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Effect of planned patient teaching and psychological support on the adaptation of the elderly patient.. 1977

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THE EFFECT OF PLANNED PATIENT TEACHING AND PSYCHOLOGICAL SUPPORT 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 i n The F a c u l t y o f Graduate S t u d i e s S c h o o l o f N u r s i n g 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 the r e q u i r e d s t a n d a r d 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 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 degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree 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 r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t p u b l i c a t i o n , i n p a r t o r i n whole, 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 f i n a n c i a l 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 p e r m i s s i o n . 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 Columbia, Vancouver, Canada V6T 1W5 i i ABSTRACT 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 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 purpose was to 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 adapt 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 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. Each s u b j e c t was asked 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 members o f the e x p e r i m e n t a l 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 the nurse i n v e s t i g a t o r on o r c l o s e t o 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 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 the o p p o r t u n i t y to e x p r e s s t h e i r c o n c e r n s and, t h e y were shown a 15 minute s l i d e - t a p e programme about pacemakers. 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 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 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 from the company s u p p l y i n g t h e i r s p e c i f i c type o f pacemaker. The hypotheses 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 i n c r e a s e 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 o t h e r . 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 d e c r e a s e 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 s i g n i f i c a n t o t h e r . 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 monstrate p u l s e t a k i n g . 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 m a i n t a i n 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 v e s t a t e . A t a p p r o x i m a t e l y two and f o u r weeks a f t e r d i s c h a r g e from the 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 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 base, 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 ; whereas, o n l y knowledge base, 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 o t h e r s . 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 groups on any o f t h e s e v a r i a b l e s . Some m e t h o d o l o g i c a l problems and c l i n 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 d i s c u s s e d . i v TABLE OF CONTENTS Chapter Page ABSTRACT i i LIST OF TABLES i x LIST OF FIGURES . . x i ACKNOWLEDGEMENTS x i i I. OVERVIEW OF THE STUDY 1 INTRODUCTION 1 THE PROBLEM 2 Statement 2 S i g n i f i c a n c e . 3 DESCRIPTION OF THE STUDY . . . . . . . . . . . . . . 6 Purpose . 6 Hypotheses 6 V a r i a b l e s 7 R a t i o n a l e f o r the C h o i c e o f Dependent V a r i a b l e s . 8 D e f i n i t i o n o f Terms . 10 Assumptions 12 Methodology 12 L i m i t a t i o n s 13 SUMMARY 15 C h a p t e r v Page I I . LITERATURE REVIEW 16 IMPLANTED CARDIAC PACEMAKERS .. 16 H i s t o r i c a l Development 16 Types 19 I n d i c a t i o n s . . . . . 20 C o m p l i c a t i o n s . 20 Follow-Up Care 22 C u r r e n t M e d i c a l Research 22 CONCERNS OF THE SURGICAL PATIENT . . . 24 F e a r 24 Time F a c t o r s . . 24 The I l l n e s s 25 KEY EXPERIMENTAL STUDIES ON THE PRE-OPERATIVE PREP- ARATION OF GENERAL SURGICAL PATIENTS 26 CONCERNS OF THE PATIENT WITH A PERMANENT PACEMAKER 30 The Kos and C u l b e r t Study . 31 THE CONCEPT OF ANXIETY 34 KEY NURSING STUDIES ON ANXIETY REDUCTION 40 INFORMATION SHARING AND PATIENT'S RIGHT TO KNOW 46 PHYSIOLOGICAL AGING AND ITS INFLUENCE ON THE TEACHING-LEARNING PROCESS 48 M e t a b o l i c Rate 49 C a r d i a c Output 50 v i C h a p t e r P a 9 e Lung Performance 50 Nerve Condu c t i o n V e l o c i t y . . 51 V i s u a l and A u d i t o r y Changes . 51 C e l l u l a r Changes i n the B r a i n 52 CULTURAL AGING AND ITS INFLUENCE ON THE TEACHING- LEARNING PROCESS 53 Independence 54 S o c i a l A c c e p t a b i l i t y 54 Adequacy o f P e r s o n a l Resources 55 A b i l i t y to Cope w i t h S e l f Change . 55 Having S i g n i f i c a n t Goals o r Meaning i n L a t e r L i f e 56 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 Loss e s . . 56 PSYCHOLOGIC AGING AND ITS INFLUENCE ON THE TEACHING- LEARNING PROCESS 57 FACILITATING LEARNING AMONG THE ELDERLY . . . . . . . . 59 M o t i v a t i o n 59 Methods 60 A u d i o v i s u a l A i d s 61 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 66 SUMMARY 69 I I I . METHODOLOGY 71 INTRODUCTION 71 THE RESEARCH DESIGN 71 C h a p t e r 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) . . . 83 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 ( S e l f E v a l u a t i o n Q u e s t i o n n a i r e ) 89 CRITERIA USED TO DETERMINE PULSE TAKING ABILITY . . 95 DATA MANAGEMENT 95 SUMMARY 96 IV. THE FINDINGS 97 INTRODUCTION 97 THE SAMPLE . : 97 HYPOTHESIS ONE . 100 HYPOTHESIS TWO . . 105 HYPOTHESIS THREE 112 HYPOTHESIS FOUR 114 v i i i C h a p t e r Page INCIDENCE OF COMPLICATIONS 1.20 LENGTH OF HOSPITAL STAY 121 SUMMARY 121 V. SUMMARY, CONCLUSIONS AND IMPLICATIONS . 122 SUMMARY . . • 122 CONCLUSIONS . 124 IMPLICATIONS 127 BIBLIOGRAPHY 129 Books 129 A r t i c l e s . 132 U n p u b l i s h e d M a n u s c r i p t s 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 P a r t 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 i x LIST OF TABLES T a b l e 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 to A c t i v i t y C h e c k l i s t . . . . 85 3. Nurses' 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 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 O t h e r . 99 6. Knowledge Base - Two Weeks A f t e r D i s c h a r g e 101 7. Knowledge Base - Four 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 the E x p e r i m e n t a l Group 104 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 . . . 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 D i s c h a r g e 115 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 116 X T a b l e Page 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 With A c t i v i t y L e v e l 117 17. P a t i e n t ' s D e s c r i p t i o n o f T h e i r Morale 118 x i LIST OF FIGURES F i g u r e Page 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 re shown w i t h s o l i d l i n e s ; those 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 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 Ja 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 the s l i d e - t a p e programme, And to the 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 you. 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 - v i d i n g c a r e . ' 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 the s i c k o r w e l l to p e r f o r m h e a l t h a c t i v i t i e s they would do unaided i f they p o s s e s s e d the 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 Peplau 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 i n s t r u m e n t . ' Now t h a t the t e a c h i n g component o f the nu r s e ' s r o l e has be- 5 6 come p a r t o f the 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 (1957), pp. 302-304. 2 V. Henderson, "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 (August, 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 Precede Goal Development," Modern H o s p i t a l , 103 (September, 1964), p. 136. 4H.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 the 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. 2 to evaluate the ef fect that th is intervent ion i s having on the well being of the pat ient and his s i gn i f i can t other. The focus of th is invest igat ion i s e lder ly patients who have had permanent cardiac pace- makers inser ted. The nurse invest igator w i l l i nd i v idua l l y assess the educational and emotional needs of these patients and the i r s i gn i f i can t other and w i l l attempt to meet these needs by employing a nursing intervent ion that consists of planned pat ient teaching and psychological support. The invest igator w i l l examine how planned pat ient teaching and psychological support during hosp i ta l i za t ion enhance the adaptab i l i t y of the pat ient and his s i gn i f i can t other a f ter the inser t ion of a permanent pacemaker. THE PROBLEM Statement The general question which th is study i s attempting to answer i s : Does pat ient teaching and psychological support enhance the adaptab i l i t y of the e lder ly person with a permanent pacemaker? S p e c i f i c a l l y ; a f ter the inser t ion of a permanent pacemaker, 1. Wi l l there be a change in the knowledge base of the patient and his s ign i f i can t other a f te r receiv ing teaching and psychological support? 3 2. W i l l t h e r e be a change i n the a n x i e t y l e v e l 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 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 p s y c h o l o g i c a l s u p p o r t ? 3. 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 the 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 s u p p o r t ? 4. W i l l 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 be a b l e to demonstrate 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 p s y c h o l o g i c a l s u p p o r t ? S i g n i f i c a n c e "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 are not ready. These words o f Dr. B a r b a r a Redman r i n g t r u e i n the n u r s i n g p r o f e s s i o n today. There i s an overwhelming f e e l i n g o f normlessness w i t h r e s p e c t t o h e a l t h c o u n s e l l i n g . P a t i e n t e d u c a t i o n , i n the p a s t , was a r e a s o n a b l y humane a c t f o r which we were not h e l d a c c o u n t a b l e 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 form o f t h e r a p y f o r which p r a c t i c e laws h o l d us r e s p o n s i b l e . 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 the 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 s t a f f . A s t r o n g b e l i e f i n the v a l u e o f h e a l t h e d u c a t i o n f o r the c h r o n i c a l l y i l l i s f r e q u e n t l y e x p r e s s e d — b u t 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 , " Canadian Nurse ( F e b r u a r y , 1975), 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 attempted 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 the S p e c i a l Committee o f the Senate 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 to 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 the Canadian 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 to 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 the community, to m a i n t a i n a sense o f s e l f - w o r t h and to be as independent as p o s s i b l e . One o f the 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 rsons ( 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 times between 1901 and 1961,whereas, the 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 times i n t h a t same time 3 p e r i o d . 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 the 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 p r o v i n c e v a r i e s c o n s i d e r a b l y b u t B r i t i s h Columbia has the h i g h e s t F i n a l Report o f the S p e c i a l Committee o f the Senate on Aging (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. V I I . 2 I b i d . , pp. 8-15. 3 I b i d . , p. 1. 4 I b i d . 5 I b i d . 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 because 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 Columbia's and Canada's p o p u l a t i o n . They a r e the p e o p l e who are 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 . D u r i n g 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 deaths 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 w i t h o v e r t h r e e - q u a r t e r s o f t h e s e deaths o c c u r r i n g i n people 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 , to 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 persons 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 to 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 peop l e had a permanent pacemaker (mean a g e = 7 0 ) . 3 In 1972, t h a t f i g u r e r o s e to 1/2500. A s i m i l a r s i t u a t i o n e x i s t s i n 4 Canada. T h i s sharp 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 c a p a b l e 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 Report 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 Survey 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 which 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 b ut o f t e n used mode o f n u r s i n g i n t e r v e n t i o n — p a t i e n t e d u c a t i o n . DESCRIPTION OF THE STUDY Purpose The purpose o f t h i s s t u d y i s : 1. to e v a l u a t e a n u r s i n g i n t e r v e n t i o n t h a t c o n s i s t s 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 , 2. to improve the 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 to p a t i e n t e d u c a t i o n , 3. to i n c r e a s e the f e e l i n g o f independence and s e l f - c o n t r o l on the p a r t o f the p a t i e n t , 4. to 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 - f o r m a t i o n r e l a t e d to t h e i r a l t e r e d h e a l t h s t a t u s , m e d i c a l regime and subsequent l i f e s t y l e . Hypotheses The hypotheses to be t e s t e d a r e : 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 i n c r e a s e the knowledge base o f the p a t i e n t a n d h i s s i g n i f i c a n t o t h e r . 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 d e c r e a s e 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 s i g n i f i c a n t o t h e r . 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 to demonstrate p u l s e t a k i n g . 4. P a t i e n t t e a c h i n g p s y c h o l o g i c a l s u p p o r t w i l l m a i n t a i n 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 from h i s p r e - o p e r a t i v e s t a t e . V a r i a b l e s The dependent 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 adapt 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 by h i s i n c r e a s e d knowledge base, h i s d e c r e a s e d a n x i e t y l e v e l , h i s a b i l i t y to demonstrate p u l s e t a k i n g and the maintenance 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 , 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 . 8 R a t i o n a l e f o r the Choice 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 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 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 o b v i o u s r e f l e c t i o n o f the v a r i o u s elements i n the c o g n i t i v e domain. The q u e s t i o n n a i r e which e v a l u a t e s the knowledge base o f the s u b j e c t s c o n t a i n s items which demonstrate r e c a l l o f f a c t s , c o m p r e h e n s i o n , a p p l i c a t i o n , a n a l y s i s , 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 the 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 degree o f a n x i e t y . Many nu 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 to meet the p a t i e n t ' s e d u c a t i o n a l needs, a n x i e t y w i l l be reduced. Redman and 3 S k i p p e r 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 . T h e r e f o r e , a change i n a n x i e t y l e v e l as an outcome 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 was c o n s i d e r e d an a p p r o p r i a t e dependent v a r i a b l e . 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 Ed.. ( 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 the 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 Le 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., 1965), 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 nurse can e v a l u a t e the degree t o which the p a t i e n t has mastered psychomotor s k i l l s . In the case 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 d e v i c e . 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 b a t t e r y f a i l u r e . ^ 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 psychomotor 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 to 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 emotional s u p p o r t . 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 maintenance 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 adjustment 2 o r h i g h morale among the e l d e r l y . C l a r k and Anderson s t u d i e d the s o u r c e s o f h i g h morale 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 . T h a t i s , s i x t y - n i n e p e r c e n t o f the 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 morale, f i f t y - s e v e n p e r c e n t mentioned s o c i a l i z i n g and f i f t y - f o u r p e r c e n t r e p l i e d t h a t p r o d u c t i v e a c t i v i t y c r e a t e d h i g h 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 the 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," Med i c a l C l i n i c s o f North America, 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. Anderson, 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 they 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 person'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 morale. 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 s u b j e c t ' 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 A d a p t a t i o n : 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 u n d e r s t a n d i n g ; 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 a p p r e c i a t i o n s . P a t i e n t T e a c h i n g : Any a c t i v i t y by which the nurse 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 the v a r i o u s a s p e c t s o f h e a l t h and i l l n e s s . P s y c h o l o g i c a l S u p p o r t : 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 nurse 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 t o e x p r e s s i n d i v i d u a l i t y , to f e e l u n d e r s t o o d , t o e x p r e s s c o n c e r n s , t o e x p l o r e problems and t o seek s o l u t i o n s . A n x i e t y : A complex, m u l t i d i m e n s i o n a l 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 esponse 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," American J o u r n a l o f N u r s i n g , 21 (March, 1971), p. 526. 11 t h e i r i n t e r a c t i o n s J 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 t h i s s t u d y . S t a t e A n x i e t y : 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 organism c h a r a c t e r i z e d by s u b j e c t i v e , c o n s c i o u s l y 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 h e i g h t e n e d 2 autonomic nervous system a c t i v i t y . T r a i t A n x i e t y : 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 tendency to respond t o s i t u a t i o n s p e r c e i v e d as t h r e a t e n i n g 3 w i t h e l e v a t i o n s i n s t a t e a n x i e t y i n t e n s i t y . N u r s i n g I n t e r v e n t i o n : A c o m b i n a t i o n o f 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 . A c t i v i t y L e v e l : 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 determined by the a c t i v i t y check l i s t . (See Appendix C ) . Knowledge Base: 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 based on a s l i d e - t ape programme on permanent pacemakers. (See A p p e n d i x E ) . Ipaul McReynolds, 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 & 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. Gorsuch and R.E. Luschene, 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 O t h e r : Any f a m i l y member o r f r i e n d t h a t t he 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 to him. Assumptions T h i s s t u d y makes the f o l l o w i n g assumptions: 1. Having 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 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 . 2. A n x i e t y can be measured. 3. A d a p t a t i o n to s t r e s s o r a n x i e t y i s b a s i c to the c o n t i n u e d w e l l b e i n g 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 whether o r not 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 st u d y 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 d a p t a b i l i t y o f the e l d e r l y p a t i e n t t o the 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 they 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 to 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 e x p e r i m e n t a l 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 f i f t h p o s t o p e r a t i v e day. They were encouraged t o e x p r e s s t h e i r f e e l i n g s and concerns and to ask any q u e s t i o n s which a r o s e i n r e l a t i o n t o t h e i r pacemaker. They were a l s o shown a s l i d e - t a p e programme about pace- makers. The members o f the c o n t r o l group r e c e i v e d the usual n u r s i n g 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 . A t a p p r o x i m a t e l y 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 base, a n x i e t y ( s t a t e and t r a i t ) l e v e l and p u l s e t a k i n g a b i l i t y . 