Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Postsurgical cataract patients’ home self-care : behaviours, difficulties and concerns Smith, Shelagh Jacqueline 1982

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1982_A5_7 S55.pdf [ 5.8MB ]
Metadata
JSON: 831-1.0095286.json
JSON-LD: 831-1.0095286-ld.json
RDF/XML (Pretty): 831-1.0095286-rdf.xml
RDF/JSON: 831-1.0095286-rdf.json
Turtle: 831-1.0095286-turtle.txt
N-Triples: 831-1.0095286-rdf-ntriples.txt
Original Record: 831-1.0095286-source.json
Full Text
831-1.0095286-fulltext.txt
Citation
831-1.0095286.ris

Full Text

POSTSURGICAL CATARACT PATIENTS' HOME SELF-CARE: BEHAVIOURS, DIFFICULTIES AND CONCERNS  by  SHELAGH JACQUELINE SMITH B . A . S c , The U n i v e r s i t y o f B r i t i s h Columbia, 1950  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING  in THE FACULTY OF GRADUATE STUDIES (School of Nursing)  We a c c e p t t h i s to  t h e s i s as conforming  the r e q u i r e d standards  THE UNIVERSITY OF BRITISH COLUMBIA March 1982  © Shelagh J a c q u e l i n e Smith, 1982  In  presenting  requirements of  British  it  freely  agree for  this f o r an  available  that  I agree  understood  that  that  may  be  fulfilment at the  University shall  and  I  study.  copying  granted  by  f i n a n c i a l gain  or p u b l i c a t i o n  shall  n o t be  allowed  further  the head  of  The U n i v e r s i t y of B r i t i s h 2075 W e s b r o o k P l a c e Vancouver, Canada V6T 1W5  Date  7*  Columbia  my  thesis  without  my  permission.  Department  thesis  It i s  of t h i s  Shelagh  make  of t h i s  h i s or her r e p r e s e n t a t i v e s . copying  of the  the L i b r a r y  f o r extensive  purposes  o r by  degree  f o r reference  permission  scholarly  in partial  advanced  Columbia,  department  for  thesis  J.  Smith  written  ii  ABSTRACT  The specific  purpose  of t h i s  self-care  performance  behaviours  related  e x p l o r a t o r y study  was  to d e s c r i b e  t o the p r o v i s i o n  of eye c a r e and  of d a i l y l i v i n g a c t i v i t i e s , o f p o s t s u r g i c a l c a t a r a c t p a t i e n t s  during t h e i r f i r s t  few weeks a t home f o l l o w i n g c a t a r a c t  twenty s u b j e c t s who of  descriptive  comprised  extraction.  The  the study sample were a l l over s i x t y  years  age, were E n g l i s h s p e a k i n g , had a best c o r r e c t e d v i s u a l a c u i t y i n the  unoperated  eye of 20/50 o r l e s s ,  and had undergone uncomplicated  e r a l s t a n d a r d c a t a r a c t s u r g e r y without  lens implant.  S u b j e c t s were i n t e r v i e w e d i n t h e i r culties jects  that  were e x p e r i e n c e d  homes on two o c c a s i o n s .  and concerns  that  and f a m i l y members i n the performance  management of d a i l y  living  f l u e n c e d the a b i l i t y tified.  unilat-  were expressed  Diffiby  sub-  of eye care procedures, and  r o u t i n e s were r e c o r d e d ; and f a c t o r s which i n -  of s u b j e c t s to manage t h e i r  c a r e a t home were i d e n -  O b s e r v a t i o n s were made of the i n s t i l l a t i o n  of eyedrops,  the ap-  p l i c a t i o n of a p r o t e c t i v e eye s h i e l d , and the s t a t u s of the operated eye. The  findings  m e d i c a t i o n regime, lowed.  opening eyedrop  a high  degree  of adherence  to the p r e s c r i b e d  and to the p r e c a u t i o n a r y measures that were to be  Difficulties  administering  majority  suggest  were r e p o r t e d o r observed  eyedrops,  i n s e v e r a l areas  a p p l y i n g the eye s h i e l d ,  reading  fol-  such  instructions,  c o n t a i n e r s , and o b t a i n i n g p r e s c r i p t i o n s or s u p p l i e s .  of concerns  expressed  were  related  as  to the performance  The  of eye  c a r e procedures, and to the p r o s p e c t i v e v i s u a l outcome of the s u r g e r y .  iii  Examples of f a c t o r s vailability community  of d i r e c t  as a f f e c t i n g home s e l f - c a r e were:  a s s i s t a n c e and e m o t i o n a l  r e s o u r c e s ; the u n d e r s t a n d i n g  covery  process;  ledge,  of expected  skills  identified  support  from  f a m i l y and  o f the s u r g i c a l procedure  the knowledge, and the t i m i n g of the r e c e i p t behaviours;  the a -  and t h e p o s s e s s i o n  and r e of know-  of adequate  manual  t o perform the eye c a r e procedures w i t h competence and c o n f i d e n c e .  Implications  f o r nursing,  medical,  and pharmacist's  d i s c u s s e d , and areas f o r f u r t h e r r e s e a r c h a r e i d e n t i f i e d .  