u r s i n g , 69 ( O c t o b e r , 1969), p. 2125.  m a t e r i a l s h o u l d be i n l a r g e p r i n t w i t h wide s p a c i n g o f words. H e a r i n g l o s s e s t h a t d e v e l o p w i t h age s p r e a d from h i g h e r t o lower f r e q u e n c i e s .  Some o f t h e a u d i t o r y changes t h a t o c c u r a r e a t t r i -  buted t o nervous system impairment ment.  or structural or atrophic involve-  Stone reminds us t h a t d i m i n i s h e d a u d i t o r y p e r c e p t i o n may d e l a y  r e a c t i o n time.  To compensate f o r t h i s , t h e n u r s e s h o u l d speak s l o w l y  and e n u n c i a t e s y l l a b l e s c l e a r l y t o g i v e t h e p e r s o n time t o comprehend 2 and p r o c e s s t h e i n f o r m a t i o n . C e l l u l a r Changes i n t h e B r a i n With o l d age comes c e r t a i n c e l l u l a r changes in. t h e b r a i n such as f a t t y i n f i l t r a t i o n and a c c u m u l a t i o n o f s u l p h u r and pigment. Many p h y s i o l o g i s t s agree t h a t t h e r e i s an a c t u a l l o s s o f neurons as w e l l as " t h e d e v e l o p m e n t o f uneven t h i c k e n i n g , s p l i t t i n g and g r a n u l a r 3 fragmentation." Some p r a c t i c a l i m p l i c a t i o n s o f t h e s e p h y s i o l o g i c a l changes i n the b r a i n a r e t h a t t h e a t t e n t i o n span s h o r t e n s , and c o n c e p t u a l i z a t i o n becomes more d i f f i c u l t .  Because o f t h i s , m a t e r i a l s t o be l e a r n e d must  be p r e s e n t e d i n a c o n c i s e , c o n c r e t e manner. have s h o r t , c l e a r s e n t e n c e s and e x t r a n e o u s deleted.  Written materials should i n f o r m a t i o n s h o u l d be  The v o c a b u l a r y must be matched t o t h e l e a r n e r ' s a b i l i t y  'P.A. C u l b e r t and B.A. Kos, " A g i n g : C o n s i d e r a t i o n s f o r H e a l t h T e a c h i n g , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , 6 (December, 1971), pp. 605-614. 2 V. S t o n e , "Give t h e O l d e r P e r s o n Time," A m e r i c a n J o u r n a l o f N u r s i n g , 69 ( O c t o b e r , 1969), p. 2126. 3 C u l b e r t and Kos, op. c i t . , p. 606.  53 and a l l terms must be c l e a r l y d e f i n e d .  Mohammed s u g g e s t s t h a t a 4 t h  grade l e v e l o f v o c a b u l a r y be used t o f a c i l i t a t e c o m p r e h e n s i o n o f w r i t t e n m a t e r i a l s b u t one must keep i n mind t h a t h e r s t u d y sample c o n s i s t e d o f m o s t l y f e m a l e , Negro, s e m i - u n s k i l l e d w o r k e r s f r o m a l o w e r s o c i o economic b a c k g r o u n d .  1  CULTURAL AGING AND ITS INFLUENCE ON THE TEACHING-LEARNING PROCESS  A g i n g i s a c u l t u r a l p r o c e s s as w e l l as a b i o l o g i c a l p r o c e s s . P e r s o n a l a d a p t a t i o n t o i t depends on s e l f - p e r c e p t i o n w h i c h i s a p r o d u c t o f c u l t u r a l norms and v a l u e s .  Most c e r t a i n l y t h e s e l f - p e r c e p t i o n s o f  the aged a r e shaped by s o c i e t a l e x p e c t a t i o n s .  T h i s s e c t i o n w i l l examine  the p e r s o n a l g o a l s o f t h e aged, t h e v a l u e o r i e n t a t i o n s w i t h i n them and t h e i r r e l a t i o n s h i p t o m o t i v a t i o n and l e a r n i n g . C l a r k and A n d e r s o n i d e n t i f i e d s i x major c l u s t e r s as a s y s t e m o f p e r s o n a l g o a l s a g a i n s t w h i c h t h e aged seem t o j u d g e t h e m s e l v e s . They a r e : 1.  Independence.  2.  Social Acceptability.  ^M.F.B. Mohammed, " P a t i e n t s U n d e r s t a n d i n g o f W r i t t e n H e a l t h I n f o r m a t i o n , " N u r s i n g R e s e a r c h , 13 ( S p r i n g , 1964), p. 100.  54 3.  Adequacy o f p e r s o n a l  resources.  4.  A b i l i t y t o cope w i t h s e l f change.  5.  Having s i g n i f i c a n t g o a l s o r meaning i n l a t e r l i f e .  6.  A b i l i t y t o cope w i t h e x t e r n a l t h r e a t s o r l o s s e s .  1  Independence The a b i l i t y t o p r o v i d e f o r one's needs was c o n s i d e r e d t o be very important r e g a r d l e s s o f the person's o n e s e l f as i n d e p e n d e n t  state of health.  Perceiving  i s an e x p r e s s i o n o f s e l f r e s p e c t , p r i d e and t h e  e l i m i n a t i o n o f t h e f e a r o f becoming a b u r d e n . ways t o m a i n t a i n t h e i r i n d e p e n d e n c e .  The e l d e r l y d e s i r e  P e r h a p s , h e a l t h t e a c h i n g i s one  o f t h e b e s t ways t o f o s t e r t h i s need f o r i n d e p e n d e n c e .  Social Acceptability In C l a r k and A n d e r s o n ' s s t u d y , s o c i a l a c c e p t a b i l i t y was d e f i n e d as a p p r o v a l o f o t h e r s .  In o u r c u l t u r e , i t i s d e r i v e d from h e a l t h ,  y o u t h , v i g o r and p h y s i c a l f i t n e s s .  T h i s c r e a t e s problems f o r the  e l d e r l y and has i n f l u e n c e d t h e v a l u e w h i c h we a s c r i b e t o t h e i r c o n t r i butions.  Many e l d e r l y p e o p l e a r e f i t and have f u n c t i o n i n g p o t e n t i a l .  H e a l t h t e a c h i n g c a n channel  t h i s p o t e n t i a l and p e r h a p s promote a g r e a t e r  d e g r e e o f r e h a b i l i t a t i o n among t h e e l d e r l y who a r e l e s s w e l l . ""M. C l a r k and B. A n d e r s o n , C u l t u r e and A g i n g ( S p r i n g f i e l d , I l l i n o i s : C h a r l e s C. Thomas, 1 9 6 7 ) , p. 177. :  55 Adequacy o f P e r s o n a l Personal as i m p o r t a n t  Resources r e s o u r c e s , both i n t e r n a l and e x t e r n a l , were viewed  by the a g i n g a d u l t i n a s s e s s i n g h i s c u r r e n t s t a t u s .  aged have w e l l d e v e l o p e d  l i f e patterns which i n c l u d e r e g u l a r i t y o f  h a b i t s , s e l f - d i s c i p l i n e and c o n s e r v a t i o n o f p h y s i c a l , e m o t i o n a l economic s t r e n g t h .  The  and  Donahue and S t o l l say t h a t a decrement i n the  a b i l i t y to l e a r n i s v e r y n o t i c e a b l e when o l d e r p e o p l e a t t e m p t to l e a r n new h a b i t s p a r t i c u l a r l y i f they r e q u i r e t h a t the o l d ones be m o d i f i e d o r i n t e g r a t e d w i t h new o n e s .  1  unlearned,  The n u r s e must be aware o f  t h i s and i n c o r p o r a t e i t i n t o her p l a n f o r h e a l t h t e a c h i n g .  Perhaps  she must, i n c o n s u l t a t i o n w i t h the p a t i e n t , seek a l t e r n a t i v e s o l u t i o n s w o r k i n g w i t h the o l d h a b i t s .  A b i l i t y to Cope w i t h S e l f Change S e l f change can be seen as a p o s i t i v e o r n e g a t i v e f o r c e .  It  i n d i c a t e s r e s i l i e n c e and r e a l i s m i n d e a l i n g w i t h the i n e v i t a b l e a g i n g process.  The n u r e s ' s  teaching i s e s s e n t i a l .  a c c u r a t e a s s e s s m e n t o f the r e a d i n e s s f o r h e a l t h She can promote h e a l t h t e a c h i n g by c l a r i f y i n g  a l t e r n a t i v e s , e x p l o r i n g s u b s t i t u t i o n s i n l i f e space,  encouraging  v e r b a l i z a t i o n o f u n r e a l i s t i c g o a l s and s e l f demands and  supporting  accomplishments.  W. Donahue and M.R. S t o l l , " P s y c h o l o g i c A s p e c t s , " The Care o f the G e r i a t r i c P a t i e n t , E.V. Cowdry, e d i t o r , 2nd e d i t i o n ( S t . L o u i s : C.V. Mosby Co., 1963), p. 51.  56  Having S i g n i f i c a n t G o a l s o r Meaning i n L a t e r L i f e The e l d e r l y p e o p l e i n C l a r k and A n d e r s o n ' s s t u d y f e l t t h a t s i g n i f i c a n t g o a l s and meaning c o u l d be o b t a i n e d by e n g a g i n g  in l i f e  a c t i v i t i e s i n a whole-hearted  They l o o k e d  y e t l e s s c o m p e t i t i v e manner.  for o p p o r t u n i t i e s to enjoy or appreciate l i f e ' s smaller pleasures. o r d e r to a c c o m p l i s h  t h i s , t h e r e i s a need t o m a i n t a i n o p t i m a l  In  health  o r management o f c h r o n i c a c u t e i l l n e s s t h r o u g h h e a l t h t e a c h i n g .  A b i l i t y t o Cope w i t h E x t e r n a l T h r e a t s o r  Losses  The v a l u e o r i e n t a t i o n i n h e r e n t here i s a g a i n t h a t o f r e s i l i e n c y . I t i s b e s t c h a r a c t e r i z e d as " r o l l i n g w i t h the punches" and making the best of things. and s t a m i n a .  I t i n c l u d e s such q u a l i t i e s as e n d u r a n c e ,  forebearance  The s o u r c e o f s e l f esteem i n t h i s a r e a d e r i v e s from  s k i l l and s t r e n g t h t o f i n d c o n t e n t m e n t i n the f a c e o f a d v e r s i t y .  the These  a t t i t u d e s may m o t i v a t e the e l d e r l y p e r s o n t o be more a c c e p t i n g o f h i s i l l n e s s as a concommitant o f o l d age and may make him more r e c e p t i v e to h e a l t h t e a c h i n g as a means o f s e l f c o n t r o l . C l a r k and A n d e r s o n ' s d e s c r i p t i v e s u r v e y o f the l i f e s t y l e t h o u g h t s o f t h o s e p e o p l e o v e r s i x t y - f i v e r e s i d i n g i n the c i t i e s  and  v i l l a g e s a c r o s s the U n i t e d S t a t e s i s a f i n e p i e c e o f work b e c a u s e : 1.  I t o b t a i n s the o p i n i o n s o f a l a r g e sample o f aged i n d i v i d u a l s , s i c k and w e l l and compares them.  2.  I t has tremendous i m p l i c a t i o n s f o r t h o s e w o r k i n g w i t h e l d e r l y as i s shown above i n r e l a t i o n to the t e a c h i n g learning  process.  the  and  57 One i n t e r e s t i n g i s s u e t o c o n s i d e r i s w h e t h e r t h i s s t u d y o f t h e A m e r i c a n e l d e r l y p e r s o n can be g e n e r a l i z e d t o the C a n a d i a n e l d e r l y population.  PSYCHOLOGIC AGING AND  ITS INFLUENCE ON  THE  TEACHING-LEARNING PROCESS  P s y c h o l o g i c a l a g i n g as i t r e l a t e s to the t e a c h i n g - l e a r n i n g p r o c e s s w i l l be examined from the p o i n t o f view o f the c o n c e p t o f l o s s and Maslow's t h e o r y o f the h i e r a r c h y o f needs. The e l d e r l y p e r s o n w i l l have s u f f e r e d many l o s s e s i n h i s lifetime.  Some o f t h e s e l o s s e s a r e c o n c e r n e d w i t h r o l e s , s t a t u s ,  f a m i l y members, f r i e n d s , h e a l t h , economic s e c u r i t y and f a m i l i a r s u r r o u n d ings.  The common d e n o m i n a t o r o f a l l t h e s e k i n d s o f l o s s e s i s l o s s o f  s e l f esteem.  Does t h i s f e e l i n g o f l o s s o f s e l f esteem c a n c e l  out  r e a d i n e s s to l e a r n as a means o f a d j u s t i n g to a new h e a l t h s t a t u s ? C u l b e r t and Kos t h i n k not and say t h a t the nurse w i l l have t o spend more time h i g h l i g h t i n g the p e r s o n ' s a c c o m p l i s h m e n t s and  strengths.  The nurse s h o u l d s t r i v e to c r e a t e an atmosphere o f a c c e p t a n c e , and empathy i n o r d e r t o enhance r e a d i n e s s t o l e a r n and s e l f  caring  confidence.  P.A. C u l b e r t . a n d B.A. Kos, " A g i n g : C o n s i d e r a t i o n s f o r H e a l t h T e a c h i n g , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , 6 (December, 1971), p. 612.  58 She must a s s e s s each e l d e r l y p e r s o n w i t h i n h i s l i f e s p a c e , i d e n t i f y t h e l o s s e s e x p e r i e n c e d , t h e i r e f f e c t and t h e p e r s o n ' s c o p i n g a b i l i t i e s . Memory l o s s i n p a r t i c u l a r can a f f e c t t h e s u c c e s s o f t h e t e a c h i n g - l e a r n i n g p r o c e s s when t h e i n f o r m a t i o n p r e s e n t e d i s new and u n r e l a t e d to the person's past experience.  Memory l o s s f o r r e c e n t e v e n t s among 1 2  the e l d e r l y has been w e l l documented. '  I t i s i n t e r e s t i n g t o note  t h a t memory o f p a s t e v e n t s i s much l e s s i m p a i r e d .  The a u t h o r i n t e r p r e t s  t h i s f i n d i n g t o mean t h a t t h e remembered e v e n t s o f t h e remote p a s t p r o b a b l y have g r e a t p s y c h o l o g i c a l s i g n i f i c a n c e f o r t h e e l d e r l y p e r s o n . What t h e o l d e r p e r s o n remembers might g i v e t h e nurse v a l u a b l e i n s i g h t i n t o t h e p a t i e n t ' s p s y c h o l o g i c a l makeup.  When a t t e m p t i n g t o t r a n s m i t  new i n f o r m a t i o n t o o l d e r p e r s o n s , t h e nurse s h o u l d p r e s e n t i t , i f p o s s i b l e , within the context o f the patient's meaningful, past experience. Maslow d e f i n e d a h i e r a r c h y o f needs f o r a l l human b e i n g s  which  p r o g r e s s e s from p h y s i c a l o r s u r v i v a l needs t o s e c u r i t y , l o v e and b e l o n g 3  i n g , s e l f - e s t e e m and f i n a l l y s e l f - a c t u a l i z a t i o n .  Often the e l d e r l y ,  d e s p i t e f o r m e r r e a l i z a t i o n o f h i g h e r growth needs, when f a c e d w i t h t h e c r i s i s o f a c u t e i l l n e s s , r e g r e s s t o t h e b a s i c s a f e t y and s e c u r i t y l e v e l . T h i s r e g r e s s i o n i s needed t o m o b i l i z e t h e i r i n n e r r e s o u r c e s so t h a t t h e s i t u a t i o n can be coped w i t h .  The n u r s e f i r s t must l o o k a t where t h e  p a t i e n t i s i n h i s a d a p t a t i o n p r o c e s s and then e v a l u a t e h i s r e a d i n e s s o r need t o l e a r n .  M i l d a n x i e t y and t h e awareness o f a need t o l e a r n can  be h i g h l y m o t i v a t i n g f a c t o r s . ^N.W. Shock, "The P h y s i o l o g y o f A g i n g , " S c i e n t i f i c American ( J a n u a r y , 1962), p. 108. 2 E.V. Cowdry, e d i t o r , The C a r e . o f t h e G e r i a t r i c P a t i e n t , 2nd e d i t i o n . ( S t . L o u i s : C.V. Mosby Co., I % 3 ) , p. b'l. 3  Pros.,  A.H. Maslow, M o t i v a t i o n and P e r s o n a l i t y 1954).  (New Y o r k : H a r p e r and  59 FACILITATING LEARNING AMONG THE  Botwinick  ELDERLY  i n h i s book, A g i n g and B e h a v i o u r ,  has o u t l i n e d  p r a c t i c a l i n f o r m a t i o n a b o u t the l e a r n i n g c a p a b i l i t i e s o f the aged.  In  o r d e r t o f a c i l i t a t e l e a r n i n g , the n u r s e must be aware t h a t : 1.  e l d e r l y p e o p l e need more time to a b s o r b ,  organize,  c o n s o l i d a t e and r e s p o n d to new  inputs,  2.  e l d e r l y people p r e f e r concrete  tasks,  3.  e l d e r l y p e o p l e need to have e x p l i c i t knowledge o f the g o a l , and  4.  e l d e r l y p e o p l e a r e more s u s c e p t i b l e to i n t e r f e r e n c e effects.  1  Motivation M o t i v a t i o n o f t h e i n d i v i d u a l p l a y s an i m p o r t a n t  part in his  a b i l i t y o r d e s i r e to l e a r n new i d e a s a n d / o r ways o f l i v i n g .  Kos  C u l b e r t , i n t h e i r s t u d y o f g e r i a t r i c pacemaker p a t i e n t s , found most o f t e n the p a t i e n t s were w e l l m o t i v a t e d  and that  and t h a t t h i s f a c t o r d i d 2  not pose a s i g n i f i c a n t p r o b l e m i n t h e i r l e a r n i n g .  Perhaps t h i s f i n d -  i n g can be e x p l a i n e d by N i e l d ' s work on a n x i e t y r e d u c t i o n .  She  J a c k B o t w i n i c k , A g i n g and B e h a v i o u r (New Y o r k : S p r i n g e r P u b l i s h i n g Co., 1 9 7 3 ) , p. 230. 2 B.A. Kos and P.A. C u l b e r t , " T e a c h i n g G e r i a t r i c P a t i e n t s w i t h I m p l a n t e d C a r d i a c Pacemakers." U n p u b l i s h e d M a s t e r ' s T h e s i s , A d e l p h i U n i v e r s i t y , 1969, p. 3.  60 s u g g e s t s t h a t i l l n e s s r e c e n t l y d i a g n o s e d and i n an u n s t a b l e phase may be c r i t i c a l f a c t o r s i n f l u e n c i n g m o t i v a t i o n t o l e a r n J reminds us t h a t the more m e a n i n g f u l  Botwinick  the t a s k and the more p e r s o n a l l y 2  r e l e v a n t i t i s , the h i g h e r the m o t i v a t i o n can be e x p e c t e d t o be. Ausubel  i n t r o d u c e s the i d e a o f " r e t r o a c t i v e " m o t i v a t i o n and  maintains that i t i s unnecessary  to d e l a y l e a r n i n g u n t i l the a p p r o p r i a t e  i n t e r e s t s o r m o t i v a t i o n have d e v e l o p e d .  He has found t h a t by f o c u s i n g  on c o g n i t i v e a s p e c t s o f a s i t u a t i o n r a t h e r than m o t i v a t i o n a l ones t h a t 3  motivation w i l l develop r e t r o a c t i v e l y . Methods To promote l e a r n i n g , a v a r i e t y o f methods can be used t o f a c i l i t a t e this task.  P a c k a r d and Van Ess use the c o n c e p t o f r o l e -  d e l i n e a t e d t e a c h i n g as a means o f a r o u s i n g and m a i n t a i n i n g an priate psychological s e t .  4  appro-  They found t h a t l e a r n i n g i n c r e a s e d w i t h  the use o f p l a n n e d c l a r i f i c a t i o n o f the n u r s e ' s r o l e as t e a c h e r , the p a t i e n t ' s r o l e as s t u d e n t and the i n t e r a c t i o n as t h a t o f a t e a c h i n g situation.  C a n e s t r a r i i n h i s s t u d y used " s e l f - p a c e d " l e a r n i n g w i t h  e l d e r l y s u b j e c t s and found t h a t when no time l i m i t was imposed t h a t ^M.A. N i e l d , "The E f f e c t o f H e a l t h T e a c h i n g on A n x i e t y L e v e l , " N u r s i n g R e s e a r c h , 20 ( 1 9 7 1 ) , p. 3. 2 J . B o t w i n i c k , A g i n g and B e h a v i o u r (New York: S p r i n g e r Pub. Co., 1973), p. 230. 3  D.P. A u s u b e l , The P s y c h o l o g y o f M e a n i n g f u l V e r b a l L e a r n i n g (New York: Gruen & S t r a t t o n , 1 9 6 3 ) , p. 226. 4 R.B. P a c k a r d and H. Van E s s , "A Comparison o f I n f o r m a l and R o l e - D e l i n e a t e d P a t i e n t T e a c h i n g S i t u a t i o n s , " N u r s i n g R e s e a r c h , 18 (1969), pp. 443-446.  61 the e l d e r l y l e a r n e d f a s t e r .  1  The g e n e r a l i z a b i l i t y o f C a n e s t r a r i ' s  r e s u l t s must be q u e s t i o n e d t h o u g h , because h i s s u b j e c t s were w e l l o u t s i d e o f t h e h o s p i t a l s i t u a t i o n , and were p e r f o r m i n g tasks.  r e a l i t y unrelated  Dodge p o i n t s o u t t h a t i n d i v i d u a l s a t t e n d t o i n f o r m a t i o n w h i c h  they p e r c e i v e as b e i n g c e n t r a l t o t h e i r p h y s i c a l , p s y c h o l o g i c a l and 2 social survival.  The u n d e r s t a n d i n g  and a c c e p t a n c e  of this information  i s f a c i l i t a t e d when an i n d i v i d u a l r e c e i v e s t h e k i n d o f d a t a t h a t f i t s i n t o h i s frame o f r e f e r e n c e and has i n d i v i d u a l meaning. Audiovisual Aids A u d i o v i s u a l t e c h n o l o g y has g r e a t l y expanded i n t h e p a s t t e n years.  I n c r e a s i n g l y , e d u c a t i o n a l i n s t i t u t i o n s and o r g a n i z a t i o n s a r e  using a v a r i e t y o f audio-visual techniques to present f a c t s , procedures c o n c e p t s and p e r s o n a l e x p e r i e n c e s  t o t h e i r membership.  the l e a r n i n g p r o c e s s i n d i c a t e s t h a t p e o p l e read  20% 30% 50% 80% 90%  hear see see and hear say s a y as they do a t h i n g .  what what what what what  they they they they they  on  remember:  10% o f what t h e y of of of of of  Research  ^R.E. C a n e s t r a r i , "Paced and S e l f - P a c e d L e a r n i n g i n Young and E l d e r l y A d u l t s , " J o u r n a l o f G e r o n t o l o g y , 18 ( 1 9 6 3 ) , pp. 165-168. 2 Joan S. Dodge, " F a c t o r s R e l a t e d t o P a t i e n t ' s P e r c e p t i o n s o f T h e i r C o g n i t i v e Needs," N u r s i n g R e s e a r c h , 18 (November-December, 1 9 6 9 ) , pp. 502-513. 3  C M . Hudak e t a l . , C r i t i c a l Care N u r s i n g ( P h i l a d e l p h i a : J.B. L i p p i n c o t t Co., 197377 p. 320.  62 In r e v i e w i n g t h e e d u c a t i o n l i t e r a t u r e , many books and a r t i c l e s are a v a i l a b l e that deal with the a p p l i c a t i o n o f a u d i o - v i s u a l l e a r n i n g a i d s i n p r i m a r y and s e c o n d a r y s c h o o l s b u t no d a t a a r e a v a i l a b l e on t h e u t i l i t y o f a u d i o - v i s u a l a i d s f o r t h e a d u l t n e v e r mind t h e aged l e a r n e r . The n u r s i n g l i t e r a t u r e d e m o n s t r a t e s  a similar pattern.  Most a u d i o -  v i s u a l t e c h n i q u e s have been employed by n u r s i n g s c h o o l s t o enhance t h e 12 3 l e a r n i n g o f the student nurse.  Several nurse researchers ' '  have  used s l i d e - t a p e programmes, b o o k l e t s o r tape r e c o r d i n g s as p a r t o f a n u r s i n g i n t e r v e n t i o n b u t t h e a u d i o - v i s u a l a i d p e r se was n o t what was s y s t e m a t i c a l l y e v a l u a t e d by t h e s t u d y . The main s o u r c e o f i n f o r m a t i o n c o n c e r n i n g s l i d e - t a p e p r o grammes which t h i s n u r s e r e s e a r c h e r has used i s Mr. V i c t o r D o r a y , Head o f t h e B i o m e d i c a l Communications Department a t t h e Vancouver G e n e r a l H o s p i t a l and t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a . o u t l i n e d t h e f o l l o w i n g advantages  Mr. Doray  o f s l i d e - t a p e programmes:  C.A. Lindeman, " N u r s i n g I n t e r v e n t i o n w i t h t h e P r e - S u r g i c a l P a t i e n t - P h a s e 11," N u r s i n g R e s e a r c h , 21 ( 1 9 7 2 ) , p. 196. ?  