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 a l s o measured. 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 base, 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 by u s i n g a o n e - t a i l t t e s t . 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 used to determine 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 the two groups. L i mi t a t i o n s Because 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 they 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 approach would be needed f o r the i l l i t e r a t e p e rson 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 nurse 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 p e o p l e 14 who i n t e r a c t w i t h the p a t i e n t and the n a t u r e o f the 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 , the t e a c h a b l e moment, and, whether the d e f i n i t i o n o f adapt- 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 to 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 to t h e i r knowledge base, a c t i v 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 . I t i s p o s s i b l e t h a t t he p r e t e s t i n g might 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 because 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 the i n v e s t i g a t o r wished t o measure. Anothe r q u e s t i o n t h a t 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 not . To a s c e r t a i n t h i s , the 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 re p r e s e n t i n the d a t a c o l l e c t i n g methods because 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 . The nurse i n v e s t i g a t o r w i l l a l s o be the per s o n who a d m i n i s t e r s the 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 un b i a s e d as p o s s i b l e , she w i l l be aware o f whether the p a t i e n t i s a member o f the e x p e r i m e n t a 1 o r c o n t r o l group. 15 SUMMARY Chapter 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 problem 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 the n u r s i n g p r o f e s s i o n today. The purpose, h y p o t h e s e s , v a r i a b l e s , assumptions 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 o u t l i n e d . 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 l i m i t a t i o n s . 16 CHAPTER II LITERATURE REVIEW INTRODUCTION The e l d e r l y person w i t h a permanent c a r d i a c pacemaker i s the s u b j e c t o f t h i s 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 . The purpose 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 the conc e r n s o f those 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 the 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 co 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 . H e a l t h 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 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 c o n s i d e r e d as they 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 H i s t o r i c a l 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 respond to e l e c - t r i c a l s t i m u l a t i o n J G a l v a n i ' s d i s c o v e r y h e r a l d e d the development o f ^S. Furman, "Fundamentals o f C a r d i a c P a c i n g , " American H e a r t J o u r n a l , 73 (1967), p. 261. 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 ve r y i n a c t i v e p e r i o d as f a r as 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 no 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 h e a r t i n a n i m a l s J Z o l l , i n 1952, d e v e l o p e d the t e c h n i q u e o f c l o s e d 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 which pr o v e d t o be l i f e s a v i n g i n many i n s t a n c e s and began the e r a o f the wi d e s p r e a d use o f d e v i c e s t h a t e l e c t r i c a l l y s t i m u l a t e d the h e a r t . W e i r i c h , i n 1957, s p u r r e d by the o c c u r r e n c e o f s u r g i c a l l y i n d u c e d 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 which e x i t e d through the c h e s t w a l l and connec t e d to an e x t e r n a l p u l s e g e n e r a t o r . The next major change to o c c u r i n pacemaker t e c h n o l o g y was demonstrated by Furman and Robinson i n 1958. They showed t h a t the e n d o c a r d i a l s u r f a c e o f the 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 t r a n s v e n o u s l y i n t r o d u c e d u n i p o l a r c a r d i a c c a t h e t e r . Glenn and 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 i m p l a n t e d pacemater system 5 f o r p u l s e d s t i m u l a t i o n o f the h e a r t v i a r a d i o f r e q u e n c i e s . The Journa l . ^1%TV'^K"^'2 °F CARDIAC " ^ " 9 . " American fart 2 I b i d . , pp. 261-277. 3 I b i d . , p. 261. 4 I b i d . , p. 262. 5 I b i d . 18 e a r l y u n r e l i a b l e component o f the pacemaker system 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 chemical 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 t o s t i m u l a t e the h e a r t f o r many y e a r s . 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 de 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, produced 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 response to 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 to t h o s e p h y s i o l o g i c (and sometimes p a t h o l o g i c ) s t i m u l i which c o n t r o l the a t r i a l r a t e J 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 system ( 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 to ensure the s a f e t y , c o m f o r t and h e a l t h o f the wearer. The 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 so 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 v e n t r i c u l a r w a l l . 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 s u b c u t a n e o u s l y 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 . There are o t h e r approaches but t h i s i s the one most commonly used. ^S. Furman, "Fundamentals o f C a r d i a c P a c i n g , " American H e a r t J o u r n a l , 73 (1967), p. 262. 2 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 T y P e s T h e r e a r e two b a s i c t y p e s o f pacemakers: 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 , f i x e d r a t e ) , 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 are the o l d e s t type and s t i m u l a t e the 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 a c t i v i t y . 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 the per 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 the 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 the v u l n e r a b l e phase o f the 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 are c o n t r o l l e d by the 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 h e a r t . Two g e n e r a l subtypes a re the v e n t r i c - u l a r i n h i b i t e d demand pacemaker and the v e n t r i c u l a r t r i g g e r e d demand pacemaker. The former 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 the h e a r t . The l a t t e r emits an impulse i n t o the 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 s e n s e s . In the absence, o f a s i g n a l from the h e a r t , the u n i t r e - v e r t s to i t s own a u t o m a t i c r a t e and paces. N o n p a r a s y s t o l i c pacemakers o f the 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. "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 North America, 57 (1973), p. 1517. 20 I n d i c a t i o n s 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 , symptomatic complete h e a r t 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 s i n u s a r r e s t , h e a r t b l o c k s e c o n d a r y t o d i g i t a l i s t h e r a p y , 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 s u s p e c t e d 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 branch b l o c k and l e f t a n t e r i o r 2 hemiblock. C o m p l i c a t i o n s 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 cause o f pace- 4 maker m a l f u n c t i o n . 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 from an a r t i c l e 5 by Dunst 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. 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 North A m e r i c a , 57 (November, 1973), p. 1518. 2 V. P a r s o n n e t , "A Survey 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 Sym- posium 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. Dunst, op. c i t . , p. 1521. 5 I b i d . , pp. 1521-1522. 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 the Pacemaker System P o t e n t i a l C o m p l i c a t i o n P u l s e g e n e r a t o r b a t t e r y f a i l u r e d e f e c t i v e p u l s e g e n e r a t o r i n t e r n a l s h o r t c i r c u i t i n g Leads and e l e c t r o d e s improper c o n n e c t i o n o f l e a d s t o p u l s e g e n e r a t o r l e a d f r a c t u r e s l e a d d i s p l a c e m e n t s m y o c a r d i a l p e r f o r a t i o n M y o c a r d i a l f a c t o r s i n c r e a s e d t h r e s h o l d o f h e a r t muscle to l o c a l e l e c t r i c a l s t i m u l a t i o n i n c r e a s e d e l e c t r i c a l r e s i s t a n c e O t h e r wound i n f e c t i o n c o m p e t i t i o n between the pacemaker and the 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 s o u r c e s 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 u n i t s a s s e s s e d 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 . A p p r o x i m a t e l y 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 s h o u l d 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 r e c o r d i n g , 2. E l e c t r o n i c waveform a n a l y s i s , and 3. T r a n s t e l e p h o n e m o n i t o r i n g . ^ D e c l i n i n g r a t e has been almo 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 o f b a t t e r y 2 e n d - o f - 1 i f e . C u r r e n t M e d i c a l Research M e d i c a l r e s e a r c h on c a r d i a c pacemakers has from the b e g i n n i n g 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 . Many l i v e s have been l e n g t h e n e d o r saved w i t h . t h e use o f a permanent c a r d i a c pacemaker. S u r v i v a l r a t e s 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 , e i g h t y - t h r e e '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 . 2 I b i d . 3 L.S. D r e i f u s and D. Cohen, "Implanted Pacemakers - M e d i c o l e g a l I m p l i c a t i o n s , " American J o u r n a l o f C a r d i o l o g y , 36 (August, 1975), p. 266. 23 p e r c e n t o f the p a t i e n t s a re s t i l l a l i v e ; a t two y e a r s , s e v e n t y - s e v e n p e r c e n t a r e s t i l l a l i v e ; a t t h r e e y e a r s , s e v e n t y p e r c e n t a r e s t i l l a l i v e 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 a l i v e . ' Dunst has o u t l i n e d the 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 taken i n pacemaker r e s e a r c h . They a r e : 1. o p e r a t i v e approaches o t h e r than thoracotomy to 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 ( l o n g e r l a s t i n g , l i g h t e r , s m a l l e r ) , and 4. b e t t e r u n d e r s t a n d i n g o f the p h y s i o l o g y o f the e l e c t r o d e - 2 h e a r t m t e r s u r f a c e . Pacemaker t e c h n o l o g y 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 the s e f i n d i n g s i n the c l i n i c a l f i e l d . The s a f e t y and s e c u r i t y o f the person w e a r i n g the pacemaking d e v i c e has been the g u i d i n g p r i n c i p l e f o r thos e i n v o l v e d i n b a s i c medical r e s e a r c h . V"Pacemaker P e o p l e " ( E d i t o r i a l ) , Canadian Med 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), p. 1298. 2 M. Dunst, " C a r d i a c Pacemakers," Med i c a l C l i n i c s o f North  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 the p r e - and p o s t - o p e r a t i v e concerns o f the g e n e r a l s u r g i c a l p a t i e n t . B r i e f l y summarized, thes e c o n c e r n s can be p l a c e d i n the f o l l o w i n g broad 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 the unknown and f e a r o f a l t e r e d body image are mentioned 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 they a w a i t e d s u r g e r y J F e a r 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 which sometimes i s m a n i f e s t e d by the r e l u c t a n c e o f the p a t i e n t to 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 con c e r n e d about the time f a c t o r s a s s o c i a t e d w i t h s u r g e r y . 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 the o p e r a t i o n w i l l be perfo r m e d , how l o n g i t w i l l t a k e 3 4 and when the person s h o u l d e x p e c t t o r e t u r n home. ' 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 , " American 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, 1966), 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 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), 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 I l l n e s s 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 1 2 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 one- h 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 they d i d n o t c a r e f o r themselves and 5 more knowledge about p r e v e n t i t i v e measures. In terms o f the type 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 person 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 - June, 1974), pp. 262-267. 6 I b i d . , p. 265. ^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 Master'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 demonstrate 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 s u r g e r y perhaps the nurse i s s p e n d i n g too much time d i s c u s s i n g c o n c r e t e , 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 the p a t i e n t and i s unable to hear 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 c o n c e r n s . 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 v a r i o u s p a t i e n t samples and the nurse must remember t h a t each p a t i e n t ' s c o n c e r n s must be a s s e s s e d 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 Leonard i n 1963 demonstrated t h a t the use o f the problem s o l v i n g approach i n c a r i n g f o r 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 p r e - o p e r a t i v e l y . r e d u c e d ' 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 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 from t h a t o f the nurse h e r s e l f to the p r a c t i c e o f n u r s i n g . Perhaps the 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 the b e l i e f t h a t c l i n i c a l l y based experiments 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 can be undertaken by any i n q u i s i t i v e , t h o u g h t f u l nurse as i s so a p t l y shown by the work o f Healy i n 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 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 a n o t h e r group o f s u r g i c a l p a t i e n t s who d i d not r e c e i v e the pre-ropera.t'ive i n s t r u c - t i o n . ^ 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 q u e s t i o n e d because 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, d i a g n o s i s , 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 planned i n s t r u c t i o n and the f a c t t h a t her e x p e r i m e n t a l and c o n t r o l group p a t i e n t s were not i n the h o s p i t a l d u r i n g the same time p e r i o d . But, H e a l y ' s s t u d y 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 case f o r the need f o r nurses 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 conduc t e d a s i m i l a r s t u d y , u s i n g a p r e - e x p e r i m e n t a l 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 i f t e e n y e a r s o f age a d m i t t e d 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). 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 o p e r a t i v e a n a l g e s i a . From a r e s e a r c h p o i n t o f view, because 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 ? " American 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), 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 - August, 1971), 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 to 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 m a t u r a t i o n . From a c l i n i c a l p o i n t o f view, 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 , because they used a sound- o n - s l i d e programme t o demonstrate a s k i l l , because i t was the ward nurses 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 development programme and f i n a l l y because i t demonstrated t h a t n u r s e s , p h y s i c i a n s and surgeons 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 to 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 conducted 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 but t h i s time she was examining 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 i n s t r u c t i o n . 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 to the v a r i o u s e x p e r i m e n t a l c o n d i t i o n s . T h i s d e s i g n i s much sounder than the s t a t i c group comparison Lindeman used i n her l a s t s t u d y because 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 and 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 . 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 Research, 21 ( M a y - J u n e , 1972), pp. 196- 209. 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 cannot g e n e r a l i z e about the 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 p r e - o p e r a t i v e c o n c e r n s . 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 the 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 the 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 the 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 a p p r o p r i a t e e x e r c i s e s . " ^ T h i s f i n d i n g has r e l e v a n c e f o r the p a t i e n t p o p u l a t i o n t h a t t h i s t h e s i s i s examining i n t h a t i t p o i n t s to the f a c t t h a t age i s n o t a b a r r i e r to 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 her stu d y i f they wished 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 nly 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 to the 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 the 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 p r e s e n t . S c h m i t t and Wooldridge i n 1973 conduct e d an e x p e r i m e n t a l s t u d y on the 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 from tho 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 sm a l l groups as w e l l as on a one-to-one b a s i s and p a t i e n t s h a v i n g major and minor s u r g e r y . 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 spectrum 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 s t u d y i n d i c a t e d t h a t t h o s e 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), p. 209. 30 p a t i e n t s who r e c e i v e d the e x p e r i m e n t a l n u r s i n g i n t e r v e n t i o n s l e p t b e t t e r 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 n a t u r e about t h e i r e x p e r i e n c e s on the 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 not r e c e i v e the e x p e r i m e n t a l n u r s i n g i n t e r - v e n t i o n . ^ One o f the 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 urse 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 Wooldridge demonstrated the 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 reduced a n x i e t y . CONCERNS OF THE PATIENT WITH A PERMANENT PACEMAKER Hunn i s one o f the 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 to the p a t i e n t w i t h a permanent pacemaker. She has i d e n t i f i e d the f o l l o w i n g p a t i e n t c o n c e r n s : 1. f e a r o f sudden death due to pacemaker f a i l u r e , 2. f e a r t h a t the h e a r t 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 t r a u m a t i z e the h e a r t , 4. a n x i e t y about the permanent pacemaker because i t i s viewed as a f o r e i g n o b j e c t upon which the 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. the c o s m e t i c e f f e c t s o f the 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. s e l e c t i n g c o m f o r t a b l e c l o t h i n g J 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 Resources found 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 the 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 concerned p a t i e n t s w i t h permanent pacemakers i s t h a t they wonder what happens to the pacemaker when they d i e . One p a t i e n t thought t h a t the pacemaker might 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 they t h i n k t h a t the 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 the nurse to 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 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 person ^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 Resources - 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 the a u t h o r by Ms. Jean Anderson, 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 General H o s p i t a l . 4No l i t e r a t u r e has appeared w i t h t h i s problem s t a t e d but 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 e n c o u n t e r e d t h i s m i s c o n c e p t i o n f r e q u e n t l y . 