p r a c t i c e are  iv  TABLE OF CONTENTS  ABSTRACT  i i  LIST OF TABLES  v i i  LIST OF FIGURES ACKNOWLEDGEMENTS  viii ix  CHAPTER I  II  INTRODUCTION  1  Purpose of the Study  5  S p e c i f i c Objectives  6  D e f i n i t i o n o f Terms  6  Limitations  8  Assumptions  8  REVIEW OF THE LITERATURE T h e o r e t i c a l and O r g a n i z a t i o n a l Framework  9 9  Medical P r a c t i c e Related to Patients with Cataracts  11  Nursing P r a c t i c e Related to Patients with Cataracts  15  P e r s o n a l and E n v i r o n m e n t a l F a c t o r s that Influence Self-Care Cataract Studies III  METHODOLOGY  18 27 29  S e l e c t i o n of P a r t i c i p a n t s  29  Development of the Instrument  31  C o l l e c t i o n of Data  33  A n a l y s i s of Data  35  V  IV  PRESENTATION AND DISCUSSION OF FINDINGS  36  Sample C h a r a c t e r i s t i c s  36  Eye  40  Care A c t i v i t i e s  Administration of Medications as P r e s c r i b e d  40  P r o t e c t i o n o f Eye from I n j u r y  50  Maintenance of C l e a n l i n e s s o f t h e Eye  54  P r o v i s i o n of Comfort Measures when Necessary R e c o g n i t i o n and R e p o r t i n g o f S i g n i f i c a n t  55  I n d i c a t o r s of C o m p l i c a t i o n  56  S t a t u s of the Operated Eye  57  Continued M e d i c a l  57  General  Supervision  Concerns R e l a t e d  t o t h e Eye  58  Daily Living A c t i v i t i e s  59  L i v i n g Arrangements  60  U t i l i z a t i o n of Community S e r v i c e s Home Maintenance A c t i v i t i e s Self-Maintenance  Activities  Leisure A c t i v i t i e s  61  .  62 62  and E x e r c i s e  P e r s o n a l and E n v i r o n m e n t a l F a c t o r s t h a t Behaviours, D i f f i c u l t i e s and Concerns  . . . .  63 Influence 64  R e q u i s i t e Knowledge and S k i l l s f o r Home Eye Care  65  Understanding o f C a t a r a c t s and C a t a r a c t Surgery  67  Support Systems  69  Length o f H o s p i t a l Stay  70  Demographic F a c t o r s  70  vi  Discussion  71  The Sample  71  Adherence  72  Performance o f R e q u i s i t e S k i l l s f o r Home Eye Care  75  Safety  78  Knowledge and U n d e r s t a n d i n g o f C a t a r a c t s / Cataract  Surgery  79  Demographic V a r i a b l e s V  80  SUMMARY, CONCLUSION, IMPLICATIONS AND RECOMMENDATIONS  81  Summary  81  Conclusions  84  Implications  85  Recommendations f o r F u r t h e r Research  91  BIBLIOGRAPHY  92  APPENDICES A.  Information  f o r Prospective  Subjects  B.  Subject  C.  L e t t e r of Agreement f o r Eyedrop  Consent Form  Administration  100 103  106  D.  Interview  E.  Discharge I n s t r u c t i o n Handout  124  F.  R e s u l t s o f Eye S t a t u s O b s e r v a t i o n s  126  G.  R e s u l t s o f A n a l y s i s f o r A s s o c i a t i o n Among S e l e c t e d V a r i a b l e s U s i n g F i s h e r Exact T e s t . . . . 128 P a t i e n t S u g g e s t i o n s t h a t F a c i l i t a t e Compliance w i t h Recommendations 131  H.  Guide  108  k  vii  LIST OF TABLES  1.  2.  Examples of Expected Eye Care B e h a v i o u r s : Adherence, Comprehension, D i f f i c u l t i e s , Concerns, Questions D e l e g a t i o n of R e s p o n s i b i l i t y f o r Eyedrop Instillation,  3.  41  F i r s t and Second V i s i t  Summary o f Reported D i f f i c u l t i e s , Frequency, and Person  . . . .  43  by Type, 49  4.  Eye S h i e l d D i f f i c u l t i e s  5.  D i s c o m f o r t s by Frequency, S e v e r i t y and Comfort Measures  55  Indicators of P o s s i b l e Complications P e r c e p t i o n of Need t o Report  57  6.  7.  by Type and Frequency  51  and S u b j e c t ' s  Methods of T r a n s p o r t t o M e d i c a l Appointments by Type and Frequency  58  8.  L i v i n g Arrangements P o s t s u r g e r y by Change and Sex  9.  U t i l i z a t i o n o f Community S e r v i c e s Pre and Postsurgery Eyedrop I n s t i l l a t i o n : Demonstration by P r e v i o u s Experience  10.  11.  60  61 66  S u b j e c t ' s Comprehension o f C a t a r a c t s and C a t a r a c t Surgery  12.  R e s u l t s of Eye S t a t u s O b s e r v a t i o n s  13.  T w o - t a i l e d S i g n i f i c a n c e L e v e l s of F i s h e r Exact of A s s o c i a t i o n Among S e l e c t e d Eye Care and Demographic V a r i a b l e s  68 127 Tests 130  viii  LIST OF FIGURES  1.  An I n t e r a c t i o n a l Model o f H e a l t h Care  11  2.  Age and Sex D i s t r i b u t i o n s of S u b j e c t s  37  3.  S e l e c t e d H e a l t h R e l a t e d C h a r a c t e r i s t i c s of Subjects  39  Observations Eyedrops  45  4.  5.  of Home A d m i n i s t r a t i o n o f P r e s c r i b e d  P a t i e n t Adherence t o Eye C l e a n s i n g Instructions  54  ix  ACKNOWLEDGEMENT S  There  a r e a number  o f people  who c o n t r i b u t e d t o the e x e c u t i o n o f  t h i s r e s e a r c h p r o j e c t whose a s s i s t a n c e I wish t o acknowledge.  I wish e s -  p e c i a l l y t o thank the members of my t h e s i s committee, S h e i l a Stanton, Ann Hilton  and Stephen  criticism.  Drance  f o r their  support,  A p p r e c i a t i o n i s a l s o extended  guidance  and c o n s t r u c t i v e  t o Mark S t a r r f o r h i s h e l p w i t h  c o d i n g techniques and computer u s e . I nurses lar  am  grateful  f o r t h e a s s i s t a n c e and i n t e r e s t  and o p h t h a l m o l o g i s t s who c r i t i q u e d  a p p r e c i a t i o n i s conveyed  the interview guide.  of encouragement.  Particu-  t o t h e o p h t h a l m o l o g i s t s who h e l p e d  the p a r t i c i p a n t s f o r t h e study, and whose i n t e r e s t source  of the o p h t h a l m i c  I am a l s o  indebted  and enthusiasm  t o t h e study  obtain were a  participants  themselves, who g e n e r o u s l y gave of t h e i r time and made me f e e l welcome i n t h e i r homes. F i n a l l y , I f e e l deeply g r a t e f u l t o my f a m i l y f o r t h e i r c o - o p e r a t i o n , and  f o r having  ours.  c o n f i d e n c e i n my a b i l i t y  A very s p e c i a l r e c o g n i t i o n  ways had time t o l i s t e n .  