C.A. Lindeman and B. Van Aernam, " N u r s i n g I n t e r v e n t i o n w i t h t h e P r e - S u r g i c a l P a t i e n t - The E f f e c t s o f S t r u c t u r e d and U n s t r u c t u r e d P r e o p e r a t i v e T e a c h i n g , " N u r s i n g R e s e a r c h , 20 ( 1 9 7 1 ) , p. 319. American  B. Kos and P. C u l b e r t , " T e a c h i n g P a t i e n t s About Pacemakers," J o u r n a l o f N u r s i n g , 71 ( 1 9 7 1 ) , p. 523.  63 1.  t h e l e a r n e r can p r o c e e d a t h i s own s p e e d ,  2.  t h e l e a r n e r can r e v i e w t h e s l i d e - t a p e programme as  3.  needed,  t h e s l i d e - t a p e programme can save time i n terms o f one p e r s o n h a v i n g t o r e p e a t t h e same information,  4.  t h e n u r s i n g s t a f f can have more time f o r i n d i v i d u a l i z e d c o n t a c t with persons viewing the s l i d e - t a p e programme, and  5.  t h e s l i d e - t a p e programme i s l e s s c o s t l y than o t h e r a u d i o - v i s u a l a i d s and can be s i m p l y and c h e a p l y updated as needed.  1  A n o t h e r i m p o r t a n t p o i n t t h a t Mr. Doray s t r e s s e d was t h a t t h e s l i d e - t a p e programme n e v e r r e p l a c e s t h e t e a c h e r .  In summary, f a c i l i t a -  t i o n o f l e a r n i n g i n t h e aged can be a c c o m p l i s h e d by u n d e r s t a n d i n g t h e e f f e c t s o f o l d age on t h e l e a r n i n g p r o c e s s , by u s i n g t h e a p p r o p r i a t e t e a c h i n g t e c h n i q u e s , by a s s e s s i n g t h e m o t i v a t i o n o f t h e l e a r n e r and by employing s e l e c t e d a u d i o - v i s u a l a i d s .  Involving the S i g n i f i c a n t Other The b e h a v i o u r o f t h e i n d i v i d u a l c a n n o t be viewed i n t o t a l i s o l a t i o n as t h a t p e r s o n i s a l s o a member o f a f a m i l y .  The e x t e n t t o  ^ T h i s i n f o r m a t i o n was o b t a i n e d from Mr. Doray a t a Workshop which he gave a t t h e Vancouver G e n e r a l H o s p i t a l , F e b r u a r y 4, 1976.  64 w h i c h he i n t e r a c t s w i t h h i s f a m i l y members o r s i g n i f i c a n t o t h e r s must be a s s e s s e d .  A change i n h e a l t h s t a t u s , knowledge base and s k i l l s o f  the i n d i v i d u a l w i l l c r e a t e an e f f e c t on h i s r e l a t i o n s h i p w i t h h i s significant others. Craven a n d Sharp i n s i s t t h a t t h e n u r s e must broaden h e r p e r s p e c t i v e and view t h e p r o b l e m s o f t h e f a m i l y as w e l l as t h e p a t i e n t .  The n u r s e  must r e c o g n i z e t h e i m p o r t a n c e o f t h e p a t i e n t - f a m i l y network and e n c o u r a g e the f a m i l y members a c t i v e p a r t i c i p a t i o n whenever p o s s i b l e . s t r e s s e s t h a t an i m p o r t a n t  Bain  a s p e c t o f t h e n u r s i n g c a r e o f a pacemaker  p a t i e n t i s dealing with the patient's family. o f the nurse's  1  She m a i n t a i n s  t h a t much  t i m e i s o c c u p i e d by l i s t e n i n g t o t h e f e a r s and a p p r e h e n -  s i o n s o f t h e f a m i l y and t e a c h i n g them t h a t t h e p a t i e n t needs t o be as 2 s e l f - s u f f i c i e n t as p o s s i b l e .  Royle's  s t u d y showed t h a t t h e needs o f  p a t i e n t s and f a m i l i e s f o r r e l e v a n t i n f o r m a t i o n r e g a r d i n g t h e i r h e a r t d i s e a s e and p r e s c r i b e d t h e r a p y were n o t a d e q u a t e l y  i d e n t i f i e d o r met  d u r i n g t h e i r h o s p i t a l i z a t i o n o r i n i t i a l p e r i o d a t home.  When s p e c i f i c  i n s t r u c t i o n s were g i v e n t o p a t i e n t s and t h e i r spouses a b o u t p r e s c r i b e d t h e r a p e u t i c measures, they e x p e r i e n c e d  l e s s a n x i e t y i n i t i a l l y upon  r e t u r n i n g home.^ Baden found t h a t when w o r k i n g w i t h groups o f c a r d i a c p a t i e n t s a l a r g e number o f f a m i l i e s were u n a b l e t o p r o v i d e t h e s u p p o r t t h e 'R.F. C r a v e n and B.H. S h a r p , "The E f f e c t s o f I l l n e s s on F a m i l y F u n c t i o n s , " N u r s i n g Forum, 11 (1972), pp. 186-193. 2  B. B a i n , "Pacemakers and t h e P e o p l e Who Need Them," A m e r i c a n J o u r n a l o f N u r s i n g , 71 (August, 1971), pp. 1582-1585. J . R o y l e , " C o r o n a r y P a t i e n t s and T h e i r F a m i l i e s R e c e i v e I n c o m p l e t e Care," C a n a d i a n N u r s e , 69 ( F e b r u a r y , 1 9 7 3 ) , pp. 21-25.  65 p a t i e n t needed b e c a u s e they l a c k e d t h e n e c e s s a r y d i s e a s e and t h e p a t i e n t ' s m e d i c a l  regimen.  t h a t w i v e s o f p a t i e n t s who had m y o c a r d i a l  1  information about heart  A d s e t t and Bruhn  found  i n f a r c t i o n s were o v e r l y 2  p r o t e c t i v e and had g u i l t f e e l i n g s a b o u t t h e i r husbands i l l n e s s . One o f t h e m a j o r changes i n f a m i l y l i f e , a c c o r d i n g t o A d s e t t and Bruhn, i s t h a t t h e person who was i l l t e n d s t o become t h e c e n t e r o f t h e h o u s e h o l d and o f t e n c o n t r o l s t h e f a m i l y as o t h e r members a r e a f r a i d to express c a r d i a c symptoms.  f e e l i n g s t o him f o r f e a r o f p r o v o k i n g  distressful  3  Kos and C u l b e r t i n v i t e d f a m i l y members t o p a r t i c i p a t e i n t h e i r s t u d y ( t h e y do n o t s a y how many f a m i l y members a c t u a l l y p a r t i c i p a t e d ) and r e p o r t e d t h a t t h e f a m i l y members found i t t o be a b e n e f i c i a l e x p e r i 4  ence. Lindeman c o n c l u d e d t h a t t h e p r e s e n c e o f a f a m i l y member d u r i n g pre-operative teaching d i d not increase the e f f e c t i v e n e s s o f that 5 teaching.  She p o i n t s o u t t h a t o n l y f o r t y - f i v e o u t o f t h r e e hundred  and f i f t y - o n e s u b j e c t s had f a m i l y members p r e s e n t and t h a t h e r c o n c l u s i o n s s h o u l d be c o n s i d e r e d t e n t a t i v e and i n need o f f u r t h e r r e s e a r c h . ^C.A. Baden, " T e a c h i n g t h e C o r o n a r y P a t i e n t and H i s F a m i l y , " N u r s i n g C l i n i c s o f North A m e r i c a , 7 (1972), pp. 563-571. 2 C.A. A d s e t t and J.G. Bruhn, " S h o r t Term Group P s y c h o - T h e r a p y f o r t h e P o s t M.I. P a t i e n t s and T h e i r Wives," C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l , 99 (1968), pp. 577-584. I b i d . , p. 584. 4 B. Kos and P. C u l b e r t , " T e a c h i n g P a t i e n t s About Pacemakers," A m e r i c a n J o u r n a l o f N u r s i n g , 71 (1971), pp. 523-527. 5 C. A. Lindeman, " N u r s i n g I n t e r v e n t i o n w i t h P r e s u r g i c a l P a t i e n t Phase 11," N u r s i n g R e s e a r c h , 21 (1972), p. 208. 3  Redman  and T y z e n h o u s e  assume a s u p p o r t i v e  both emphasize t h a t f a m i l i e s need t o  r a t h e r than d i r e c t i v e r o l e i n a t t e m p t i n g t o h e l p  the p a t i e n t a d j u s t t o h i s i l l n e s s . o t h e r s must be g i v e n t h e o p p o r t u n i t y t h e i r questions  and t o e x p l o r e  The f a m i l y members o r s i g n i f i c a n t t o e x p r e s s t h e i r f e e l i n g s , ask  t h e i r c o n c e r n s i n o r d e r t o c r e a t e a home  atmosphere o f warmth, u n d e r s t a n d i n g and a c c e p t a n c e .  I n d i v i d u a l T e a c h i n g and  Counselling  Humans a r e n o t a l i k e . T h e i r d i f f e r e n c e s a r e r e a l , i n e v i t a b l e , more s u b t l e and numerous than we o f t e n recognize. 3 When i n d i v i d u a l i z i n g i n s t r u c t i o n , t h e t e a c h e r must promote i n d i v i d u a l i n t e r e s t s , a l l o w f o r i n d i v i d u a l s t y l e s and r e s p o n d t o i n d i v i d ual needs.  4  F r a s e says t h a t i n d i v i d u a l i z e d i n s t r u c t i o n has f o u r b a s i c 5  elements: pacing, o b j e c t i v e s , materials  and p e r s o n a l i z a t i o n .  The  purpose o f i n d i v i d u a l i z i n g the i n s t r u c t i o n o f a p o t e n t i a l l e a r n e r i s to f o s t e r the development o f c r i t i c a l t h i n k i n g , s e l f - d i r e c t i o n , c r e a t i v i t y and one's s e l f c o n c e p t . ^B.K. Redman, The P r o c e s s o f P a t i e n t T e a c h i n g i n N u r s i n g , 2nd e d i t i o n ( S t . L o u i s : The C.V. Mosby Co., 1972), p. 4. 2 P.S. T y z e n h o u s e , " M y o c a r d i a l I n f a r c t i o n : I t s E f f e c t on t h e F a m i l y , " A m e r i c a n J o u r n a l o f N u r s i n g , 73 ( 1 9 7 3 ) , p. 1013. 3  R.E. K e u s c h e r , "Why I n d i v i d u a l i z e I n s t r u c t i o n ? " I n d i v i d u a l i z a t i o n o f I n s t r u c t i o n - A T e a c h i n g S t r a t e g y , V.M. Howes, e d i t o r (New Y o r k : The M a c m i l l a n Co., 1970), p. 6. 4  Strategy.  5  B.J. W o l f s o n , I n d i v i d u a l i z a t i o n o f I n s t r u c t i o n - A T e a c h i n g V.M. Howes, e d i t o r (New Y o r k : The M a c m i l l a n C o . , 1 9 7 0 ) , p. 101.  L.E. F r a s e , "Open Space," I n d i v i d u a l i z e d I n s t r u c t i o n - A Book o f R e a d i n g s , E. Gene T a l b e r t and L . E . F r a s e , e d i t o r s ( O h i o : C h a r l e s E. M e r r i l l Pub. Co., 1972), p. 38. K e u s c h e r , op. c i t . , pp. 9-13.  67 These n o t i o n s o f t h e c o n c e p t o f i n d i v i d u a l i z e d t e a c h i n g have been s t u d i e d e x t e n s i v e l y i n t h e n u r s i n g l i t e r a t u r e . D a l z e l l e v a l u a t e d a p r e - n a t a l t e a c h i n g programme and found t h a t i n d i v i d u a l c o u n s e l l i n g a p p e a r e d b e t t e r than group work f o r p a t i e n t s who had o r had n o t received p r i o r teaching.  1  P u t t c o n d u c t e d an e x p e r i m e n t w i t h p a t i e n t s who had p e p t i c u l c e r s i n order to determine the e f f e c t s o f d i f f e r e n t types o f n u r s i n g i n t e r v e n t i o n on t h e p a t i e n t ' s w e l l b e i n g .  She found t h a t i n d i v i d u a l  i n s t r u c t i o n o f t h e p a t i e n t was more e f f e c t i v e than p s y c h o l o g i c a l  support  w h i c h was, i n t u r n , s i g n i f i c a n t l y more e f f e c t i v e than t h e usual  routine  nursing care i n reducing discomfort a f t e r admission,  i n decreasing  the l e n g t h o f h o s p i t a l s t a y and i n a l t e r i n g t h e p a t i e n t ' s of s e l e c t e d concepts  r e l a t i n g to his i l l n e s s .  the e f f e c t i v e n e s s o f p l a n n e d ,  perception  Goodman d e m o n s t r a t e d  i n d i v i d u a l i n s t r u c t i o n on t h e s e l f 3  medication  p r a c t i c e s o f ambulatory c a r d i a c p a t i e n t s .  r e c e i v e d t h e i n d i v i d u a l i n s t r u c t i o n made f e w e r m e d i c a t i o n t h o s e who d i d n o t .  Those who e r r o r s than  S k e l t o n showed t h a t p r o v i d i n g s t r u c t u r e d ,  i n d i v i d u a l i z e d teaching with the a i d o f a d i a b e t i c teaching t o o l , 4 improved t h e knowledge and s k i l l s o f t h e e x p e r i m e n t a l p a t i e n t s . ' I . D a l z e l l , " E v a l u a t i o n o f a P r e n a t a l T e a c h i n g Programme," N u r s i n g R e s e a r c h , 14 ( S p r i n g , 1 9 6 5 ) , pp. 160-163. 2 A.M. P u t t , "One E x p e r i m e n t i n N u r s i n g A d u l t s w i t h P e p t i c U l c e r s , " N u r s i n g R e s e a r c h , 19 (1970), pp. 484-494. 3  G.W. Goodman,"An E x p e r i m e n t a l S t u d y t o E v a l u a t e the E f f e c t o f P l a n n e d T e a c h i n q on S e l f - M e d i c a t i o n P r a c t i c e s o f O l d e r A m b u l a t o r y C a r d i a c P a t i e n t s . " U n p u b l i s h e d M a s t e r ' s T h e s i s , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1972. J . M . Skelton,".An E x p e r i m e n t a l S t u d y t o E v a l u a t e t h e E f f e c t i v e ness o f a D i a b e t i c T e a c h i n g T o o l . " U n p u b l i s h e d M a s t e r s T h e s i s , U n i v e r s i t y o f B r i t i s h ' C o l u m b i a , 1973. 4  68 Power p r o v i d e d p l a n n e d ,  i n d i v i d u a l i z e d i n s t r u c t i o n t o mothers o f c h i l d r e n  seen i n the emergency d e p a r t m e n t f o r c a s t a p p l i c a t i o n t o f r a c t u r e d limbs.  She found t h a t the mothers who  received this nursing intervention  were b e t t e r a b l e t o cope w i t h the a f t e r c a r e o f the c h i l d than mothers who  r e c e i v e d no p l a n n e d ,  individual teaching.  a group o f e l d e r l y p a t i e n t s w i t h i m p l a n t a b l e  Kos and C u l b e r t s t u d i e d  1  c a r d i a c pacemakers who  had  been t a u g h t i n d i v i d u a l l y and found t h a t they knew c o n s i d e r a b l y more a b o u t pacemaker f u n c t i o n i n g and r e l a t e d s e l f - c a r e than t h o s e who  had  not  2  r e c e i v e d the same s t r u c t u r e d t e a c h i n g programme. These s t u d i e s have been w e l l d e s i g n e d and have sampled a l a r g e number o f s u b j e c t s .  They have s u c c e s s f u l l y d e m o n s t r a t e d the v a l u e o f  i n d i v i d u a l and i n d i v i d u a l i z e d t e a c h i n g n o t o n l y among v a r i o u s age groups but a l s o d u r i n g d i f f e r e n t phases o f w e l l n e s s and i l l n e s s and w i t h i n  the  h o s p i t a l , o u t p a t i e n t d e p a r t m e n t and home s e t t i n g . Dodge r e m i n d s us t h a t u n d e r s t a n d i n g  i s f a c i l i t a t e d when an  i n d i v i d u a l r e c e i v e s the k i n d o f i n f o r m a t i o n t h a t he f e e l s he needs i n 3  a particular situation.  Palm m a i n t a i n s  t h a t group t e a c h i n g c a n n o t i n  any way meet the l e a r n i n g needs o f each and e v e r y p a t i e n t . Several 'D.M. Power,"The E f f e c t i v e n e s s o f P l a n n e d T e a c h i n g o f Mothers w i t h C h i l d r e n T r e a t e d i n Emergency Departments." U n p u b l i s h e d M a s t e r ' s T h e s i s , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1972. 4  2  Ibid.  3  J.S. Dodge, " F a c t o r s R e l a t e d t o P a t i e n t ' s P e r c e p t i o n s o f T h e i r C o g n i t i v e Needs," N u r s i n g R e s e a r c h , 18 (1969), pp. 502-513. 4  Teaching,"  M.L. Palm, " R e c o g n i z i n g O p p o r t u n i t i e s f o r I n f o r m a l P a t i e n t N u r s i n g C l i n i c s o f N o r t h A m e r i c a , 6 (1971), pp. 669-678.  69 studies '  have compared group v e r s u s i n d i v i d u a l i n s t r u c t i o n i n the  of preoperative  p r e p a r a t i o n but n e i t h e r o f them show t h a t group  i s any more e f f e c t i v e than i n d i v i d u a l i n s t r u c t i o n . C u l b e r t say  L a s t l y , Kos  area  teaching and  that  When the t e a c h i n g - l e a r n i n g p r o c e s s i n v o l v e s an e l d e r l y p e r s o n , g o a l s , methods o f t e a c h i n g , t o o l s and methods o f e v a l u a t i n g must be t a i l o r - d e s i g n e d f o r e a c h i n d i v i d u a l i f l e a r n i n g i s to o c c u r . . . . The o l d e r l e a r n e r b e n e f i t s f r o m c o n t i n u o u s i n t e r a c t i o n d u r i n g t e a c h i n g s e s s i o n s . For t h e s e r e a s o n s , t e a c h i n g on a o n e - t o - o n e b a s i s i s u s u a l l y most effective.3  SUMMARY  A c r i t i c a l r e v i e w o f the l i t e r a t u r e on the e l d e r l y p a t i e n t  who  has had a permanent pacemaker i n s e r t e d , has e s t a b l i s h e d the c o n c e r n s o f the s u r g i c a l p a t i e n t i n g e n e r a l pacemaker i n p a r t i c u l a r .  and the p a t i e n t w i t h a permanent  Many o f the i s s u e s r a i s e d stem from the  C.A. Lindeman, " N u r s i n g I n t e r v e n t i o n w i t h the P r e s u r g i c a l P a t i e n t - Phase 11," N u r s i n g R e s e a r c h , 21 ( 1 9 7 2 ) , pp. 196-209. 1  2  C. B a i n e s , An E x p e r i m e n t a l S t u d y to Compare the E f f e c t i v e n e s s o f I n d i v i d u a l and Group P r e o p e r a t i v e I n s t r u c t i o n . U n p u b l i s h e d M a s t e r ' s T h e s i s , U n i v e r s f t y o f B r i t i s h C o l u m b i a , 1974. 3 P.A. C u l b e r t and B.A. Kos, " A g i n g : C o n s i d e r a t i o n s f o r H e a l t h T e a c h i n g , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , 6 ( 1 9 7 1 ) , p. 613.  presence o f anxiety.  H e a l t h t e a c h i n g has been s u g g e s t e d as a m a j o r  n u r s i n g i n t e r v e n t i o n t o combat t h i s p s y c h o l o g i c a l r e a c t i o n .  The  t e a c h i n g - l e a r n i n g p r o c e s s has been viewed i n terms o f the age group to w h i c h the e d u c a t i o n a l e x p e r i e n c e i s d i r e c t e d .  Facilitating learn-  i n g among the e l d e r l y was d i s c u s s e d i n terms o f m o t i v a t i o n , methods, a u d i o - v i s u a l a i d s , i n v o l v i n g the s i g n i f i c a n t o t h e r and p r o v i d i n g i n d i v i d u a l t e a c h i n g and c o u n s e l l i n g .  By r e v i e w i n g t h e s t u d i e s t h a t  have been c a r r i e d o u t , d i f f e r e n t avenues o f approach t o the have been s u g g e s t e d .  The subsequent  problem  s t u d y w i l l f o c u s on the use o f  a u d i o - v i s u a l and w r i t t e n t e a c h i n g a i d s , p a r t i c i p a t i o n by s i g n i f i c a n t o t h e r s , and d i s c h a r g e p l a n n i n g .  The r e s u l t s o f each o f t h e s e f o c i  w i l l be e v a l u a t e d by a v a r i e t y o f c r i t e r i o n measures.  71  CHAPTER I I I METHODOLOGY  INTRODUCTION  T h i s c h a p t e r w i l l examine t h e r e s e a r c h d e s i g n chosen t o s t u d y t h e problem;  t h e s e t t i n g i n w h i c h t h e s t u d y was c a r r i e d o u t , t h e  sample s e l e c t e d f o r t e s t i n g ; t h e p r o c e d u r e used t o implement t h e p r o j e c t ; a n d , t h e d a t a g a t h e r i n g t o o l s employed t o a c c u m u l a t e t h e necessary information.  THE RESEARCH DESIGN  A p r e t e s t - p o s t t e s t c o n t r o l group d e s i g n , w i t h r e p e a t e d measures, was used.  This design c o n t r o l s f o r the e f f e c t s o f t e s t i n g , maturation,  h i s t o r y , i n s t r u m e n t a t i o n , r e g r e s s i o n and s e l e c t i o n mainly through the process o f randomization.  What i t c a n n o t a c c o u n t f o r i s t h e unique  i n t r a s e s s i o n h i s t o r y that the p a t i e n t s i n the experimental ienced.  group e x p e r -  T h i s d e s i g n a l s o was a p p r o p r i a t e b e c a u s e t h e d e p e n d e n t v a r i a -  b l e s chosen f o r t h i s s t u d y were such t h a t b a s e l i n e i n f o r m a t i o n was needed i n o r d e r t o d e t e r m i n e  i f a d a p t a t i o n had o c c u r r e d .  A potential  t h r e a t t o t h e e x t e r n a l v a l i d i t y o f t h i s " b e f o r e a n d a f t e r " d e s i g n was  72 accounted  f o r by h a v i n g the s u b j e c t s t e s t e d not o n l y two weeks a f t e r  t h e i r d i s c h a r g e from the h o s p i t a l b u t a l s o a t the f o u r to s i x week period.  By d o i n g t h i s , i t was  hoped t h a t the e f f e c t s o f b e i n g  i n the h o s p i t a l as opposed to t h e i r own  tested  home would be m i n i m i z e d .  THE SETTING  The s t u d y was  c o n d u c t e d a t a 570 bed, a c u t e c a r e  h o s p i t a l i n B r i t i s h Columbia.  teaching  There a r e f o u r c a r d i o l o g i s t s and  three  c a r d i o v a s c u l a r s u r g e o n s on s t a f f whose r e s p o n s i b i l i t y i t i s to d e t e r m i n e the need f o r a permanent pacemaker and t o c a r r y o u t the i n s e r t i o n . c l i n i c a l s p e c i a l i s t i n n u r s i n g i s a s s i g n e d to p a t i e n t s who permanent pacemakers i n s e r t e d .  transvenous  have had  The p a t i e n t s a r e c a r e d f o r by a g r e a t  v a r i e t y o f I n t e n s i v e Care U n i t and Ward n u r s i n g s t a f f . p a t i e n t s who  No  Most o f the  have had permanent pacemakers i n s e r t e d have t e m p o r a r y pacemakers i n p l a c e b e f o r e t h e i r s u r g e r y .  These p a t i e n t s  a r e u s u a l l y i n the i n t e n s i v e c a r e u n i t p r e o p e r a t i v e l y but o c c a s i o n a l l y t h e y can be found on the g e n e r a l m e d i c a l  o r s u r g i c a l wards.  p a t i e n t i s seen p r e o p e r a t i v e l y by the a n a e s t h e t i s t and the  The cardiovascular  s u r g e o n a t w h i c h time the p r o c e d u r e i s e x p l a i n e d to him and he i s a s k e d t o s i g n the c o n s e n t form.  The p r o c e d u r e i s u s u a l l y done under g e n e r a l  a n a e s t h e t i c and t a k e s a b o u t one hour.  Most o f the permanent pacemaker  i n s e r t i o n s a r e done l a t e i n the day o r when they can be s c h e d u l e d busy o p e r a t i n g room.  A l l o f the p a t i e n t s r e t u r n from the  in a  operating  room w i t h a t e m p o r a r y , c o m p l e t e d i d e n t i f i c a t i o n c a r d and a b o o k l e t  73 a b o u t the pacemaker model w h i c h t h e y have.  The h o s p i t a l p u r c h a s e s  permanent pacemakers from f o u r d i f f e r e n t companies.  The d e c i s i o n r e -  g a r d i n g which pacemaking s y s t e m to use i s dependent upon the i n d i v i d u a l s u r g e o n and the p a t i e n t ' s c o n d i t i o n . The f i r s t t w e n t y - f o u r  h o u r s p o s t o p e r a t i v e l y i s s p e n t by a l l  p a t i e n t s i n the I n t e n s i v e Care U n i t i n o r d e r to e s t a b l i s h t h a t t h e i r pacemakers a r e f u n c t i o n i n g p r o p e r l y .  