32 w i t h a permanent pacemaker. Kos and C u l b e r t have done the o n l y s t u d 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 have had permanent pacemakers.implanted. T h e i r purpose was to d e t e r m i n e whether 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 t e a c h i n g 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 , the p a t i e n t s and f a m i l y members ( i f they wished) were g i v e n i n f o r m a t i o n about 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 , pacemaker f u n c t i o n i n g , p u l s e and m e d i c a t i o n 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 - s t r i c t i o n s . 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 demonstrated 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 about 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 than 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 , 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 the pacemaker p a t i e n t i n p a r t i c u l a r demonstrate 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 p r e - 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 p l a n n i n g , ^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," American 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 used, 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 haphazard way, 4. t h a t the outcome v a r i a b l e s used t o e v a l u a t e the n u r s i n g 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 the 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 p e r i p h e r a l l y . 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 the e f f e c t o f t e a c h i n g the p a t i e n t because, 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 the s e l e c t i o n o f the dependent 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 urses and the t i m i n g o f the i n t e r v e n t i o n . 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 , " American J o u r n a l o f P u b l i c H e a l t h , 64 (June, 1974), p. 597. 34 THE CONCEPT OF ANXIETY To v e n t u r e causes a n x i e t y , but n o t to v e n t u r e i s to l o s e o n e s e l f . A n x i e t y i s the f e a r o f n o t h i n g n e s s . K i e r k e g a a r d " 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 everyday 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 o f 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 about 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 m a i n l y 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 . From 1930-1950, most o f the 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 i n l a b o r a t o r y s e t t i n g s u s i n g v a r i o u s animal s p e c i e s but no humans. 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, T h a t many more s t u d i e s on human a n x i e t y were a b l e to be performed. 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 today i s one o f the key n o t i o n s 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 s c i e n t i s t s . In o r d e r to u n d e r s t a n d how the c o n c e p t o f a n x i e t y has d e v e l o p e d , i t i s n e c e s s a r y to b r i e f l y r eview v a r i o u s r e s e a r c h e r ' s d e f i n i t i o n s . R. May, The Meaning o f A n x i e t y (New York: Ronald P r e s s Co., 1952), p. 13. 2 E. L e v i t t , The P s y c h o l o g y o f A n x i e t y ( I n d i a n a p o l i s : The B o b b s - M e r r i l l Co., IncI 1967). 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 fundamen- t 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 unique 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 se x u a l t e n s i o n s . Mowrer (1950) viewed a n x i e t y as o r i g i n a t - i n g , not from a c t s which the i n d i v i d u a l would commit i f he d a r e d , but from a c t s which he had committed but wished he had n o t . S u l l i v a n (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) thought 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 to some v a l u e which the i n d i v i d u a l h e l d e s s e n t i a l to 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 the d e f i n i t i o n s mentioned so f a r a l l u d e to the 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 response f a c t o r s and t h e i r i n t e r a c t i o n . L e s s e 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 11.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 York: 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 York: Academic P r e s s , 1966), p. 20. 3 I b i d . , p. 21. 4 I b i d . , p. 23. 5 Paul McReynolds, "The Assessment 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 Assessment, V o l . 1, P. McReynolds, 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 and B e h a v i o u r Books, I n c . , 1968), p. 246. 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 compon- en 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 which a r e motor, a f f e c t i v e , autonomic and v e r b a l J L a d e r 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 they 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 which t h e r e i s no agreed corpus 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 not d i s p r o p o r t i o n a t e to the o b j e c t i v e t h r e a t , not 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 , not 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 o f 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 awareness. 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 c o n c e p t 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 to the development 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 York: Grune and S t r a t t o n , 1970), p. 13. 2 M. Lader 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 a n x i e t y o r a n x i e t y p r o n e n e s s . 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 the f i r s t t o i n t r o d u c e an a n x i e t y measuring d e v i c e which e v a l u a t e d b o t h t r a i t and s t a t e a n x i e t y . 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 - m o t i v a t i o n a l p r o c e s s . 1 Lader and Marks have d e v e l o p e d a model o f normal a n x i e t y based on the work o f S p i e l b e r g e r . 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 s t a t u s . These components i n t e r a c t t o produce a n x i e t y proneness o r " t r a i t " a n x i e t y . The i n d i v i d u a l ' s a n x i e t y proneness then i n f l u e n c e s the sequence o f e v e n t s which produces 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 ) are s c r e e n e d f o r t h e i r r e a l 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 c o g n i t i v e 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 . I f the e x t e r n a l s t i m u l i a r e judged t o be t h r e a t e n i n g then the c e n t r a l nervous system 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 are m o b i l i z e d . The c e n t r a l nervous system a r o u s a l produces p h y s i o l o g i c a l changes which 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 (London: W i l l i a m Heinemann M e d i c a l Books L t d . , 1971), p. 156. "TRAIT ANXIETY EXTERNAL STIMULI S o c i a l , Man' t a l , Work, e t c . change environment GENETIC ENDOWMENT PAST EXPERIENCE CURRENT STATUS p r e s e n t 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 F i g u r e 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 are shown with s o l i d l i n e s ; t hose 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 the c o g n i t i v e a p p r a i s a l o f the t h r e a t and the person i s made aware t h a t he i s a n x i o u s . The per s o n a t t e m p t s to cope by c h a n g i n g the t h r e a t e n i n g 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 the 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 t e c h n i q u e s ( e . g . , r e l a t i o n t h e r a p y , t r a n s c e n d e n t a l m e d i t a t i o n , h y p n o s i s ) . The s u c c e s s o f the 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 the 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 1 s model o f normal a n x i e t y i s u s e f u l because i t g i v e s the c l i n i c i a n n o t o n l y an o v e r a l l frame- work w i t h which to view normal a n x i e t y but a l s o i t p r o v i d e s i n f o r m a t i o n as t o what type o f and where i n t e r v e n t i o n can 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 review 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 the 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 i s s u e . 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 measuring t h i s c o n c e p t . A n x i e t y i s c e n t r a l to o u r ev e r y d a y l i f e and i s a . powerful d e t e r m i n a n t o f much o f o u r b e h a v i o u r . I t i s c r u c i a l 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 to 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 d e a l t w i t h . 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 are 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 a n x i e t y ? 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 the methodology sound? Dumas and Leonard (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 - i n g a n o t h e r 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 v o m i t i n g . They showed t h a t by u s i n g the n u r s i n g p r o c e s s t o encourage t h e e x p r e s s i o n o f c o n c e r n s 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 p o s t - 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 major cause o f p o s t o p e r a t i v e v o m i t i n g . 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 , then t h e i r r e s u l t s are v a l i d . 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 the t y p e o f a n a e s t h e t i c agent used o r the type 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 might i n f l u e n c e the 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 . A n o t h e r f e a t u r e o f t h e i r s t u d y 1R.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 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. 41 which must be q u e s t i o n e d i s t h a t they 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 and 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 a n a l y z e d , the p r o b a b i l i t y t h a t the r e s u l t was due to one o f the randomized v a r i a - b l e s r a t h e r than t he e x p e r i m e n t a l t r e a t m e n t was found t o be h i g h ( p = .13, p = .19, p= .08) J Y e t , when th e y combined the r e s u l t s o f the 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 they were d i f f e r e n t ) they 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 the .05 l e v e l . The changes made i n the 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 the l e n g t h o f time t he i n v e s t i g a t o r s p e n t w i t h t he e x p e r i m e n t a l p a t i e n t ; h a v i n g a d i f f e r e n t n u r s e , as opposed to the i n v e s t i g a t o r , a s s e s s the p o s t - o p e r a t i v e s t a t u s o f the p a t i e n t s i n the 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 . T h i s a u t h o r f e e l s t h a t t h e s e changes are o f a g r e a t enough magnitude to c o n s i d e r t h a t t he 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 . The r e s u l t s were i n the p r e d i c t e d d i r e c t i o n but the sample s i z e was too s m a l l to 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 the c r i t i c i s m o f the methodology, t h i s s t u d y r e p r e s e n t s a p r e l i m i n a r y e f f o r t to r e - f o c u s n u r s i n g r e s e a r c h to 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 w a r r a n t f u r t h e r s t u d y . Meyers (1964) conducted an e x p e r i m e n t a l s t u d y t o examine the e f f e c t o f d i f f e r e n t t ypes o f communication on the p a t i e n t ' s r e a c t i o n s to s t r e s s . One p a t t e r n o f communication was s t r u c t u r e d ; t h a t i s , a R.G. Dumas and R.C. Leo n a r d , "The E f f e c t o f N u r s i n g on the 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 pat ient that th is tes t was done rout ine ly . A th i rd type of communication consisted of the invest igator making i r re levant comments about the weather as she performed the procedure. She found that less tension was created when the pat ient was given spec i f i c information about a procedure so that he could cogn i t ive ly structure the impending s t ress fu l even t J The nursing intervent ion used was giv ing the pat ient d i f fe rent types of information about a new procedure. Anxiety or stress was measured by the pa t ien t ' s subject ive response to what he perceived was about to happen to him, h is reca l l of items of equipment on the procedure tray and his feel ings during the procedure. From a methodological view- poin t , several concerns a r i se . The subjects for th is study were not randomly assigned to each of the three experimental condit ions 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 uncontrol led var iable present which could have accounted for the di f ference in the responses of the subjects. Another point to con- s ider i s that the invest igator was the one who provided the experimental treatment as wel l as the one who conducted the post experiment i n te r - view. She was then well aware of which pat ient received which form of M.E. Meyers, "The Ef fect of Types of Communication on Pa t ien t ' s Reaction to S t r ess , " Nursing Research, 13 (Spr ing, 1964), pp. 126-131. 43 communication. Presumably t o m i n i m i z e t h i s b i a s , the p o s t e x p e r i m e n t a l 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 whether both o f these n u r s e s conducted each i n t e r v i e w o r whether they each d i d some. 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 i s s u e s , Meyer's s t u d y p o i n t s o u t the g r e a t importance o f t r e a t i n g the p a t i e n t as a person 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 approach 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) conducted 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 t h r e e groups o f p a t i e n t s — t h o s e who were ta u g h t i n d i v i d u a l l y , those 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 t h r e e g r o u p s . 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 . T h i 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 minutes e a c h — 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 s u b j e c t ' 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 ex e c u t e d and the 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 not o b t a i n e d does not d e t r a c t from i t s v a l u e . P o s s i b l e e x p l a n a t i o n s 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 the 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 those p a t i e n t s who have not been r e c e n t l y d i a g n o s e d o r who are 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 ver y s h o r t time between c o m p l e t i o n o f the 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 to i n c o r p o r a t e and c o n s o l i d a t e the i n f o r m a t i o n . From the 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 the s u b j e c t s who r e c e i v e d the 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 the lo 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 the 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 the goal i s reduced a n x i e t y J Johnson (1972) conducted a l a b o r a t o r y and c l i n i c a l e x p e r i m e n t which 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 about s e n s a t i o n s reduced d i s - 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 tap e d r e c o r d i n g s o f messages which d i f f e r e d by h a v i n g the 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 to o c c u r and h a v i n g the o t h e r d e s c r i b e the p r o c e d u r e per s e . D i s t r e s s o f the 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 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 Lung D i s e a s e , " N u r s i n g Research, 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 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 to 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 (November- December, 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 degree 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 . Johnson'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 ' t h e o r y o f s t r e s s t o n u r s i n g r e s e a r c h . 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 p r e p - 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 a n x i e t y . 1 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 b e f o r e s u r g e r y and i n d i v i d u a l l y t h e morning 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 about the d i s e a s e p r o c e s s and she encouraged 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 the s t u d y by a s k i n g the s u b j e c t s whether they 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 morning 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 they c o u l d r e c a l l . P h y s i o l o g i c a l v a r i a b l e s 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 , b l o o d 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 demonstrates 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 parameters 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 which 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 - i n g h e a l t h t e a c h i n g and/or p s y c h o l o g i c a l s u p p o r t . 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 o c c a s i o n s , p s y c h o l o g i c a l t e s t s . The r e s u l t s have g e n e r a l l y been f a v o u r a b l e . INFORMATION SHARING AND THE PATIENT'S RIGHT TO KNOW Most p e o p l e want to know what i s g o i n g on about them so t h a t 1 2 they can have some degree 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 . P a t i e n t s s h a r e the r i g h t to know what i s happening t o them o r what th e y might a n t i c i p a t e o c c u r r i n g so t h a t they can p a r t i c i p a t e i n d e c i s i o n s c o n c e r n - 3 i n g t h e i r w e l l b e i n g . Gregg m a i n t a i n s t h a t the p a t i e n t e x p e r i e n c e s r e a s s u r a n c e when 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 . 4 'C.A. Baden, " T e a c h i n g the Coronary 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 erica, 7 (September, 1972), p. 564. 2 M.A. Neuman, " I d e n t i f y i n g and Mee t i n g P a t i e n t Needs i n the Short-Span 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. Rozovsky, 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). 4 D. Gregg, "Reassurance," American 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 reduced a n x i e t y . 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 the i n d i v i d u a l to f i n d meaning i n i l l n e s s as w e l l as to co n s e r v e h e a l t h and to c o n t r o l the symptoms o f 3 d i s e a s e . As T a g l i a c o z z o s a y s , the p a t i e n t ' s response to t h i s form o f n u r s i n g i n t e r v e n t i o n i n d i c a t e s l e s s t h a t the p a t i e n t i s com p l y i n g w i t h 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 the tr 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 to Mohammed, the 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 i n t e s t s , t r e a t m e n t s 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 c o m f o r t a b l y than the p o o r l y i n f o r m e d p a t i e n t . 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 m p o r t a n t i s s u e i n today's s o c i e t y . 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 the p a t i e n t ' s r i g h t o f a c c e s s to the i n f o r m a t i o n on h i s medical r e c o r d . A t the May, 1976 g e n e r a l meeting o f the 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 the 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. Leonard ( 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, op. c i t . , p. 3. 4 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 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 (June, 1964), p. 596. 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 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 esearch, 13 ( S p r i n g , 1964), p. 100. 48 Nurses A s s o c i a t i o n o f B r i t i s h Columbia, a r e s o l u t i o n was passed which 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 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 medical 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 medical r e c o r d be g i v e n t o the consumer i n language t h a t he can u n d e r s t a n d . 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 about h i m s e l f and demonstrate the b e n e f i t s a c c r u e d by p r o - v i d i n g h e a l t h t e a c h i n g . 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 i m p o r t a n t to examine the c o n c e p t s 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 group. The f o l l o w - 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 p s y c h o l o g i c a l 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 p r o c e s s . 2 Shock's model f o r a g i n g 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 psychomotor f u n c t i o n s 1RNABC 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 , " S c i e n t i f i c American ( J a n u a r y , 1963), p. 101. 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 system d e c l i n e . Normal a g i n g 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 p r o c e s s 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 p a r a m e t e r s : M e t a b o l i c Rate M e t a b o l i c 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 c a p a b i l i t y and 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 . Changes i n m e t a b o l i c r a t e o v e r time p a r a l l e l the p r o c e s s o f a g i n g . There o c c u r s 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 a p p r o x i m a t e l y 80 p e r c e n t a t 80 - 90. 