t o succeed  i s saved  i n academic  endeav-  f o r my husband E r i c , who a l -  1  CHAPTER  ONE  INTRODUCTION  . Cataract  surgery  for  documented as e a r l y as the  present  time  the  1000  between  mechanism  of  cataract  cataract,  appears  the l e n s . in  older  Senile  85  1978;  persons  (Stedman, 1972,  i s not  well  Shock, 1978),  and  the  crystalline  p. 214).  The but  but  the  occur  as  percent  of  some s y s t e m i c d i s e a s e s most  a  natural  part  It i s reported  a l l people have  are recognized  (Shafer,  common form  characteristically  t o x i c chemi-  are  the  associated  aging  effect  Beck,  both  eyes,  In a recent  other.  acid retards  o f t e n the  the  senile process  80 years of  some degree of  i s considerably  acetylsalicylic  structure  cataract,  that by  McCluskey,  precise  cataracts  clouding  as the most common cause of  Sawyer,  worse than the  of  of  and  that  At are  Radiation,  c a t a r a c t development i s u n p r e d i c t a b l e ,  reports  is  extractions  understood,  development of o p a c i t y .  f a c t o r s , and  to  Cataracts  cataracts  eye  (Shock, 1978).  "a l o s s of t r a n s p a r e n c y of  Gardener, 1979).  approximately  (Jaffe,  i n the  p r o t e i n undergoes a change i n m o l e c u l a r  formation,  (Kwitko, 1978;  as  formation  lens  trauma, g e n e t i c cataract  lens  500,000 c a t a r a c t  States  or of i t s c a p s u l e "  that r e s u l t s i n gradual  with  opaque  of t h a t number are performed i n Canada (Kwitko, 1978).  develop when the  cals,  an  i n Sanskrit writings  United  A cataract i s defined l e n s of the eye,  B.C.  400,000 and  performed each y e a r i n the about t e n percent  removal of  &  the  cataract  1975). rate  i n one  study, C o t l i e r  development  of  blindness  Phipps,  but  age,  of eye  (1981)  of  cataracts.  However, once the l e n s i s opaque, s u r g i c a l removal i s the o n l y  treatment.  2  Teaching will  enable  p a t i e n t s and f a m i l y members the knowledge and s k i l l s them  t o manage  their  own  care  a t home  that  following cataract  s u r g e r y , and a r r a n g i n g f o r a s s i s t a n c e from community s e r v i c e s t o f a c i l i t a t e home s e l f - c a r e ,  i s an important  component of n u r s i n g p r a c t i c e .  Two  t r e n d s e v i d e n t i n t h e r e c e n t l i t e r a t u r e have p a r t i c u l a r import f o r nurses c a r i n g f o r p a t i e n t s undergoing  c a t a r a c t surgery;  cataract  e x t r a c t i o n s performed  on persons  creasing  (Nadler & Schwartz, 1980), and s e c o n d l y ,  s t a y i s d e c r e a s i n g ( G a l i n , Baras., Barasch, Williamson,  over  of age i s  a t a r a t e of 4.9 p e r c e n t  population  during  statistics  indicate  1968 t o 1976; t h e number of  per year.  the same p e r i o d  technology  a  similar  that  enables  65 y e a r s  a r e suggested  as f a c t o r s  of age  T h i s f i g u r e was age con-  over the r a t e of age s h i f t  (Nadler  trend  over  & Schwartz,  (Statistics  more e l d e r l y  1980).  Canada,  persons  influencing  i n the Canadian  1969, 1977).  to t o l e r a t e  gery, and an i n c r e a s e d demand on t h e p a r t of t h e e l d e r l y vision,  in-  the l e n g t h of h o s p i t a l  cataract extractions f o r individuals  so t h a t i t r e f l e c t s an excess  Improved  65 years  1978).  intracapsular  trolled  the numbers of  & Boniuk, 1974; K i d g e r , 1977;  In t h e U n i t e d S t a t e s , d u r i n g t h e y e a r s  increased  firstly,  sur-  f o r functional  the i n c r e a s e  i n r a t e of  i n t r a c a p s u l a r c a t a r a c t e x t r a c t i o n s (Nadler & Schwartz, 1980). Available v o l v e persons  data over  Schwartz, 1980). increased  and  (Brody,  65 y e a r s  the  1980).  t h a t 70 p e r c e n t  of c a t a r a c t procedures i n -  of age ( S t a t i s t i c s  Canada,  1977; Nadler  &  T h i s p a r t i c u l a r p o p u l a t i o n has, d u r i n g t h e p a s t decade,  by 23 p e r c e n t w h i l e  6.3 p e r c e n t . age,  indicate  Within this  t h e under  65 age group  i n c r e a s e d by o n l y  e l d e r l y group, 38 p e r c e n t a r e over 75 y e a r s of  85-and-over-group  a r e assuming  increasing  proportions  3  This  population  shift,  concomitant  with  the i n c r e a s e d  i n c i d e n c e of  c a t a r a c t e x t r a c t i o n s among the e l d e r l y , s i g n i f i e s an i n c r e a s e of e l d e r l y people t h a t w i l l need c a r e . alone  or with  veloping of  an e q u a l l y  the necessary  eye c a r e  that  second  current age  trend,  interest.  length  7.6 days  that  (Brody,  and r o u t i n e  may p r e s e n t  of reduced  live  1980), and many a r e de-  make s e l f - c a r e d i f f i c u l t .  procedures  home f o l l o w i n g h o s p i t a l d i s c h a r g e The  Many of these e l d e r l y people  e l d e r l y spouse  p h y s i c a l handicaps  i n numbers  living  Performance a c t i v i t i e s at  problems.  h o s p i t a l stay,  i s a subject  of  N a d l e r and Schwartz (1980) r e p o r t a decrease i n a v e r -  f o r h o s p i t a l stay  i n 1968 t o 4.8 days  of i n t r a c a p s u l a r i n 1976.  