Upon t r a n s f e r f r o m the  Care U n i t , the p a t i e n t i s r e l o c a t e d on a g e n e r a l m e d i c a l ward u n t i l h i s d i s c h a r g e home.  Intensive  or surgical  D u r i n g h i s s t a y on the ward, the  p a t i e n t (and h i s f a m i l y i f p r e s e n t when the d o c t o r makes h i s r o u n d s ) i s informed,  i n more d e t a i l , by h i s c a r d i o l o g i s t , a b o u t h i s pacemaker,  i t s p u r p o s e and any l i f e s t y l e a l t e r a t i o n s r e q u i r e d . education  T h e r e i s no  formal  programme c a r r i e d o u t by the n u r s i n g s t a f f f o r p a t i e n t s and  their families.  The t e a c h i n g t h a t i s done by the n u r s i n g s t a f f  i n g pacemakers i s on an i n f o r m a l , s p o r a d i c , o n e - t o - o n e b a s i s .  regard-  The  amount o f time s p e n t t e a c h i n g p a t i e n t s and t h e i r f a m i l i e s i s h i g h l y v a r i a b l e d e p e n d i n g on the p r i o r i t i e s o f the ward, the p a t i e n t c e n s u s and the e x p e r t i s e o f t h e n u r s i n g s t a f f on duty a t any one  time.  The f o l l o w u p c a r e p a t t e r n s o f p a t i e n t s w i t h permanent pacemakers a t  this  hospital  i n c l u d e t h r e e to s i x m o n t h l y checkups  ( o r more f r e q u e n t l y d e p e n d i n g on the age o f the b a t t e r y ) a t the p a c e maker c l i n i c and i f the p a t i e n t i s from o u t o f town, b i m o n t h l y  check-  ups v i a a t e l e p h o n e  The  s c r e e n i n g s y s t e m to the pacemaker c l i n i c .  l a t t e r method o f f o l l o w u p r e q u i r e s t h a t the p a t i e n t p u r c h a s e s the c a r d i a c s c r e e n e r (1977 c o s t = $100.00 p l u s 1% s a l e s tax) and t h a t he  74 be taught how and when to use i t .  This i n s t r u c t i o n i s done by the  screener salesman.  THE SAMPLE  A random sample of nine p a t i e n t s , who met the following c r i t e r i a , were included in t h i s study: 1.  Patients who were f i f t y years of age or over.  2.  Patients who could see, hear, speak and read E n g l i s h .  3.  Patients who were h o s p i t a l i z e d for t h e i r f i r s t permanent pacemaker i n s e r t i o n .  4.  Patients who were able to answer a questionnaire (that i s , were not unconscious, severely mentally retarded, ] had not had a serious cerbrovascular a c c i d e n t ) .  5.  Patients who had not had open heart surgery at the same time as the permanent pacemaker was i n s e r t e d .  6.  Patients who w i l l i n g l y consented to p a r t i c i p a t e  after  an explanation of the study was provided by the investigator. When the nurse i n v e s t i g a t o r was informed that a p a t i e n t , who met the study c r i t e r i a , a c t u a l l y had the permanent pacemaker i n s e r t e d , she randomly assigned that patient to e i t h e r the experimental or control group.  The nurse i n v e s t i g a t o r then approached the patient  and h i s s i g n i f i c a n t o t h e r and sought t h e i r w r i t t e n , i n f o r m e d to p a r t i c i p a t e . (See Appendix A)  consent  No p a t i e n t o r s i g n i f i c a n t o t h e r  refused to p a r t i c i p a t e a t the beginning o f the study.  One p a t i e n t  r e f u s e d t o be seen a t t h e s i x week p o s t d i s c h a r g e v i s i t and a n o t h e r p a t i e n t , a f t e r c o m p l e t i n g t h e p r e t e s t s , d i d n o t want t o be f o l l o w e d up p o s t d i s c h a r g e .  Both o f t h e s e p a t i e n t s b e l o n g e d t o t h e c o n t r o l  group.  ETHICAL CONSIDERATIONS  In a d d i t i o n t o o b t a i n i n g w r i t t e n , i n f o r m e d c o n s e n t from a l l o f t h e s u b j e c t s , t h e n u r s e i n v e s t i g a t o r made i t c l e a r t h a t each was f r e e t o w i t h d r a w from t h e p r o j e c t a t any t i m e .  person  The raw d a t a  was i d e n t i f i e d by i n i t i a l s o n l y and was examined by members o f t h e nurse i n v e s t i g a t o r ' s t h e s i s committee a l o n e .  When t h e s u b j e c t s  r e q u e s t e d f e e d b a c k on t h e i r p r o g r e s s as r e f l e c t e d i n t h e q u e s t i o n n a i r e s , t h e y were t o l d t h a t t h e y would be p r o v i d e d w i t h t h a t information a t the completion o f the p r o j e c t .  The p a t i e n t s who were  members o f t h e c o n t r o l group were g i v e n t h e o p t i o n o f v i e w i n g t h e s l i d e - t a p e programme, which t h e e x p e r i m e n t a l group s u b j e c t s saw i n the h o s p i t a l , a t t h e f i n a l home v i s i t .  76 THE SLIDE-TAPE PROGRAMME  A s l i d e - t a p e programme (Appendix B) was p r e p a r e d by t h e n u r s e i n v e s t i g a t o r f o r t h e Vancouver  General H o s p i t a l , under t h e a u s p i c e s o f  a Local I n i t i a t i v e s P r o j e c t Grant, i n order t o g r a p h i c a l l y i l l u s t r a t e c e r t a i n b a s e l i n e i n f o r m a t i o n a b o u t permanent pacemakers.  The o b j e c t i v e s  o f t h e programme were: P a r t 1 - "Your H e a r t Has Nine L i v e s . " To help  the patient  understand  and accept  and his s i g n i f i c a n t the rationale  i n s e r t i o n of a permanent  other  for the  pacemaker.  (Length: 5 minutes)  P a r t 2 - " L i v i n g With Y o u r Pacemaker." To help  the patient  understand  and accept  and his s i g n i f i c a n t a change in  other  lifestyle.  ( L e n g t h : 12 m i n u t e s )  The g o a l s o f t h e s l i d e - t a p e programme were t o meet t h e educat i o n a l needs o f t h e p a t i e n t and h i s s i g n i f i c a n t o t h e r and t o s e r v e as a focus f o r d i s c u s s i o n .  The c o n t e n t o f t h e programme was d e t e r m i n e d  by r e v i e w i n g t h e l i t e r a t u r e t o e s t a b l i s h t h e e x p r e s s e d needs and c o n c e r n s o f p e o p l e w i t h pacemakers.  The programme was d e l i b e r a t e l y s h o r t s o  t h a t t h e n u r s e i n v e s t i g a t o r w o u l d have s u f f i c i e n t time t o i n t e r a c t t h e r a p e u t i c a l l y w i t h t h e p a t i e n t and h i s s i g n i f i c a n t o t h e r .  Using  77 t h i s a u d i o - v i s u a l medium e n s u r e d t h a t each p a t i e n t and h i s s i g n i f i c a n t o t h e r r e c e i v e d the same amount o f f a c t u a l i n f o r m a t i o n and i n the same manner.  THE PROCEDURE.  T h i s s t u d y was c o n d u c t e d between November, 1976 and A p r i l , 1977.  The n u r s e i n v e s t i g a t o r was i n f o r m e d by the Head Nurse i n the  I n t e n s i v e Care U n i t when a p o t e n t i a l c a n d i d a t e was a d m i t t e d .  At that  time t h e n u r s e i n v e s t i g a t o r randomly a s s i g n e d the p o t e n t i a l p a t i e n t to e i t h e r the e x p e r i m e n t a l o r c o n t r o l group.  The Head N u r s e , n o t  knowing  to w h i c h group the p a t i e n t b e l o n g e d , i n t r o d u c e d the n u r s e i n v e s t i g a t o r by s a y i n g t h e f o l l o w i n g : ( P a t i e n t ' s name), I would l i k e you to meet V a l e r i e Shannon. She i s a n u r s e from the U n i v e r s i t y o f B r i t i s h Columbia and i s a s p e c i a l i s t i n pacemakers. She wants t o ask you to take p a r t i n a s p e c i a l p r o j e c t . The Head Nurse then l e f t and the n u r s e i n v e s t i g a t o r e x p l a i n e d the s t u d y u s i n g t h e c o n s e n t forms ( A p p e n d i x A) as g u i d e s .  When t h e  p a t i e n t a g r e e d t o p a r t i c i p a t e and s i g n e d t h e c o n s e n t form, t h e n u r s e i n v e s t i g a t o r made an a p p o i n t m e n t t o see t h e p a t i e n t and h i s s i g n i f i c a n t o t h e r on t h e t h i r d , f o u r t h and f i f t h p o s t o p e r a t i v e day ( o r when i t was c o n v e n i e n t f o r them) i f t h e y were members o f t h e e x p e r i m e n t a l group.  I f t h e y were randomly a s s i g n e d t o the c o n t r o l group» the  n u r s e i n v e s t i g a t o r made an a p p o i n t m e n t t o see the p a t i e n t and h i s  78  s i g n i f i c a n t o t h e r on t h e t h i r d p o s t o p e r a t i v e day ( o r a l s o when i t was c o n v e n i e n t f o r them).  Usually during t h i s i n t r o d u c t o r y interview, the  nurse i n v e s t i g a t o r conducted view S c h e d u l e  t h e f i r s t two pages o f t h e A c t i v i t y I n t e r -  ( s e e A p p e n d i x C)  (See A p p e n d i x D)  and completed  t h e P a t i e n t Data  Sheet.  T h i s f i r s t s e s s i o n u s u a l l y l a s t e d about twenty  m i n u t e s t o o n e - h a l f an hour.  The E x p e r i m e n t a l  Group  The p a t i e n t s and t h e i r s i g n i f i c a n t o t h e r s i n t h e e x p e r i m e n t a l group e x p e r i e n c e d t h e f o l l o w i n g n u r s i n g i n t e r v e n t i o n p r o v i d e d by t h e nurse i n v e s t i g a t o r . I n t e r v i e w No. 1 - T h i r d P o s t o p e r a t i v e Day 1.  Greeting  2.  Administer ( i n this order) (a) S t a t e A n x i e t y  Inventory  (b) Knowledge Base Q u e s t i o n n a i r e (c) T r a i t Anxiety 3.  Inventory  Ask i f t h e y know why t h e p a t i e n t has a pacemaker. (a) L i s t e n (b) P o s i t i v e l y r e i n f o r c e c o r r e c t r e s p o n s e and explore  misconceptions  4.  Show P a r t One o f t h e s l i d e - t a p e programme  5.  E n c o u r a g e q u e s t i o n s , c o n c e r n s , and f e e l i n g s .  6.  Terminate  t h e i n t e r v i e w and a r r a n g e a meeting time f o r  the n e x t s e s s i o n .  I n t e r v i e w No. 2 - F o u r t h . P o s t o p e r a t i v e 1.  Greeting  2.  Encourage q u e s t i o n s .  Day  I n q u i r e as to w h e t h e r the p a t i e n t s  d o c t o r o r n u r s e has d i s c u s s e d the e f f e c t o f the pacemaker on way o f 1 i v i n g 3.  Show P a r t Two o f the S l i d e - t a p e programme  4.  Go o v e r p u l s e t a k i n g i f i t i s a p p r o p r i a t e ,  5.  Encourage questions  6.  Terminate  the i n t e r v i e w and a r r a n g e a c o n v e n i e n t time f o r  the n e x t s e s s i o n .  I n t e r v i e w No. 3 - F i f t h P o s t o p e r a t i v e  Day  1.  Greeting  2.  E l i c i t q u e s t i o n s a b o u t g o i n g home  3.  Have the p a t i e n t and h i s s i g n i f i c a n t o t h e r  demonstrate  pulse taking 4.  Make an a p p o i n t m e n t  t o see p a t i e n t and s i g n i f i c a n t  other  two weeks a f t e r d i s c h a r g e  I n t e r v i e w No. 4 - Two Weeks P o s t D i s c h a r g e - In the P a t i e n t ' s Home 1.  Greeting  2.  Administer A c t i v i t y Interview  3.  Administer ( i n this order) (a) S t a t e A n x i e t y  Schedule  Inventory  (b) Knowledge Base Q u e s t i o n n a i r e (c) T r a i t Anxiety  Inventory  80 4.  Encourage the expression of concerns or f e e l i n g s  5.  Stress that the next v i s i t w i l l be the l a s t and make the necessary time arrangements  Interview No. 5 - Four Weeks Post Discharge - In the P a t i e n t ' s Home 1.  Same as 1-4 above  2.  Bring r e s u l t s of the knowledge base questionnaire and anxiety inventory should the patient or s i g n i f i c a n t other request feedback  3.  Thank the patient and s i g n i f i c a n t other f o r  participating  in the p r o j e c t .  The Control Group The patients and t h e i r s i g n i f i c a n t others i n the control group r e ceived the usual nursing care provided by the ward s t a f f . On the t h i r d postoperative day, the nurse i n v e s t i g a t o r met with the patient and his s i g n i f i c a n t other to administer the questionnaires and conduct the i n t e r view regarding the p a t i e n t ' s a c t i v i t y l e v e l .  The questionnaires were  given i n the following order: A c t i v i t y Check L i s t , State Anxiety Knowledge Base Questionnaire, T r a i t Anxiety Inventory.  Inventory,  At l e a s t once before  the patient was discharged, the nurse i n v e s t i g a t o r paid him a s o c i a l and reminded him of the two week post-discharge home v i s i t .  visit  The f i r s t  home interview was begun by asking the subject how he or she was getting along.  Subsequently, the A c t i v i t y Interview Schedule was conducted.  The nurse i n v e s t i g a t o r  then  administered  three  questionnaires  81 i n the f o l l o w i n g o r d e r :  S t a t e A n x i e t y I n v e n t o r y , Knowledge Base  Questionnaire, T r a i t Anxiety Inventory.  The s u b j e c t was  the n e x t v i s i t , two weeks hence, w o u l d be the f i n a l v i s i t .  reminded t h a t The  nurse  i n v e s t i g a t o r a l s o made i t c l e a r t h a t she w o u l d be p r e p a r e d to d i s c u s s the c o n t e n t o f the q u e s t i o n n a i r e s i f the s u b j e c t s d e s i r e d .  The sub-  j e c t s were a l s o t o l d t h a t a s l i d e - t a p e programme on pacemakers  was  a v a i l a b l e and t h a t t h e y c o u l d view i t a t the f i n a l home v i s i t . The f i n a l i n t e r v i e w w i t h the members o f the c o n t r o l group was c o n d u c t e d  i n the same manner as the f i r s t i n t e r v i e w and i n c l u d e d  the a d m i n i s t r a t i o n o f the t h r e e q u e s t i o n n a i r e s and the a c t i v i t y i n t e r view s c h e d u l e .  The n u r s e i n v e s t i g a t o r was p r e p a r e d to show the s l i d e - t a p e  programme and to answer any q u e r i e s a b o u t the q u e s t i o n n a i r e s .  The  subjects  were thanked f o r t h e i r p a r t i c i p a t i o n .  THE DATA GATHERING TOOLS  T h r e e d i f f e r e n t t o o l s were used to e v a l u a t e the knowledge b a s e , a n x i e t y l e v e l and a c t i v i t y l e v e l o f the s u b j e c t s and t h e i r s i g n i f i cant others.  The knowledge base q u e s t i o n n a i r e and a c t i v i t y c h e c k  l i s t were d e v e l o p e d  by the n u r s e i n v e s t i g a t o r e x p r e s s l y f o r t h i s  study.  S p i e l b e r g e r ' s S t a t e - T r a i t A n x i e t y I n v e n t o r y , an e s t a b l i s h e d m e a s u r i n g d e v i c e , was c h o s e n to a s s e s s the s u b j e c t ' s a n x i e t y l e v e l .  82 Knowledge Base Q u e s t i o n n a i r e I n i t i a l l y , a t w e n t y - t h r e e - i t e m q u e s t i o n n a i r e was d e v e l o p e d by the nurse i n v e s t i g a t o r . The c h o i c e o f q u e s t i o n s was d e t e r m i n e d by the c o n t e n t o f the s l i d e - t a p e programme.  The q u e s t i o n s r e f l e c t e d a b a s i c under-  s t a n d i n g o f the purpose o f the h e a r t ; the r e a s o n f o r i n s e r t i n g an a r t i f i c i a l pacemaker; s i g n s o f pacemaker m a l f u n c t i o n ; and,  activities  i n which one can e x p e c t to p a r t i c i p a t e i f one has a pacemaker.  Once  a g a i n , the c o n t e n t o f the s l i d e - t a p e programme was based on the e x p r e s s e d needs and c o n c e r n s o f p a t i e n t s w i t h pacemakers as d e s c r i b e d i n the current literature. In o r d e r to a s s e s s the v a l i d i t y and s e n s i t i v i t y o f the knowledge base q u e s t i o n n a i r e , the f o l l o w i n g p r e t e s t was c o n d u c t e d .  The  nurse  i n v e s t i g a t o r met w i t h two s i mi l i a r groups o f e i g h t p e o p l e each and gave them the knowledge base q u e s t i o n n a i r e .  One group saw the s l i d e - t a p e  programme b e f o r e c o m p l e t i n g the q u e s t i o n n a i r e and the o t h e r d i d n o t . None o f the members o f e i t h e r group had a permanent pacemaker b u t s e v e r a l p e o p l e i n each group knew o f someone who had a pacemaker.  Some  o f the members i n each group had a d i a g n o s e d h e a r t a i l m e n t b u t t h a t would be e x p e c t e d s i n c e a l l members o f the p r e t e s t group were f i f t y y e a r s o f age o r o v e r .  No members o f the p r e t e s t group were h o s p i t a l i z e d  when t h e y c o m p l e t e d the q u e s t i o n n a i r e . The f o l l o w i n g a n a l y s i s was made: Sample Saw S l i d e - T a p e Programme Did Not See S l i d e - T a p e Programme  Mean S c o r e s on Knowledge S t a n d a r d Base Q u e s t i o n n a i r e Deviation 1.28 20.75 18.88  1.81  83 A t - t e s t was  done on the above s c o r e s and i t showed t h a t the  r e s u l t s were s i g n i f i c a n t a t the .05 l e v e l .  (T = 2.393, d f = 1 4 ) .  An i t e m a n a l y s i s o f the q u e s t i o n s r e v e a l e d t h a t one  question  was answered i n c o r r e c t l y 8/8 times i n the group t h a t saw the s l i d e - t a p e programme and 7/8 times i n the group t h a t d i d n o t ; t h e r e f o r e , t h a t q u e s t i o n was  removed.  times i n the group who  A n o t h e r q u e s t i o n was answered i n c o r r e c t l y 3/8 saw the s l i d e - t a p e programme and 6/8  group t h a t d i d n o t ; t h a t q u e s t i o n was  reworded.  times i n the  The f i n a l d r a f t o f  the knowledge base q u e s t i o n n a i r e used i n the s t u d y c o n s i s t e d o f twentytwo items and a p p e a r s i n A p p e n d i x E.  The A c t i v i t y Check L i s t  (ACL)  The n u r s e i n v e s t i g a t o r d e v e l o p e d  an A c t i v i t y I n t e r v i e w  Schedule,  ( A p p e n d i x C) the f i r s t two pages o f w h i c h c o n t a i n the A c t i v i t y Check List.  The p u r p o s e o f the A c t i v i t y I n t e r v i e w S c h e d u l e was  to  evaluate  the k i n d and f r e q u e n c y o f common a c t i v i t i e s o f d a i l y l i v i n g , the p h y s i c a l and e m o t i o n a l  responses  to those a c t i v i t i e s , the degree o f c o m p l i a n c e  w i t h s p e c i f i c pacemaker r e l a t e d a c t i v i t i e s , ( e . g . , r e g u l a r p u l s e c a r r y i n g a pacemaker i d e n t i f i c a t i o n c a r d , r e p o r t i n g c o m p l i c a t i o n s  taking, to the  d o c t o r ) , and the p a t i e n t ' s r e p o r t e d d e g r e e o f s a t i s f a c t i o n w i t h h i s pre and p o s t - i l l n e s s a c t i v i t y l e v e l s . In o r d e r to d e t e r m i n e i f the a c t i v i t i e s s e l e c t e d by the i n v e s t i g a t o r were r e p r e s e n t a t i v e o f those w h i c h an e l d e r l y , d i s c h a r g e d pacemaker p a t i e n t d i d p e r f o r m , the l i s t was  shown to seven  people  (males and f e m a l e s ) , o v e r s i x t y - f i v e y e a r s o f age, l i v i n g i n a  84 r e s i d e n t i a l home f o r r e t i r e d s e n i o r c i t i z e n s .  They were a s k e d t o  r e s p o n d t o each a c t i v i t y by c h e c k i n g one o f t h r e e o p t i o n s :  (1) y e s , I  d i d p e r f o r m t h i s a c t i v i t y ; (2) I am u n a b l e to p e r f o r m t h i s a c t i v i t y ; (3) does n o t a p p l y .  The r e s u l t s a r e t a b u l a t e d i n T a b l e 2.  Because o n l y seven p e o p l e r e s p o n d e d , t h e i n v e s t i g a t o r examined o n l y t h o s e a c t i v i t i e s which no one was a b l e to p e r f o r m . 1.  working a t a r e g u l a r job  2.  gardening  3.  washing  4.  d o i n g minor h o u s e h o l d r e p a i r s  5.  bowling  6.  r e c r e a t i o n a l swimming, and  7.  w a l k i n g one m i l e .  They were:  floors/walls  T h i s c o n v e n i e n c e sample o f seven had t o be a t l e a s t age s i x t y f i v e and r e t i r e d i n o r d e r to l i v e i n t h a t p a r t i c u l a r apartment  complex.  The apartment was a h i g h r i s e which n o t o n l y p r e v e n t e d them from h a v i n g a garden b u t a l s o p r o v i d e d them w i t h h o u s e k e e p i n g and facilities.  maintenance  The apartment was w i t h i n s e v e r a l b l o c k s o f a v a r i e t y o f  s t o r e s so t h a t t h e y had no need t o walk l o n g d i s t a n c e s . A bus s t o p p e d o u t s i d e the d o o r o f the b u i l d i n g .  Due to the i n h e r e n t c h a r a c t e r i s t i c s  o f the sample s e l e c t e d f o r p r e t e s t i n g , i t i s u n d e r s t a n d a b l e t h a t the a f o r e m e n t i o n e d a c t i v i t i e s were n o t p a r t o f t h e i r d a i l y l i v i n g p a t t e r n . The i n v e s t i g a t o r gave the same l i s t o f a c t i v i t i e s to f o u r n u r s e s c o n s i d e r e d to be e x p e r t s on the p o s t o p e r a t i v e and f o l l o w u p c a r e of  p e o p l e w i t h permanent pacemakers.  The r e s u l t s can be f o u n d i n T a b l e 3.  85 TABLE 2 S e n i o r C i t i z e n s ' Response t o A c t i v i t y Check L i s t (A.C.L.) (N = 7) A c t i vi ty  Did Perform  D i d Not Perform  Does Not Apply  walking 1 block  6  1  walking 5 blocks walking 1 mile  4 0 5 0 1 7 7 7 6 5 3 1 2  3 5 1 6 6  2 1 1  1 3  grocery shopping gardening lawn mowing dressing oneself feeding oneself u s i n g the washroom a l o n e bathing showering climbing stairs sexual a c t i v i t y vacuuming dusting washing dishes  5  1 2 3 3 5 2  6  1  w a s h i n g c l o t h i n g by hand  5  2  w a s h i n g c l o t h i n g by machine  5  1  washing f l o o r s / w a l l s  0  cooking  3  6 3  1 1  minor r e p a i r s to the house  0  4  2  4 2  1  5  3 4 2  5 6  2 1  using a l l e l e c t r i c a l appliances driving a car t a k i n g a bus taking a plane t a k i n g a boat  F a i l e d to Respond  1  1  86 Did Perform  D i d Not Perform  Does Not Apply  taking a train v i s i t i n g with friends in  5  1  1  y o u r home o r t h e i r s playing cards  5 6 7 7 0 0  2 1  A c t i vi ty  w a t c h i n g T.V. l i s t e n i n g to the r a d i o bowling r e c r e a t i o n a l swimming attending senior citizen's meetings working taking your pulse hobbies  4 0 3 4  Other a c t i v i t i e s l i s t e d by r e s p o n d e n t s (N = 4 ) * l i s t e n i n g to music  1  km* t t i n g sewing  3 1  *  F a i l e d to Respond  7 7  4  T h r e e r e s p o n d e n t s f a i l e d t o answer the s e c o n d page o f ACL.  1  3* 3* 3* 3*  87 Each n u r s e was a s k e d t o e s t i m a t e t h e p r o b a b i l i t y , on a s c a l e o f 1-10, o f a p e r s o n age f i f t y o r o v e r , w i t h a permanent pacemaker, b e i n g a b l e to p e r f o r m each o f t h e l i s t e d a c t i v i t i e s .  