1 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 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 a d r e n a l a c t i v i t y . The pace a t which 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 appear anxious 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 . The nurse 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 p a t i e n t as the o l d e r person w i l l need a l o n g e r time and perhaps more s u p p o r t i n a t t e m p t i n g to cope w i t h the l e a r n i n g e x p e r i e n c e . 1N.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. 101. 2 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 C a r d i a c Output C a r d i a c o u t p u t i s markedly d e c r e a s e d w i t h e i t h e r r e s t o r e x e r c i s e i n the 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 p r e s s u r e . T h i s i s p r i m a r i l y due to s t r u c t u r a l changes which have o c c u r r e d i n the h e a r t such as the i n c r e a s e d l a y i n g down o f pigments, 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 m y o c a r d i a l i s c h e m i a which i n t u r n m a n i f e s t s 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 t h e s e symptoms have newly d e v e l o p e d and a r e u n c o n t r o l l e d , i t w i l l p r o b a b l y be v e r y d i f f i c u l t and even unwise to c o n s i d e r a f o r m a l , comprehensive 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 q u e s t i o n s s h o u l d n o t be answered but t h a t h i s p h y s i c a l needs may need to 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 Performance Lung performance i n the e l d e r l y i s reduced by l e s s e n e d mechan- i 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 o x y g e n a t i o n o f v i t a l organs may produce 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, the 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 There 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 w i t h a g i n g . 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 o r g a n s . 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 taken to 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 response 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 are 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 , reduced 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 ensure t h a t the environment and m a t e r i a l s to be used a r e geared to poor v i s i o n . For example, adequate l i g h t i n g i s 1 2 n e c e s s a r y to 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 North A m e r i c a , 6 (December,1971(, pp.605-614. 2 V. Stone, "Give the O l d e r Person 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 to lower f r e q u e n c i e s . Some o f the a u d i t o r y changes t h a t o c c u r are a t t r i - buted to nervous system impairment o r s t r u c t u r a l o r a t r o p h i c i n v o l v e - ment. 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 , the nurse 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 to g i v e the person time to comprehend 2 and p r o c e s s the i n f o r m a t i o n . C e l l u l a r Changes i n the 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. the 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 "the development 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 f r a g m e n t a t i o n . " 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 the 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 to 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. W r i t t e n m a t e r i a l s s h o u l d 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 i n f o r m a t i o n s h o u l d be d e l e t e d . The v o c a b u l a r y must be matched to the 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, "Ag 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. Stone, "Give the O l d e r Person 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. 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 4th grade l e v e l o f v o c a b u l a r y be used to f a c i l i t a t e comprehension o f w r i t t e n m a t e r i a l s b ut one must keep i n mind t h a t her st u d y sample c o n s i s t e d o f mos t l y female, Negro, s e m i - u n s k i l l e d workers from a lower s o c i o - economic background. 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 to i t depends on s e l f - p e r c e p t i o n which 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 the s e l f - p e r c e p t i o n s o f the aged a re 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 the aged, the 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 Anderson i d e n t i f i e d s i x major c l u s t e r s as a system o f p e r s o n a l g o a l s a g a i n s t which the aged seem to judge t h e m s e l v e s . They a r e : 1. Independence. 2. S o c i a l A c c e p t a b i l i t y . ^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 Research, 13 ( S p r i n g , 1964), p. 100. 54 3. Adequacy o f p e r s o n a l r e s o u r c e s . 4. A b i l i t y to 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 to p r o v i d e f o r one's needs was c o n s i d e r e d to be ve r y i m p o r t a n t r e g a r d l e s s o f the person's s t a t e o f h e a l t h . P e r c e i v i n g o n e s e l f as ind e p e n d e n t 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 the e l i m i n a t i o n o f the f e a r o f becoming a burden. The e l d e r l y d e s i r e ways to m a i n t a i n t h e i r independence. Perhaps, h e a l t h t e a c h i n g i s one o f the b e s t ways to f o s t e r t h i s need f o r independence. S o c i a l A c c e p t a b i l i t y In C l a r k and Anderson'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 the v a l u e which we a s c r i b e to t h e i r c o n t r i - b u t i o n s . Many e l d e r l y p e o p l e a re 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 can channel t h i s p o t e n t i a l and perhaps promote a g r e a t e r degree o f r e h a b i l i t a t i o n among the e l d e r l y who are l e s s w e l l . ""M. C l a r k and B. Anderson, 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. 177. 55 Adequacy o f P e r s o n a l Resources P e r s o n a l 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 as i m p o r t a n t 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 . The aged have w e l l d e v e l o p e d l i f e p a t t e r n s 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 and economic s t r e n g t h . 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 attempt 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 u n l e a r n e d , 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 The nurse 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 . I t 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 p r o c e s s . The n u r e s ' s a c c u r a t e assessment o f the r e a d i n e s s f o r h e a l t h t e a c h i n g i s e s s e n t i a l . 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 s p ace, e n c o u r a g i n g 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 s u p p o r t i n g a ccomplishments. 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 Goals 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 Anderson'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 engaging i n l i f e a c t i v i t i e s i n a w h o l e - h e a r t e d y e t l e s s c o m p e t i t i v e manner. They l o o k e d f o r o p p o r t u n i t i e s t o e n j o y o r a p p r e c i a t e l i f e ' s s m a l l e r p l e a s u r e s . In 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 h e a l t h 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 L o s s e s 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 b e s t o f t h i n g s . I t i n c l u d e s such q u a l i t i e s as endurance, f o r e b e a r a n c e and s t a m i n a . The s o u r c e o f s e l f esteem i n t h i s area d e r i v e s from the s k i l l and s t r e n g t h t o f i n d contentment i n the f a c e o f a d v e r s i t y . 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 person 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 Anderson'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 and thoughts 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 because: 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 working w i t h the 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 - l e a r n i n g p r o c e s s . 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 whether t h i s s t u d y o f the American 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 Canadian e l d e r l y p o p u l a t i o n . 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 l i f e t i m e . Some o f t h e s e l o s s e s a r e concerned 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 - i n g s . The common denominator 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 o u t 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 person's accomplishments and s t r e n g t h s . 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 , c a r i n g 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 c o n f i d e n c e . 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 North 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 person 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 the person'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 the s u c c e s s o f the t e a c h - i n g - l e a r n i n g p r o c e s s when the 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 t o the person's p a s t e x p e r i e n c e . 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 to mean t h a t the remembered events o f the 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 the e l d e r l y p e r s o n . What the o l d e r p e r s o n remembers might g i v e the nurse v a l u a b l e i n s i g h t i n t o the 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 to 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 , the 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 , w i t h i n the c o n t e x t o f the p a t i e n t ' s m e a n i n g f u l , p a s t e x p e r i e n c e . 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 be 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 . O f t e n t he 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 the 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 the 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 the s i t u a t i o n can be coped w i t h . The nurse f i r s t must l o o k a t where the 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 the awareness o f a need to 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 . N̂.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 the 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 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 (New York: Harper and P r o s . , 1954). 59 FACILITATING LEARNING AMONG THE ELDERLY B o t w i n i c k 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 about 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 nurse 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 , o r g a n i z e , c o n s o l i d a t e and respond to new i n p u t s , 2. e l d e r l y p e o p l e p r e f e r c o n c r e t e t a s k s , 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 e f f e c t s . 1 M o t i v a t i o n M o t i v a t i o n o f the 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 p a r t i n h i s 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 and/or ways o f l i v i n g . Kos and 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 t h a t 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 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 problem 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 Jack 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 P u b l i s h i n g Co., 1973), 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 Implanted C a r d i a c Pacemakers." U n p u b l i s h e d Master'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 to l e a r n J B o t w i n i c k reminds us t h a t the more meaningful 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 m a i n t a i n s t h a t i t i s u n n e c e s s a r y 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 m o t i v a t i o n w i l l d e v e l o p 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 to f a c i l i t a t e t h i s t a s k . 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 appro- p r i a t e p s y c h o l o g i c a l s e t . 4 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 s i t u a t i o n . 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 Research, 20 (1971), 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 Meaningful 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 , 1963), p. 226. 4 R.B. Packard and H. Van E s s , "A Comparison o f In 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 though, 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 the 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 r e a l i t y u n r e l a t e d t a s k s . 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 which they p e r c e i v e as b e i n g c e n t r a l to 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 s o c i a l s u r v i v a l . 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 o f t h i s i n f o r m a t i o n 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 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. A u d i o v i s u a l A i d s 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 the p a s t ten y e a r s . 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 re u s i n g a v a r i e t y o f a u d i o - v i s u a l t e c h n i q u e s to p r e s e n t f a c t s , p r o c e d u r e s 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 to t h e i r membership. Research on 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 remember: 10% o f what they r e a d 20% o f what they hear 30% o f what they see 50% o f what they see and hear 80% o f what they say 90% o f what they say as they do a t h i n g . ^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 (1963), pp. 165-168. 2 Joan S. Dodge, " F a c t o r s R e l a t e d to 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), 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 the 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 a r e a v a i l a b l e t h a t d e a l w i t h 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 secondary s c h o o l s b ut no d a t a a r e a v a i l a b l e on the 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 the a d u l t never mind the 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 demonstrates a s i m i l a r p a t t e r n . 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 to enhance the 1 2 3 l e a r n i n g o f the s t u d e n t n u r s e . S e v e r a l nurse r e s e a r c h e r s ' ' 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 but the a u d i o - v i s u a l a i d per 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 the 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 nurse r e s e a r c h e r has used i s Mr. V i c t o r Doray, Head o f the B i o m e d i c a l Communications Department a t the Vancouver General H o s p i t a l and the U n i v e r s i t y o f B r i t i s h Columbia. Mr. Doray o u t l i n e d the f o l l o w i n g advantages 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 the 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 (1972), 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 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 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 (1971), p. 319. 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," American J o u r n a l o f N u r s i n g , 71 (1971), p. 523. 63 1. the l e a r n e r can p r o c e e d a t h i s own speed, 2. the l e a r n e r can review the s l i d e - t a p e programme as needed, 3. the s l i d e - t a p e programme can save time i n terms o f one person h a v i n g t o r e p e a t the same i n f o r m a t i o n , 4. the 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 w i t h persons v i e w i n g the s l i d e - t a p e programme, and 5. the 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 the s l i d e - t a p e programme never r e p l a c e s the 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 the 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 the e f f e c t s o f o l d age on the l e a r n i n g p r o c e s s , by u s i n g t he 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 the m o t i v a t i o n o f the 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 . 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 The b e h a v i o u r o f the i n d i v i d u a l cannot be viewed i n t o t a l i s o l a t i o n as t h a t person 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 the Vancouver General H o s p i t a l , F e b r u a r y 4, 1976. 64 which 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 s i g n i f i c a n t o t h e r s . Craven and Sharp i n s i s t t h a t the nurse must broaden h e r p e r s p e c t i v e and view the problems o f the f a m i l y as w e l l as the p a t i e n t . The nurse must r e c o g n i z e the importance o f the p a t i e n t - f a m i l y network and encourage 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 . 1 B a i n s t r e s s e s t h a t an i m p o r t a n t a s p e c t o f the n u r s i n g c a r e o f a pacemaker p a t i e n t i s d e a l i n g w i t h the p a t i e n t ' s f a m i l y . She m a i n t a i n s t h a t much o f the nur s e ' s time i s o c c u p i e d by l i s t e n i n g t o the f e a r s and apprehen- s i o n s o f the f a m i l y and t e a c h i n g them t h a t the p a t i e n t needs to 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 the 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 about 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 wor 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 unable to p r o v i d e the s u p p o r t the 'R.F. Craven and B.H. Sharp, "The E f f e c t s o f I l l n e s s on Fa 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 the People Who Need Them," American  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 , "Coronary 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 -complete Care," Canadian Nurse, 69 ( F e b r u a r y , 1973), pp. 21-25. 65 p a t i e n t needed because they l a c k e d the n e c e s s a r y i n f o r m a t i o n about h e a r t d i s e a s e and the p a t i e n t ' s medical r e g i m e n . 1 A d s e t t and Bruhn found t h a t wives o f p a t i e n t s who had m y o c a r d i a l 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 about t h e i r husbands i l l n e s s . One o f the major 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 the person who was i l l tends to become the c e n t e r o f the h o u s e h o l d and o f t e n c o n t r o l s the f a m i l y as o t h e r members are a f r a i d to e x p r e s s f e e l i n g s to him f o r f e a r o f p r o v o k i n g d i s t r e s s f u l c a r d i a c symptoms. 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 not say 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 the f a m i l y members found i t to 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 the p r e s e n c e o f a f a m i l y member d u r i n g p r e - o p e r a t i v e t e a c h i n g d i d not i n c r e a s e the e f f e c t i v e n e s s o f t h a t 5 t e a c h i n g . 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 her 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 the Coronary 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 Psycho-Therapy f o r the 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 (1968), pp. 577-584. 3 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," American 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. Redman and Tyzenhouse both emphasize t h a t f a m i l i e s need t o assume a s u p p o r t i v e 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 . The 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 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 f e e l i n g s , ask t h e i r q u e s t i o n s and to e x p l o r e t h e i r c o n c e r n s i n o r d e r to 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 C o u n s e l l i n g Humans are not a l i k e . T h e i r d i f f e r e n c e s are 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 r e c o g n i z e . 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 , the 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 respond to i n d i v i d - 4 ual needs. 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 e l e m e n t s : p a c i n g , o b j e c t i v e s , m a t e r i a l s 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 t o 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. Tyzenhouse, " 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 (1973), p. 1013. 3 R.E. Keuscher, "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 York: The M a c m i l l a n Co., 1970), p. 6. 4 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 S t r a t e g y . V.M. Howes, e d i t o r (New York: The M a c m i l l a n Co.,1970), p. 101. 5 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 Readings, 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. Keuscher, op. c i t . , pp. 9-13. 67 These n o t i o n s o f the 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 the 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 appeared 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 r e c e i v e d p r i o r t e a c h i n g . 