cataract  extraction  from  In a s i m i l a r time p e r i o d , the  average h o s p i t a l s t a y i n Canada f o r i n t r a c a p s u l a r e x t r a c t i o n changed from 12.3  days  t o 7.9 days  also  reported  i n the  Thompson, 1980; K i d g e r , Improvements  United  Canada,  Kingdom  (Boyd-Monk, 1977). curred  with  Several  Banerjee,  development  and t h e use of an o p e r a t i n g  restrictions  This  trend i s  Traynar,  of a c t i v i t y  risk  of f i n e r  instru-  microscope have of c o m p l i c a t i o n  a r e no l o n g e r  considered  reduced so t h a t  necessary  These f a c t o r s , p l u s the obvious economic b e n e f i t s i n -  reduced  hospital  stay,  have  influenced  medical  authors r e p o r t p r a c t i c e s wherein p a t i e n t s undergo an o u t p a t i e n t  1979;  Low, 1978), o r a r e admitted as day cases and a r e d i s c h a r g e d  claim  that  basis  (Williamson,  cataract  on  hours f o l l o w i n g s u r g e r y  ambulatory  practice.  gery  authors  &  1977).  the i n t r a o p e r a t i v e and p o s t o p e r a t i v e  stringent  1969, 1976).  (Ingram,  i n s u r g i c a l techniques,  ments and s u t u r e s , both  (Statistics  1978; V u k c e v i c h ,  ( G a l i n e t a l . , 1974; Ingram e t a l . , 1980).  there  i s no s i g n i f i c a n t  difference  sur-  a few These  i n the r a t e o f  4  complications stay.  or i n the v i s u a l outcome r e l a t e d to the decreased  However, these  r e l a t i v e s and  criteria  do not  decreased  t e a c h i n g and  "the  extra effort  f r i e n d s of the p a t i e n t s i n c a r i n g f o r them i n the  p o s t o p e r a t i v e phase" ( S t r a c h a n the  consider  hospital  h o s p i t a l stay  & Bowell, will  discharge planning  give  aspects  1972, nurses  p. 629), less  of n u r s i n g  nor  time  immediate  the f a c t  which  are  follow a prescribed medical presented  in  the  (1976), e f f e c t i v e t e a c h i n g not  only  the  necessary  knowledge  based on an u n d e r s t a n d i n g tant  to him.  tients for  An  chapter.  of p a t i e n t s and and  so  to  of  Davies include  teaching  must  be  of the p a t i e n t ' s environment and what i s impor-  understanding  that  the  pro-  details  According  but  of  the  experiences  have a t home f o l l o w i n g h o s p i t a l d i s c h a r g e  nurses,  care  f a m i l y members s h o u l d  skills,  the  care.  regimen a t home, the  following  that  to p r o v i d e  P o s t s u r g i c a l c a t a r a c t p a t i e n t s are expected to p e r f o r m eye cedures and  made by  they  can  make t h e i r  t h a t p o s t s u r g i c a l pai s therefore  teaching  relevant  important  and  approp-  riate. Discharge  planning  w i t h p a t i e n t needs.  is  contingent  In B r i t i s h  on  Columbia  matching there  available  resources  i s a government  financed  Home Care Programme which p r o v i d e s , among o t h e r s e r v i c e s , n u r s i n g homemaker 1976).  This  Columbia 70). is  visits,  meals  service  (British  on  wheels,  i s a v a i l a b l e to  Columbia  Ministry  Nurses are i n s t r u m e n t a l  of  and 80%  transportation of  Health  the  residents  Annual  visits,  (McClelland, of  Report,  British 1980,  p.  i n o r d e r i n g Home Care s e r v i c e s i f the need  perceived. Few  their  studies  describe  s e l f - c a r e at  the  way  p o s t s u r g i c a l c a t a r a c t p a t i e n t s manage  home f o l l o w i n g h o s p i t a l d i s c h a r g e .  Little  i s known  5  about t h e changes i n l i v i n g concerns ience. aract of  and d i f f i c u l t i e s  p a t t e r n s the s u r g e r y may n e c e s s i t a t e , or t h e  these  With more knowledge c a r e , h o s p i t a l nurses  p a t i e n t s and t h e i r  may  exper-  of t h e home component of p o s t s u r g i c a l c a t would be b e t t e r a b l e t o f u l f i l l  t e a c h i n g and a s s i s t i n g w i t h  discharge  planning,  would be a s s i s t e d i n i d e n t i f y i n g s i t u a t i o n s be  families  their  roles  and community  nurses  i n which n u r s i n g care  should  provided. In summary, t h e t r e n d s of d e c r e a s i n g l e n g t h of h o s p i t a l s t a y f o r an  i n c r e a s i n g number of e l d e r l y p a t i e n t s undergoing tuate  t h e importance  of t h e t e a c h i n g and d i s c h a r g e  n u r s i n g c a r e of p o s t s u r g i c a l c a t a r a c t p a t i e n t s . ens  to patients after  c a t a r a c t surgery  they  planning  accen-  a s p e c t s of  Knowledge of what happ-  go home from h o s p i t a l  charge t e a c h i n g and p l a n n i n g a r e t o be e f f e c t i v e .  i s essential  i f dis-  The d e a r t h of i n f o r -  mation a v a i l a b l e r e g a r d i n g home s e l f - c a r e of c a t a r a c t p a t i e n t s s t i m u l a t e d this  study.  Purpose o f the Study The iours  purpose of t h i s study was t o d e s c r i b e s p e c i f i c  of i n d i v i d u a l s  over  60 y e a r s  weeks a t home f o l l o w i n g uncomplicated aract  extraction; to i d e n t i f y  self-care  of age d u r i n g t h e f i r s t  behav-  two t o t h r e e  i n t r a c a p s u l a r or extracapsular c a t -  difficulties  and concerns  experienced  by  these p a t i e n t s and f a m i l y members; and t o d e s c r i b e p e r s o n a l and e n v i r o n mental f a c t o r s t h a t a f f e c t e d t h e b e h a v i o u r s ,  difficulties  or c o n c e r n s .  