Most o f t h e a c t i v i t i e s  were g i v e n a h i g h r a t i n g , t h a t i s , t h e a v e r a g e s c o r e / a c t i v i t y was 8/10 o r o v e r .  Those a c t i v i t i e s r a t e d below e i g h t were:  1.  walking a mile  2.  washing  3.  bowling  4.  r e c r e a t i o n a l swimming, and  5.  mowing t h e lawn.  floors/walls  S i n c e t h e r e were so few a c t i v i t i e s which were deemed unperf o r m a b l e by e i t h e r t h e s e n i o r c i t i z e n s who were p r e t e s t e d o r t h e panel o f e x p e r t n u r s e s whose o p i n i o n was o b t a i n e d , a l l o f t h e a c t i v i t i e s on t h e o r i g i n a l c h e c k l i s t were r e t a i n e d .  The c r i t e r i a f o r t h e s e l e c t i o n  o f t h e s t u d y sample i n c l u d e d p e o p l e who were f i f t y and o v e r who would p r o b a b l y be w o r k i n g , l i v i n g i n , t h e i r own home, and perhaps would be more p h y s i c a l l y a c t i v e ; t h e r e f o r e , i t seemed r e a s o n a b l e t o i n c l u d e t h e more s t r e n u o u s a c t i v i t i e s l i s t e d  above.  A d m i n i s t r a t i o n o f t h e A c t i v i t y Check L i s t (ACL) When t h e ACL was g i v e n as a p r e t e s t , t h e n u r s e i n v e s t i g a t o r s a i d t o t h e p a t i e n t , " D u r i n g t h e month p r i o r t o y o u r h o s p i t a l i z a t i o n , d i d y o u p e r f o r m any o f t h e s e a c t i v i t i e s ? "  When t h e ACL was g i v e n as  88 TABLE 3 N u r s e s ' O p i n i o n o f Pacemaker P a t i e n t ' s A c t i v i t y C a p a b i l i t i e s * A c t i vi t y  Mean  dress o n e s e l f feed oneself use t h e t o i l e t a l o n e bath shower  10 10 10 9.5 9.75  climb s t a i r s walk .1 b l o c k  8.75 9.75  walk 5 b l o c k s walk 1 m i l e  9.0 6.25  resume s e x u a l vacuum dust  activity  wash c l o t h i n g by hand wash f l o o r s / w a l l s cook  10 8.0 10 9 5.75 10  do m i n o r house r e p a i r s g r o c e r y shop take a bus  9.75 9.5 9.5  take a p l a n e v i s i t with f r i e n d s  9.3* 10  Acti vi t y  Mean  watch TV l i s t e n to radio bowl r e c r e a t i o n a l swimming attend Senior Citizen's meetings return to previous job return to lighter job take own p u l s e hobbies (e.g., reading, g o l f woodworking, k n i t t i n g , e t c . ) p l a y i n g bingo  10 10  going to church wash d i s h e s wash c l o t h i n g by machine  10 10 9.75  garden  10*  mow t h e lawn use a l l e l e c t r i c a l drive a car take a t r a i n take a boat play cards  appliances  10 10 5.0 6.75 10 10* 10* 8.5  6.0 8.3* 9.0 9.5 9.5 10  n = 3 •kic  N u r s e s ' o p i n i o n as t o t h e chance t h a t a p e r s o n , age f i f t y o r o v e r , w i t h a permanent pacemaker, c o u l d p e r f o r m t h e f o l l o w i n g a c t i v i t i e s o f d a i l y 1 i v i n g (n = 4 ) . Mean = 9 . 1 5 Median = 9 . 7 5 Mode = 10 Range = 5 - 1 0  89 a p o s t t e s t , the n u r s e i n v e s t i g a t o r asked, " S i n c e y o u r d i s c h a r g e  from  the h o s p i t a l , have you been a b l e t o p e r f o r m any o f t h e s e a c t i v i t i e s ? . " The p o s t t e s t a l s o i n c l u d e d the c o m p l e t i o n o f the A c t i v i t y  Interview  Schedule.  S c o r i n g o f the A c t i v i t y Check L i s t The main message i n the s l i d e - t a p e programme i s t h a t r e g u l a r e x e r c i s e i s good f o r the p a t i e n t both p h y s i c a l l y and p s y c h o l o g i c a l l y . T h e r e f o r e , the a c t i v i t y check l i s t l o o k e d a t the usual s e l f - c a r e and s o c i a l a c t i v i t i e s o f the p a t i e n t s to d e t e r m i n e changed.  i f t h e i r frequency  had  Two p o i n t s were awarded i f an a c t i v i t y was done r e g u l a r l y ;  one p o i n t i f i t was done o c c a s i o n a l l y ; and, z e r o p o i n t s i f i t was done a t a l l .  not  The t o t a l s c o r e o b t a i n e d was c o n s i d e r e d to be t h a t  person's a c t i v i t y l e v e l .  S t a t e - T r a i t Anxiety Inventory ( S e l f Evaluation Questionnaire) The S t a t e - T r a i t A n x i e t y I n v e n t o r y (STAI) was d e v e l o p e d  by  C h a r l e s D. S p i e l b e r g e r , R i c h a r d L. Gorsuch and R o b e r t E. L u s c h e n e between 1964 and 1970.  I t was d e s i g n e d as an o b j e c t i v e , s e l f - r e p o r t r e s e a r c h  t o o l to measure b o t h s t a t e and t r a i t a n x i e t y i n normal ( n o n p s y c h i a t r i c a l l y d i s t u r b e d ) a d u l t s , j u n i o r and s e n i o r h i g h s c h o o l s t u d e n t s , n e u r o p s y c h i a t r y , m e d i c a l and s u r g i c a l p a t i e n t s .  and  The q u e s t i o n n a i r e  i s c o m p r i s e d o f s e p a r a t e , twenty items e a c h , s e l f - r e p o r t s c a l e s f o r measuring  the two d i s t i n c t a n x i e t y c o n c e p t s .  The two s c a l e s a r e  90 p r i n t e d on t h e o p p o s i t e s i d e o f t h e same t e s t s h e e t .  A copy o f t h e  STAI c a n be f o u n d i n A p p e n d i x F.  A d m i n i s t r a t i o n o f t h e STAI The STAI can be s e l f - a d m i n i s t e r e d and may be g i v e n e i t h e r i n d i v i d u a l l y o r i n groups.  Complete i n s t r u c t i o n s a r e p r i n t e d on t h e  top o f each s i d e o f t h e t e s t form. on t h e r e s p o n d e n t .  T h e r e a r e no time l i m i t s  imposed  A c c o r d i n g t o t h e e x p e r i e n c e o f S p i e l b e r g e r , Gorsuch  and L u s c h e n e , c o l l e g e s t u d e n t s g e n e r a l l y r e q u i r e o n l y s i x t o e i g h t minutes t o complete e i t h e r the A n x i e t y - S t a t e o r the A n x i e t y - T r a i t s c a l e , and l e s s t h a n twenty minutes t o c o m p l e t e b o t h .  Less educated and/or  e m o t i o n a l l y d i s t u r b e d p e r s o n s may r e q u i r e t e n t o t w e l v e m i n u t e s t o c o m p l e t e one o f t h e s c a l e s and a p p r o x i m a t e l y twenty m i n u t e s t o c o m p l e t e both.  1  The v a l i d i t y o f t h e STAI i s based on t h e a s s u m p t i o n t h a t t h e  r e s p o n d e n t c l e a r l y u n d e r s t a n d s t h e i n s t r u c t i o n s which a r e d i f f e r e n t f o r each s c a l e .  The A - S t a t e i n v e n t o r y asks him t o r e p o r t how he  f e e l s at this moment and t h e A - T r a i t i n v e n t o r y asks him t o i n d i c a t e how he generally  feels.  I f b o t h o f t h e s c a l e s a r e g i v e n a t t h e same t i m e , i t i s recommended t h a t t h e A - S t a t e s c a l e be g i v e n f i r s t , f o l l o w e d by t h e 2 A-Trait scale. Because t h e A - S t a t e s c a l e i s d e s i g n e d t o be s e n s i t i v e  C D . S p i e l b e r g e r , R.L. G o r s u c h , R.E. L u s c h e n e , S t a t e - T r a i t A n x i e t y I n v e n t o r y Manual ( P a l o A l t o , C a l i f o r n i a : C o n s u l t i n g P s y c h o l o g i s t s P r e s s , I n c . , 1970), p. 4. 2  Ibid.  91 to the c o n d i t i o n s under w h i c h the t e s t i s g i v e n , s c o r e s on t h i s s c a l e can be i n f l u e n c e d by the e m o t i o n a l atmosphere t h a t may be c r e a t e d i f the A - T r a i t s c a l e i s g i v e n f i r s t .  S c o r i n g o f the STAI The r e s p o n d e n t s  can o b t a i n a s c o r e r a n g i n g from twenty t o  e i g h t y on each p a r t o f the a n x i e t y i n v e n t o r y by r a t i n g t h e m s e l v e s four-point scale.  on a  Some o f the items ( e . g . , I am t e n s e ) a r e worded i n  such a way t h a t a r a t i n g o f f o u r i n d i c a t e s a h i g h l e v e l  of anxiety,  w h i l e o t h e r items ( e . g . , I f e e l p l e a s a n t ) a r e worded so t h a t a h i g h r a t i n g i n d i c a t e s low a n x i e t y .  The s c o r i n g w e i g h t s f o r items on w h i c h  h i g h r a t i n g s i n d i c a t e h i g h a n x i e t y a r e the same as the b l a c k e n e d number on the t e s t form..  out  F o r i t e m s on w h i c h a h i g h r a t i n g i n d i c a t e s  low a n x i e t y , the s c o r i n g r a t e s a r e r e v e r s e d .  A template  purchased  from the C o n s u l t i n g P s y c h o l o g i s t s P r e s s was used t o s c o r e the A - S t a t e and A - T r a i t s c a l e s by hand.  The v a l u e s f o r each i t e m were w r i t t e n a t  the s i d e o f the page and were added. The p o t e n t i a l problem o f a c q u i e s c e n c e s e t on t h e STAI r e sponses was d e a l t w i t h on the A - S t a t e s c a l e by h a v i n g t e n d i r e c t l y s c o r e d and t e n r e v e r s e d i t e m s .  However, i t was  impossible to develop  a b a l a n c e d A - T r a i t s c a l e from the o r i g i n a l ' i t e m pool and so t h e r e a r e seven r e v e r s e d items and t h i r t e e n d i r e c t l y s c o r e d items on the A - T r a i t scale. Most i n d i v i d u a l s w i t h a f i f t h o r s i x t h grade r e a d i n g a b i l i t y spontaneously  r e s p o n d t o a l l o f the STAI items w i t h o u t s p e c i a l  92 i n s t r u c t i o n s or prompting.  1  S h o u l d the s u b j e c t omit one o r two  items  on e i t h e r the A - T r a i t o r A - S t a t e s c a l e , h i s p r o r a t e d f u l l s c a l e s c o r e can be o b t a i n e d 1.  by:  d e t e r m i n i n g the mean s c o r e f o r the items t o w h i c h the s u b j e c t has  responded;  2.  m u l t i p l y i n g t h a t v a l u e by twenty; and  3.  r o u n d i n g the p r o d u c t t o the n e x t h i g h e r , whole number.  2 I f t h r e e o r more items a r e o m i t t e d , t h e v a l i d i t y o f the s c a l e must be questioned.  N o r m a t i v e Data f o r the STAI Normative data are a v a i l a b l e f o r c o l l e g e students, high school s t u d e n t s , male p s y c h i a t r i c , g e n e r a l m e d i c a l , s u r g i c a l p a t i e n t s and y o u n g , male p r i s o n e r s .  A l t h o u g h the STAI norms a r e not based on r e p r e s e n t a t i v e  o r s t r a t i f i e d samples,  they can s t i l l be used as a means o f  comparison  w i t h s c o r e s o b t a i n e d from e x p e r i m e n t a l groups o r i n d i v i d u a l c l i e n t s . The n o r m a t i v e d a t a , used as a p o i n t o f comparison  for this  t h e s i s , were based on the g e n e r a l m e d i c a l a n d ' s u r g i c a l p a t i e n t s w i t h o u t p s y c h i a t r i c c o m p l i c a t i o n s . (N = 110)  A l l s u b j e c t s were m a l e s ; t h e i r 3  mean age was 55 y e a r s ; and t h e i r mean e d u c a t i o n a l l e v e l was grade t e n .  I b i d . , p. 5 2  Ibid.  3  I b i d . , p. 9.  93 The mean s c o r e which t h e y had on t h e A - T r a i t s c a l e was 41.33 and on the A r S t a t e s c a l e was  42.68.  1  Reliability The t e s t - r e t e s t r e l i a b i l i t y o f t h e STAI was documented by s t u d y i n g a group o f male and female u n d e r g r a d u a t e c o l l e g e s t u d e n t s .  The  c o r r e l a t i o n s f o r t h e A - T r a i t s c a l e r a n g e d f r o m .73 t o .86, w h e r e a s , t h o s e f o r the A - S t a t e s c a l e ranged from .16 t o .54.  The low c o r r e l a t i o n  f o r the A - S t a t e s c a l e a r e e x p e c t e d because o f the n a t u r e o f the t e s t which s h o u l d r e f l e c t t h e unique s i t u a t i o n a l f a c t o r s o p e r a t i n g a t the time o f t e s t i n g . Because a n x i e t y s t a t e s a r e so f l e e t i n g , the a l p h a c o e f f i c i e n t measure o f i n t e r n a l c o n s i s t e n c y p r o v i d e s a more a p p r o p r i a t e i n d e x o f r e l i a b i l i t y o f the STAI.  U s i n g a m o d i f i e d K-R 20 f o r m u l a , t h e a l p h a  r e l i a b i l i t y c o e f f i c i e n t s f o r the A - S t a t e s c a l e a r e .83 t o .92 and f o r 3 t h e A - T r a i t s c a l e , .86 t o .92.  S p i e l b e r g e r concluded t h a t both the  A - T r a i t and A - S t a t e s c a l e s have a h i g h degree o f i n t e r n a l consistency. I b i d . , p. 9. 2  I b i d . , p. 8.  3  IbM.  94 Validity The c o n s t r u c t v a l i d i t y o f t h e A - S t a t e  s c a l e was d e t e r m i n e d  by t e s t i n g a l a r g e number o f male and f e m a l e u n d e r g r a d u a t e c o l l e g e students  under " n o r m a l " and " s t r e s s f u l " c o n d i t i o n s .  The mean s c o r e s  f o r b o t h males and f e m a l e s were c o n s i d e r a b l y h i g h e r i n t h e s t r e s s f u l condition.  1  C o n c u r r e n t v a l i d i t y o f t h e A - T r a i t s c a l e was e s t a b l i s h e d by comparing t h e s c o r e s o f male and f e m a l e c o l l e g e s t u d e n t s  and n e u r o -  p s y c h i a t r y p a t i e n t s on t h e I n s t i t u t e f o r P e r s o n a l i t y and A b i l i t y T e s t i n g (IPAT) A n x i e t y S c a l e , t h e T a y l o r M a n i f e s t A n x i e t y S c a l e and t h e Zuckerman A f f e c t A d j e c t i v e Check L i s t (AACL).  (TMAS),  The c o r r e l a t i o n s  between t h e STAI - A - T r a i t S c a l e , t h e IPAT a n d t h e TMAS r a n g e d f r o m .75 2 to .85.  I n c o n t r a s t , t h e AACL, General  Form, was o n l y m o d e r a t e l y  c o r r e l a t e d w i t h t h e o t h e r A - T r a i t measures ( r a n g e = .41 t o . 5 8 ) . S i n c e t h e i n t e r c o r r e l a t i o n s among t h e s e s c a l e s a p p r o a c h e d t h e s c a l e r e l i a b i l i t i e s , S p i e l b e r g e r e t aj_. c o n c l u d e d  t h a t t h e IPAT, TMAS and  STAI A - T r a i t s c a l e c o u l d be used as a l t e r n a t e measures o f a n x i e t y trait. The STAI was s e l e c t e d as a m e a s u r i n g d e v i c e o f t h e p a t i e n t ' s a n x i e t y l e v e l b e c a u s e o f i t s v a l i d i t y , r e l i a b i l i t y , l e n g t h , and ease o f a d m i n i s t r a t i o n and s c o r i n g . I b i d . , p. 11. 2  I b i d . , p. 10.  3  Ibid.  CRITERIA USED TO DETERMINE PULSE TAKING ABILITY  The f o l l o w i n g b e h a v i o u r a l c r i t e r i a were used t o e s t a b l i s h w h e t h e r the p a t i e n t and h i s s i g n i f i c a n t o t h e r c o u l d demonstrate taking.  pulse  I f the p a t i e n t and h i s s i g n i f i c a n t o t h e r p e r f o r m e d a l l t h r e e  a c t s , they were c o n s i d e r e d t o be a b l e to t a k e t h e i r p u l s e . 1.  P l a c e d f i r s t two f i n g e r s o f the o p p o s i t e hand on r a d i a l s i d e o f the o p p o s i t e w r i s t a t t h e base o f the thumb,  2.  Counted the p u l s e f o r 60 s e c o n d s ,  and  3.  Was a c c u r a t e w i t h i n t h r e e b e a t s when the s u b j e c t ' s p u l s e was checked by the n u r s e i n v e s t i g a t o r .  DATA MANAGEMENT  A o n e - t a i l t t e s t o f the d i f f e r e n c e s between sample means a c r o s s the e x p e r i m e n t a l and c o n t r o l groups was measured w i t h r e s p e c t to knowledge base, t r a i t and s t a t e a n x i e t y and l e v e l o f a c t i v i t y . r e s u l t s o f the a b i l i t y o f members o f the e x p e r i m e n t a l group to demonstrate  The  and c o n t r o l  p u l s e t a k i n g were a s s e s s e d by u s i n g the F i s h e r -  Yates Exact P r o b a b i l i t y Test. The s i g n i f i c a n c e o f the d a t a was d e t e r m i n e d level.  a t the  .05  T h i s v a l u e was chosen because o f the s m a l l sample s i z e ,  the low degree o f c o n t r o l o f a l l v a r i a b l e s i n the s t u d y s e t t i n g , the  96  f a c t t h a t t h i s r e s e a r c h e x p l o r e d a s e t o f i n t e r r e l a t i o n s f o r the o f d e v e l o p i n g a d d i t i o n a l hypotheses  and t h a t w i t h t h i s l e v e l o f s i g n i f i -  c a n c e , fewer Type II e r r o r s ( f a i l i n g t o r e j e c t the f a l s e n u l l w i l l be made.  purpose  hypothesis)  The .05 l e v e l a l s o was a p p r o p r i a t e b e c a u s e e m p i r i c a l  e v i d e n c e s u p p o r t s the c o n c l u s i o n o f the a l t e r n a t i v e h y p o t h e s e s  and  because no d r a s t i c o r s e r i o u s l o n g term e f f e c t s o f p o s s i b l e e r r o r can be f o r e s e e n .  SUMMARY  T h i s c h a p t e r has d e s c r i b e d the m e t h o d o l o g y used i n t h i s s t u d y . A p r e t e s t - p o s t t e s t c o n t r o l group d e s i g n was s e l e c t e d t o e x p l o r e the problem o f the a d a p t a b i l i t y o f e l d e r l y p a t i e n t s to the i n s e r t i o n o f a permanent c a r d i a c pacemaker.  A 570 a c u t e bed, t e a c h i n g h o s p i t a l p r o -  v i d e d the s e t t i n g f o r the p r o j e c t and a l l p a t i e n t s who met the s t u d y c r i t e r i a were a s k e d t o p a r t i c i p a t e .  Those who a c c e p t e d were randomly  a s s i g n e d t o e i t h e r the e x p e r i m e n t a l o r c o n t r o l group.  The  experimental  group s u b j e c t s r e c e i v e d p l a n n e d p a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t from the n u r s e i n v e s t i g a t o r and the c o n t r o l group r e c e i v e d the u s u a l n u r s i n g c a r e g i v e n by the ward s t a f f .  The h e a l t h s t a t u s o f a l l  s u b j e c t s was e v a l u a t e d b e f o r e and a f t e r t h e i r pacemaker i n s e r t i o n by h a v i n g them r e s p o n d t o the A c t i v i t y Check L i s t , the Knowledge Base Q u e s t i o n n a i r e , and the S t a t e - T r a i t A n x i e t y I n v e n t o r y . a b i l i t y - w a s measured a g a i n s t the a f o r e m e n t i o n e d  Their pulse taking  behavioural  criteria.  97  CHAPTER IV THE FINDINGS  INTRODUCTION  This chapter w i l l present the data that was c o l l e c t e d i n r e l a t i o n to the hypotheses to be tested.  In a d d i t i o n , the i n v e s t i g a t o r  w i l l examine selected c o r r e l a t i o n s among the dependent v a r i a b l e s . C l i n i c a l observations  that were made during the course of the study w i l l  also be included when appropriate.  THE SAMPLE  Over a f i v e month period, a t o t a l of sixteen subjects  (nine  p a t i e n t s , seven s i g n i f i c a n t others) were followed from the time that the patients had t h e i r permanent pacemakers inserted u n t i l they had been home from the hospital f o r approximately four weeks.  The demographic  data pertaining to t h i s sample of nine patients i s presented i n Table 4.  98 TABLE 4 Demographic Data - P a t i e n t s Experimental Group  Control Group  5  4  T o t a l Number Mean Age  (years)  78.8  76.8  Mean Number o f Y e a r s o f Schooling  9.0  9.0  Ratio of  3/2  1/3  2/3  2/2  Males/Females  R a t i o o f Married/Widowed  A t - t e s t , done on mean age ( t = .376, d f = 7) and mean number o f y e a r s o f s c h o o l i n g ( t = 0, d f = 7 ) between the two g r o u p s , showed no s i g n i f i c a n t d i f f e r e n c e a t the .05 l e v e l on t h e s e two v a r i a b l e s . A F i s h e r - Y a t e s E x a c t P r o b a b i l i t y T e s t was done on the v a r i a b l e s o f sex and m a r i t a l s t a t u s and, a g a i n r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e . In summary, t h e r e was no s i g n i f i c a n t d i f f e r e n c e between the e x p e r i m e n t a l and c o n t r o l group on the v a r i a b l e s o f age, sex, m a r i t a l s t a t u s and y e a r s of schooling.  No d e m o g r a p h i c d a t a was c o l l e c t e d c o n c e r n i n g the  significant others.  T h r e e o u t o f f i v e p a t i e n t s i n the e x p e r i m e n t a l  group and 4/4 p a t i e n t s i n the c o n t r o l group had s i g n i f i c a n t o t h e r s were w i l l i n g t o p a r t i c i p a t e i n the s t u d y .  The s i g n i f i c a n t o t h e r ' s  r e l a t i o n s h i p t o the p a t i e n t i s shown i n T a b l e 5.  who  99  TABLE 5 R e l a t i o n s h i p Between P a t i e n t and S i g n i f i c a n t O t h e r Experimental  Group  Patient  Significant Other  Husband  Wife  C o n t r o l Group Patient  Significant Other  Mother  Daughter  Father  Daughter  Mother  Daughter  Mother  Son  Mother  Daughter  Husband  Wife  U s i n g a p r e t e s t - p o s t t e s t c o n t r o l group d e s i g n the f o l l o w i n g h y p o t h e s e s were t e s t e d . 1.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  increase  the knowledge base o f the p a t i e n t and h i s s i g n i f i c a n t other. 2.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  decrease  the s t a t e and t r a i t a n x i e t y l e v e l s o f the p a t i e n t and h i s significant 3.  other.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  enable  the p a t i e n t and h i s s i g n i f i c a n t o t h e r to d e m o n s t r a t e pulse 4.  taking.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  maintain  o r i n c r e a s e the a c t i v i t y l e v e l o f the p a t i e n t from h i s p r e o p e r a t i ve.-state.  100 HYPOTHESIS ONE Patient crease  teaching  and psychological  the knowledge  significant  support  base of the patient  w i l l inand his  other.  From T a b l e s 6 and 7 i t i s c l e a r t h a t the c o n t r o l group had a h i g h e r mean p r e t e s t knowledge base s c o r e than the e x p e r i m e n t a l  group.  