1 P u t t conducted 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 o r d e r 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 the 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 the 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 s u p p o r t which 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 the usual r o u t i n e n u r s i n g c a r e i n r e d u c i n g d i s c o m f o r t a f t e r a d m i s s i o n , i n d e c r e a s i n g 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 the p a t i e n t ' s p e r c e p t i o n o f s e l e c t e d c o n c e p t s r e l a t i n g t o h i s i l l n e s s . Goodman demonstrated the e f f e c t i v e n e s s o f p l a n n e d , i n d i v i d u a l i n s t r u c t i o n on the s e l f - 3 m e d i c a t i o n 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 . Those who r e c e i v e d the i n d i v i d u a l i n s t r u c t i o n made fewer m e d i c a t i o n e r r o r s than t h o s e who d i d n o t . 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 t e a c h i n g w i t h the a i d o f a d i a b e t i c t e a c h i n g t o o l , 4 improved the knowledge and s k i l l s o f the 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 , 1965), pp. 160-163. 2 A.M. P u t t , "One Experiment 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 Study to E v a l u a t e the E f f e c t o f Planned 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 Ambulatory 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 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 Columbia, 1972. 4J.M. Skelton,".An E x p e r i m e n t a l Study to E v a l u a t e the 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 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. 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 department 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 l i m b s . She found t h a t the mothers who r e c e i v e d t h i s n u r s i n g i n t e r v e n t i o n 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 , i n d i v i d u a l t e a c h i n g . 1 Kos and C u l b e r t s t u d i e d 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 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 about 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 n o t 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 demonstrated 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 department and home s e t t i n g . Dodge reminds 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 p a r t i c u l a r s i t u a t i o n . Palm m a i n t a i n s t h a t group t e a c h i n g cannot 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 . 4 S e v e r a l 'D.M. Power,"The E f f e c t i v e n e s s o f P lanned 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 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 Columbia, 1972. 2 I b i d . 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 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 T e a c h i n g , " N u r s i n g C l i n i c s o f North A m e r i c a , 6 (1971), pp. 669-678. 69 s t u d i e s ' 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 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 but n e i t h e r o f them show t h a t group t e a c h i n g 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 . L a s t l y , Kos and C u l b e r t say t h a t 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 each 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 from 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 one-to-one b a s i s i s u s u a l l y most e f f e c t i v e . 3 SUMMARY A c r i t i c a l r e view 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 and the p a t i e n t w i t h a permanent pacemaker i n p a r t i c u l a r . Many o f the i s s u e s r a i s e d stem from the 1C.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 (1972), pp. 196-209. 2 C. B a i n e s , An E x p e r i m e n t a l Study 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 Master'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 Columbia, 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 North A m e r i c a , 6 (1971), p. 613. p r e s e n c e o f a n x i e t y . 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 major 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 which 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 . F a c i l i t a t i n g l e a r n - 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 the 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 problem have been s u g g e s t e d . The subsequent 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 the r e s e a r c h d e s i g n chosen t o stud y the problem; the s e t t i n g i n which the stu d y was c a r r i e d o u t , the sample s e l e c t e d f o r t e s t i n g ; the pr o c e d u r e used to implement the p r o j e c t ; and, the data g a t h e r i n g t o o l s employed to accumulate the n e c e s s a r y i n f o r m a t i o n . 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. T h i s d e s i g n 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 , m a t u r a t i o n , 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 m a i n l y through the p r o c e s s o f r a n d o m i z a t i o n . What i t ca n n o t account f o r i s the unique i n t r a s e s s i o n h i s t o r y t h a t the p a t i e n t s i n the e x p e r i m e n t a l group exper- i e n c e d . 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 because the dependent v a r i a - b l e s chosen f o r t h i s study 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 to determine i f a d a p t a t i o n had o c c u r r e d . A p o t e n t i a l t h r e a t to the 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 and a f t e r " d e s i g n was 72 a c c o u n t e d 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 but a l s o a t the f o u r to s i x week p e r i o d . 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 t e s t e d i n the h o s p i t a l as opposed to t h e i r own home would be m i n i m i z e d . THE SETTING The s t u d y was conducted a t 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 n B r i t i s h Columbia. There are f o u r c a r d i o l o g i s t s and t h r e e c a r d i o v a s c u l a r surgeons 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 . No 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 have had permanent pacemakers i n s e r t e d . 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 . Most o f the p a t i e n t s who have had permanent pacemakers i n s e r t e d have temporary tr a n s v e n o u s 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 they can be found on the g e n e r a l medical o r s u r g i c a l wards. The 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 c a r d i o v a s c u l a r surgeon a t which 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 asked 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 about 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 i n a 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 o p e r a t i n g room w i t h a temporary, completed 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 about the pacemaker model which they 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 system to use i s dependent upon the i n d i v i d u a l surgeon 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 hours 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 from the I n t e n s i v e 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 medical o r s u r g i c a l ward u n t i l h i s d i s c h a r g e home. Du 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 rounds) i s i n f o r m e d , 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 , about h i s pacemaker, i t s purpose 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 . There i s no formal e d u c a t i o n 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 t h e i r f a m i l i e s . 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 r e g a r d - i n g pacemakers i s on an i n f o r m a l , s p o r a d i c , one-to-one b a s i s . 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 depending on the p r i o r i t i e s o f the ward, the p a t i e n t census and the e x p e r t i s e o f the 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 pace- makers a t t h i s h o s p i t a l i n c l u d e t h r e e to s i x monthly checkups ( o r more f r e q u e n t l y depending on the age o f the b a t t e r y ) a t the pace- 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 s c r e e n i n g system to the pacemaker c l i n i c . The 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 urchases 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 ins t ruc t ion i s done by the screener salesman. THE SAMPLE A random sample of nine pat ien ts , who met the fo l lowing c r i t e r i a , were included in th is study: 1. Pat ients who were f i f t y years of age or over. 2. Pat ients who could see, hear, speak and read Engl ish . 3. Pat ients who were hosp i ta l ized for the i r f i r s t perman- ent pacemaker i nse r t i on . 4. Pat ients who were able to answer a questionnaire (that i s , were not unconscious, severely mentally retarded, ] had not had a serious cerbrovascular accident) . 5. Pat ients who had not had open heart surgery at the same time as the permanent pacemaker was inser ted. 6. Pat ients who w i l l i n g l y consented to par t i c ipa te a f ter an explanation of the study was provided by the invest igator . When the nurse invest igator was informed that a pat ient , who met the study c r i t e r i a , ac tua l ly had the permanent pacemaker inser ted , she randomly assigned that pat ient to e i ther the experimental or control group. The nurse invest igator then approached the pat ient 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 c o n s e n t to p a r t i c i p a t e . (See Appendix A) 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 r e f u s e d to p a r t i c i p a t e a t the b e g i n n i n g o f the s t u d y . One p a t i e n t r e f u s e d t o be seen a t the 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 the p r e t e s t s , d i d not 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 belonged t o the 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 the s u b j e c t s , the nurse 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 p e r s o n was f r e e t o withdraw from the p r o j e c t a t any time. The raw data 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 the 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 the s u b j e c t s r e q u e s t e d feedback 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 the q u e s t i o n - n a i r e s , they were t o l d t h a t they would be p r o v i d e d w i t h t h a t i n f o r m a t i o n a t the c o m p l e t i o n o f the p r o j e c t . The p a t i e n t s who were members o f the c o n t r o l group were g i v e n the o p t i o n o f v i e w i n g the s l i d e - t a p e programme, which the 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 the 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 the nurse i n v e s t i g a t o r f o r the Vancouver General H o s p i t a l , under the a u s p i c e s o f a L o c a l I n i t i a t i v e s P r o j e c t G r a n t , i n o r d e r 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 about permanent pacemakers. The o b j e c t i v e s o f the programme were: P a r t 1 - "Your H e a r t Has Nine L i v e s . " To help the patient and his s i g n i f i c a n t other understand and accept the rationale for the i n s e r t i o n of a permanent pacemaker. ( L e n g t h : 5 minutes) P a r t 2 - " L i v i n g With Your Pacemaker." To help the patient and his s i g n i f i c a n t other understand and accept a change in lifestyle. ( L e n g t h : 12 minutes) The g o a l s o f the s l i d e - t a p e programme were to meet the educa- t i o n a l needs 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 o t h e r and to s e r v e as a f o c u s f o r d i s c u s s i o n . The c o n t e n t o f the programme was determined by r e v i e w i n g the l i t e r a t u r e to e s t a b l i s h the e x p r e s s e d needs and conce 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 so t h a t the nurse i n v e s t i g a t o r would have s u f f i c i e n t time to 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 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 . U s i n g 77 t h i s a u d i o - v i s u a l medium ens 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 nurse 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 . A t t h a t time the nurse 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 Nurse, n o t knowing to which 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 nurse i n v e s t i g a t o r by s a y i n g the 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 to 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 nurse 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 the c o n s e n t forms (Appendix A) as g u i d e s . When the p a t i e n t a greed t o p a r t i c i p a t e and s i g n e d the c o n s e n t form, the n u r s e i n v e s t i g a t o r made an appointment to see 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 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 when i t was c o n v e n i e n t f o r them) i f they were members o f the e x p e r i m e n t a l group. I f they were randomly a s s i g n e d to the c o n t r o l group» the nurse i n v e s t i g a t o r made an appointment to 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 the 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). U s u a l l y d u r i n g t h i s i n t r o d u c t o r y i n t e r v i e w , the nurse i n v e s t i g a t o r c o n d u c t e d the f i r s t two pages o f the A c t i v i t y I n t e r - view S c h e d u l e (see Appendix C) and completed the P a t i e n t Data Sheet. (See Appendix D) 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 minutes to 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 the e x p e r i m e n t a l group e x p e r i e n c e d the 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 the 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. G r e e t i n g 2. A d m i n i s t e r ( i n t h i s o r d e r ) - (a) S t a t e A n x i e t y I n v e n t o r y (b) Knowledge Base Q u e s t i o n n a i r e ( c ) T r a i t A n x i e t y I n v e n t o r y 3. Ask i f they know why the 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 response and e x p l o r e m i s c o n c e p t i o n s 4. Show P a r t One o f the s l i d e - t a p e programme 5. Encourage 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. T e r m i n a t e the 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 - Fourth. P o s t o p e r a t i v e Day 1. G r e e t i n g 2. Encourage q u e s t i o n s . I n q u i r e as to whether the p a t i e n t s d o c t o r o r nurse 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 q u e s t i o n s 6. T e r m i n a t e 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. G r e e t i n g 2. E l i c i t q u e s t i o n s about 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 p u l s e t a k i n g 4. Make an appointment to see p a t i e n t and s i g n i f i c a n t o t h e r 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. G r e e t i n g 2. A d m i n i s t e r 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 3. A d m i n i s t e r ( i n t h i s o r d e r ) (a) S t a t e A n x i e t y I n v e n t o r y (b) Knowledge Base Q u e s t i o n n a i r e ( c ) T r a i t A n x i e t y I n v e n t o r y 80 4. Encourage the expression of concerns or feel ings 5. Stress that the next v i s i t w i l l be the l as t and make the necessary time arrangements Interview No. 5 - Four Weeks Post Discharge - In the Pa t ien t ' s Home 1. Same as 1-4 above 2. Bring resul ts of the knowledge base questionnaire and anxiety inventory should the pat ient or s i gn i f i can t other request feedback 3. Thank the pat ient and s i gn i f i can t other for par t i c ipa t ing in the pro ject . The Control Group The patients and the i r s i gn i f i can t others in the control group re- ceived the usual nursing care provided by the ward s ta f f . On the th i rd postoperative day, the nurse invest igator met with the pat ient and his s i gn i f i can t other to administer the questionnaires and conduct the in te r - view regarding the pat ien t 's a c t i v i t y l e v e l . The questionnaires were given in the fol lowing order: A c t i v i t y Check L i s t , State Anxiety Inventory, Knowledge Base Questionnaire, T ra i t Anxiety Inventory. At least once before the pat ient was discharged, the nurse invest igator paid him a soc ia l v i s i t and reminded him of the two week post-discharge home v i s i t . The f i r s t home interview was begun by asking the subject how he or she was gett ing along. Subsequently, the A c t i v i t y Interview Schedule was conducted. The nurse invest igator 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 Q u e s t i o n n a i r e , T r a i t A n x i e t y I n v e n t o r y . The s u b j e c t was reminded t h a t the n e x t v i s i t , two weeks hence, would be the f i n a l v i s i 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 would 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 conducted 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 nurse 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 about the q u e s t i o n n a i r e s . The s u b j e c t s 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 Three 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 base, 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 - c a n t o t h e r s . 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 check l i s t were d e v e l o p e d by the nurse 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 s t u d y . 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 measuring d e v i c e , was chosen 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 determined 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 reason 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, a c t i v i t i e s 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 c u r r e n t l i t e r a t u r e . 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 n u r s e 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 not. 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 but 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 they completed 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 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 D e v i a t i o n Saw S l i d e - T a p e Programme 20.75 1.28 D i d Not See S l i d e - T a p e Programme 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 q u e s t i o n 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. Anothe r q u e s t i o n was answered i n c o r r e c t l y 3/8 times i n the group who saw the s l i d e - t a p e programme and 6/8 times i n the 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. 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 twenty- two items and appears i n Appendix E. The A c t i v i t y Check L i s t (ACL) The nurse 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 S c h e d u l e , (Appendix C) the f i r s t two pages o f which c o n t a i n the A c t i v i t y Check L i s t . The purpose 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 e v a l u a t e 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 r e s p o n s e s 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 t a k i n g , 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 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 degree 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 determine 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 which 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 p e o p l e (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 asked to respond to 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 unable 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 are 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 responded, the i n v e s t i g a t o r examined o n l y those a c t i v i t i e s which no one was a b l e to perform. They were: 1. w o r k i n g a t a r e g u l a r j o b 2. g a r d e n i n g 3. washing f l o o r s / w a l l s 4. d o i n g minor h o u s e h o l d r e p a i r s 5. b o w l i n g 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 . T h i s c o n v e n i e n c e sample o f seven had to 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 but a l s o p r o v i d e d them w i t h housekeeping and maintenance f a c i l i t i e s . 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 to 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 door 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 not 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 o f p e o p l e w i t h permanent pacemakers. The r e s u l t s can be found 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 to A c t i v i t y Check L i s t (A.C.L.) (N = 7) A c t i v i t y D i d P e r f o r m Did Not P e r f o r m Does Not A p p l y F a i l e d to Respond w a l k i n g 1 b l o c k 6 1 w a l k i n g 5 b l o c k s 4 3 w a l k i n g 1 m i l e 0 5 2 g r o c e r y s h o p p i n g 5 1 1 g a r d e n i n g 0 6 1 lawn mowing 1 6 d r e s s i n g o n e s e l f 7 f e e d i n g o n e s e l f 7 u s i n g the washroom a l o n e 7 b a t h i n g 6 1 showering 5 2 c l i m b i n g s t a i r s 3 3 1 sexual a c t i v i t y 1 3 3 vacuuming 2 5 d u s t i n g 5 2 washing d i s h e s 6 1 washing c l o t h i n g by hand 5 2 washing c l o t h i n g by machine 5 1 1 washing f l o o r s / w a l l s 0 6 1 c o o k i n g 3 3 1 minor r e p a i r s to the house 0 4 2 1 u s i n g a l l e l e c t r i c a l a p p l i a n c e s 4 3 d r i v i n g a c a r 2 4 1 t a k i n g a bus 5 2 t a k i n g a p l a n e 5 2 t a k i n g a boat 6 1 86 A c t i v i t y Di d D i d Not Does Not F a i l e d to P e r f o r m P e r f o r m A p p l y Respond t a k i n g a t r a i n 5 1 1 v i s i t i n g w i t h f r i e n d s i n y o u r home o r t h e i r s 5 2 p l a y i n g c a r d s 6 1 w a t c h i n g T.V. 7 l i s t e n i n g to the r a d i o 7 b o w l i n g 0 7 r e c r e a t i o n a l swimming 0 7 a t t e n d i n g s e n i o r c i t i z e n ' s meetings 4 3* w o r k i n g 0 4 3* t a k i n g y o u r p u l s e 3 1 3* hobbies 4 3* O t h e r 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 3 sewing 1 * Three r e s p o n d e n t s f a i l e d to answer the second page o f ACL. 87 Each nurse was asked t o e s t i m a t e the 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 person 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 the l i s t e d a c t i v i t i e s . Most o f the a c t i v i t i e s were g i v e n a high r a t i n g , t h a t i s , the average 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. w a l k i n g a m i l e 2. washing f l o o r s / w a l l s 3. b o w l i n g 4. r e c r e a t i o n a l swimming, and 5. mowing the lawn. 