6  Specific The  Objectives  s i x o b j e c t i v e s o f the study were as f o l l o w s :  1.  To d e s c r i b e s e l e c t e d b e h a v i o u r s r e l a t e d t o the p r o v i s i o n of eye care i n the f o l l o w i n g a)  Administration  b)  P r o t e c t i o n of the eye from i n j u r y .  c)  Maintenance o f c l e a n l i n e s s o f the eye.  d)  P r o v i s i o n of comfort measures when n e c e s s a r y .  e)  Ability  to  possible f) 2.  categories: of m e d i c a t i o n s as p r e s c r i b e d .  recognize  and  report  significant  indicators  of  complications.  Arrangement f o r c o n t i n u e d  medical  To a s s e s s p r o v i s i o n s f o r accomplishment  supervision. of a c t i v i t i e s  of d a i l y  liv-  ing. 3.  To d e s c r i b e d i f f i c u l t i e s the p r o v i s i o n of eye c a r e daily  i d e n t i f i e d by p a t i e n t s o r f a m i l y members i n o r i n the accomplishment  of a c t i v i t i e s of  living.  4.  To d e s c r i b e  concerns e x p r e s s e d by p a t i e n t s and f a m i l y members.  5.  To i d e n t i f y  personal  and e n v i r o n m e n t a l  s e l f - c a r e behaviours, d i f f i c u l t i e s 6.  To a s s e s s the s t a t u s c a t i v e of p o s s i b l e  factors  that  i n f l u e n c e d the  or c o n c e r n s .  of the o p e r a t e d eye and r e p o r t  any s i g n s  indi-  complications.  D e f i n i t i o n o f Terms S p e c i f i c s e l f - c a r e behaviours: eye  care  daily  procedures  living.  Actions  and t o p r o v i d e  taken by the p a t i e n t t o c a r r y out  f o r t h e e s s e n t i a l requirements of  7 Uncomplicated I n t r a c a p s u l a r o r E x t r a c a p s u l a r a)  Uncomplicated:  No u n u s u a l o r untoward happenings e i t h e r d u r i n g the  s u r g i c a l procedure o r d u r i n g orrhage,  major  loss  the h o s p i t a l s t a y , e.g. e x p u l s i v e hem-  of v i t r e o u s ,  wound r u p t u r e , s e r i o u s m e d i c a l b)  i t s capsule,  lens c)  endophthalmitis,  iritis,  i e . without  Removal of the c a t a r a c t o u s  planned  or a c c i d e n t a l rupture  lens  of the  capsule.  Extracapsular cataract e x t r a c t i o n :  Removal o f the n u c l e a r and c o r t -  i c a l m a t e r i a l , l e a v i n g the p o s t e r i o r c a p s u l e Concern:  severe  event.  Intracapsular cataract extraction: in  Cataract E x t r a c t i o n  i n place.  A s i t u a t i o n t h a t was p e r c e i v e d by p a t i e n t s or f a m i l y members as  s t r e s s f u l , c a u s i n g worry, o r t h a t s t i m u l a t e d a q u e s t i o n . Difficulty:  A circumstance  member as hard  t h a t was p e r c e i v e d  t o do, understand  by the p a t i e n t or f a m i l y  o r surmount;  that  posed  a problem o r  obstacle. Personal a)  and E n v i r o n m e n t a l F a c t o r s  Personal  factors:  Examples  were  t i o n i n g , knowledge and s k i l l s ual  a c u i t y , hearing,  i n g s of c o n f i d e n c e , tus,  previous  experience  with  dexterity, physical  r e l a t e d t o home care  perceptions education  manual  of the s u r g i c a l  level,  of the eye, v i s experience,  feel-  e t h n i c background, h e a l t h  eye s u r g e r y  func-  or i n s t i l l a t i o n  sta-  o f eye  drops. b)  Environmental support  factors:  Examples were f a m i l y , s o c i a l and community  groups, smoking s t a t u s , housing,  l e n g t h of s t a y i n h o s p i t a l ,  neighbourhood  transportation, proximity  environment, of s t o r e s and  o t h e r s e r v i c e s , socio-economic s t a t u s , season of the y e a r .  8 Activities basis  to  of  Daily  provide  Living:  for  basic  i n a t i o n , s a f e t y , s h e l t e r and Signs  Indicative  conjunctiva, crusting  of  of  hazy the  Actions needs  that  of  are undertaken  rest,  eye  a regular  exercise, nutrition,  elim-  companionship.  Possible Complications:  cornea,  on  shallow  anterior  lashes, severe  Swollen chamber,  lids,  unduly  unusual  red  discharge,  headache, browache, nausea,  pain i n  the eye, change i n v i s i o n .  Limitations C a u t i o n must be used of  i n generalizing  the s m a l l sample s i z e  selection. and  The  data  (N =  20),  collection  and  results  of  this  the convenience  method which  used  study  because  method of  open-ended  sample  questions  o b s e r v a t i o n s i n a d d i t i o n t o s t r u c t u r e d items, i n t r o d u c e d the r i s k  bias  both  in  the  interpretation  of  subject's  responses  to  of  open-ended  i t e m s , and i n the a c c u r a t e r e c o r d i n g of p a t i e n t b e h a v i o u r s .  Assumptions For t h i s study sonal  and  i t was  environmental  assumed  factors  t h a t behaviour  are  important  c a r e p r o c e s s , i n t e r a c t i n g w i t h m e d i c a l and the outcome of h e a l t h c a r e .  of p a t i e n t s ,  components  nursing practice  of  and  per-  the h e a l t h  to i n f l u e n c e  9  CHAPTER REVIEW OF THE  T h i s l i t e r a t u r e review p r o v i d e s surgical  cataract  patients'  II  LITERATURE  a perspective  self-care  presented i n f i v e s e c t i o n s :  f o r the study of  behaviours.  