A p o s s i b l e e x p l a n a t i o n f o r t h i s i s t h a t 5/8 p e o p l e i n the c o n t r o l group and o n l y 2/8 p e o p l e i n the e x p e r i m e n t a l on pacemakers b e f o r e t h e y d i d the p r e t e s t .  group had r e a d a b o o k l e t The n u r s e i n v e s t i g a t o r  f i r s t saw the p a t i e n t a f t e r h i s pacemaker had been i n s e r t e d .  It is  a l s o p o s s i b l e t h a t the ward n u r s e s o r the p a t i e n t ' s p h y s i c i a n may have done some p r e - o p e r a t i v e t e a c h i n g .  Another confounding  v a r i a b l e which  p r o b a b l y i n f l u e n c e d the knowledge base s c o r e s o f t h e c o n t r o l group i s t h a t two s i g n i f i c a n t o t h e r s were n u r s e s a n d one p a t i e n t had h e a r t d i s e a s e f o r t e n y e a r s a n d r e a d a v i d l y a l l he c o u l d on the s u b j e c t . Both groups l e a r n e d more about pacemakers d u r i n g t h e i r hosp i t a l i z a t i o n and r e t a i n e d t h a t knowledge o v e r a f o u r week p o s t d i s c h a r g e time p e r i o d .  However, a s i g n i f i c a n t c o r r e l a t i o n  coeffic-  i e n t , r = . 9 6 , between knowledge base a t two weeks p o s t d i s c h a r g e and f o u r weeks p o s t d i s c h a r g e was o n l y a v a i l a b l e f o r the group ( s e e T a b l e 8 ) .  experimental  There were no s i g n i f i c a n t c o r r e l a t i o n s a t the  .05 l e v e l i n the c o n t r o l group b e c a u s e the sample c o n s i s t e d o f o n l y three people.  When a t - t e s t was done on the mean d i f f e r e n c e between  101 TABLE 6 * Knowledge Base S c o r e s - Two Weeks A f t e r D i s c h a r g e  Pretest E  17 21..  xP E R I M N T A L L  G R 0 U  P  N=8 Mean'  C 0 N T R 0 L G R 0 Pu N=8 Mean  *  15 19 21 20 22 18  19.125  Posttest 16 21 20 20 21 20 22 18  19.750  Difference -1 0 +5 +1 0 0 0 0  +0.625  22  22  0  20 22 18  21  +1  21 20  -1 +2  15  21  +6  18 22  19 22  20  22  +1 0 +2  19.625  21.000  +1.375  H i g h e s t p o s s i b l e s c o r e = 22  102 TABLE 7 Knowledge Base S c o r e s - Four Weeks A f t e r Pretest  E X P E R I M E T A L  G R 0 U P*  N =7 Mean  Discharge  Posttest  Difference  17 21 15  17 21 21  0 0 +6  19 21  22  +3  21 21 20  0 +1 +2  20.43  +1.71  20 18 18.71  C 0 G N R T 0 R U Q p** L  22 20 22 18 22  21 21 22 18 22  -1 +1 0 0 0  N =6  20  22  +2  Mean  20.67  * **  21.00  +0.33  One s i g n i f i c a n t o t h e r was u n a v a i l a b l e f o r t e s t i n g . One p a t i e n t and h e r s i g n i f i c a n t o t h e r r e f u s e d t o c o m p l e t e t h e q u e s t i o n n a i r e s the second t i m e .  103 the two groups on knowledge base s c o r e s a t two weeks p o s t d i s c h a r g e , the r e s u l t s were n o n s i g n i f i c a n t a t t h e .05 l e v e l ( t = 0.876, d f = 1 4 ) . L i k e w i s e , a t - t e s t done on t h e mean d i f f e r e n c e between t h e two groups on knowledge base s c o r e s a t f o u r weeks p o s t d i s c h a r g e r e v e a l e d no s i g n i f i c a n c e a t t h e .05 l e v e l ( t = 1.616, d f = 9 ) . Each p a t i e n t , a f t e r s u r g e r y , was g i v e n a b o o k l e t p r e p a r e d by t h e company w h i c h made h i s pacemaker.  A l l p a t i e n t s i n the study  r e p o r t e d t h a t t h e y had r e a d t h e b o o k l e t and t h a t a t l e a s t one o t h e r member o f t h e i r f a m i l y had done s o .  The r e a c t i o n t o t h e b o o k l e s t by  p a t i e n t s and f a m i l y members was v e r y f a v o u r a b l e .  The i n v e s t i g a t o r  d i d n o t i n q u i r e about t h e s u b j e c t ' s r e s p o n s e t o t h e s l i d e - t a p e program which those i n the experimental member o f t h e e x p e r i m e n t a l  group saw i n t h e h o s p i t a l b u t no  group o f f e r e d any s p o n t a n e o u s comments.  TABLE 8 C o r r e l a t i o n C o e f f i c i e n t s Among S e l e c t e d Dependent V a r i a b l e s f o r the E x p e r i m e n t a l Variables  Knowledge - P  Knowledge - 2  State Anxiety - P  State Anxiety - 2  Knowledge - P Knowledge - 2 Knowledge - 4  1.00  State Anxiety - P State Anxiety - 2  -.42  .23  -.23  State Anxiety - 4  -.25  .44 .53  .90* .95*  1.00 .94*  T r a i t Anxiety - P T r a i t Anxiety - 2 T r a i t Anxiety - 4  -.59  .30 .11 .74  .59 .86 .72  .76  .59 .37  -.10  .04 -.67 -.16  Activity - P Activity - 2 Activity - 4  .20 .28  -.56 -.43 .87 .47 .96*  4 = P o s t t e s t - 4 weeks a f t e r d i s c h a r g e  Activity - P  1.00 .96*  .43  1.00  -.73 -.34  P = Pretest 2 = P o s t t e s t - 2 weeks a f t e r d i s c h a r g e  Group  S i g n i f i c a n t a t t h e .05 l e v e l  .90* .77 1.00 .51 .96*  105 HYPOTHESIS TWO  Patient the state his  teaching  and psychological  and trait  significant  anxiety  levels  support  will  decrease  of the patient  and  other.  The mean t r a i t a n x i e t y s c o r e s o f t h e e x p e r i m e n t a l  group were  h i g h e r than t h o s e o f the c o n t r o l group on t h e p r e t e s t , two week p o s t d i s c h a r g e p o s t t e s t a n d t h e f o u r week p o s t d i s c h a r g e p o s t t e s t , ( T a b l e s 9 a n d 10).  When a t - t e s t was done on t h e mean change between t h e two groups  a t two and f o u r weeks a f t e r d i s c h a r g e , r e s p e c t i v e l y , ( t = .298, d f = 7; t = .454, d f = 12) t h e r e s u l t was n o t s i g n i f i c a n t .  According to  S p i e l b e r g e r ] t r a i t a n x i e t y s c o r e s s h o u l d be s t a b l e o v e r time and s h o u l d r e f l e c t the person's c h a r a c t e r i s t i c l e v e l o f anxiety. demonstrated  by t h e d a t a .  t r a i t a n x i e t y , has n o t been  T h i s has been  The h y p o t h e s i s , t h o u g h , as i t r e l a t e s t o supported.  The mean s t a t e a n x i e t y s c o r e s ( T a b l e s 11 and 12) a r e h i g h e r f o r the e x p e r i m e n t a l group than t h e c o n t r o l group on t h e p r e t e s t , two week p o s t d i s c h a r g e p o s t t e s t , and t h e f o u r week p o s t d i s c h a r g e p o s t test.  The mean s t a t e a n x i e t y s c o r e s f o r t h e c o n t r o l group s t e a d i l y  d e c r e a s e o v e r time; w h e r e a s , t h e y a r e d e c r e a s e d two weeks a f t e r d i s charge b u t r i s e a g a i n t o a l m o s t t h e p r e t e s t l e v e l f o u r weeks a f t e r discharge f o r the experimental  group.  A g a i n , when a t - t e s t was done  ^C.D. S p i e l b e r g e r e t a l _ . , Manual f o r t h e S t a t e - T r a i t A n x i e t y I n v e n t o r y , ( C a l i f o r n i a : C o n s u l t i n g P s y c h o l o g i s t s P r e s s , 1970), p. 3.  106 TABLE 9 T r a i t A n x i e t y S c o r e s - Two Weeks A f t e r D i s c h a r g e Pretest  r  Posttest  Difference  L.  X P G E R R 0 I U M P E N A L N=8 Mean  C 0 N T R 0 L  G R 0 U P  N= 8  Mean  33  56 35  -2 +2  40 54 51 37 40 38  43 52 24 41 57 27  +3 -2 -27 +4 +17 +11  58  43.875  41.875  •r.2  33 37  36 .. 35  +3  30 37 38  29  -1  36 34  -1  26 35  25 39  -1 +4  27  29  +2  32.875  32.875  0  -2  -4  107 TABLE 10 T r a i t A n x i e t y S c o r e s - F o u r Weeks A f t e r  E R I M E N T A L  Posttest  Difference  58 33 40 54 37  67 26 38 39 47  40 38  52 39  +9 -7 -2 -15 +10 +12 +1  44.00  +1.14  33  37  +4  30 37  35 32  +5 -5  35 27  29 24  -6 -3  32.4  31.4  -1.0  Pretest  E X G R  ° p * v  Discharge  N =7 Mean  42.86  C 0 N G T R R 0 0 U L P * * N =5 Mean  F a m i l y member  **  unavailable  One p a t i e n t o m i t t e d t h e t r a i t q u e s t i o n n a i r e and one p a t i e n t and h e r s i g n i f i c a n t o t h e r r e f u s e d t o be seen f o u r weeks a f t e r d i s c h a r g e  108  TABLE 11 S t a t e A n x i e t y S c o r e s - Two Weeks A f t e r D i s c h a r g e Posttest  Difference  50  57  +7  25 28 51 22  -10 0 +11 0  xA  35 28 40 22 45 60  51 33  L  26  25  +6 -27 -1  36.50  -1.75  39  Pretest E X R I M E N  R 0 U P  N=8 Mean  C 0  38.25  35 25 20 47  0 -12 -10 -14 +6  N =8  39 47 33 34 41 35 27  41 27  +6 0  41  27  -14  Mean  37.13  32.63  -4.75  ? L  6  S  P  109 TABLE 12 S t a t e A n x i e t y S c o r e s - F o u r Weeks A f t e r Pretest E X P E R I M E N T A L  G R 0 U P  Posttest  Discharge Difference  50 35 28 40  63  +13  26 25 42  -9 -3 +2  22 45  21 57  -1 +12  60 26  44 24  -16 -2  38.25  . 37.75  -0.5  39 47 33 34 27  37  -2 -9 -2 -1 -7 -20 -6.83  N= 8 Mean  C 0 N T R 0 L  N =6  41  38 31 33 20 21  Mean  36.83  30.00  o G  R 0 U  p*  One p a t i e n t and h e r s i g n i f i c a n t o t h e r r e f u s e d t o answer t h e p o s t t e s t s f o u r weeks a f t e r d i s c h a r g e  110 on t h e mean d i f f e r e n c e between t h e e x p e r i m e n t a l  and c o n t r o l group on  the s t a t e a n x i e t y s c o r e s two and f o u r weeks a f t e r d i s c h a r g e , no s i g n i f i c a n t d i f f e r e n c e s were e s t a b l i s h e d ( t = .119, d f = 14 (2 w e e k s ) ; t = 1.097, d f = 14 (4 w e e k s ) ) . The mean s t a t e and t r a i t s c o r e s o f t h e e x p e r i m e n t a l group can be compared w i t h t h e n o r m a t i v e  and c o n t r o l  d a t a s u p p l i e d by S p i e l b e r g e r  on 110 male, m e d i c a l - s u r g i c a l p a t i e n t s who do n o t have p s y c h i a t r i c complications.  The g e n e r a l m e d i c a l - s u r g i c a l p a t i e n t ' s mean s t a t e  a n x i e t y s c o r e was 42.68 and t h e i r mean t r a i t a n x i e t y s c o r e was 41.33. A t no time d i d e i t h e r t h e e x p e r i m e n t a l  o r c o n t r o l group r e a c h t h e mean  s t a t e a n x i e t y l e v e l shown i n t h e n o r m a t i v e  data.  p a t t e r n a p p e a r s f o r t h e mean t r a i t a n x i e t y s c o r e s .  A somewhat d i f f e r e n t The c o n t r o l group  mean t r a i t a n x i e t y s c o r e s o v e r time a r e much l o w e r than t h e v a l u e from t h e n o r m a t i v e  patients  taken  d a t a (32.88 v s . 4 1 . 3 3 ) ; however, t h e mean t r a i t  anxiety scores f o r the experimental (44.0 v s . 4 1 . 3 3 ) .  1  group a r e s l i g h t l y  higher  Perhaps t h i s s u g g e s t s t h a t t h e a n x i e t y l e v e l o f t h e  s t u d i e d was n o t h i g h enough t o be a more powerful  motivating  f o r c e t o seek new i n f o r m a t i o n a b o u t t h e i r a l t e r e d h e a l t h s t a t u s . A n o t h e r p o s s i b l e c o n c l u s i o n m i g h t be t h a t t h e n o r m a t i v e  data  S p i e l b e r g e r i s n o t an a p p r o p r i a t e p o p u l a t i o n f o r c o m p a r i s o n .  from His  sample c o n s i s t s o n l y o f m a l e s , whose a v e r a g e age i s 55, w i t h an uns p e c i f i e d v a r i e t y o f general m e d i c a l - s u r g i c a l problems.  On t h e o t h e r  hand, t h e sample from t h i s s t u d y i s composed o f males and f e m a l e s  I b i d . , p. 8.  Ill  whose a v e r a g e age i s between 76.8 and 78.8 y e a r s , and who a l l s u f f e r e d from heart block r e q u i r i n g s u r g i c a l i n t e r v e n t i o n . alone could account f o r the lessened  The age f a c t o r  degree o f s t a t e a n x i e t y  exhibited  i n t h i s s t u d y , f o r p e r h a p s t h e o l d e r p e r s o n i s more w i l l i n g t o a c c e p t d e c l i n i n g h e a l t h as a concommitant o f o l d age. In terms o f t h e a n x i e t y components i n t h e s u b j e c t s o f t h i s s t u d y , a s t r o n g p o s i t i v e c o r r e l a t i o n was e s t a b l i s h e d i n t h e  experimental  group between p r e t e s t s t a t e a n x i e t y and two week p o s t t e s t s t a t e  anxiety  ( r = . 9 0 ) ; between p r e t e s t s t a t e a n x i e t y and f o u r week p o s t t e s t s t a t e a n x i e t y ( r = . 9 5 ) ; and between two week p o s t t e s t s t a t e a n x i e t y and f o u r week p o s t t e s t s t a t e a n x i e t y ( r = .94) ( T a b l e 8 ) .  These f i n d i n g s r e -  i n f o r c e the f a c t that the nursing i n t e r v e n t i o n o f planned p a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t d i d n o t reduce t h e s t a t e l e v e l o f members o f t h e e x p e r i m e n t a l  group.  anxiety  A p o s s i b l e reason f o r  t h i s can be found when t h e t r a i t a n x i e t y s c o r e s o f t h e e x p e r i m e n t a l s u b j e c t s a r e examined ( T a b l e s 9 and 1 0 ) .  The mean t r a i t a n x i e t y  scores  of the experimental  group a r e h i g h e r than t h o s e o f t h e c o n t r o l group.  If the experimental  s u b j e c t s were i n h e r e n t l y more a n x i o u s p e r h a p s  p r o v i d i n g them w i t h i n f o r m a t i o n a b o u t t h e i r c o n d i t i o n would n o t s e r v e to r e d u c e t h e i r a n x i e t y .  Perhaps t h e n u r s e i n v e s t i g a t o r d i d n o t  spend enough time w i t h t h e p a t i e n t s t o p r o v i d e t h e needed p s y c h o l o g i c a l s u p p o r t o r i t i s v e r y p o s s i b l e t h a t t h e t e a c h a b l e moment was m i s s e d . By t h e t e a c h a b l e moment, t h e i n v e s t i g a t o r i s r e f e r r i n g t o t h e n u r s e ' s a b i l i t y t o d e t e c t and a c t on t h e p a t i e n t ' s d e m o n s t r a t e d r e a d i n e s s t o learn.  A l s o , t h e p a t i e n t was b e i n g bombarded w i t h i n f o r m a t i o n  from  112 a v a r i e t y o f sources. and b o o k l e t s ) .  (The n u r s e i n v e s t i g a t o r , ward n u r s e s ,  physicians,  I n e v i t a b l y some o f t h i s i n f o r m a t i o n would be  c o n t r a d i c t o r y , thereby  increasing the patient's feelings of frustration.  For example, t h e i s s u e o f t h e s a f e t y o f microwave ovens was c o n t r o v e r s i a l . Each c a r d i o l o g i s t d i f f e r e d i n h i s a d v i c e t o h i s p a t i e n t .  Sometimes t h e  i n v e s t i g a t o r ' s s l i d e - t a p e programme c o n t r a d i c t e d t h e d o c t o r though i t s c o n t e n t was s u p p o r t e d  by t h e c u r r e n t m e d i c a l l i t e r a t u r e .  A l t h o u g h no s i g n i f i c a n t c o r r e l a t i o n was f o u n d between s t a t e o r t r a i t a n x i e t y s c o r e s and t h e p a t i e n t ' s knowledge b a s e , i t i s i n t e r e s t i n g t o s p e c u l a t e a b o u t t h e i r r e l a t i o n s h i p when e x a m i n i n g t h e raw d a t a ( T a b l e s 6, 7, 9, 10, 1 1 , and 1 2 ) .  The e x p e r i m e n t a l  group when compared  to t h e c o n t r o l group had h i g h e r mean s t a t e and t r a i t a n x i e t y  scores  and l o w e r mean knowledge base s c o r e s on t h e p r e t e s t , two week p o s t d i s c h a r g e p o s t t e s t and f o u r week p o s t d i s c h a r g e p o s t t e s t . f u l l l e a r n i n g p o t e n t i a l o f the experimental correspondingly  Perhaps the  group was hampered by t h e i r  h i g h e r l e v e l s o f s t a t e and t r a i t  anxiety.  HYPOTHESIS THREE  Patient  teaching  the patient pulse  and psychological  support  and his s i g n i f i c a n t other  to  will  enable  demonstrate  taking.  From T a b l e 13, i t c a n be seen t h a t more members o f t h e e x p e r i mental group c o u l d d e m o n s t r a t e p u l s e t a k i n g than c o u l d members o f t h e  113 c o n t r o l group.  When t h e F i s h e r - Y a t e s E x a c t P r o b a b i l i t y T e s t was  a p p l i e d by i n s p e c t i o n o f t a b l e s , no s i g n i f i c a n t d i f f e r e n c e was found 1  between t h e two groups on t h e dependent v a r i a b l e o f p u l s e t a k i n g ability.  TABLE 13 P u l s e T a k i n g A b i l i t y - Two Weeks A f t e r D i s c h a r g e Experimental Can Demonstrate  Group Cannot Demonstrate  C o n t r o l Group Can Cannot Demonstrate Demonstrate  Patient  3  2  1  3  Si gni f i c a n t Other  3  0  3  1  Total  6  2  4  4  Two c o n f o u n d i n g  v a r i a b l e s p r o b a b l y had a p o w e r f u l e f f e c t on t h e  r e s u l t s s i n c e t h e sample s i z e was s o s m a l l .  Two o u t o f f o u r s i g n i f i -  c a n t o t h e r s i n t h e c o n t r o l group were n u r s e s and had a l r e a d y the s k i l l o f p u l s e t a k i n g .  mastered  Also a p a t i e n t i n the experimental  group  s u f f e r e d from s u b a c u t e combined d e g e n e r a t i v e d i s e a s e o f t h e s p i n a l c o r d w h i c h l e f t h i s f i n g e r t i p s numb.  Because o f t h i s l a c k o f s e n s a t i o n i n  h i s f i n g e r t i p s , he was u n a b l e t o f e e l h i s p u l s e e i t h e r b e f o r e o r a f t e r the e x p e r i m e n t a l  Sciences, 343.  nursing intervention.  R.H. K o l s t o e , I n t r o d u c t i o n t o S t a t i s t i c s f o r t h e B e h a v i o u r a l R e v i s e d E d i t i o n ( I l l i n i o s : The Dorsey P r e s s , 1973), pp. 342-  114 HYPOTHESIS FOUR  Patient  teaching  or increase preoperative  the  and  psychological  activity  level  support  will  of the patient  maintain  from  his  state.  From T a b l e 14 i t i s e v i d e n t t h a t t h e members o f t h e c o n t r o l group were more a c t i v e than t h e e x p e r i m e n t a l group a t t h e time o f t h e pretest.  Both groups d e c r e a s e d t h e i r a c t i v i t y l e v e l two weeks a f t e r  d i s c h a r g e b u t t h e members o f t h e e x p e r i m e n t a l group d e c r e a s e d activity level less.  their  Four weeks a f t e r d i s c h a r g e ( T a b l e 1 5 ) , both  a c t i v i t y l e v e l was a p p r o a c h i n g t h e p r e t e s t l e v e l .  groups'  The members o f t h e  e x p e r i m e n t a l group came c l o s e r t o a c h i e v i n g t h e i r p r e t e s t l e v e l o f a c t i v i t y than members o f t h e c o n t r o l group.  A point  t o remember  though i s t h a t t h e members o f t h e e x p e r i m e n t a l group were l e s s a c t i v e than t h e c o n t r o l group t o b e g i n w i t h .  Perhaps i t was e a s i e r f o r t h e  e x p e r i m e n t a l group t o r e a c h t h e i r p r e t e s t l e v e l o f a c t i v i t y .  Upon  e x a m i n i n g t h e k i n d o f a c t i v i t i e s which members o f t h e e x p e r i m e n t a l group p e r f o r m e d , t h e y  represented those o f a l e s s strenuous  generally at a subsistence level.  nature  When a t - t e s t was a p p l i e d t o t h e  d a t a a t two and f o u r weeks p o s t d i s c h a r g e r e s p e c t i v e l y ( t = .87, d f = 8; t = 0.261, d f = 8 ) , no s i g n i f i c a n t d i f f e r e n c e between t h e two groups on t h e v a r i a b l e o f a c t i v i t y l e v e l was e s t a b l i s h e d f o r a one t a i l e d test.  115  TABLE 14 A c t i v i t y C h e c k l i s t S c o r e s - Two Weeks A f t e r D i s c h a r g e Pretest  Posttest  Difference  22  20  -2  27  14  -13  21  25  +4  56  28  -28  42  47  +5  33.6  26.8  -6.8  33  27  -6  54  28  -26  G  49  24  -25  0 U  26  14  -12  E X P R  G  I  M E N  R  0 U  P V  T A L  N = 5  Mean  c 0 N  T R  R  L  P  0  N = 4  Mean  40.5  23.3  -17.2  116 TABLE 15 A c t i v i t y C h e c k l i s t S c o r e s - Four Weeks A f t e r D i s c h a r g e Pretest E X P E G R R I 0 M U E P N T A L  Posttest  Difference  22  19  -3  27  28  +1  21  24  +3  56  43  -13  42  38  -4  33.6  30.4  33  29  -4  54  43  -11  26  23  -3  37.7  31.7  -6.0  N=5 Mean  C 0 T  G  «  0  0 L  ~ p *  -3.2  N=3 Mean  One p a t i e n t r e f u s e d t o do t h e p o s t t e s t s f o u r weeks a f t e r d i s c h a r g e  117 T a b l e 16 shows the p a t i e n t ' s l e v e l b e f o r e the pacemaker was  s a t i s f a c t i o n with his a c t i v i t y  i n s e r t e d , two weeks a f t e r d i s c h a r g e f r o m  the h o s p i t a l and f o u r weeks a f t e r d i s c h a r g e f r o m the h o s p i t a l .  The  r e s u l t s were o b t a i n e d by a s k i n g e a c h p a t i e n t , a t the s t a t e d time i n t e r v a l s , to say w h e t h e r he f e l t s a t i s f i e d o r d i s s a t i s f i e d w i t h h i s a c t i v i t y level.  A F i s h e r - Y a t e s E x a c t P r o b a b i l i t y T e s t was  inspection  of tables.  p e r f o r m e d by  No s i g n i f i c a n t d i f f e r e n c e was  1  the two groups w i t h r e s p e c t  f o u n d between  to t h e i r r e p o r t e d s a t i s f a c t i o n / d i s s a t i s f a c t i o n  w i t h t h e i r a c t i v i t y l e v e l a t any  time.  TABLE 16 Reported S a t i s f a c t i o n / D i s s a t i s f a c t i o n Pretest S  E X  IR  I M E N T A L  D  0  / /  U P  /  / /  /  / /  / /  /  Level  P o s t t e s t - 4 Weeks A f t e r Discharqe S D  / /  R  With A c t i v i t y  P o s t t e s t - 2 Weeks After Discharqe S D  V  G  (S/D)  /  N = 5  C o  fi  N T R 0 L  R 0 U  /  /  / /  P  /  N = 4 Ibid.  /  /  /  /  /  /  /  118 Another portion o f the A c t i v i t y Interview Schedule d e a l t with the p a t i e n t ' s d e s c r i p t i o n o f h i s m o r a l e two and f o u r weeks a f t e r d i s charge from the h o s p i t a l .  T a b l e 17 d e p i c t s t h e r e s u l t s .  TABLE 17 Patient's D e s c r i p t i o n o f T h e i r Morale  E X P R I M E N T A L  °  R 0 U  P  Y  Two Weeks After Discharge  F o u r Weeks After Discharge  low  good  low  low  good  high  good  good  low  low  good  good  fair  good  good  good  good  good  N =5 C 0  r  ?  «  N=4  The n u r s e i n v e s t i g a t o r p r e s e n t e d t h e p a t i e n t s w i t h a s c a l e from w h i c h t o choose t h e word w h i c h b e s t d e s c r i b e d  t h e i r morale.  from l e f t t o r i g h t , i n d i c a t e d d e g r e e s o f improvement high).  The s c a l e ,  (low, f a i r ,  good,  No change i n m o r a l e o v e r t i m e was r e p o r t e d i n 3/5 members o f  119 t h e e x p e r i m e n t a l group and 3/4 members o f the c o n t r o l group.  