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 unper- formable by e i t h e r the 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 the 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 the a c t i v i t i e s on the 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 the s e l e c t i o n o f the 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 to i n c l u d e the 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 the A c t i v i t y Check L i s t (ACL) When the ACL was g i v e n as a p r e t e s t , the nurse i n v e s t i g a t o r s a i d to the p a t i e n t , " D u r i n g the month p r i o r to y o u r h o s p i t a l i z a t i o n , d i d you p e r f o r m any o f thes e a c t i v i t i e s ? " When the ACL was g i v e n as 88 TABLE 3 Nurses' 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 v i t y Mean A c t i v i t y Mean d r e s s o n e s e l f 10 watch TV 10 f e e d o n e s e l f 10 l i s t e n t o r a d i o 10 use the t o i l e t a l o n e 10 bowl 5.0 bath 9.5 r e c r e a t i o n a l swimming 6.75 shower 9.75 a t t e n d S e n i o r C i t i z e n ' s meetings 10 c l i m b s t a i r s 8.75 r e t u r n to p r e v i o u s j o b 10* walk .1 b l o c k 9.75 r e t u r n t o l i g h t e r j o b 10* walk 5 b l o c k s 9.0 take own p u l s e 8.5 walk 1 m i l e 6.25 hobbies ( e . g . , r e a d i n g , g o l f woodworking, k n i t t i n g , e t c . ) 10 resume s e x u a l a c t i v i t y 10 p l a y i n g bingo 10 vacuum 8.0 goi n g to church 10 d u s t 10 wash d i s h e s 10 wash c l o t h i n g by hand 9 wash c l o t h i n g by machine 9.75 wash f l o o r s / w a l l s 5.75 garden 10* cook 10 mow the lawn 6.0 do minor house r e p a i r s 9.75 use a l l e l e c t r i c a l a p p l i a n c e s 8.3* g r o c e r y shop 9.5 d r i v e a c a r 9.0 take a bus 9.5 take a t r a i n 9.5 take a p l a n e 9.3* take a boat 9.5 v i s i t w i t h f r i e n d s 10 p l a y c a r d s 10 n = 3 •kic Nurses' o p i n i o n as to the 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 the 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 =9.15 Median =9.75 Mode = 10 Range = 5 - 1 0 89 a p o s t t e s t , the nurse 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 to 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 I n t e r v i e w S c h e d u l e . 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 determine i f t h e i r f r e q u e n c y had changed. 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 n o t done a t a l l . 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 A n x i e t y I n v e n t o r y ( S e l f E v a l u a t i o n Q u e s t i o n n a i r e ) 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 Robert E. Luschene 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 both 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 , and n e u r o p s y c h i a t r y , medical and s u r g i c a l p a t i e n t s . The q u e s t i o n n a i r e i s comprised o f s e p a r a t e , twenty items each, 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 the o p p o s i t e s i d e o f the same t e s t s h e e t . A copy o f the STAI can be found i n Appendix F. A d m i n i s t r a t i o n o f the 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 the top o f each s i d e o f the t e s t form. There a r e no time l i m i t s imposed on the re s p o n d e n t . A c c o r d i n g t o the 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 Luschene, 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 than twenty minutes to complete both. Less e d u c a t e d and/or e m o t i o n a l l y d i s t u r b e d persons may r e q u i r e t e n t o twelve minutes t o complete one o f the s c a l e s and a p p r o x i m a t e l y twenty minutes t o complete b o t h . 1 The v a l i d i t y o f the STAI i s based on the assumption t h a t the r e s p o n d e n t c l e a r l y u nderstands the 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 the A - T r a i t i n v e n t o r y asks him to i n d i c a t e how he generally f e e l s . I f both o f the s c a l e s a r e g i v e n a t the same time, i t i s recommended t h a t t he 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 the 2 A - T r a i t s c a l e . Because the 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. Gorsuch, R.E. Luschene, 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 I b i d . 91 to the c o n d i t i o n s under which 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 emotional 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 to 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 themselves on a f o u r - p o i n t s c a l e . 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 o f a n x i e t y , 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 which 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 are the same as the b l a c k e n e d out number on the t e s t form.. For items on which 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 p u r c h a s e d 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 to 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 the 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 i m p o s s i b l e t o d e v e l o p 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 s c a l e . 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 s p o n t a n e o u s l y respond to 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 o r p r o m p t i n g . 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 by: 1. d e t e r m i n i n g the mean s c o r e f o r the items to which 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 2 3. r o u n d i n g the p r o d u c t t o the next h i g h e r , whole number. I f t h r e e o r more items a r e o m i t t e d , the v a l i d i t y o f the s c a l e must be q u e s t i o n e d . Normative Data f o r the STAI Normative d a t a are a v a i l a b l e f o r c o l l e g e s t u d e n t s , h i g h s c h o o l 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 young, 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 f o r t h i s 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 males; 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 I b i d . 3 I b i d . , p. 9. 93 The mean s c o r e which they had on the 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 R e l i a b i l i t y The t e s t - r e t e s t r e l i a b i l i t y o f the STAI was documented by s t u d y i n g a group o f male and female undergraduate 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 the A - T r a i t s c a l e ranged from .73 t o .86, whereas, t h o s e f o r the A - S t a t e s c a l e ranged from .16 to .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 the 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 index 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 , the 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 to .92 and f o r 3 the 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 c o n c l u d e d t h a t b o t h 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 c o n s i s t e n c y . I b i d . , p. 9. 2 I b i d . , p. 8. 3 I b M . 94 V a l i d i t y The c o n s t r u c t v a l i d i t y o f the A - S t a t e s c a l e was determined by t e s t i n g a l a r g e number o f male and female undergraduate c o l l e g e s t u d e n t s under "normal" 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 both males and females were c o n s i d e r a b l y h i g h e r i n the s t r e s s f u l c o n d i t i o n . 1 C o n c u r r e n t v a l i d i t y o f the 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 the s c o r e s o f male and female c o l l e g e s t u d e n t s and neuro- p s y c h i a t r y p a t i e n t s on the 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 , 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 (TMAS), and the Zuckerman A f f e c t A d j e c t i v e Check L i s t (AACL). The c o r r e l a t i o n s between the STAI - A - T r a i t S c a l e , the IPAT and the TMAS ranged from .75 2 to .85. In c o n t r a s t , the 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 the o t h e r A - T r a i t measures ( r a n g e = .41 to .58). S i n c e the 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 approached the 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 the 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 t r a i t . The STAI was s e l e c t e d as a measuring d e v i c e o f the p a t i e n t ' s a n x i e t y l e v e l because 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 I b i d . 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 to e s t a b l i s h whether 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 p u l s e t a k i n g . 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 performed 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 take 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 the base o f the thumb, 2. Counted the p u l s e f o r 60 seconds, and 3. Was a c c u r a t e w i t h i n t h r e e beats when the s u b j e c t ' s p u l s e was checked by the nurse 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 . The 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 and c o n t r o l group to demonstrate 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 E x a c t P r o b a b i l i t y T e s t . The s i g n i f i c a n c e o f the d a t a was determined a t the .05 l e v e l . T h i s v a l u e was chosen because o f the small 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 purpose 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 ance, 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 h y p o t h e s i s ) w i l l be made. The .05 l e v e l a l s o was a p p r o p r i a t e because 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 hypotheses 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 methodology used i n t h i s s tudy. 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 to 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 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 e x p e r i m e n t a l group s u b j e c t s r e c e i v e d 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 from the nurse 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 usual 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 respond 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 . T h e i r p u l s e t a k i n g 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 b e h a v i o u r a l c r i t e r i a . 97 CHAPTER IV THE FINDINGS INTRODUCTION This chapter w i l l present the data that was collected i n relation to the hypotheses to be tested. In addition, the investigator w i l l examine selected correlations among the dependent variables. 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 five month period, a total of sixteen subjects (nine patients, seven s i g n i f i c a n t others) were followed from the time that the patients had their permanent pacemakers inserted u n t i l they had been home from the hospital for approximately four weeks. The demographic data pertaining to this sample of nine patients i s presented in Table 4. 98 TABLE 4 Demographic Data - P a t i e n t s E x p e r i m e n t a l Group C o n t r o l Group T o t a l Number 5 4 Mean Age ( y e a r s ) 78.8 76.8 Mean Number o f Years o f S c h o o l i n g 9.0 9.0 R a t i o o f Males/Females 3/2 1/3 R a t i o o f Married/Widowed 2/3 2/2 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 groups, 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 o f s c h o o l i n g . No demographic 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 s i g n i f i c a n t o t h e r s . Three 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 who were w i l l i n g to 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 to the p a t i e n t i s shown i n T a b l e 5. 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 E x p e r i m e n t a l Group C o n t r o l Group P a t i e n t S i g n i f i c a n t P a t i e n t S i g n i f i c a n t O t h e r O t h e r Husband Wife Mother Daughter F a t h e r 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 hypotheses 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 i n c r e a s e 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 o t h e r . 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 d e c r e a s e 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 s i g n i f i c a n t o t h e r . 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 to demonstrate p u l s e t a k i n g . 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 m a i n t a i n 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 teaching and psychological support w i l l in- crease the knowledge base of the patient and his s i g n i f i c a n t 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 pe o p l e i n the e x p e r i m e n t a l group had re a d a b o o k l e t on pacemakers b e f o r e they d i d the p r e t e s t . The nurse 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 . I t i s 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 . A n o t h e r c o n f o u n d i n g 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 the 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 nurses and 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 and read 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 hos- p 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 c o e f f i c - 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 e x p e r i m e n t a l group (see T a b l e 8 ) . 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 because the sample c o n s i s t e d o f o n l y t h r e e p e o p l e . 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 P r e t e s t P o s t t e s t D i f f e r e n c e E x 17 16 -1 P 21.. 21 0 E R I 15 20 +5 19 20 +1 M N G T R A 0 L U   P 21 20 22 18 21 20 22 18 0 0 0 0 N = 8 Mean' 19.125 19.750 +0.625 C 22 22 0 0 N 20 21 +1 T 22 21 -1 R 0 L 18 20 +2 15 21 +6 G R 18 19 +1 22 22 0 0 u 20 22 +2 P N = 8 Mean 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 D i s c h a r g e E P r e t e s t P o s t t e s t D i f f e r e n c e X P E G R R I 0 17 21 15 17 21 21 0 0 +6 M U E P* 19 22 +3 T 21 21 0 A L 20 21 +1 N = 7 18 20 +2 Mean 18.71 20.43 +1.71 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 her s i g n i f i c a n t o t h e r r e f u s e d to complete the 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 the .05 l e v e l ( t = 0.876, d f = 14). L i k e w i s e , a t - t e s t done on the mean d i f f e r e n c e between the 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 the .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 the company which made h i s pacemaker. A l l p a t i e n t s i n t h e s t u d y r e p o r t e d t h a t they had read the 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 so. The r e a c t i o n t o the 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 the s u b j e c t ' s response to the s l i d e - t a p e program which those i n the e x p e r i m e n t a l group saw i n the h o s p i t a l but no member o f the e x p e r i m e n t a l group o f f e r e d any spontaneous 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 Experimental Group V a r i a b l e s Knowledge - P Knowledge - 2 S t a t e A n x i e t y - P S t a t e A n x i e t y - 2 A c t i v i t y - P Knowledge - P 1.00 Knowledge - 2 .20 1.00 Knowledge - 4 .28 .96* S t a t e A n x i e t y - P -.42 .23 1.00 S t a t e A n x i e t y - 2 -.23 .44 .90* 1.00 S t a t e A n x i e t y - 4 -.25 .53 .95* .94* T r a i t A n x i e t y - P -.59 .30 .59 .76 T r a i t A n x i e t y - 2 -.56 .11 .86 .90* T r a i t A n x i e t y - 4 -.43 .74 .72 .77 A c t i v i t y - P .87 .59 -.10 .04 1.00 A c t i v i t y - 2 .47 .37 -.73 -.67 .51 A c t i v i t y - 4 .96* .43 -.34 -.16 .96* P = P r e t e s t 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 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 S i g n i f i c a n t a t the .05 l e v e l 105 HYPOTHESIS TWO Patient teaching and psychological support w i l l decrease the state and trait anxiety levels of the patient and his s i g n i f i c a n t other. The mean t r a i t a n x i e t y s c o r e s o f the e x p e r i m e n t a l group were h i g h e r than those o f the c o n t r o l group on the p r e t e s t , two week p o s t d i s - charge p o s t t e s t and th 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 and 10). When a t - t e s t was done on the mean change between the 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) the r e s u l t was n o t s i g n i f i c a n t . A c c o r d i n g t o 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 pers o n ' s c h a r a c t e r i s t i c l e v e l o f a n x i e t y . T h i s has been demonstrated by the d a t a . The h y p o t h e s i s , though, as i t r e l a t e s to t r a i t a n x i e t y , has not been s u p p o r t e d . 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) are 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 the 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 the 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 . The mean s t a t e a n x i e t y s c o r e s f o r the 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; whereas, they a r e d e c r e a s e d two weeks a f t e r d i s - charge but r i s e a g a i n to almost the p r e t e s t l e v e l f o u r weeks a f t e r d i s c h a r g e f o r the e x p e r i m e n t a l 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 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 , ( 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 r P r e t e s t P o s t t e s t D i f f e r e n c e L. X P G E R 58 33 56 35 -2 +2 R 0 I U 40 43 +3 M P 54 52 -2 E N 51 24 -27 A 37 41 +4 L 40 57 +17 N=8 38 27 +11 Mean 43.875 41.875 •r.2 C 0 33 36 .. +3 N G 37 35 -2 T R R 0 30 29 -1 0 U 37 36 -1 L P 38 34 -4 26 25 -1 N = 8 35 39 +4 27 29 +2 Mean 32.875 32.875 0 107 TABLE 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 E P r e t e s t P o s t t e s t D i f f e r e n c e X E G R R I ° M p * E v N 58 33 40 54 37 67 26 38 39 47 +9 -7 -2 -15 +10 T 40 52 +12 A L 38 39 +1 N = 7 Mean 42.86 44.00 +1.14 C 0 33 37 +4 N G T R 30 35 +5 R 0 0 U L P * * 37 35 32 29 -5 -6 N = 5 27 24 -3 Mean 32.4 31.4 -1.0 Fam i l y member u n a v a i l a b l e ** One p a t i e n t o m i t t e d the 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 her s i g n i f i c a n t o t h e r r e f u s e d to 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 P r e t e s t P o s t t e s t D i f f e r e n c e E X 50 57 +7 R R I 0 M U E P 35 28 40 22 25 28 51 22 -10 0 +11 0 N x 45 51 +6 A 60 33 -27 L 26 25 -1 N = 8 Mean 38.25 36.50 -1.75 C 39 39 0 0 ? 6 L S P 47 33 34 41 35 25 20 47 -12 -10 -14 +6 35 41 +6 N = 8 27 41 27 27 0 -14 Mean 37.13 32.63 -4.75 109 TABLE 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 P r e t e s t P o s t t e s t D i f f e r e n c e E X 50 63 +13 P E G R R 35 28 26 25 -9 -3 I 0 M U 40 42 +2 E P 22 21 -1 N T 45 57 +12 A 60 44 -16 L 26 24 -2 N = 8 Mean 38.25 . 37.75 -0.5 C 39 37 -2 0 N o 47 38 -9 T G R R 0 0 L U p* 33 34 27 31 33 20 -2 -1 -7 N = 6 41 21 -20 Mean 36.83 30.00 -6.83 One p a t i e n t and her s i g n i f i c a n t o t h e r r e f u s e d to answer the 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 the mean 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 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 weeks); t = 1.097, d f = 14 (4 weeks)). The mean s t a t e and t r a i t s c o r e s o f the e x p e r i m e n t a l and c o n t r o l group can be compared w i t h the norma t i v e data 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 c o m p l i c a t i o n s . 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. 1 A t no time d i d 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 r e a c h the mean s t a t e a n x i e t y l e v e l shown i n the no r m a t i v e d a t a . A somewhat d i f f e r e n t p a t t e r n appears f o r the mean t r a i t a n x i e t y s c o r e s . 