1) t h e o r e t i c a l and  The  review  related  to  patients  with  cataracts;  f a c t o r s that i n f l u e n c e patient's  4)  is  o r g a n i z a t i o n a l framework;  2) m e d i c a l p r a c t i c e r e l a t e d t o p a t i e n t s w i t h c a t a r a c t s ; 3) n u r s i n g tice  post-  personal  and  s e l f - c a r e b e h a v i o u r s ; and  prac-  environmental 5) s t u d i e s  of  p o s t s u r g i c a l c a t a r a c t p a t i e n t s i n t h e i r homes.  T h e o r e t i c a l and Psychological  theories  categories,  firstly  between the  stimulus  and in  of  Organizational behaviour  may  those t h a t contend t h a t and  the  response,  Framework be  divided  there  into  two  is a direct  minimizing  mediating  main  connection variables,  s e c o n d l y those t h a t view the m e d i a t i n g v a r i a b l e s as important f a c t o r s a behavioral  category  are  response.  Thorndike,  Examples of Pavlov,  work i n the h e a l t h c a r e f i e l d may niques and The tors  govern the  46-77).  and  Skinner,  and  mentioned of  their  be seen i n behaviour m o d i f i c a t i o n  tech-  the  psychologists,  reception  of  stimuli,  who their  contend  uses  that  mediating  reorganization,  G e s t a l t i s t s , such as K o h l e r and  such as Lewin and personality  Watson  first  programmed l e a r n i n g .  second group of  sponse, a r e  t h e o r i s t s i n the  Koffka;  and  field  Tolman; phenomenologists, such as Combs and  theorists,  such  as  Freud  and  Maslow  (Clayton,  the  facre-  theorists, Snygg; 1965,  and p.  10  T h e o r i e s of t h i s second group o f p s y c h o l o g i s t s a r e a p p e a l i n g t o many health professionals behaviour,  because they p r o v i d e a r a t i o n a l e  and a f o c u s f o r i n t e r v e n i n g t o modify  f o r understanding  behaviours  i n a direc-  t i o n t h a t w i l l f o s t e r p o s i t i v e h e a l t h outcomes. The  major  concepts  inherent  i n t h e work  (1958), and Combs and Snygg (1959),  are:  of Lewin  1) t h a t  both i n t e r n a l and e x t e r n a l t o the i n d i v i d u a l ,  (1951),  a variety  Tolman  of f a c t o r s ,  i n f l u e n c e behaviour; and 2)  t h a t the i n d i v i d u a l ' s p e r c e p t i o n of a s i t u a t i o n i s an important f a c t o r i n mediating behaviour. nursing 1974; is  models  These concepts have become a c e n t r a l theme of many  (Campbell,  Roy, 1974).  C r u i s e & Murakami,  The importance  r e c o g n i z e d , and a c t i v e p a t i e n t  cess  i s encouraged.  nurse, i s changing  The r o l e  1976; K i n g ,  1968; Neuman,  of c o n s i d e r i n g the p a t i e n t ' s v i e w p o i n t p a r t i c i p a t i o n i n the h e a l t h c a r e  pro-  of the h e a l t h p r o v i d e r , p a r t i c u l a r l y the  from one of d o i n g t h i n g s f o r o r t o the p a t i e n t ,  to a  more c o l l a b o r a t i v e r e l a t i o n s h i p where the p a t i e n t i s h e l p e d t o assume h i s own s e l f - c a r e  (Kinlein,  1977; N o r r i s ,  1979).  An o r g a n i z a t i o n a l framework which i n c o r p o r a t e s the concepts of media t i n g f a c t o r s i n behaviour, t i o n s h i p , has been adapted model proposed  and the c o l l a b o r a t i v e  patient/provider r e l a -  f o r t h i s study from a h e a l t h s e r v i c e s r e s e a r c h  by S t a r f i e l d  (1973).  model wherein  patients,  nurses  health care.  The outcome of such  Figure 1 i l l u s t r a t e s  and d o c t o r s  this  adapted  a r e seen  as c o - p r o v i d e r s of  c a r e i s the r e s u l t  of the i n t e r a c t i o n  of p a t i e n t behaviour, p e r s o n a l and e n v i r o n m e n t a l f a c t o r s , and m e d i c a l and nursing p r a c t i c e . now be d i s c u s s e d .  The v a r i o u s a s p e c t s o f t h i s  interactional  model  will  11  ]////\ Outcome  Figure  1.  An I n t e r a c t i o n a l Model o f H e a l t h Care  Medl c a l P r a c t i c e R e l a t e d to P a t i e n t s The m e d i c a l p r a c t i c e the  literature.  component  gical  Cataracts  of the model i s w e l l  Many authors d e s c r i b e  new i n s t r u m e n t s and suture m a t e r i a l s ,  with  v a r i a t i o n s i n s u r g i c a l procedures, v a r i a t i o n s i n h o s p i t a l and p o s t s u r -  management, p r e v e n t i o n and c o n t r o l o f c o m p l i c a t i o n s ,  v i s u a l outcomes.  However,  documented i n  the d i s c u s s i o n  i n this  and  section w i l l  resultant be  limit-  12  ed  t o aspects  t h a t have r e l e v a n c e  t o the s e l f - c a r e  behaviours  of p o s t -  surgical cataract patients. Cataract to  operate  surgery  I s u s u a l l y an e l e c t i v e procedure,  i s c u s t o m a r i l y made when the v i s u a l  b e t t e r eye had decreased performed general  (Jaffe,  a c u i t y i n the p a t i e n t ' s  t o t h e p o i n t where normal a c t i v i t i e s  1978).  