Of t h o s e  s u b j e c t s r e p o r t i n g no change, a l l t h r e e i n t h e c o n t r o l group s a i d t h a t t h e y were i n good s p i r i t s , , whereas, two o u t o f t h r e e i n t h e e x p e r i m e n t a l group s a i d t h a t t h e i r s p i r i t s were low.  When a change i n morale  was  n o t e d , r e g a r d l e s s o f t h e i r group membership, i t was c o n s i s t e n t l y i n a positive direction. M o r a l e a p p e a r s t o be more c o n s i s t e n t l y "good" i n t h e c o n t r o l group.  Because t h e sample s i z e was so s m a l l , the n u r s e i n v e s t i g a t o r  was a b l e t o a s s e s s each p a t i e n t o v e r time v e r y t h o r o u g h l y .  I t i s the  i n v e s t i g a t o r ' s judgement t h a t the low m o r a l e e n c o u n t e r e d i n t h e e x p e r i m e n t a l group was due t o many u n r e s o l v e d problems s u c h as d e p r e s s i o n , l o n e l i n e s s , f e a r o f d y i n g , l o s s o f a p p e t i t e , n e r v o u s n e s s and l a c k o f energy.  These were much more e v i d e n t i n t h e e x p e r i m e n t a l group as  opposed  t o t h e c o n t r o l group i n s p i t e o f the p r o c e s s o f r a n d o m i z a t i o n . L a s t , with r e s p e c t to a c t i v i t y l e v e l , the nurse i n v e s t i g a t o r  examined t h o s e a c t i v i t i e s which were g i v e n up by the p a t i e n t s and t h e r e a s o n s why.  T h r e e o u t o f f i v e members o f the e x p e r i m e n t a l group  and  two o u t o f f o u r members o f the c o n t r o l group d i d not r e l i n q u i s h any o f t h e i r pre-pacemaker a c t i v i t i e s .  A c t i v i t i e s w h i c h were g i v e n up by  members o f the e x p e r i m e n t a l group f o u r weeks a f t e r d i s c h a r g e were t h i n g s l i k e v i g o r o u s p h y s i c a l e x e r c i s e , bike r i d i n g u p h i l l , l i v i n g by o n e s e l f , sewing and housework. permanently  These a c t i v i t i e s were g i v e n up t e m p o r a r i l y o r  because o f f e a r o r on t h e i r d o c t o r ' s a d v i c e .  Members o f the c o n t r o l group gave up e i t h e r p e r m a n e n t l y  or  t e m p o r a r i l y a c t i v i t i e s such as s h o p p i n g , w a l k i n g around the b l o c k ,  120 l i g h t g a r d e n i n g , u s i n g a c h a i n saw, l i f t i n g o v e r twenty pounds and w o r k i n g w i t h hands o v e r . t h e head.  T h e i r reasons f o r not i n d u l g i n g i n  t h e s e a c t i v i t i e s were t h a t t h e y were t o o i l l (own d e c i s i o n ) and t h a t i t had been t h e i r d o c t o r ' s a d v i c e t o do s o . From T a b l e 8, s e v e r a l s i g n i f i c a n t c o r r e l a t i o n s have been n o t e d . T h e r e i s a s t r o n g p o s i t i v e r e l a t i o n s h i p between t h e p r e t e s t a c t i v i t y l e v e l and t h e f o u r week p o s t d i s c h a r g e a c t i v i t y p o s t t e s t ( r = .96). c o r r e l a t i o n s u g g e s t s t h a t i f t h e members o f t h e e x p e r i m e n t a l were a c t i v e p r e o p e r a t i v e l y  This  group  then by f o u r weeks a f t e r d i s c h a r g e t h e y were  v e r y l i k e l y t o be as a c t i v e as t h e y were b e f o r e t h e i r s u r g e r y .  It is  i n t e r e s t i n g t o n o t e t h a t i t took f o u r weeks a f t e r b e i n g d i s c h a r g e d f o r the e l d e r l y p a t i e n t t o r e t u r n t o h i s f o r m e r a c t i v i t y l e v e l . A l s o , a s t r o n g p o s i t i v e r e l a t i o n s h i p ( T a b l e 8) e x i s t s between p r e t e s t knowledge base and f o u r week p o s t d i s c h a r g e a c t i v i t y l e v e l ( r = .96).  T h i s s u g g e s t s t h a t i f t h e s u b j e c t s knew t h a t t h e i r a c t i v i t y  would be u n a l t e r e d o r i n c r e a s e d by h a v i n g t h e pacemaker i n s e r t e d , then t h e y were m o t i v a t e d t o a t t e m p t t o r e t u r n t o t h e i r p r e v i o u s l e v e l o f activity.  They knew what t o e x p e c t and r e a l i z e d t h a t e x p e c t a t i o n .  INCIDENCE OF COMPLICATIONS  The i n v e s t i g a t o r a l s o m o n i t o r e d t h e o c c u r r e n c e o f any pacemaker r e l a t e d c o m p l i c a t i o n s i n t h e f o u r week p o s t d i s c h a r g e time p e r i o d . R e g a r d l e s s o f group membership, no c o m p l i c a t i o n s ( e . g . , wound i n f e c t i o n , pacemaker m a l f u n c t i o n ) were n o t e d .  121 LENGTH OF HOSPITAL STAY  The mean l e n g t h o f h o s p i t a l s t a y f o r members o f t h e  experimental  group was 15.8 d a y s ; w h e r e a s , t h e mean l e n g t h o f s t a y f o r members o f the c o n t r o l group was twenty d a y s .  A one-tail t-test applied to this  data shows no s i g n i f i c a n t d i f f e r e n c e a t t h e .05 l e v e l ( t = .407, d f = 7 ) .  SUMMARY  Chapter four presented  the f i n d i n g s o f t h i s experimental  study  w h i c h s o u g h t t o d e t e r m i n e t h e e f f e c t o f p l a n n e d p a t i e n t t e a c h i n g and psychological  s u p p o r t on t h e a b i l i t y o f t h e e l d e r l y p a t i e n t t o a d a p t  t o t h e i n s e r t i o n o f a permanent c a r d i a c pacemaker.  Four hypotheses  were d e v e l o p e d i n r e l a t i o n t o knowledge b a s e , s t a t e and t r a i t l e v e l , a c t i v i t y l e v e l and p u l s e t a k i n g a b i l i t y .  anxiety  None o f t h e f i n d i n g s  p r o v e d t o be s t a t i s t i c a l l y s i g n i f i c a n t a t t h e .05 l e v e l .  122  CHAPTER V SUMMARY, CONCLUSIONS AND  IMPLICATIONS  C h a p t e r F i v e w i l l p r e s e n t a summary o f the s t u d y and t h e major c o n c l u s i o n s a r i s i n g from t h e f i n d i n g s .  The i m p l i c a t i o n s g e n e r a t e d by  t h e s t u d y i t s e l f and from a s s o c i a t e d problems w i l l be examined i n r e l a t i o n t o n u r s i n g p r a c t i c e , e d u c a t i o n and r e s e a r c h .  SUMMARY  An e x p e r i m e n t a l s t u d y , u s i n g a p r e t e s t - p o s t t e s t c o n t r o l group d e s i g n , was c o n d u c t e d i n a 580-bed a c u t e c a r e t e a c h i n g h o s p i t a l .  Its  purpose was t o e v a l u a t e t h e e f f e c t o f p l a n n e d p a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t on the a b i l i t y o f t h e e l d e r l y p a t i e n t t o a d a p t t o the s u r g i c a l i n s e r t i o n o f a permanent c a r d i a c pacemaker.  Nine  s u b j e c t s , who met t h e s t u d y c r i t e r i o n were randomly a s s i g n e d t o e i t h e r t h e e x p e r i m e n t a l o r c o n t r o l group.  Each s u b j e c t was a s k e d i f he would  l i k e to i n c l u d e a s i g n i f i c a n t other i n the p r o j e c t .  The members o f  the e x p e r i m e n t a l group ( f i v e p a t i e n t s , t h r e e s i g n i f i c a n t o t h e r s ) were seen i n d i v i d u a l l y by t h e n u r s e i n v e s t i g a t o r on the t h i r d , f o u r t h and f i f t h p o s t o p e r a t i v e day o r t h e r e a b o u t s a t which time t h e i r q u e s t i o n s were answered;  t h e y were g i v e n t h e o p p o r t u n i t y t o e x p r e s s t h e i r c o n c e r n s ;  123 and, t h e y were shown a f i f t e e n - m i n u t e s l i d e - t a p e programme. tape programme was d i v i d e d i n t o two p a r t s — o n e w h i c h d e a l t w i t h why  the permanent pacemaker was  The  slide-  f i v e minute segment i n s e r t e d and  another  t e n m i n u t e segment w h i c h examined l i f e s t y l e changes and common m i s c o n c e p t i o n s a b o u t pacemakers.  The members o f the c o n t r o l group ( f o u r  p a t i e n t s , f o u r s i g n i f i c a n t o t h e r s ) were p r o v i d e d w i t h the u s u a l  nursing  c a r e g i v e n by t h e ward n u r s i n g s t a f f to p a t i e n t s h a v i n g permanent pacemakers i n s e r t e d .  A l l p a t i e n t s received a booklet about t h e i r  pacemaker f r o m the company whose b r a n d o f pacemaker t h e y had.  The  s p e c i f i c h y p o t h e s e s t e s t e d were: 1.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  increase  t h e knowledge base o f the p a t i e n t and h i s s i g n i f i c a n t other. 2.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  decrease  t h e s t a t e and t r a i t a n x i e t y l e v e l s o f the p a t i e n t and his s i g n i f i c a n t other. 3.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l e n a b l e  the  p a t i e n t and h i s s i g n i f i c a n t o t h e r t o d e m o n s t r a t e p u l s e taking. 4.  P a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t w i l l  maintain  o r i n c r e a s e t h e a c t i v i t y l e v e l o f the p a t i e n t f r o m h i s preoperative  state.  At approximately  two and f o u r weeks a f t e r d i s c h a r g e f r o m the  h o s p i t a l , t h e n u r s e i n v e s t i g a t o r v i s i t e d a l l o f the p a t i e n t s i n t h e  124 s t u d y and t h e i r s i g n i f i c a n t o t h e r s .  Knowledge b a s e , a c t i v i t y l e v e l ,  s t a t e a n d t r a i t a n x i e t y l e v e l s a n d p u l s e t a k i n g a b i l i t y were measured on a l l p a t i e n t s ; w h e r e a s , o n l y t h e knowledge b a s e , p u l s e t a k i n g a b i l i t y and s t a t e and t r a i t a n x i e t y l e v e l s were measured on a l l s i g n i f i c a n t others.  No s i g n i f i c a n t d i f f e r e n c e s were f o u n d between t h e two g r o u p s  on any o f t h e s e  variables.  CONCLUSIONS  The d a t a o b t a i n e d hypothesis  i n t h i s study f a i l e d to r e j e c t the n u l l  o f no d i f f e r e n c e between t h e e x p e r i m e n t a l  w i t h r e s p e c t t o s e l e c t e d p a t i e n t outcome v a r i a b l e s .  a n d c o n t r o l group In o t h e r words,  p l a n n e d p a t i e n t t e a c h i n g and p s y c h o l o g i c a l s u p p o r t among t h e members o f the e x p e r i m e n t a l  group was n o t shown t o s i g n i f i c a n t l y i n c r e a s e  knowledge b a s e ; d e c r e a s e t h e i r s t a t e and t r a i t a n x i e t y l e v e l s ; or maintain  their increase  t h e i r a c t i v i t y l e v e l ; o r , t o enable the p a t i e n t o r h i s  s i g n i f i c a n t other to a c c u r a t e l y demonstrate t h e i r pulse taking a b i l i t y more  o f t e n than t h e members o f t h e c o n t r o l g r o u p . T h i s l a c k o f s t a t i s t i c a l s i g n i f i c a n c e may be due t o small  sample s i z e .  K e r l i n g e r says that  " L a r g e samples a r e n o t a d v o c a t e d  because l a r g e numbers a r e good i n and o f t h e m s e l v e s . in order to give the p r i n c i p l e o f randomization 'work.'"  ...  They a r e a d v o c a t e d a chance to  1  ^F.N. K e r l i n g e r , F o u n d a t i o n s o f B e h a v i o u r a l R e s e a r c h , 2nd E d i t i o n (New Y o r k : H o l t , R i n e h a r t a n d W i n s t o n I n c . , 1964), p. 128.  125 Because t h e p r o c e s s o f r a n d o m i z a t i o n  may n o t have been a b l e t o  e q u a l i z e t h e two groups on a l l o t h e r v a r i a b l e s e x c e p t those b e i n g exami n e d , c e r t a i n e x t r a n e o u s v a r i a b l e s may have had a s i g n i f i c a n t i n f l u e n c e on t h e r e s u l t s .  F o r example, t h e r e was t w i c e t h e i n c i d e n c e o f i n -  h o s p i t a l c a r d i a c a r r e s t as o p p o s e d t o f a i n t i n g a t home among t h e members o f the experimental  group.  A l s o , n o t a l l members o f t h e e x p e r i m e n t a l  group had t h e s u p p o r t o f a s i g n i f i c a n t o t h e r ; w h e r e a s , e a c h p a t i e n t i n the c o n t r o l group d i d have a f a m i l y member p r e s e n t f o r t h e t e a c h i n g and discussion sessions.  These f a c t s combined may have c o n t r i b u t e d t o t h e  u n r e s o l v e d a n x i e t i e s and s u b s e q u e n t p o o r e r p e r f o r m a n c e on t h e c o g n i t i v e and p s y c h o m o t o r t a s k s by members o f t h e e x p e r i m e n t a l  group.  Another p o s s i b l e explanation f o r the lack o f s t a t i s t i c a l  signifi-  c a n c e c o u l d a r i s e o u t o f t h e p a t i e n t outcome v a r i a b l e s s e l e c t e d f o r evaluation.  Knowledge b a s e , a n x i e t y l e v e l , a c t i v i t y l e v e l a n d p u l s e  taking a b i l i t y are not s o l e l y related to nursing care.  Obviously,  o t h e r h e a l t h c a r e p r o f e s s i o n a l s , t h e p a t i e n t ' s p r i o r h e a l t h s t a t u s and h i s a t t i t u d e s towards h e a l t h and i l l n e s s a r e i m p o r t a n t variables.  Although  confounding  t h e a u t h o r would c o n s i d e r l o o k i n g a t t h e f i r s t  f o u r v a r i a b l e s a g a i n w i t h a l a r g e r sample, p e r h a p s p r o c e s s - t y p e m a t i o n s h o u l d a l s o be g a t h e r e d .  infor-  F o r example, one c o u l d measure p a t i e n t  s a t i s f a c t i o n w i t h t h e n u r s i n g c a r e r e c e i v e d i n h o s p i t a l as i t r e l a t e s to h e l p i n g him a d j u s t t o h i s c i r c u m s t a n c e s  a t home.  One c o u l d a l s o  d e t e r m i n e f r o m t h e p a t i e n t and f a m i l y w h i c h a c t i o n s o f t h e n u r s e f a c i l i t a t e d t h e i r l e a r n i n g a b o u t h i s pacemaker.  126 The t i m i n g o f t h e n u r s i n g i n t e r v e n t i o n i n t h i s s t u d y a l s o be r e - e x a m i n e d .  In t h e h o s p i t a l i n w h i c h t h i s s t u d y was done,  p a t i e n t e d u c a t i o n assumes p r i o r i t y s t a t u s on many wards. and n u r s e s attempt  should-  Both d o c t o r s  t o a s s e s s and meet t h e p a t i e n t ' s l e a r n i n g needs i n  h o s p i t a l on an i n f o r m a l b a s i s .  The f i r s t month a f t e r d i s c h a r g e i s a  t u r b u l e n t one f o r t h e e l d e r l y p a t i e n t who has had a permanent p a c e maker i n s e r t e d . of nervousness,  Many were d e p r e s s e d , weak and l o n e l y and c o m p l a i n e d l a c k o f e n e r g y and l o s s o f a p p e t i t e .  Several patients  made i m p o r t a n t d e c i s i o n s w h i l e i n t h e h o s p i t a l as t o t h e i r f u t u r e l i v i n g quarters.  N o t o n l y d i d they have t o a d j u s t t o t h e i r new pacemaker o r  the e x p e r i e n c e o f h a v i n g had a c a r d i a c a r r e s t b u t t h e y a l s o had t o become a c c u s t o m e d t o l i v i n g i n a new a p a r t m e n t o r n u r s i n g home.  Perhaps  the nurse s h o u l d assume a c o u n s e l l i n g and s u p p o r t i v e r o l e d u r i n g t h e f i r s t month a f t e r d i s c h a r g e from t h e h o s p i t a l when t h e p a t i e n t i s attempting to r e i n t e g r a t e himself i n t o h i s former  lifestyle.  A n o t h e r time w h i c h m i g h t be more a p p r o p r i a t e f o r t e a c h i n g t h e p a t i e n t i s d u r i n g t h e pacemaker c l i n i c .  About t h r e e months a f t e r t h e  pacemaker has been i n s e r t e d , most p a t i e n t s r e t u r n t o t h e c l i n i c f o r followup care.  I f the p a t i e n t expresses  t h e need f o r i n f o r m a t i o n O r  s u p p o r t o r i t i s o t h e r w i s e d e t e c t e d , p e r h a p s t h i s i s t h e time t o p r o v i d e it.  R a t h e r than i n d i v i d u a l c o u n s e l l i n g , group t e a c h i n g c o u l d be  c o n s i d e r e d so t h a t t h e p a t i e n t s c o u l d b e n e f i t by s h a r i n g t h e i r t h o u g h t s , f e e l i n g s and c o n c e r n s w i t h e a c h o t h e r .  127 IMPLICATIONS  T h i s s t u d y has i m p l i c a t i o n s f o r n u r s i n g r e s e a r c h , and p r a c t i c e .  education  W i t h r e s p e c t to n u r s i n g r e s e a r c h , the i n v e s t i g a t o r  s u g g e s t s t h a t the s t u d y , as i s , be r e p l i c a t e d b u t t h a t the sample s i z e be i n c r e a s e d t o a t l e a s t t h i r t y .  A l s o , i f one n u r s e c o u l d do the  i n t e r v e n t i o n and a n o t h e r n u r s e measure the r e s u l t s , any p o s s i b l e b i a s c o u l d be m i n i m i z e d .  A s i m i l a r s t u d y c o u l d be e x e c u t e d b u t w i t h  t i m i n g o f the i n t e r v e n t i o n a l t e r e d .  the  Assuming t h a t the p a t i e n t and h i s  s i g n i f i c a n t o t h e r do have a c c e s s to i n f o r m a t i o n and s u p p o r t w h i l e i n the h o s p i t a l , i t m i g h t be more t h e r a p e u t i c f o r the nurse to v i s i t the p a t i e n t a l o n g w i t h h i s s i g n i f i c a n t o t h e r d u r i n g the f i r s t month a f t e r discharge.  A t t h i s time the n u r s e c o u l d a s c e r t a i n what d i f f i c u l t i e s  t h e y a r e h a v i n g and i n t e r v e n e when a p p r o p r i a t e .  Another p o s s i b l e  t e a c h a b l e moment m i g h t be d u r i n g the t h r e e month checkup i n the p a c e maker c l i n i c .  A s t u d y c o u l d be done t h a t would a t t e m p t to meet the  e d u c a t i o n a l and e m o t i o n a l  needs o f the pacemaker p a t i e n t and h i s  s i g n i f i c a n t o t h e r e i t h e r i n d i v i d u a l l y o r i n groups i n the c l i n i c s e t ting.  L a s t l y , t h e r e i s a need f o r the d e v e l o p m e n t o f a r e l i a b l e and  v a l i d range o f i n d i c a t o r s o f p r o c e s s and outcome v a r i a b l e s to measure the e f f e c t o f h e a l t h t e a c h i n g . T h i s s t u d y a l s o has i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n practice.  and  I t e m p h a s i z e s the c r i t i c a l n a t u r e o f the p a t i e n t ' s r e a d i -  ness to l e a r n and the need to f i n d the t e a c h a b l e moment.  I t demon-  128 s t r a t e s t h a t s i g n i f i c a n t o t h e r s do want t o be i n c l u d e d i n h e a l t h c o u n s e l l i n g and want t o be s u p p o r t i v e t o t h e p a t i e n t b u t t h a t t h e y a l s o need t o have a c c e s s t o a c c u r a t e and c o n s i s t e n t i n f o r m a t i o n .  The  consumer o f h e a l t h c a r e has demanded the r i g h t t o know b u t he a l s o maintains the r i g h t to refuse information.  The n u r s e must be a b l e t o  p r o v i d e t h a t knowledge when the p a t i e n t asks f o r i t .  Knowledge means  power and power i m p l i e s more c o n t r o l o v e r y o u r own s i t u a t i o n .  Patient  e d u c a t i o n i s one means o f g i v i n g power t o t h e consumer o f h e a l t h c a r e . I t i s an i n t e g r a l and unique r e s p o n s i b i l i t y o f n u r s i n g b e c a u s e n u r s i n g has t h e n e c e s s a r y knowledge and s k i l l s and most i m p o r t a n t l y , t h e p a t i e n t ' s support i n doing so.  B I B L I O G R A P H Y  129  BIBLIOGRAPHY Books A u s u b e l , D a v i d P. The P s y c h o l o g y o f M e a n i n g f u l V e r b a l L e a r n i n g . York: Grune and S t r a t t o n , 1963.  New  B o t w i n i c k , J a c k . A g i n g and B e h a v i o u r . New Y o r k : S p r i n g e r P u b l i s h i n g Co., I n c . , 1973. C a m p b e l l , D.T. and S t a n l e y , J.C. E x p e r i m e n t a l and Q u a s i - E x p e r i m e n t a l D e s i g n s f o r R e s e a r c h . C h i c a g o : Rand M c N a l l y C o l l e g e P u b l i s h i n g Co., 1963. C a t t e l l , R.B. and S c h e i e r , I.H. The Meaning and Measurement o f N e u r o t i c ism and A n x i e t y . New York: The R o n a l d P r e s s Co., 1961. C l a r k , M. and A n d e r s o n , B. C u l t u r e and A g i n g . C h a r l e s C. Thomas, 1967.  Springfield,  Illinois:  Cowdry, E.V. E d i t o r . 2nd E d i t i o n . The Care o f the G e r i a t r i c P a t i e n t . S t . L o u i s : C.V. Mosby, 1963. Dumas, R.G. " U t i l i z a t i o n o f a C o n c e p t o f S t r e s s as a B a s i s f o r N u r s i n g . " ANA C l i n i c a l S e s s i o n s , A m e r i c a n N u r s e s ' A s s o c i a t i o n , San F r a n c i s c o , 1966. New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1967. F r a n k l i n ' , B.L. P a t i e n t A n x i e t y on ^Admission t o H o s p i t a l . The W h i t e f r i a r s P r e s s L t d . , 1974.  London:  Howes, V.M. E d i t o r . Individualization- of Instruction - A Teaching S t r a t e g y . New Y o r k : The M a c m i l l a n ' C o . , 1970. H u d a k , C M . , G a l l o , B.M.» and L o h r , T. d e l p h i a : J.B. L i p p i n c o t t Co.,  C r i t i c a l Care N u r s i n g . 1973.  Phila-  130 J a n i s , I.L. P s y c h o l o g i c a l S t r e s s : P s y c h o a n a l y t i c and B e h a v i o u r a l S t u d i e s o f S u r g i c a l P a t i e n t s . New York: John W i l e y and Sons, 1958. K e r l i n g e r , F.N. F o u n d a t i o n s o f B e h a v i o u r a l R e s e a r c h . 2nd E d i t i o n . York: H o l t , R i n e h a r t and W i n s t o n I n c . , 1964. K o l s t o e , R.H. I n t r o d u c t i o n t o S t a t i s t i c s f o r the B e h a v i o u r a l R e v i s e d E d i t i o n . I l l i n o i s : The Dorsey P r e s s , 1973. Labovitz, Sanford. "Criteria for Selecting a on the S a c r e d n e s s o f .05." S t a g e s o f p o r a r y P e r s p e c t i v e s . E d i t e d by Dennis R i c h e r , Englewood C l i f f s , New J e r s e y : L a d e r , M. and M a r k s , I. C l i n i c a l Anxiety. M e d i c a l Books L t d . , 1971.  New  Sciences.  S i g n i f i c a n c e L e v e l : A Note S o c i a l Research-ContemP. F o r c e s s e and S t e p h e n P r e n t i c e - H a l l I n c . , 1970.  