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 re much lower than the v a l u e taken from the no r m a t i v e d a t a (32.88 vs. 41.33); however, the mean t r a i t a n x i e t y s c o r e s f o r the e x p e r i m e n t a l group are s l i g h t l y h i g h e r (44.0 vs. 41.33). Perhaps t h i s s u g g e s t s t h a t the a n x i e t y l e v e l o f the p a t i e n t s s t u d i e d was not hi g h enough to be a more powerful m o t i v a t i n g f o r c e to seek new i n f o r m a t i o n about 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 might be t h a t the no r m a t i v e d a t a from S p i e l b e r g e r i s not 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 comparison. H i s sample c o n s i s t s o n l y o f males, whose average age i s 55, w i t h an un- s p e c i f i e d v a r i e t y o f g e n e r a l m e d i c a l - s u r g i c a l problems. On the o t h e r hand, the sample from t h i s s t u d y i s composed o f males and females I b i d . , p. 8. I l l whose average 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 h e a r t b l o c k 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 . The age f a c t o r a l o n e c o u l d a c c o u n t f o r the l e s s e n e d degree o f s t a t e a n x i e t y e x h i b i t e d i n t h i s s t u d y , f o r perhaps the o l d e r person 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 the a n x i e t y components i n the 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 the e x p e r i m e n t a l 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 a n x i e t y ( r = .90); 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 = .95); 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 t h a t the n u r s i n g i n t e r v e n t i o n 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 d i d not reduce the s t a t e a n x i e t y l e v e l o f members o f the e x p e r i m e n t a l group. A p o s s i b l e reason f o r t h i s can be found when the t r a i t a n x i e t y s c o r e s o f the e x p e r i m e n t a l s u b j e c t s are examined ( T a b l e s 9 and 10). The mean t r a i t a n x i e t y s c o r e s o f the e x p e r i m e n t a l group are h i g h e r than those o f the c o n t r o l group. I f the e x p e r i m e n t a l s u b j e c t s were i n h e r e n t l y more anxious perhaps 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 about t h e i r c o n d i t i o n would not s e r v e to reduce t h e i r a n x i e t y . Perhaps the nurse 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 the p a t i e n t s t o p r o v i d e the 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 ver y p o s s i b l e t h a t the t e a c h a b l e moment was missed. By the t e a c h a b l e moment, the 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 the n u r s e ' s a b i l i t y to d e t e c t and a c t on the p a t i e n t ' s demonstrated r e a d i n e s s to l e a r n . A l s o , the 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 s o u r c e s . (The nurse i n v e s t i g a t o r , ward n u r s e s , p h y s i c i a n s , and b o o k l e t s ) . 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 , t h e r e b y i n c r e a s i n g t h e p a t i e n t ' s f e e l i n g s o f f r u s t r a t i o n . For example, the i s s u e o f the 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 to h i s p a t i e n t . Sometimes the 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 the 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 the 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 found 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 the p a t i e n t ' s knowledge base, i t i s i n t e r e s t - i n g to s p e c u l a t e about t h e i r r e l a t i o n s h i p when examining t he raw data ( T a b l e s 6, 7, 9, 10, 11, and 12). The e x p e r i m e n t a l group when compared to the 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 s c o r e s and lower mean knowledge base s c o r e s on the 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 . Perhaps the f u l l l e a r n i n g p o t e n t i a l o f the e x p e r i m e n t a l group was hampered by t h e i r c o r r e s p o n d i n g l y 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 a n x i e t y . HYPOTHESIS THREE Patient teaching and psychological support w i l l enable the patient and his s i g n i f i c a n t other to demonstrate pulse taking. From T a b l e 13, i t can be seen t h a t more members o f the e x p e r i - mental group c o u l d demonstrate p u l s e t a k i n g than c o u l d members o f the 113 c o n t r o l group. When the 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 , 1 no s i g n i f i c a n t d i f f e r e n c e was found between the two groups on the dependent v a r i a b l e o f p u l s e t a k i n g a b i l i t y . 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 E x p e r i m e n t a l Group C o n t r o l Group Can Demonstrate Cannot Demonstrate Can Demonstrate Cannot Demonstrate P a t i e n t 3 2 1 3 S i gni f i c a n t O t h e r 3 0 3 1 T o t a l 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 powerful e f f e c t on the r e s u l t s s i n c e the sample s i z e was so 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 the c o n t r o l group were nurses and had a l r e a d y mastered the s k i l l o f p u l s e t a k i n g . A l s o a p a t i e n t i n the e x p e r i m e n t a l group s u f f e r e d from subacute combined d e g e n e r a t i v e d i s e a s e o f the s p i n a l c o r d which 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 unable to 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 n u r s i n g i n t e r v e n t i o n . R.H. K o l s t o e , I n t r o d u c t i o n to 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 S c i e n c e s , 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- 343. 114 HYPOTHESIS FOUR Patient teaching and psychological support w i l l maintain or increase the activity level of the patient from his preoperative state. From T a b l e 14 i t i s e v i d e n t t h a t the members o f the c o n t r o l group were more a c t i v e than the e x p e r i m e n t a l group a t the time o f the p r e t e s t . 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 the members o f the e x p e r i m e n t a l group 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 l e s s . Four weeks a f t e r d i s c h a r g e ( T a b l e 1 5 ) , both groups' 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 the p r e t e s t l e v e l . The members o f the e x p e r i m e n t a l group came c l o s e r to 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 the c o n t r o l group. A p o i n t to remember though i s t h a t the members o f the 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 the c o n t r o l group to be g i n w i t h . Perhaps i t was e a s i e r f o r the e x p e r i m e n t a l group to re 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 examining the k i n d o f a c t i v i t i e s which members o f the 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 r e p r e s e n t e d those o f a l e s s s t r e n u o u s n a t u r e g e n e r a l l y a t a s u b s i s t e n c e l e v e l . When a t - t e s t was a p p l i e d to the data 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 the two groups on the 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 t e s t . 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 P r e t e s t P o s t t e s t D i f f e r e n c e E X 22 20 -2 P 27 14 -13 R G I R M 0 E U P N V T A L 21 56 42 25 28 47 +4 -28 +5 N = 5 Mean 33.6 26.8 - 6 . 8 c 33 27 -6 0 54 28 -26 N G T R 49 24 -25 R 0 0 U L P 26 14 -12 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 P r e t e s t P o s t t e s t D i f f e r e n c e E X P E G R R I 0 M U E P N T A L 22 27 21 56 42 19 28 24 43 38 -3 +1 +3 -13 -4 N = 5 Mean 33.6 30.4 -3.2 C 33 29 -4 0 T G « 0 0 ~ L p * 54 26 43 23 -11 -3 N = 3 Mean 37.7 31.7 -6.0 One p a t i e n t r e f u s e d t o do the 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 s a t i s f a c t i o n w i t h h i s a c t i v i t y l e v e l b e f o r e the pacemaker was i n s e r t e d , two weeks a f t e r d i s c h a r g e from 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 from 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 each 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 whether 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 l e v e l . 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 performed by i n s p e c t i o n o f t a b l e s . 1 No s i g n i f i c a n t d i f f e r e n c e was found between the two groups w i t h r e s p e c t 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 t ime. TABLE 16 R eported 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 (S/D) With A c t i v i t y L e v e l E X I G R R I 0 M U E P N T A L N = 5 P r e t e s t P o s t t e s t - 2 Weeks A f t e r D i s c h a r q e P o s t t e s t - 4 Weeks A f t e r D i s c h a r q e S D V / / / / S D / / / / / S D / / / / / C o fi N R T 0 R U 0 P L N = 4 / / / / / / / / / / / / I b i d . 118 A n o t h e r p o r t i o n 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 d e a l t w i t h 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 morale 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 the r e s u l t s . TABLE 17 P a t i e n t ' s D e s c r i p t i o n o f T h e i r Morale E Two Weeks A f t e r D i s c h a r g e Four Weeks A f t e r D i s c h a r g e X P R ° I R M 0 E U P N Y T low low good good good low h i g h good A L low low N = 5 C 0 r ? « good f a i r good good good good good good N = 4 The nurse i n v e s t i g a t o r p r e s e n t e d the p a t i e n t s w i t h a s c a l e from which to choose the word which b e s t d e s c r i b e d t h e i r morale. The s c a l e , from l e f t to r i g h t , i n d i c a t e d degrees o f improvement (low, f a i r , good, h i g h ) . No change i n morale o v e r time was r e p o r t e d i n 3/5 members o f 119 the 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 the 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 p o s i t i v e d i r e c t i o n . M o r a l e appears 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 the sample s i z e was so s m a l l , the nurse 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 morale e n c o u n t e r e d i n the 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 such 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 , nervousness and l a c k o f energy. These were much more e v i d e n t i n the e x p e r i m e n t a l group as opposed to the 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 , w i t h r e s p e c t t o a c t i v i t y l e v e l , t he n u r s e 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 the r e a s o n s why. Three out 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 out 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 which 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. 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 permanently 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 permanently o r 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 work 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 th e s e a c t i v i t i e s were t h a t they were t oo 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 so. 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 noted. There 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 the p r e t e s t a c t i v i t y l e v e l and the 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). T h i s 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 the members o f the e x p e r i m e n t a l group were a c t i v e p r e o p e r a t i v e l y 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 to be as a c t i v e as they were b e f o r e t h e i r s u r g e r y . I t i s i n t e r e s t i n g t o note 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 to r e t u r n t o h i s former 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 the 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 he pacemaker i n s e r t e d , then they were m o t i v a t e d t o attempt to 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 a c t i v i t y . 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 the 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 the 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 noted. 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 the e x p e r i m e n t a l group was 15.8 days; whereas, the 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 days. A o n e - t a i l t - t e s t a p p l i e d t o t h i s 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 the .05 l e v e l ( t = .407, d f = 7 ) . SUMMARY Chapter f o u r p r e s e n t e d the f i n d i n g s o f t h i s e x p e r i m e n t a l s t u d y which sought 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 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 the e l d e r l y p a t i e n t t o adapt t o t he 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 base, s t a t e and t r a i t 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 and p u l s e t a k i n g a b i l i t y . None o f the f i n d i n g s proved 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 the .05 l e v e l . 122 CHAPTER V SUMMARY, CONCLUSIONS AND IMPLICATIONS Chapter 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 the major c o n c l u s i o n s a r i s i n g from the 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 the 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 . I t s purpose was t o e v a l u a t e the e f f e c t 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 on the a b i l i t y o f the e l d e r l y p a t i e n t to adapt 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 the s t u d y c r i t e r i o n were randomly a s s i g n e d 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. Each s u b j e c t was asked 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 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 the nurse 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 abouts a t which time t h e i r q u e s t i o n s were answered; they 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 ; 123 and, they 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. The s l i d e - tape programme was d i v i d e d i n t o two p a r t s — o n e f i v e minute segment which d e a l t w i t h why the permanent pacemaker was i n s e r t e d and a n o t h e r t e n minute segment which examined l i f e s t y l e changes and common miscon- c e p t i o n s about 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 n u r s i n g c a r e g i v e n by the 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 r e c e i v e d a b o o k l e t about t h e i r pacemaker from the company whose brand o f pacemaker they had. The s p e c i f i c hypotheses 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 i n c r e a s e 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 o t h e r . 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 d e c r e a s e 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 s i g n i f i c a n t o t h e r . 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 demonstrate p u l s e t a k i n g . 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 m a i n t a i n 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 v e s t a t e . A t a p p r o x i m a t e l y two and f o u r weeks a f t e r d i s c h a r g e from the h o s p i t a l , the nurse 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 the 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 base, a c t i v i t y l e v e l , s t a t e and t r a i t a n x i e t y l e v e l s 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 ; whereas, o n l y the knowledge base, 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 o t h e r s . 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 groups on any o f thes e v a r i a b l e s . CONCLUSIONS The d a t a o b t a i n e d i n t h i s s t u d y f a i l e d to r e j e c t the n u l l h y p o t h e s i s o f no 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 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 . 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 the members o f the e x p e r i m e n t a l group was not shown to s i g n i f i c a n t l y i n c r e a s e t h e i r knowledge base; 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 ; i n c r e a s e o r m a i n t a i n t h e i r a c t i v i t y l e v e l ; o r , t o e n a b l e the p a t i e n t o r h i s s i g n i f i c a n t o t h e r t o a c c u r a t e l y demonstrate t h e i r p u l s e t a k i n g a b i l i t y more o f t e n than the members o f the c o n t r o l group. 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 to small sample s i z e . K e r l i n g e r says t h a t " 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 . They are a d v o c a t e d i n o r d e r to g i v e the p r i n c i p l e o f r a n d o m i z a t i o n . . . a chance to 'work.'" 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 esearch, 2nd E d i t i o n (New York: H o l t , R i n e h a r t and Winston I n c . , 1964), p. 128. 125 Because the p r o c e s s o f r a n d o m i z a t i o n may not have been a b l e to e q u a l i z e the 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 exam- i 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 the r e s u l t s . F or example, t h e r e was t w i c e the 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 opposed to f a i n t i n g a t home among the members o f the e x p e r i m e n t a l group. A l s o , not a l l members o f the e x p e r i m e n t a l group had the 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 ; whereas, each 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 the t e a c h i n g and d i s c u s s i o n s e s s i o n s . These f a c t s combined may have c o n t r i b u t e d to the u n r e s o l v e d a n x i e t i e s and subsequent p o o r e r performance on the c o g n i t i v e and psychomotor t a s k s by members o f the e x p e r i m e n t a l group. A n o t h e r p o s s i b l e e x p l a n a t i o n f o r the l a c k o f s t a t i s t i c a l s i g n i f i - cance c o u l d a r i s e o u t o f the 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 e v a l u a t i o n . Knowledge base, 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 and p u l s e t a k i n g a b i l i t y a r e not s o l e l y r e l a t e d to n u r s i n g c a r e . O b v i o u s l y , 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 , the 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 c o n f o u n d i n g v a r i a b l e s . A l t h o u g h the a u t h o r would c o n s i d e r l o o k i n g a t the 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, perhaps p r o c e s s - t y p e i n f o r - mation s h o u l d a l s o be g a t h e r e d . 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 the 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 to 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 determine from the p a t i e n t and f a m i l y which a c t i o n s o f the nurse f a c i l i t a t e d t h e i r l e a r n i n g about h i s pacemaker. 126 The t i m i n g o f the 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 should- a l s o be re-examined. In the h o s p i t a l i n which 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. Both d o c t o r s and nurses attempt to a s s e s s and meet the 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 the e l d e r l y p a t i e n t who has had a permanent pace- maker i n s e r t e d . Many were d e p r e s s e d , weak and l o n e l y and compl a i n e d o f n e r v o u s n e s s , l a c k o f energy and l o s s o f a p p e t i t e . S e v e r a l p a t i e n t s 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 the h o s p i t a l as to t h e i r f u t u r e l i v i n g q u a r t e r s . Not o n l y d i d they have to a d j u s t to 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 ut they a l s o had to become accustomed to l i v i n g i n a new apartment 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 the f i r s t month a f t e r d i s c h a r g e from the h o s p i t a l when the p a t i e n t i s a t t e m p t i n g t o r e i n t e g r a t e h i m s e l f i n t o h i s f o r m e r l i f e s t y l e . A n o t h e r time which might be more a p p r o p r i a t e f o r t e a c h i n g the p a t i e n t i s d u r i n g the pacemaker c l i n i c . About t h r e e months a f t e r the 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 the c l i n i c f o r f o l l o w u p c a r e . I f the p a t i e n t e x p r e s s e s the need f o r i n f o r m a t i o n Or 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 , perhaps t h i s i s the time t o p r o v i d e i t . R a ther 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 the 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 conc e r n s w i t h each 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 , e d u c a t i o n and p r a c t i c e . With 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 but 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 nurse 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 nurse 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 but w i t h the 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 . 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 might 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 d i s c h a r g e . A t t h i s time the nurse 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 hey 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 might be d u r i n g the t h r e e month checkup i n the pace- maker c l i n i c . A study c o u l d be done t h a t would attempt 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 - t i n g . L a s t l y , t h e r e i s a need f o r the development 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 and p r a c t i c e . I t emphasizes 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 to be s u p p o r t i v e to the p a t i e n t but t h a t they a l s o need t o have a c c e s s to 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 but he a l s o m a i n t a i n s the r i g h t to r e f u s e i n f o r m a t i o n . The nurse must be a b l e to 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 . P a t i e n t e d u c a t i o n i s one means o f g i v i n g power to the consumer o f h e a l t h c a r e . 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"An E x p e r i m e n t a l Study 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 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 Columbia, 1974. Goodman, G.W. "An.iExperimental Study to 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 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 Ambulatory 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 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 Columbia, 1972. Kos, B. and C u l b e r t , B. " 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 Implanted C a r d i a c Pacemakers." U n p u b l i s h e d Master'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. 