anaesthetic,  and the d e c i s i o n  The s u r g e r y  depending  upon  may  be performed  cannot be  under  the s u r g e o n / p a t i e n t  l o c a l or  p r e f e r e n c e and  the p a t i e n t ' s m e d i c a l s t a t u s . There a r e two b a s i c techniques  f o r c a t a r a c t removal;  the i n t r a c a p -  s u l a r t e c h n i q u e which removes t h e l e n s and i t s c a p s u l e , and the e x t r a c a p s u l a r technique  i n which the c a p s u l e  removed, and the p o s t e r i o r c a p s u l e standard  procedures  closed with  left  either  a t the c o r n e a l - s c l e r a l  direct  the c o r t e x and n u c l e u s  i n place.  the l e n s i s removed through  which i s made s u p e r i o r l y is  i s ruptured,  or running  Customarily  i n these  an 11 - 18 mm.  incision  junction.  The i n c i s i o n  multiple fine sutures.  The de-  gree o f r e a c t i o n and d i s c o m f o r t p o s t o p e r a t i v e l y depends t o some e x t e n t on the s i z e and type of s u t u r e m a t e r i a l used, and whether knots  a r e l e f t ex-  posed o r a r e b u r i e d (Troutman, 1971). Complications Weinstock, cases tion  1978),  related  and v i s u a l  the s u r g e r y  improvement  are rare  i s achieved  (Gardener,  (Luckman  & Sorensen,  loss,  retinal  1980, p. 1992).  uveitis,  of  refrac-  O c c a s i o n a l l y the f o l l o w i n g  i n f e c t i o n , hemorrhage, wound d i s r u p t i o n ,  detachment,  1979;  i n 95 p e r c e n t  of standard c a t a r a c t s u r g e r y when combined w i t h c o r r e c t i v e  c o m p l i c a t i o n s may o c c u r : ous  to  or glaucoma  (Havener,  vitre-  Saunders,  K e i t h , & P r e s c o t t , 1974, chap. 11; Johnson, 1978; Smith & Nachazel, 1980, chap. 5 ) .  P o s t o p e r a t i v e l y , p a t i e n t s a r e taught  precautionary  measures  13  d e s i g n e d t o reduce  t h e o c c u r r e n c e of c o m p l i c a t i o n s .  c u s s i o n of p a t i e n t t e a c h i n g i s p r e s e n t e d ing  A more d e t a i l e d  i n the ensuing  dis-  s e c t i o n on n u r s -  practice. Mydriatic,  anti-inflammatory,  ments may be p r e s c r i b e d t o be used cataract  surgery  t o reduce  and a n t i b i o t i c  and/or  oint-  f o r s e v e r a l weeks f o l l o w i n g s t a n d a r d  the r i s k  of c o m p l i c a t i o n s , and t o i n c r e a s e  comfort  (Smith & Nachazel,  1980).  As  the l e n s n o r m a l l y  c o n t r i b u t e s about  power of the eye (Smith & Nachazel,  eyedrops  one-quarter  of the f o c u s i n g  1980), i t s f u n c t i o n must be r e p l a c e d  by some form of o p t i c a l c o r r e c t i o n such as s p e c t a c l e s , c o n t a c t l e n s e s o r an i n t r a o c u l a r l e n s i m p l a n t .  The advantages and disadvantages  these c o r r e c t i v e measures a r e important  f o r p a t i e n t s to c o n s i d e r .  C a t a r a c t s p e c t a c l e s c r e a t e many d i f f i c u l t i e s . approximately of  vision  of each of  Objects are magnified  30 p e r c e n t , p e r i p h e r a l images a r e d i s t o r t e d , and the f i e l d  i s reduced.  The weight  of t h i c k l e n s e s i s uncomfortable, and  the cosmetic appearances a r e o b j e c t i o n a b l e t o a number o f people  (Jaffe,  1978).  plastic  Some a m e l i o r a t i o n of these problems may be o b t a i n e d w i t h  l e n s e s which a r e l i g h t e r i n weight than g l a s s l e n s e s , and w i t h new manufacturing  techniques  which  reduce  peripheral distortion.*  The s p a t i a l  d i s o r i e n t a t i o n a s s o c i a t e d w i t h c a t a r a c t s p e c t a c l e s r e q u i r e s major a d j u s t ments and i s d i f f i c u l t performed  f o r many p e o p l e .  I n o n l y one eye, the d i s c r e p a n c y  binocular vision (Jaffe,  R i c h a r d Stewart; 1981.  In a d d i t i o n , i f s u r g e r y has been i n size  of images  precludes  1978).  D i s p e n s i n g O p t i c i a n ; p e r s o n a l communication, June  14  A contact eral vision.  l e n s produces l e s s d i s t o r t i o n and Objects  o c u l a r v i s i o n can  be a c h i e v e d  However, management dexterity,  which  are m a g n i f i e d  contact  lenses  older  persons  often  o f f e r a viable option  d a i l y i n s e r t i o n and p.  be to  only f i v e  to t e n p e r c e n t ,  i n i n s t a n c e s when o n l y one  of  wear l e n s e s , ones which may may  by  permits adequate p e r i p h -  requires lack.  a high  The  eye  so  is  degree  bin-  aphakic.  of  manual  p e r f e c t i o n of  extended  worn f o r s e v e r a l months without  removal,  those persons who  removal of a c o n t a c t  lens  are unable to manage (Luckman & Sorensen,  the 1980,  1992-96). Permanent c o r r e c t i o n w i t h  glasses  l a y e d u n t i l changes i n r e f r a c t i o n due lized  - a period  temporary  spectacles  c o r r e c t i o n are The that  the  entailing  with  of  patient's  two  three  States  v i s i o n , and  a plastic  three  lens, with  lens,  According  there  that  i s no  the  to  is a  Occasionally the  permanent  of  J a f f e (1978),  power s i m i l a r to  optical at  the  cataract operations The  correction time  of  m a g n i f i c a t i o n produced  his  peformed  advantages of the i s only  p a t i e n t s have u s e f u l v i s i o n almost immediately.  to J a f f e (1976),  good, but  have s t a b i -  months.  