London: W i l l i a m Heinemann  L a z a r u s , R.S. " S t r e s s Theory and P s y c h o p h y s i o l o g i c a l R e s e a r c h . " Stress, E d i t e d by L e n n e r t , L. New York: A m e r i c a n E l s e r v e r P u b l i s h i n g Co., I n c . , 1967. Lesse, Stanley. A n x i e t y : I t s Components, Development and New York: Grune and S t r a t t o n , 1970. L e v i t t , Eugene. The P s y c h o l o g y o f A n x i e t y . M e r r i l l Co. I n c . , 1967. Maslow, A.H. M o t i v a t i o n and P e r s o n a l i t y . 1954. May,  R o l l o . The Meaning o f A n x i e t y . 1952.  Treatment.  I n d i a n a p o l i s : The Bobbs-  New Y o r k : H a r p e r and  New York: Ronald P r e s s  Bros.,  Co.,  M e l t z e r , L.E. " A n x i e t y i n C a r d i o v a s c u l a r D i s e a s e . " A n x i e t y F a c t o r s i n Comprehensive P a t i e n t Care. E d i t e d by Rees, W. L i n f o r d , E x c e r p t a Medica Amsterdam, New Y o r k : American E l s e r v e r Co., 1973.  131 M c R e y n o l d s , P a u l . "The Assessment o f A n x i e t y : A S u r v e y o f A v a i l a b l e T e c h n i q u e s . " McReynolds, P a u l , E d i t o r , Advances i n P s y c h o l o g i c a l Assessment. V o l . 1, P a l o A l t o , C a l i f o r n i a : S c i e n c e and B e h a v i o u r Books, I n c . , 1968. P a r s o n n e t , V. A S u r v e y o f C a r d i a c P a c i n g i n t h e U.S.A. a n d Canada. Cardiac Pacing: Proceedings o f the Fourth I n t e r n a t i o n a l Symposium on C a r d i a c P a c i n g . T h a l e n , H.J., E d i t o r . The N e t h e r l a n d s : Van Gorcum & Co., 1973. P e p l a u , H.E. I n t e r p e r s o n a l R e l a t i o n s i n N u r s i n g . New Y o r k : Putman's and S o n s , 1952. Redman, B.K. The P r o c e s s o f P a t i e n t T e a c h i n g i n N u r s i n g . S t . L o u i s : The C.V. Mosby Co., 1972. Rozovsky,  CP.  2nd E d i t i o n  L . E . Canadian H o s p i t a l Law. Canadian H o s p i t a l A s s o c i a t i o n : T o r o n t o , Southam Murray, 1974.  S a r a s o n , I.G. and S p i e l b e r g e r , C D . New York: John W i l e y , 1975.  S t r e s s and A n x i e t y . V o l s 1 and 2,  S i s t e r O l i v i a . "Aims o f N u r s i n g A d m i n i s t r a t i o n - 1947." C i t e d by E.L. Brown i n N u r s i n g f o r t h e F u t u r e . New Y o r k : R u s s e l l Sage F o u n d a t i o n , 1948. S k i p p e r , J.K. "Communication and t h e H o s p i t a l i z e d P a t i e n t . " S o c i a l I n t e r a c t i o n and P a t i e n t Care. E d i t e d by J.K. S k i p p e r and. R . C L e o n a r d , P h i l a d e l p h i a : J.B. L i p p i n c o t t Co., 1965. S p i e l b e r g e r , C D . E d i t o r . A n x i e t y and B e h a v i o u r . P r e s s , 1966.  New Y o r k : Academic  S p i e l b e r g e r , C D . , G o r s u c h , R., and Lushene, R.E. Manual f o r t h e S t a t e T r a i t Anxiety Inventory. Palo A l t o , C a l i f o r n i a : Consulting P s y c h o l o g i s t s P r e s s , 1970. Symonds, P e r c i v a l . The Dynamics o f Human A d j u s t m e n t . A p p l e t o n - C e n t u r y - C r o f t s I n c . , 1942.  New York:  132 T a l b e r t , E.G. and F r a s e , L.E. E d i t o r s . Individualized Instruction- A Book o f R e a d i n g s . O h i o : C h a r l e s E. M e r r i l l P u b l i s h i n g Co., 1972.  Articles A b d e l l a h , F.G. " C r i t e r i o n Measures i n N u r s i n g . " ( W i n t e r , 1961), 21-26.  Nursing Research  10  A d s e t t , C.A., and! Bruhn,,J.G. " S h o r t - t e r m Group P s y c h o t h e r a p y f o r P o s t M.I. P a t i e n t s and T h e i r Wives." Canadian M e d i c a l A s s o c i a t i o n J o u r n a l 99: 577-584. A l t , R.E.  " P a t i e n t E d u c a t i o n Program Answers Many Unanswered Q u e s t i o n s . H o s p i t a l s 40 (November 16, 1966), 76-78.  Baden, C.A. " T e a c h i n g the C o r o n a r y P a t i e n t and H i s F a m i l y . " N u r s i n g C l i n i c s o f N o r t h A m e r i c a 7 (September, 1972), 563-571. C a n e s t r a r i , R o b e r t E. "Paced and S e l f - P a c e d L e a r n i n g i n Young and Elderly Adults." J o u r n a l o f G e r o n t o l o g y 18 ( 1 9 6 3 ) , 165168. C a r n e v a l i , D.I. " P r e o p e r a t i v e A n x i e t y . " ( J u l y , 1966), 1536-1538.  American J o u r n a l o f N u r s i n g 66  C a s s i d y , J.R. and A l t r o c c h i , J . " P a t i e n t ' s Concerns About S u r g e r y . " N u r s i n g R e s e a r c h 9 ( F a l l , 1960), 219-221. C r a v e n , R.F., and Sharp, B.H. "The E f f e c t s o f I l l n e s s on F a m i l y F u n c t i o n s . " N u r s i n g Forum 11 ( 1 9 7 2 ) , 186-193. C u l b e r t , P.A. and Kos, B.A. "Aging: C o n s i d e r a t i o n s f o r Health Teaching.' N u r s i n g C l i n i c s o f N o r t h America 6 (December, 1971), 604-614. D a l z e l l , I. " E v a l u a t i o n o f a P r e n a t a l T e a c h i n g Programme." R e s e a r c h 14 ( S p r i n g , 1965), 160-163.  Nursing  133 Dodge, Joan S. " F a c t o r s R e l a t e d t o P a t i e n t ' s P e r c e p t i o n s o f T h e i r C o g n i t i v e Needs." N u r s i n g Research 18 (November - December, 1969), 502-513. D r e i f u s , L.S. and Cohen, D. " I m p l a n t e d Pacemakers - M e d i c o l e g a l c a t i o n s . " A m e r i c a n J o u r n a l o f C a r d i o l o g y 36 ( A u g u s t , 266-267.  Impli1975),  Dumas, R.G. and L e o n a r d , R.C. "The E f f e c t o f N u r s i n g on t h e I n c i d e n c e o f P o s t o p e r a t i v e V o m i t i n g . " N u r s i n g R e s e a r c h 12 ( W i n t e r , 1963), 12-15. Dunst, M.  " C a r d i a c Pacemakers." M e d i c a l C l i n i c s o f N o r t h America (November, 1973), 1515-1524.  Furman, S. "Funadmentals o f C a r d i a c P a c i n g . " 73 (1967), 261-277. Gregg, D.  "Reassurance." 174.  57  American H e a r t J o u r n a l  A m e r i c a n J o u r n a l o f N u r s i n g 5 5 ( 1 9 5 5 ) , 171-  H e a l y , K.M. "Does P r e o p e r a t i v e I n s t r u c t i o n Make A D i f f e r e n c e ? " J o u r n a l o f N u r s i n g 68 ( J a n u a r y , 1968), 62-67. H e n d e r s o n , V. "The N a t u r e o f N u r s i n g . " 64 ( A u g u s t , 1964), 62-68.  American  American Journal o f Nursing  H i n k l e , L.H. "The Concept o f S t r e s s i n B i o l o g i c a l and S o c i a l S c i e n c e s . S c i e n c e , M e d i c i n e and Man 1 ( A p r i l , 1973), 31-48. Hunn, V.  " C a r d i a c Pacemakers." ( A p r i l , 1969), 749-754.  A m e r i c a n J o u r n a l o f N u r s i n g 69:  J o h n s o n , J . E . " E f f e c t s o f S t r u c t u r i n g P a t i e n t ' s E x p e c t a t i o n s on T h e i r R e a c t i o n s t o T h r e a t e n i n g E v e n t s . " N u r s i n g R e s e a r c h 21 (NovemberDecember, 1972), 499-503.  134 Kos, B. and C u l b e r t , B. " T e a c h i n g P a t i e n t s A b o u t Pacemakers." J o u r n a l o f N u r s i n g 71 (March, 1971), 523-527. K r e u t e r , F.R. "What i s Good N u r s i n g C a r e . " 302-304.  American  Nursing Outlook 5 (1957),  Lambertsen, E.C. " N u r s i n g D e f i n i t i o n and P h i l o s o p h y P r e c e d e Goal Development." Modern H o s p i t a l 103 (September, 136.  Nursing 1964),  Lindeman, C.A. " N u r s i n g I n t e r v e n t i o n With the P r e s u r g i c a l P a t i e n t Phase 11." N u r s i n g R e s e a r c h 21 (May-June, 1972), 196-209. Lindeman, C.A. and Van Aernam, B. " N u r s i n g I n t e r v e n t i o n w i t h the P r e - S u r g i c a l P a t i e n t - The E f f e c t s o f S t r u c t u r e d and Uns t r u c t u r e d Preoperative Teaching." N u r s i n g R e s e a r c h 20 ( J u l y - A u g u s t , 1971), 319-332. Maddox, G. and E i s d o r f e r , C. Among the E l d e r l y . "  "Some C o r r e l a t e s o f A c t i v i t y and M o r a l e S o c i a l F o r c e s 40 ( 1 9 6 2 ) , 254-260.  Meyers, M.E. "The E f f e c t s o f Types o f Communication on a P a t i e n t ' s R e a c t i o n t o S t r e s s . " N u r s i n g R e s e a r c h 13 ( S p r i n g , 1964), 126-131. Mohammed, M.F.B. " P a t i e n t ' s U n d e r s t a n d i n g o f W r i t t e n H e a l t h I n f o r m a t i o n . N u r s i n g R e s e a r c h 13 ( S p r i n g , 1964), 100-108. Neuman, M.A. " I d e n t i f y i n g and M e e t i n g P a t i e n t Needs i n the S h o r t - S p a n N u r s e - P a t i e n t R e l a t i o n s h i p . " N u r s i n g Forum 2 ( 1 9 6 3 ) , 25. N i e l d , M.A. "The E f f e c t o f H e a l t h T e a c h i n g on A n x i e t y L e v e l o f P a t i e n t s With C h r o n i c O b s t r u c t i v e Lung D i s e a s e . " N u r s i n g R e s e a r c h 20 (November-December, 1971), 537-541. N o l a n , S.P., Crampton, R.S., McGuire, L.B., McGann, H o l z , H.C., and M u l l e r , W.H. "Factors Influencing Survival of Patients with Permanent Pacemakers." A n n a l s o f S u r g e r y 185 ( J a n u a r y , 1977), 122-127.  135 "Pacemaker P e o p l e " - E d i t o r i a l . Canadian M e d i c a l A s s o c i a t i o n J o u r n a l 111 (December 21, 1974), 1297-1298. P a c k a r d , R.B. and Van E s s , H. "A Comparison o f I n f o r m a l and R o l e D e l i n e a t e d P a t i e n t Teaching S i t u a t i o n s . " Nursing Research 18 ( 1 9 6 9 ) , 443-446. Palm, M.L. " R e c o g n i z i n g O p p o r t u n i t i e s f o r I n f o r m a l P a t i e n t T e a c h i n g . " N u r s i n g C l i n i c s o f N o r t h A m e r i c a 21 ( 1 9 7 2 ) , 669-678. Pender, N . J . " P a t i e n t I d e n t i f i c a t i o n o f H e a l t h I n f o r m a t i o n R e c e i v e d D u r i n g H o s p i t a l i z a t i o n . " N u r s i n g R e s e a r c h 23 (May-June, 1974), 262-267. P o h l , M.L. " T e a c h i n g A c t i v i t i e s o f t h e Nurse P r a c t i t i o n e r . " R e s e a r c h 14 ( W i n t e r , 1965), 4-11.  Nursing  P u t t , A.M. "One E x p e r i m e n t i n N u r s i n g A d u l t s w i t h P e p t i c U l c e r s . " N u r s i n g R e s e a r c h 19: 484-494. Redman, B.K. " G u i d e l i n e s f o r Q u a l i t y o f Care i n P a t i e n t E d u c a t i o n . " Canadian Nurse ( F e b r u a r y , 1975), 19-21. R e p o r t o f t h e I n t e r - S o c i e t y Commission f o r H e a r t D i s e a s e R e s o u r c e s . I m p l a n t a b l e C a r d i a c Pacemakers. C i r c u l a t i o n 50 ( O c t o b e r , 1974), A21-A35. RNABC News 8 ( J u l y , 1976), 7. R o y l e , J . " C o r o n a r y P a t i e n t s and T h e i r F a m i l i e s R e c e i v e Incomplete C a r e . " Canadian Nurse 69 ( F e b r u a r y , 1973), 21-25. S c h m i t t , F.E. and W o o l d r i d g e , P . J . " P s y c h o l o g i c a l P r e p a r a t i o n o f S u r g i c a l P a t i e n t s . " N u r s i n g R e s e a r c h 22 ( M a r c h - A p r i l , 1973) 108-116. Shock, N.W. "The P h y s i o l o g y o f A g i n g . " 1962), 100-110.  S c i e n t i f i c American  (January,  136 S t o n e , V.  " G i v e t h e O l d e r P e r s o n Time." 69 ( O c t o b e r , 1969), 2124-2129.  Sweetwood, H. " P a t i e n t s With Pacemakers." 44-52.  American J o u r n a l o f N u r s i n g  N u r s i n g 77 (March,  1977),  T a g l i a c o z z o , D.M., L u s k i n , D.B., L a s h o f , J.C. and Ima, K. "Nurse I n t e r v e n t i o n and P a t i e n t B e h a v i o u r . " American J o u r n a l o f P u b l i c H e a l t h 64 ( J u n e , 1974), 596-603. Tyzenhouse, P.S. " M y o c a r d i a l I n f a r c t i o n : I t s E f f e c t on the F a m i l y . " American J o u r n a l o f N u r s i n g 73 ( J u n e , 1973), 1012-1013. Zuckerman, M. "Development o f an A f f e c t i v e A d j e c t i v e Check L i s t f o r the Measurement o f A n x i e t y . " J o u r n a l o f C o n s u l t a n t P s y c h o l o g y 24 ( O c t o b e r , 1960), 457-462.  Unpublished Manuscripts B a i n e s , C. "An E x p e r i m e n t a l S t u d y to Compare the E f f e c t i v e n e s s o f I n d i v i d u a l and Group P r e o p e r a t i v e I n s t r u c t i o n . " U n p u b l i s h e d M a s t e r ' s T h e s i s , U n i v e r s i t y o f B r i t i s h Columbia, 1974. Goodman, G.W. "An.iExperimental S t u d y t o E v a l u a t e t h e E f f e c t o f P l a n n e d T e a c h i n g o n the S e l f - M e d i c a t i o n P r a c t i c e s o f O l d e r A m b u l a t o r y Cardiac P a t i e n t s . " Unpublished Master's T h e s i s , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1972. Kos, B. and C u l b e r t , B. "Teaching G e r i a t r i c P a t i e n t s with Implanted C a r d i a c Pacemakers." Unpublished Master's T h e s i s , Adelphi U n i v e r s i t y , 1969. O'Leary, N. "An Assessment o f P a t i e n t ' s A c t i v i t y , Knowledge and A n x i e t y a f t e r P r o s t h e t i c A o r t i c V a l v e Replacement." Unpublished M a s t e r ' s T h e s i s , U n i v e r s i t y o f T o r o n t o , 1974.  137 Power, D.M. "The E f f e c t i v e n e s s o f P l a n n e d T e a c h i n g o f Mothers w i t h C h i l d r e n T r e a t e d i n Emergency Departments." Unpublished M a s t e r s T h e s i s , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1972. S k e l t o n , J.M. "An E x p e r i m e n t a l S t u d y t o E v a l u a t e the E f f e c t i v e n e s s o f a Diabetic Teaching T o o l . " Unpublished Masters T h e s i s , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1973.  Government P u b l i c a t i o n s F i n a l R e p o r t o f t h e S p e c i a l Committee o f the Senate on A g i n g . Queen's P r i n t e r and C o n t r o l l e r o f S t a t i o n a r y , 1966.  Ottawa  V i t a l S t a t i s t i c s - Canada. 1967. Dominion Bureau o f S t a t i s t i c s , Ottawa: The Queen's P r i n t e r , 1969.  138  A P P E N D I X  A  139 CONSENT FORM - GROUP 1 (Experimental I, t h e u n d e r s i g n e d ,  Group)  agree t o p a r t i c i p a t e i n t h i s p r o j e c t and u n d e r s t a n d  that: 1.  The aim i s t o p r o v i d e p a t i e n t s and t h e i r f a m i l i e s w i t h i n f o r m a t i o n a b o u t pacemakers and t o e x p l o r e t h e i r concerns.  2.  T h e r e w i l l be 3 i n - h o s p i t a l i n t e r v i e w s , a s l i d e - t a p e programme and 2 home v i s i t s , two and f o u r weeks a f t e r discharge.  3.  I w i l l be asked t o f i l l o u t 2 q u e s t i o n n a i r e s  (maximum  20 m i n u t e s each) d u r i n g t h e f i r s t i n t e r v i e w and a t each home v i s i t . 4.  T h e r e a r e no r i s k s i n v o l v e d .  5.  A l l i n f o r m a t i o n g a t h e r e d w i l l be c o n f i d e n t i a l .  6.  I am f r e e t o withdraw from t h e p r o j e c t a t any time.  Signature o f the P a r t i c i p a n t  S i g n a t u r e o f t h e Nurse Date:  140 CONSENT FORM - GROUP 2 ( C o n t r o l Group) I, t h e u n d e r s i g n e d , a g r e e t o p a r t i c i p a t e i n t h i s p r o j e c t a n d u n d e r s t a n d that: 1.  The a i m i s t o d e t e r m i n e t h e need f o r a t e a c h i n g programme f o r p a t i e n t s w i t h permanent pacemakers a n d t h e i r f a m i l i e s .  2.  I w i l l be a s k e d t o f i l l o u t 2 q u e s t i o n n a i r e s w h i l e i n t h e h o s p i t a l , each q u e s t i o n n a i r e l a s t i n g about 20 m i n u t e s .  3.  T h e r e w i l l be two home v i s i t s (two and f o u r weeks a f t e r d i s c h a r g e ) a t which time I w i l l be a s k e d t o f i l l o u t 2 q u e s t i o n n a i r e s ( t a k i n g n o t more than 20 m i n u t e s each t o do).  4.  T h e r e a r e no r i s k s i n v o l v e d .  5.  A l l i n f o r m a t i o n g a t h e r e d w i l l be c o n f i d e n t i a l .  6.  I am f r e e t o withdraw f r o m t h e p r o j e c t a t any t i m e .  Signature o f the P a r t i c i p a n t  S i g n a t u r e o f t h e Nurse Date:  141  A P P E N D I X  B  SCRIPT AND STORYBOARD FOR THE SLIDE-TAPE W r i t t e n by: V a l e r i e J . Shannon,  PROGRAMME  B.Sc.N.  P r o d u c e d by: S t u a r t C r y e r and J e a n P e d l a r  PART 1 YOUR HEART HAS NINE LIVES t-tusic:  "Rainbows A l l O v e r Y o u r B l u e s " W r i t t e n and P e r f o r m e d by J o h n B. S e b a s t i a n  Lyrics:  " I ' v e been w a i t i n g my t i m e , Just to talk to you.  You've been l o o k i n a l l down a t t h e mouth  And down a t y o u r shoes  Well baby, I've come t o g i v e y o u the news, I ' l l p a i n t rainbows a l l o v e r your blues."  "Come on, C h a r l i e . can do i t . " {Shouted by a crowd)  You  {Female voice) " C h a r l i e j u s t i s n ' t h i m s e l f these d a y s . Look, he i s even having trouble l i f t i n g a bowling ball."  (Charlie  to the  Doctor)  " I t a l l s t a r t e d a c o u p l e o f weeks ago. I j u s t f e l t t i r e d , weak and f o r the f i r s t t i m e i n my l i f e I f a i n t e d . And the f u n n i e s t t h i n g was, I t h i n k I even f e l t my h e a r t s k i p p i n g b e a t s ! " {The Doctor) " W e l l , I t h i n k t h a t I can h e l p you C h a r l i e . From the symptoms t h a t you d e s c r i b e and y o u r c a r d i o g r a m , I can see t h a t you have a c o n d i t i o n known as h e a r t b l o c k . A c a r d i a c p a c e maker i s the answer f o r y o u r p r o b l e m . "  So you a r e a b o u t to become the owner o f a h e a r t pacemaker.  Your d o c t o r and n u r s e want you to know why you need t h i s pacemaker and what y o u r f u t u r e r e s p o n s i b i l i t i e s w i l l be.  F i r s t , l e t ' s l o o k a t the h e a r t , what i t d o e s , and how i t does i t .  The h e a r t i s a pump made o f v e r y s t r o n g muscle. I t pumps b l o o d t h r o u g h o u t y o u r body b r i n g i n g oxygen and f o o d t o a l l p a r t s o f y o u r body.  To do i t s ' work, y o u r h e a r t m u s c l e uses e l e c t r i c a l i m p u l s e s p r o d u c e d by a s p e c i a l c e n t e r c a l l e d t h e n a t u r a l pacemaker.  From t h i s n a t u r a l pacemaker, i m p u l s e s t r a v e l down a c e r t a i n path a l o n g t h e muscle w a l l s c a u s i n g the h e a r t to c o n t r a c t a n d t o pump b l o o d .  145  E v e r y b o d y has a n a t u r a l pacemaker  However, some h e a r t s d o n ' t b e a t i n a h e a l t h y way. For v a r i o u s r e a s o n s , s o m e t h i n g happens t o p r e v e n t the e l e c t r i c a l i m p u l s e s from t r a v e l l i n g t h r o u g h the h e a r t a l o n g t h e u s u a l pathways. The n a t u r a l pacemaker d o e s n ' t work as w e l l as i t once did.  Because o f t h i s , y o u r h e a r t may pump too q u i c k l y . . . .  Too s l o w l y .  Irregularly.  T h i s c a u s e s the o t h e r p a r t s o f y o u r body t o be d e p r i v e d o f the f o o d and osygen t h a t t h e y need i n o r d e r t o do their job.  M e d i c a l s c i e n c e has f o u n d the answer to t h i s p r o b l e m .  §  < Bi.ocx.B3  The answer i s t o p l a c e an a r t i f i c i a l pacemaker i n s i d e y o u r body.  The a r t i f i c i a l pacemaker works i n much the same way as y o u r n a t u r a l pacemaker once d i d . The a r t i f i c i a l pacemaker i s a SMALL d e v i c e t h a t uses e l e c t r i c a l c h a r g e s to s t i m u l a t e y o u r h e a r t .  These charges,  WHICH YOU CANNOT FEEL,  help your h e a r t beat a t a h e a l t h y and steady rate.  Your new pacemaker has t h r e e i m p o r t a n t parts: The b a t t e r y , w h i c h s u p p l i e s t h e e l e c t r i c a l impulses The l e a d ; which i s a t i n y w i r e c o n n e c t i n g the b a t t e r y t o y o u r h e a r t The e l e c t r o d e ; w h i c h d e l i v e r s t h e e l e c t r i c a l charges t o the heart  A l l t h r e e o f t h e s e i t e m s make up y o u r a r t i f i c i a l pacemaker and h e l p y o u r h e a r t pump a l m o s t a s w e l l a s i t once did.  You must remember t h o u g h , t h i s new pacemaker d o e s n ' t change y o u r u n d e r l y i n g heart trouble.  147 In the n e x t p a r t o f t h i s s e r i e s , we w i l l t a l k a b o u t the p r o c e d u r e f o r h a v i n g an a r t i f i c i a l pacemaker i n s e r t e d .  I f you have any q u e s t i o n s a b o u t WHY you need an a r t i f i c i a l pacemaker, ASK y o u r nurse o r d o c t o r . Meanwhile back a t t h e b o w l i n g a l l e y . C h a r l i e i s home from the h o s p i t a l and back to h i s u s u a l l e i s u r e time activities.  His team i s r e a l l y c o u n t i n g on him to bowl a good game. C h a r l i e , t r u e to form d o e s n ' t d i s a p p o i n t them.  You would be s u r p r i s e d who has a pacemaker t o d a y .  Music: "Rainbows A l l Over Your B l u e s " Lyrics:  "Ah, g i v e up i s a l l you've got t o s a y ,  really  I t ' s time t o f i n d a new l i f e s t y l e , Cuz t h i s r e a l l y a i n ' t the way. L e t ' s go f o r a r i d e on my t r a m p o l i n e , I can show you the p r e t t i e s t mountain t h a t you've e v e r seen  You b e t t e r r u s h to y o u r c l o s e t , And f i s h o u t y o u r b l u e suede s h o e s , I ' l l p a i n t rainbows a l l o v e r y o u r blues'!  PART 2 LIVING WITH YOUR PACEMAKER  Instrumental  Music:  " C e l e b r a t i o n F o r A Grey Day"  Written and Performed by:  First  Richard Farina  Voice:  "When I f i r s t g o t my pacemaker, o r b e f o r e t h a t I s h o u l d s a y , I was a s t r o n g , h a r d w o r k i n g man. And a f t e r I g o t t h e pacemaker n a t u r a l l y I wasn't a b l e to work a n d t h a t s e t me back and I f e l t b a d a b o u t i t . B u t now I c a n s e e t h e l i g h t and w i t h t h e pacemaker, o r I s h o u l d s a y , w i t h o u t t h e pacemaker, I w o u l d n ' t be a l i v e t o d a y . " Second Voice:  " W e l l , a c t u a l l y , I d o n ' t t h i n k o f i t anymore . . . I know i t i s t h e r e and i t ' s a good t h i n g t o have there too."  