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." U n p u b l i s h e d Master'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." U n p u b l i s h e d 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 Columbia, 1972. S k e l t o n , J.M. "An E x p e r i m e n t a l Study to 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 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 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 Columbia, 1973. Government P u b l i c a t i o n s F i n a l R eport 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. 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 ( E x p e r i m e n t a l Group) I, the u n d e r s i g n e d , 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 un d e r s t a n d t h a t : 1. The aim i s to 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 about pacemakers and to e x p l o r e t h e i r c o n c e r n s . 2. There 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 d i s c h a r g e . 3. I w i l l be asked to f i l l o u t 2 q u e s t i o n n a i r e s (maximum 20 minutes each) d u r i n g t he 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. There a re 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 to withdraw from the p r o j e c t a t any time. S i g n a t u r e 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 the Nurse Date: 140 CONSENT FORM - GROUP 2 ( C o n t r o l Group) I, the u n d e r s i g n e d , agree to 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 t h a t : 1. The aim i s to determine the 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 and t h e i r f a m i l i e s . 2. I w i l l be asked to 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 the 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 minutes. 3. There 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 asked to 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 minutes each to do). 4. There a re 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 to withdraw from the p r o j e c t a t any time. S i g n a t u r e 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 the Nurse Date: 141 A P P E N D I X B SCRIPT AND STORYBOARD FOR THE SLIDE-TAPE PROGRAMME W r i t t e n by: V a l e r i e J . Shannon, B.Sc.N. Produced by: S t u a r t C r y e r and Jean P e d l a r PART 1 YOUR HEART HAS NINE LIVES t-tusic: "Rainbows A l l Over Your B l u e s " W r i t t e n and Performed by John B. S e b a s t i a n Lyrics: "I've been w a i t i n g my t i m e , J u s t t o t a l k t o y o u . You've been l o o k i n a l l down a t the mouth And down a t y o u r shoes Well baby, I've come t o g i v e you the news, I ' l l p a i n t rainbows a l l o v e r y o u r b l u e s . " "Come on, C h a r l i e . You can do i t . " {Shouted by a crowd) {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 days. Look, he i s even h a v i n g t r o u b l e l i f t i n g a b o w l i n g b a l l . " (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 time 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 pace- maker i s the answer f o r y o u r problem." So you a r e about to become the owner o f a h e a r t pacemaker. Your d o c t o r and nurse 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 does, 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 muscle uses e l e c t r i c a l i m p u l s e s produced by a s p e c i a l c e n t e r c a l l e d the n a t u r a l pacemaker. From t h i s n a t u r a l pacemaker, impulses t r a v e l down a c e r t a i n path a l o n g the 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 and to pump b l o o d . 145 Everybody has a n a t u r a l pacemaker However, some h e a r t s don't b e a t i n a h e a l t h y way. Fo r v a r i o u s r e a s o n s , something happens to 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 the usual 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 d i d . § < Bi.ocx.B3 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 . I r r e g u l a r l y . T h i s causes the o t h e r p a r t s o f y o u r body to be d e p r i v e d o f the f o o d and osygen t h a t they need i n o r d e r to do t h e i r j o b . M e d i c a l s c i e n c e has found the answer to t h i s problem. The answer i s to 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 c h a r g e s , WHICH YOU CANNOT FEEL, h e l p y o u r h e a r t beat a t a h e a l t h y and s t e a d y r a t e . Your new pacemaker has t h r e e i m p o r t a n t p a r t s : The b a t t e r y , which s u p p l i e s the e l e c t r i c a l i m p u l s e s 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 to y o u r h e a r t The e l e c t r o d e ; which d e l i v e r s the e l e c t r i c a l c h a r g e s to the h e a r t A l l t h r e e o f th e s e items 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 almos t as w e l l as i t once d i d . You must remember though, t h i s new pace- maker 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 t r o u b l e . 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 about 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 about 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 the 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 usual l e i s u r e time a c t i v i t i e s . H i s 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 form d o e s n ' t d i s a p p o i n t them. to You would be s u r p r i s e d who has a pace- maker today. 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 r e a l l y got t o say, 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 ush 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 shoes, 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: R i c h a r d F a r i n a First Voice: "When I f i r s t got my pacemaker, o r b e f o r e t h a t I s h o u l d say, 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 got the pacemaker n a t u r a l l y I wasn't a b l e to work and t h a t s e t me back and I f e l t bad about i t . But now I can see the l i g h t and w i t h the pacemaker, o r I s h o u l d say, w i t h o u t t he pacemaker, I w ouldn't be a l i v e today." 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 to have t h e r e t o o . " 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 never have t o have one m y s e l f . ' Interviewer: "And now t h a t you have one do you s t i l l f e e l t h a t way about a pacemaker." Third Voice: "No, I don'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 don't weigh ve r y much, so i t ' s heavy and the 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 the pacemaker and I don't know t h a t I have i t w i t h o u t something c a l l my a t t e n t i o n to i t . . . . Having a pacemaker as f a r as I'm c o n c e r n e d , i s no worse than h a v i n g a t o o t h p u l l e d . " When you go home from the h o s p i t a l , you w i l l p r o b a b l y be a b l e to l e a d a normal l i f e l i k e any o t h e r person o f y o u r age. With the h e l p o f the 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 to be c a r e d f o r ant the 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 you lo 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 you s h o u l d ask y o u r d o c t o r about what a c t i v i t i e s you can 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 can: - Bath and shower. Your pacemaker i s com- p l e t e l y p r o t e c t e d a g a i n s t c o n t a c t w i t h 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 you have. - Resume s e x u a l a c t i v i t y . - Go back to work. - T r a v e l by p l a n e , t r a i n , boat, 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 not 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 , choose garments t h a t f i t w e l l and do not put much p r e s s u r e on the s k i n o v e r y o u r pace- 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 padding under the s t r a p on the s i d e o f the 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 the 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: Only 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 grounded. Never use an e l e c t r i c a l i t e m i n damp or wet a r e a s . S p e c i f i c a l l y . . . i f you use an e l e c t r i c r a z o r , do not use i t r i g h t o v e r the 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 you have a microwave oven, s t a n d a t l e a s t t h r e e f e e t from i t . Your 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 because o f the metal i n i t , so b e f o r e g o i n g 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 you have a pacemaker. I f you a r e working on the en g i n e o f y o u r c a r , t u r n o f f the i g n i t i o n . I f you d o n ' 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 pace- maker. 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 he work i n g o f y o u r pace- maker. Your 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 you 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 . I t i s i m p o r t a n t f o r you to t e l l o t h e r 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 you have a pacemaker. They might 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 can and s h o u l d c a r r y w i t h you 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 or a medic a l e r t b r a c e l e t s a y i n g t h a t you a r e the owner o f a pacemaker. A c a r d w i l l be g i v e n t o you b e f o r e you l e a v e the h o s p i t a l . As mentioned i n P a r t 1, the new pacemaker do e s n ' t change y o u r u n d e r l y i n g h e a r t problem so i t i s n e c e s s a r y t h a t you c o n t i n u e t o take the 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 you. There a r e ways t h a t you can determine 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 c a r d a l s o . Your own p u l s e s h o u l d never be more than 5 beats below the r a t e y o u r pacemaker i s s e t a t . 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 he 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 from 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 the number o f beats you f e e l i n s i x t y s e c o n ds. T h a t i s y o u r p u l s e r a t e . 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 the 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 . Your 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 you 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 slows down more than 5 beats per minute, check y o u r p u l s e a second time. I f i t remains a t t h i s lower r a t e , CALL YOUR DOCTOR IMMEDIATELY. A n o t h e r way you 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 , check y o u r p u l s e and C a l l Your D o c t o r . A l t h o u g h t h i s happens r a r e l y , i f you have a f e v e r , a l o n g w i t h r e d n e s s , s w e l l i n g o r d r a i n a g e a l o n g the s c a r where y o u r pace- 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 from 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 the 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 to d i s c u s s t h i s w i t h y o u r d o c t o r . 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 t o 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 to l a s t . Your 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 you r e g u l a r l y . The d o c t o r and you 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 the 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 and drugs y o u may be t a k i n g t o see how w e l l they 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 , which i s done BEFORE the 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 put t o s l e e p w h i l e a new pacemaker system i s put 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 nurse f o r one. I'm s u r e t h a t you 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 d o c t o r o r n u r s e . I n s t r u m e n t a l Music {same as opening) Fifth Voice: " I ' v e had mine i n two y e a r s , J u l y 6 t h . " Interviewer: "Have you had any problems w i t h y o u r pacemaker?" Fifth Voice: "No problems whatsoever." First Voice: "I t a k e a g r e a t i n t e r e s t i n bow l i n g and we bowl t w i c e a week and . . . I have a ne i g h b o u r which 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 the S e n i o r C i t i z e n s . . . . Oh, we're kept p r e t t y busy." Third Voice: " A t f i r s t h a v i n g a pacemaker made me n e r - vous b ut I have been on a p l a n e and I have been on a Mexican c r u i s e and d i d v e r y w e l l . " Interviewer: "Have you been a b l e to 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 whatsoever. In f a c t , I am g o i n g away on A p r i l 23rd on a t r i p . . . W e l l , I might 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 can 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 you know, but I do g et 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 ot to pace y o u r s e l f t o i t you 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 not to be a f r a i d o f a pacemaker because i t i s a wonderful t h i n g and i t h e l p s you and . . . w e l l , what more can I say." Fifth Voice: " H o n e s t l y , i t ' s w o n d e r f u l you know, to have i t t h e r e . I t seems t o g i v e you a l o t more s e c u r i t y . I t h i n k t h a t I might not 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 the A p p r o p r i a t e Response) A c t i v i t y Frequency Reasons f o r (-) Response Reg. Occ. Never No Need No I n t e r e s t Unable A f r a i d d r e s s o n e s e l f f e e d o n e s e l f use the t o i l e t a l o n e b a t h shower c l i m b 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 sex vacuum d u s t wash d i s h e s wash c l o t h i n g by hand washing 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 the lawn do minor house r e p a i r s use a l l e l e c t r i c a l a p p l i a n c e s g r o c e r y shop d r i v e a c a r take a bus take a p l a n e i A c t i v i t y Check L i s t ( c o n t i n u e d ) 160 A c t i v i t y Frequency Reasons f o r (-) Response Reg. Occ. Never No Need I n t e r e s t Unable A f r a i d t ake a b o a t take a t r a i n v i s i t w i t h f r i e n d s g o i n g to c h u r c h p l a y i n g b i n g o p l a y c a r d s watch TV l i s t e n to r a d i o bowl r e c r e a t i o n a l swimming a t t e n d S e n i o r Ci t i zens r e t u r n to p r e v i o u s j o b r e t u r n to l i g h t e r work take own p u l s e h o b b i e s ( l i s t them) o t h e r Were/are you 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 161 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 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 i n s e r t e d ? Yes No In what way? More Less Have you had to 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 to you 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 ) D o c t o r ' s a d v i c e A f r a i d O t h e r 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 ? ( e . g . , w a l k i n g s e v e r a l b l o c k s , vacumning t he house) (a) S h o r t n e s s o f b r e a t h - s e v e r e ' m i l d s l i g h t (b) D i z z y ( c ) T i r e d (d) F e l t f i n e Can the 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 ) demonstrate 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 you a pacemaker i d e n t i f i c a t i o n c a r d ? Yes No Where do you keep i t ? May I see i t ? Have you 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 ? Yes No Why? 162 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 ( c o n t i n u e d ) Have you had any s h o r t n e s s o f b r e a t h ? Chest p a i n ? Wound d r a i n a g e ? What d i d you do? S.O.B. Chest P a i n Wound Dr a i n a g e c a l l e d t h e d o c t o r r e s t e d n o t h i n g o t h e r Are you t a k i n g any m e d i c a t i o n s ? Yes No Which ones and why? Are you f o l l o w i n g any typ e o f d i e t ? What i s y o u r w e i g h t ? don't Know no s c a l e s l o w e r than a t d i s c h a r g e h i g h e r than d i s c h a r g e D i d you r e c e i v e a b o o k l e t about y o u r pacemaker? Yes No Have you r e a d i t ? Yes No _ _ _ I f no, why? No time No i n t e r e s t Don't know O t h e r Was i t h e l p f u l ? Yes No In what way Di 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 time No i n t e r e s t _ How does i t f e e l t o have a pacemaker? No Don't know O t h e r Have you 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 No How o f t e n do you see them? Occ. Never QD 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 ( c o n t i n u e d ) i 163 Do you 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 you have someone w i t h whom you can d i s c u s s y o u r problems? Yes No Are y o u happy w i t h y o u r way o f l i f e a t the moment? Yes No How would you d e s c r i b e y o u r morale ( s p i r i t s ) a t the moment? ( e . g . , low, 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 N o ; A d d r e s s : • Phone: Age: P l a c e o f B i r t h : M a r i t a l S t a t u s : 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) spouse (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 : O c c u p a t i o n : Employed now? When d i d he/she become unemployed r e t i r e 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 : D i s c h a r g e : PACEMAKER i m p l a n a t i o n : D o c t o r : ( i n - h o s p i t a l ) ( f a m i l y ) Surgeon: D i a g n o s i s : P r e v i o u s m e d i c a l 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: 166 i A P P E N D I X E KNOWLEDGE BASE QUESTIONNAIRE I n i t i a l s : INSTRUCTIONS: C i r c l e the l e t t e r t h a t b e s t answers the q u e s t i o n o r s t a t e m e n t . 1. The main purpose o f the h e a r t i s : (a) to pump b l o o d t h r o u g h o u t y o u r body (b) to make y o u r p u l s e r e g u l a r ( c ) to make you f e e l good 2. The h e a r t has a n a t u r a l pacemaker which makes i t b e a t r e g u l a r l y . (a) True (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 r e g u l a r l y . (a) T rue (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 rue (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 to make y o u r h e a r t b e a t r e g u l a r l y . (a) True (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) you w i l l f e e l d i z z y (c ) you 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 y o u r p u l s e 9. When you have an a r t i f i c i a l pacemaker, y o u won't need to v i s i t y o u r d o c t o r r e g u l a r l y . (a) True (b) F a l s e 10. Which a c t i v i t y might 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 organ ( c ) l e a n i n g under the hood o f y o u r c a r when the e n g i n e i s r u n n i n g 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 you to use. (a) True (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 you f e e l worse. (a) True (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 p r o p e r l y . (a) T r u e (b) F a l s e 14.. Why do you take y o u r p u l s e each day? (a) to s t a y i n p r a c t i c e (b) to make the 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 he r a t e s e t on y o u r pacemaker 169 15. What would you do i f you s u s p e c t e d t h a t y o u r pacemaker was n o t wo r k i n g p r o p e r l y ? (a) c a l l t h e d o c t o r i m m e d i a t e l y (b) c a l l the d o c t o r tomorrow a f t e r you have had a good n i g h t ' s s l e e p (c) go to 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) True (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 to l a s t f o r e v e r . (a) True (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 a l e r t b r a c e l e t . (a) o n l y when you go to the d o c t o r (b) a t a l l times (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 run up a f l i g h t o f s t a i r s t o answer y o u r phone. You f e e l y o u r h e a r t r a c i n g and d e c i d e t o take y o u r p u l s e . ( P r e t e n d t h a t y o u r pacemaker r a t e i s 70). Your p u l s e r a t e , a f t e r r u n n i n g up the s t a i r s , i s 90. What does t h i s mean? (a) y o u r pacemaker i s n ' t w o r k i n g p r o p e r l y (b) y o u r own h e a r t i s b e a t i n g f a s t because you have run u p s t a i r s - - t h i s i s normal (c) you s h o u l d c a l l y o u r d o c t o r 20. 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 you have a pacemaker. (a) T r u e (b) F a l s e 170 21. When you 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 to t e l l them t h a t you have a pacemaker. (a) T rue (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 rue (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 STAI FORM X-1 172 NAME DATE DIRECTIONS: A number of statements which people have used to describe themselves are given below. Read each state- ment and then blacken in the appropriate circle to the right of the statement to indicate how you feel right now, that is, at o 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. P 1. I feel calm - © 2. I feel secure - © 3. I am tense - © 4. I am regretful © 5. I feel at ease -•— © 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 © ® ® © ® © ® ® ® ® © ® ® © ® ® ® ® ® ® ® © © © © © ® © © ® © ® ® ® , ® ® © ® ® © © © © ® ® © ® ® © © © © © © © ® ® © © © © 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 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 SELF-EVALUATION QUESTIONNAIRE STAI FORM X-2 173 NAME : DIRECTIONS: A number of statements which people have used to describe themselves are given below. Read each state- ment 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. DATE > S o cn H cn O PJ PJ w z > r v o cn -J > > 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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