Third  Voice:  "I o r d e r e d pacemakers f o r o t h e r p e o p l e and hoped t h a t I ' d n e v e r have t o have one m y s e l f . '  Interviewer:  "And now t h a t y o u have one do y o u s t i l l f e e l way a b o u t a pacemaker." Third  that  Voice:  "No, I d o n ' t f e e l t h a t way now. I t h i n k t h a t i t s done a l o t o f good. . . . I'm aware t h a t I have my pacemaker, o f c o u r s e . I d o n ' t weigh v e r y much, so i t ' s heavy and t h e s t r a p s b o t h e r i t o r any heavy c l o t h i n g wi11." Fourth  Voice:  " W e l l , I n e v e r knew t h a t I had i t . As a m a t t e r o f f a c t , I n e v e r t h i n k o f t h e pacemaker and I d o n ' t know t h a t I have i t w i t h o u t s o m e t h i n g c a l l my a t t e n t i o n t o i t . . . . H a v i n g a pacemaker as f a r as I'm c o n c e r n e d , i s no worse t h a n h a v i n g a t o o t h pulled."  When y o u go home from t h e h o s p i t a l , y o u w i l l p r o b a b l y be a b l e t o l e a d a normal l i f e l i k e any o t h e r p e r s o n o f y o u r age. W i t h t h e h e l p o f t h e a r t i f i c i a l pacemaker, y o u r h e a r t s h o u l d pump as r e g u l a r l y as i t once d i d . A pacemaker, l i k e any o t h e r m e c h a n i c a l d e v i c e , needs t o be c a r e d f o r a n t t h e f o l l o w i n g i n f o r m a t i o n p l u s y o u r common sense w i l l h e l p y o u l o o k a f t e r y o u r s e l f and y o u r h e a l t h .  N a t u r a l l y y o u s h o u l d a s k y o u r d o c t o r about what a c t i v i t i e s y o u c a n now do b u t g e n e r a l l y most p e o p l e w i t h pacemakers c a n :  - Bath and shower. Y o u r pacemaker i s comp l e t e l y protected against contact with water.  -Take p a r t i n moderate r e c r e a t i o n and e x e r c i s e such as w a l k i n g , d a n c i n g , swimming, g a r d e n i n g , lawn mowing, f i s h i n g , w a t c h i n g TV, d o i n g h o u s e h o l d c h o r e s o r any o t h e r hobby t h a t y o u have.  - Resume s e x u a l  activity.  - Go back t o work.  - T r a v e l by p l a n e , t r a i n , b o a t , and even d r i v e y o u r own c a r .  The r i g h t amount o f a c t i v i t y s h o u l d make you f e e l b e t t e r n o t worse.  As f a r as c l o t h i n g i s c o n c e r n e d , c h o o s e garments t h a t f i t w e l l and do n o t p u t much p r e s s u r e on t h e s k i n o v e r y o u r p a c e maker b a t t e r y .  The women w i l l f i n d t h a t a w e l l f i t t i n g b r a , w i t h p a d d i n g under t h e s t r a p on t h e s i d e o f t h e pacemaker b a t t e r y , w i l l p r o v i d e c o m f o r t and s u p p o r t .  Most e l e c t r i c a l d e v i c e s a r e s a f e and w i l l not i n t e r r u p t t h e w o r k i n g o f y o u r pacemaker.  A few words o f c a u t i o n though:  O n l y use e l e c t r i c a l d e v i c e s t h a t a r e i n good r e p a i r and p r o p e r l y g r o u n d e d . Never use an e l e c t r i c a l i t e m i n damp o r wet a r e a s .  S p e c i f i c a l l y . . . i f y o u use an e l e c t r i c r a z o r , do n o t use i t r i g h t o v e r t h e a r e a where y o u r b a t t e r y i s p l a c e d .  I f y o u have a microwave o v e n , s t a n d a t l e a s t three f e e t from i t .  Y o u r pacemaker w i l l t r i g g e r a i r p o r t s c r e e n i n g d e v i c e s b e c a u s e o f t h e metal i n i t , so before going through the s c r e e n e r , t e l l the a i r p o r t p e r s o n n e l t h a t y o u have a pacemaker. I f y o u a r e w o r k i n g on t h e e n g i n e o f y o u r car, turn o f f the i g n i t i o n . I f you don't, the e n g i n e may i n t e r f e r e w i t h y o u r pacemaker.  Remember, most e l e c t r i c a l d e v i c e s won't i n t e r f e r e w i t h t h e w o r k i n g o f y o u r pacemaker. Y o u r pacemaker i s s a f e and r e l i a b l e .  I f a d e v i c e does i n t e r f e r e , how w i l l y o u know? You w i l l f e e l weak, d i z z y o r l i g h t - h e a d e d . The s o l u t i o n i s s i m p l e . Move away from the d e v i c e . Get the d e v i c e f i x e d . It i s important f o r you to t e l l other d o c t o r s , y o u r d e n t i s t and p h y s i o t h e r a p i s t t h a t y o u have a pacemaker. They m i g h t be u s i n g equipment t h a t c o u l d i n t e r f e r e w i t h y o u r pacemaker.  You c a n and s h o u l d c a r r y w i t h y o u a t a l l times an i n d e n t i f i c a t i o n c a r d o r a medic a l e r t b r a c e l e t saying that you are the owner o f a pacemaker. A c a r d w i l l be given to you before you leave the hospital. As m e n t i o n e d i n P a r t 1, t h e new pacemaker d o e s n ' t change y o u r u n d e r l y i n g h e a r t p r o b l e m so i t i s n e c e s s a r y t h a t y o u c o n t i n u e t o t a k e t h e m e d i c a t i o n s and t h e d i e t t h a t y o u r d o c t o r may have p r e s c r i b e d f o r y o u .  T h e r e a r e ways t h a t you can d e t e r m i n e i f y o u r pacemaker i s w o r k i n g w e l l .  D a i l y p u l s e t a k i n g i s one o f them.  Your pacemaker i s s e t a t a c e r t a i n r a t e . ASK y o u r d o c t o r what y o u r r a t e i s . I t w i l l p r o b a b l y be w r i t t e n on y o u r i d e n t i f i c a t i o n card also. Y o u r own p u l s e s h o u l d n e v e r be more t h a n 5 b e a t s below the r a t e y o u r pacemaker is set at. To t a k e y o u r p u l s e , l i g h t l y f e e l t h e o u t e r p a r t o f y o u r w r i s t j u s t down f r o m y o u r thumb u s i n g the f i r s t two f i n g e r s o f y o u r o p p o s i t e hand.  Count t h e number o f b e a t s you f e e l in s i x t y seconds. That i s your pulse rate.  W r i t e on a c a l e n d a r o r d i a r y y o u r p u l s e r a t e each day. Take y o u r p u l s e a t t h e same time each day, p r e f e r a b l y a f t e r you have been r e s t i n g . Y o u r d o c t o r w i l l f i n d i t h e l p f u l t o know what y o u r p u l s e i s . I t i s normal f o r y o u r p u l s e t o v a r y s l i g h t l y from day to day and o f c o u r s e y o u r p u l s e w i l l go up when y o u e x e r c i s e .  P u l s e t a k i n g i s a way you can t e l l i f y o u r pacemaker i s w o r k i n g p r o p e r l y . I f y o u r p u l s e r a t e s l o w s down more t h a n 5 b e a t s per m i n u t e , check y o u r p u l s e a s e c o n d t i m e . I f i t remains a t t h i s l o w e r r a t e , CALL YOUR DOCTOR IMMEDIATELY.  A n o t h e r way y o u w i l l know i f y o u r pacemaker i s n o t w o r k i n g w e l l i s t o watch f o r any o f t h e s e symptoms: DIZZINESS CHORTNESS OF BREATH CHEST PAIN PROLONGED HICCOUGHS MUSCLE TWITCHING A g a i n , c h e c k y o u r p u l s e and C a l l Your Doctor.  A l t h o u g h t h i s happens r a r e l y , i f you have a fever, along with redness, s w e l l i n g or d r a i n a g e a l o n g the s c a r where y o u r p a c e maker b a t t e r y i s . . . . C a l l Your D o c t o r because you p r o b a b l y have an i n f e c t i o n .  L a s t l y , a s m a l l machine c a l l e d a SCREENER can be p u r c h a s e d f r o m y o u r d o c t o r . T h i s d e v i c e sends an e l e c t r i c a l p i c t u r e o f y o u r h e a r t v i a y o u r t e l e p h o n e a t home t o t h e C o r o n a r y U n i t a t y o u r l o c a l h o s p i t a l . Not a l l p a t i e n t s need one b u t you might l i k e t o discuss this with your doctor. Your b a t t e r y has been d e s i g n e d t o work f o r a c e r t a i n number o f y e a r s and then i t w i l l have to be changed. Your d o c t o r w i l l t e l l y o u how l o n g y o u r b a t t e r y w i l l be e x p e c t e d t o l a s t .  Y o u r b a t t e r y wears down s l o w l y and r a r e 1 y does i t f a i l s u d d e n l y .  For t h i s r e a s o n , y o u r d o c t o r w i l l want t o see y o u r e g u l a r l y . The d o c t o r a n d y o u w i l l be c o n t i n u o u s l y c h e c k i n g y o u r pacemaker and d e c i d i n g when t h e b a t t e r y needs t o be changed. Your d o c t o r w i l l a l s o be l o o k i n g a t t h e d i e t a n d drugs y o u may be t a k i n g t o see how w e l l t h e y a r e w o r k i n g . The pacemaker b a t t e r y r e p l a c e m e n t p r o c e d u r e , w h i c h i s done BEFORE t h e b a t t e r y wears o u t , i s a SIMPLE one. You w i l l a g a i n come i n t o the h o s p i t a l and be p u t t o s l e e p w h i l e a new pacemaker system i s p u t i n t o y o u r h e a r t .  B o o k l e t s a r e a v a i l a b l e w i t h much o f t h i s i n f o r m a t i o n i n them. Ask y o u r n u r s e f o r one.  I'm s u r e t h a t y o u have many q u e s t i o n s . J o t them down and have a t a l k w i t h y o u r doctor o r nurse.  Instrumental Music {same as opening)  Fifth  Voice:  " I ' v e had mine i n two y e a r s , July 6th."  Interviewer:  "Have y o u had a n y p r o b l e m s w i t h y o u r pacemaker?"  Fifth  Voice:  "No problems w h a t s o e v e r . "  First  Voice:  Third  Voice:  "I t a k e a g r e a t i n t e r e s t i n b o w l i n g and we bowl t w i c e a week and . . . I have a n e i g h b o u r w h i c h has a pool room and we go p l a y i n g pool . . . and we go p l a y i n g w h i s t w i t h t h e S e n i o r C i t i z e n s . . . . Oh, we're k e p t p r e t t y busy."  " A t f i r s t h a v i n g a pacemaker made me n e r vous b u t I have been on a p l a n e and I have been on a M e x i c a n c r u i s e and d i d v e r y well."  Interviewer:  "Have y o u been a b l e t o t r a v e l ? " Fifth  Voice:  "Oh y e s . . . d r i v e my c a r . . . no r e s t r i c t i o n s w h a t s o e v e r . In f a c t , I am g o i n g away on A p r i l 2 3 r d on a t r i p . . . W e l l , I m i g h t as w e l l do i t w h i l e my b a t t e r i e s a r e good."  "I c a n d i g h o l e s f o r f e n c e p o s t s and c a r r y on my normal t h i n g y o u know, b u t I do g e t s h o r t o f b r e a t h j u s t once i n a w h i l e . . . when I o v e r do i t . O t h e r w i s e , you've g o t t o pace y o u r s e l f t o i t y o u know."  Second Voice:  "The o n l y a d v i c e I c o u l d g i v e t o someone e l s e from my own e x p e r i e n c e i s n o t t o be a f r a i d o f a pacemaker b e c a u s e i t i s a w o n d e r f u l t h i n g and i t h e l p s y o u a n d . . . w e l l , what more c a n I s a y . "  Fifth  Voice:  " H o n e s t l y , i t ' s w o n d e r f u l y o u know, t o have i t t h e r e . I t seems t o g i v e y o u a l o t more s e c u r i t y . I think t h a t I might n o t be here today i f I d i d n ' t have i t  158  A P P E N D I X  C  159 ACTIVITY INTERVIEW SCHEDULE A c t i v i t y Check L i s t (Check t h e A p p r o p r i a t e  Activity  Response)  Frequency Reg. Occ. N e v e r  Reasons f o r (-) Response No No Need I n t e r e s t U n a b l e  dress o n e s e l f feed o n e s e l f use t h e t o i l e t a l o n e bath shower climb s t a i r s walk 1 b l o c k walk 5 b l o c k s walk 1 m i l e resume s e x vacuum dust wash d i s h e s wash c l o t h i n g by hand w a s h i n g c l o t h i n g by machine wash f l o o r s / w a l l s cook garden mow t h e lawn do m i n o r house r e p a i r s use a l l e l e c t r i c a l appliances g r o c e r y shop drive a car t a k e a bus take a p l a n e  i  Afraid  160  A c t i v i t y Check L i s t ( c o n t i n u e d ) A c t i vi t y  Frequency Reg. Occ. N e v e r  Reasons f o r (-) No Need  Interest  Response  Unable  take a boat take a t r a i n v i s i t with friends going to church p l a y i n g bingo play cards w a t c h TV l i s t e n to r a d i o bowl recreational swimming attend Senior Ci t i zens r e t u r n to p r e v i o u s job r e t u r n to l i g h t e r work t a k e own  pulse  hobbies ( l i s t them) other  Were/are y o u s a t i s f i e d w i t h y o u r l e v e l o f a c t i v i t y ?  Yes  No  Afraid  161 A c t i v i t y Interview Schedule Has y o u r o v e r a l l l e v e l o f a c t i v i t y changed s i n c e y o u r pacemaker was inserted? Yes No In what way?  More  Less  Have y o u had t o g i v e up any a c t i v i t i e s t h a t were i m p o r t a n t t o y o u s i n c e y o u r pacemaker was i n s e r t e d ?  Why?  Too i l l (own d e c i s i o n ) Doctor's advice Afraid Other  What was y o u r r e s p o n s e t o m i l d e x e r c i s e ? vacumning t h e house) (a) Shortness o f b r e a t h - severe  (e.g., walking several blocks, '  mild slight (b) D i z z y (c) T i r e d (d) F e l t f i n e Can t h e p a t i e n t ( o r h i s / h e r s i g n i f i c a n t o t h e r ) d e m o n s t r a t e p u l s e t a k i n g ? Yes No What r a t e i s y o u r pacemaker s e t a t ? Have y o u a pacemaker i d e n t i f i c a t i o n c a r d ?  Yes  No  Where do y o u keep i t ? May I s e e i t ? Have y o u c a l l e d y o u r d o c t o r s i n c e y o u were d i s c h a r g e d ? Why?  Yes  No  162 A c t i v i t y Interview Schedule  (continued)  Have y o u had any s h o r t n e s s o f b r e a t h ? Chest pain? Wound d r a i n a g e ? What d i d y o u do? c a l l e d the doctor rested nothing other  S.O.B.  Chest Pain  A r e y o u t a k i n g any m e d i c a t i o n s ?  Yes  Wound D r a i n a g e  No  Which ones and why?  A r e y o u f o l l o w i n g any t y p e o f d i e t ? What i s y o u r w e i g h t ? discharge  d o n ' t Know  no s c a l e s  lower than a t  h i g h e r than d i s c h a r g e  D i d y o u r e c e i v e a b o o k l e t a b o u t y o u r pacemaker? Have y o u r e a d i t ? Yes No time No i n t e r e s t Don't know Other Was i t h e l p f u l ? Yes  No  Yes  No  ___  I f no, why?  No  In what way D i d y o u r s i g n i f i c a n t o t h e r r e a d i t ? Yes I f no, why?  No t i m e  No  No i n t e r e s t _  Don't know  Other  How does i t f e e l t o have a pacemaker?  Have y o u many f r i e n d s , r e l a t i v e s , e t c . t h a t y o u a r e c l o s e t o ? Yes How o f t e n do y o u s e e them?  Occ.  Never  QD  No  163 i  A c t i v i t y Interview Schedule  (continued)  Do y o u e n j o y o u t i n g s w i t h o t h e r s ?  Yes  No  Do y o u have someone w i t h whom y o u c a n d i s c u s s y o u r Yes No  problems?  A r e y o u happy w i t h y o u r way o f l i f e a t t h e moment? Yes No How w o u l d y o u d e s c r i b e y o u r m o r a l e ( s p i r i t s ) a t t h e moment? ( e . g . , l o w , f a i r , good, h i g h , e t c )  164  A P P E N D I X  D  PATIENT DATA SHEET Name:  U n i t  Address:  N o ;  •  Phone:  Age:  Place o f B i r t h :  Marital Status: I f widowed, s e p a r a t e d , d i v o r c e d , when L i v e s w i t h (1) s p o u s e  (2) r e l a t i v e s  (3) a l o n e  (4) o t h e r  Years o f s c h o o l i n g : Occupation: When d i d he/she become unemployed  Employed now? retire  I f r e t i r e d , was i t a f o r c e d o r v o l u n t a r y d e c i s i o n ?  Date o f A d m i s s i o n : Discharge: PACEMAKER i m p l a n a t i o n : Doctor: ( i n - h o s p i t a l ) Surgeon: Diagnosis:  Previous medical h i s t o r y :  Number o f h o s p i t a l i z a t i o n s : Type o f Pacemaker i n s e r t e d : Rate:  (family)  166 i  A P P E N D I X  E  KNOWLEDGE BASE QUESTIONNAIRE Initials: INSTRUCTIONS:  1.  C i r c l e t h e l e t t e r t h a t b e s t answers t h e q u e s t i o n o r statement.  The main p u r p o s e o f t h e h e a r t i s : (a) t o pump b l o o d t h r o u g h o u t y o u r body (b) t o make y o u r p u l s e r e g u l a r (c) t o make y o u f e e l good  2.  The h e a r t has a n a t u r a l pacemaker w h i c h makes i t b e a t r e g u l a r l y . (a) T r u e (b) F a l s e  3.  I f p a r t o f y o u r h e a r t becomes damaged, y o u r h e a r t may n o t b e a t regularly. (a) T r u e (b) F a l s e  4.  An a r t i f i c i a l pacemaker c u r e s a l l h e a r t damage. (a) T r u e (b) F a l s e  5.  The a r t i f i c i a l pacemaker i s a s m a l l d e v i c e t h a t uses e l e c t r i c a l c h a r g e s t o make y o u r h e a r t b e a t r e g u l a r l y . (a) T r u e (b) F a l s e  6.  When y o u r pacemaker i s w o r k i n g p r o p e r l y , (a) y o u w i l l h i c c o u g h (b) y o u w i l l f e e l d i z z y (c) y o u won't f e e l a n y t h i n g  7.  B a t h i n g , s h o w e r i n g and swimming w i l l a f f e c t y o u r pacemaker. (a) T r u e (b) F a l s e  168 8.  S h o u l d y o u r i n c i s i o n become r e d , s o r e o r d r a i n any l i q u i d : (a) i g n o r e i t , i t w i l l d i s a p p e a r g r a d u a l l y (b) c a l l y o u r d o c t o r i m m e d i a t e l y , i t may be i n f e c t e d (c) take your pulse  9.  When y o u have an a r t i f i c i a l pacemaker, y o u won't need t o v i s i t your doctor regularly. (a) T r u e (b) F a l s e  10.  Which a c t i v i t y m i g h t i n t e r f e r e w i t h y o u r pacemaker? (a) s h o p p i n g i n an a p p l i a n c e s t o r e (b) p l a y i n g an e l e c t r i c o r g a n ( c ) l e a n i n g under t h e hood o f y o u r c a r when t h e e n g i n e i s running  11.  Most e l e c t r i c a l d e v i c e s a r e s a f e f o r y o u t o u s e . (a) T r u e (b) F a l s e  12.  E x e r c i s i n g r e g u l a r l y w i l l make y o u f e e l  worse.  (a) T r u e (b) F a l s e 13.  P r o l o n g e d h i c c o u g h s a r e a s i g n t h a t y o u r pacemaker i s n o t w o r k i n g properly. (a) T r u e (b) F a l s e  14.. Why do y o u t a k e y o u r p u l s e each day? (a) t o s t a y i n p r a c t i c e (b) t o make t h e pacemaker work ( c ) t o know t h a t y o u r h e a r t i s b e a t i n g a t o r above t h e r a t e s e t on y o u r pacemaker  169  15.  What would y o u do i f y o u s u s p e c t e d t h a t y o u r pacemaker was n o t working properly? (a) c a l l t h e d o c t o r immediately (b) c a l l t h e d o c t o r tomorrow a f t e r y o u have had a good n i g h t ' s sleep (c) go t o y o u r f r i e n d ' s house anyway  16.  The a r t i f i c i a l pacemaker runs on b a t t e r i e s . (a) T r u e (b) F a l s e  17.  These b a t t e r i e s a r e d e s i g n e d t o l a s t f o r e v e r . (a) T r u e (b) F a l s e  18.  You s h o u l d c a r r y a pacemaker i d e n t i f i c a t i o n c a r d o r medic bracelet.  alert  (a) o n l y when y o u go t o t h e d o c t o r (b) a t a l l t i m e s (c) n e v e r , i t d o e n s ' t r e a l l y m a t t e r 19.  You have j u s t You f e e l y o u r (Pretend that a f t e r running  r u n up a f l i g h t o f s t a i r s t o answer y o u r phone. h e a r t r a c i n g and d e c i d e t o t a k e y o u r p u l s e . y o u r pacemaker r a t e i s 7 0 ) . Your p u l s e r a t e , up t h e s t a i r s , i s 90. What does t h i s mean?  ( a ) y o u r pacemaker (b) y o u r own h e a r t upstairs--this (c) y o u s h o u l d c a l l 20.  i s n ' t working p r o p e r l y i s b e a t i n g f a s t b e c a u s e y o u have r u n i s normal your doctor  T r a v e l i n c a r s and a i r p l a n e s i s n o t recommended when y o u have a pacemaker. (a) T r u e (b) F a l s e  170  21.  When y o u v i s i t any d o c t o r , d e n t i s t , o r p h y s i o t h e r a p i s t , i t i s i m p o r t a n t t o t e l l them t h a t y o u have a pacemaker. (a) T r u e (b) F a l s e  22.  Most p e o p l e w i t h pacemakers l e a d f u l l , normal and s a f e l i v e s . (a) T r u e (b) F a l s e  171  A P P E N D I X  F  SELF-EVALUATION QUESTIONNAIRE  Developed by C. D. Spielberger, R. L. Gorsuch and R. Lushene  172  STAI FORM X-1  NAME  DATE  DIRECTIONS: A number of statements which people have used to describe themselves are given below. Read each statement and then blacken in the appropriate circle to the right of the statement to indicate how you feel right now, that is, at this moment. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe your present feelings best. 1. I feel calm  o > > P -  ©  ®  ®  ©  ©  ®  ©  ®  ©  ®  ®  ®  ©  ©  ®  ®  ©  ©  ®  ®  6. I feel upset  ©  ®  ®  ®  7. I am presently worrying over possible misfortunes  ©  ®  ®  ©  8. I feel rested  ©  ©  ©  ©  9. I feel anxious  ©  ©  ®  ©  10. I feel comfortable  ©  ©  ®  ©  11. I feel self-confident  ©  ®  ®  ® ,  12. I feel nervous  ©  ®  ®  ©  13. I am jittery  ©  ®  ®  ©  14. I feel "high strung"  ©  ©  ©  ©  15. I am relaxed  ©  ®  ®  ©  16. I feel content  ©  ®  ®  ©  17. I am worried  ©  ©  ©  ©  18. I feel over-excited and "rattled"  ©  ©  ©  ©  19. I feel joyful  ©  ®  ®  ©  20. I feel pleasant  ©  ©  ©  ©  2. I feel secure  -  3. I am tense  -  4. I am regretful 5. I feel at ease  -•—  CONSULTING PSYCHOLOGISTS PRESS 577 College Avenue, Palo Alto, California 94306  R e p r i n t e d by S p e c i a l p e r m i s s i o n f r o m t h e Consulting Psychologists Press  SELF-EVALUATION QUESTIONNAIRE STAI FORM X-2  NAME  :  173 DATE  DIRECTIONS: A number of statements which people have used to describe themselves are given below. Read each statement and then blacken in the appropriate circle to the right of the statement to indicate how you generally feel. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe how you generally feel.  > S  o cn  > r v  o cn  cn O  -J  H  >  PJ  PJ  w  z  >  21. I feel pleasant  ©  ®  ©  ©  22. I tire quickly  ©  ©  ©  ©  23. I feel like crying  ©  ©  ©  ©  24. I wish I could be as happy as others seem to be  ©  ©  ©  ©  25. I am losing out on things because I can't make up my mind soon enough ....  ©  ®  ©  ©  26. I feel rested  ©  ®  ©  ©  27. I am "calm, cool, and collected"  ©  ©  ©  ©  28. I feel that difficulties are piling up so that I cannot overcome them  ©  ©  ©  ©  29. I worry too much over something that really doesn't matter  ©  ©  ©  ©  30. I am happy  ©  ©  ©  ©  31. I am inclined to take things hard  ©  ®  ©  ©  32. I lack self-confidence  ©  ©  ©  ©  33. I feel secure  ©  ©  ©  ©  34. I try to avoid facing a crisis or difficulty  ©  ®  ©  ©  35. I feel blue  ©  ®  ©  ©  36. I am content  ©  ®  ©  ©  37. Some unimportant thought runs through my mind and bothers me  ©  ©  ©  ©  38. I take disappointments so keenly that I can't put them out of my mind ....  ©  ®  ©  ©  39. I am a steady person  ©  ©  ©  ©  ©  ©  ©  ©  40. I get in a state of tension or turmoil as I think over my recent concerns and  Copyright © 1968 by Charles D. Spielberger. Reproduction of this test or any portion thereof by any process without written permission of the Publisher is prohibited.  

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