optical  method  in  intraone  short  The  to  implant-  to accommodate, so r e a d i n g g l a s s e s  worn f o r c l o s e work (Luckman & Sorensen,  cording  de-  s p a t i a l d i s o r i e n t a t i o n or abnormal p e r i p h e r a l  ed l e n s does not have the a b i l i t y to be  to  involved a lens i n p l a n t .  l e n s a r e namely: percent,  i s usually  power a p p r o x i m a t i n g  w r i t i n g a p p r o x i m a t e l y one-quarter of the  ocular  lenses  to the h e a l i n g process  refractive  natural  i n popularity.  the U n i t e d  contact  provided.  implantation  of  gaining  commonly  or  term r e s u l t s of  1980, the  t h e r e a r e as y e t no w e l l documented l o n g  p.  need  1992-96).  Ac-  i n t r a o c u l a r lens term s t u d i e s .  are  For  a  15  young i n d i v i d u a l t h e r e but  f o r older,  i s a question  dextrously  impaired  of l o n g persons,  term i n t r a o c u l a r  tolerance,  the i n t r a o c u l a r lens  offers  many advantages.  Nursing P r a c t i c e Related  to Patients with  Cataracts  Because t h i s study i s concerned w i t h p o s t s u r g i c a l c a t a r a c t at  home, the d i s c u s s i o n o f n u r s i n g  patients  c a r e w i l l be l i m i t e d t o those measures  t h a t h e l p p a t i e n t s and f a m i l y members assume r e s p o n s i b i l i t y f o r s e l f - c a r e at  home f o l l o w i n g  that  h o s p i t a l discharge.  are pertinent  t o home eye c a r e  have been s e l e c t e d from n u r s i n g 96;  Widely  accepted  f o r postoperative  articles  (Berkoben,  cataract  patients  t e x t s (Luckman & Sorensen, 1980, p. 1992-  Shafer e t a l . , 1975, chap. 31; Smith & Nachazel,  journal  recommendations  1978; Boyd-Monk,  1977;  1980, chap. 5 ) , and Shanahan  &  Pelham,  1978), and have been summarized by t h i s w r i t e r . Since  i t i s customary  weeks f o l l o w i n g s u r g e r y , sponsible eye  care  family  f o r eyedrops  i t i s necessary  member how  procedures  to i n s t i l l  and c l e a n s i n g  be recommended, and t h e r e f o r e A  number  of a c t i v i t y  advocated  i n an endeavour  cations.  The f o l l o w i n g l i s t  prescribed  f o r several  to teach  patients  and/or a r e -  t h e drops a p p r o p r i a t e l y .  such as i n s t i l l a t i o n  protective s h i e l d at night,  t o be  of ointment,  Other  a p p l i c a t i o n of a  the eye of mucus or c r u s t s may  require i n s t r u c t i o n .  restrictions t o reduce  and p r e c a u t i o n a r y  the r i s k  measures a r e  of p o s t o p e r a t i v e  summarizes major recommendations t h a t  complinurses  convey t o p a t i e n t s . 1.  Avoid  actions  straining pressure  such  during  as  bowel  coughing, movements,  sneezing, that  and p l a c e s t r a i n on t h e s u t u r e  may line.  bending, increase  lifting,  and  intraocular  16  2.  Avoid eye,  sudden movements, j a r r i n g , t h a t might  bumping, squeezing,  c o n t r i b u t e to wound r u p t u r e , i r i s  or r u b b i n g  prolapse,  the  hemor-  rhage, or r e t i n a l detachment. 3.  Wear dark g l a s s e s or p r e s c r i p t i o n g l a s s e s d u r i n g the day, t e c t i v e eye s h i e l d a t n i g h t t o prevent  4.  Wash hands b e f o r e t r e a t m e n t s ,  and  a c c i d e n t a l r u b b i n g or  Be  pouring  hot  liquids,  as  there  may  p e r c e p t i o n t h a t i n f l u e n c e the a b i l i t y 6.  Be  aware o f , and  r e p o r t any  be  of curbs and Shanahan  and  S i g n i f i c a n t s i g n s and  discharge  tient  Pelham  (1978)  and  procedures.  describe  a  a s c e r t a i n before  practice  In a d d i t i o n to  hospital  wherein  teaching  crusting,  edges  responsible  Nurses demonstrate that  performing  f a m i l y members,  the the  nurses  papremake  i f home care a s s i s t a n c e i s r e q u i r e d .  manual  skills  a r e s p o n s i b i l i t y to prepare  t h a t may  a  discharge  of adequately  In c o l l a b o r a t i o n w i t h  r e f e r r a l s to community a g e n c i e s  situations  or  stairs.  skills,  the nurse has  symptoms are  s t i c k f o r s t a b i l i t y , and f o r j u d g i n g h e i g h t s and  or the f a m i l y member i s capable  scribed  depth  lights.  f a m i l y member i s i n c l u d e d i n home c a r e i n s t r u c t i o n s . necessary  with  headache or browache t h a t i s u n r e l i e v e d by a u s u a l  change i n v i s i o n , f l a s h i n g Use a w a l k i n g  difficulties  streets,  to judge d i s t a n c e s .  headache remedy, nausea or v o m i t i n g , unusual  7.  with  s i g n s or symptoms of p o s s i b l e c o m p l i c a -  t i o n s to the d o c t o r immediately. p a i n i n the eye,  injury.  infection.  c a u t i o u s on s t a i r s , uneven ground, c u r b s , c r o s s i n g busy  and  a pro-  r e f r a i n from t o u c h i n g the eye  f i n g e r s or o t h e r u n c l e a n m a t e r i a l s , to a v o i d 5.  and  and  precautionary  measures,  p a t i e n t s and f a m i l y members f o r  a r i s e d u r i n g the p o s t o p e r a t i v e r e c o v e r y p e r i o d .  The  17  possibility bright  of  light  gested.  experiencing  should  minor  glasses  ments need t o be d i s c u s s e d . waiting  and  sensitivity  be d i s c u s s e d , and methods of a l l e v i a t i n g  I f temporary  pected  eye d i s c o m f o r t s  are provided,  Patients should  p e r i o d o f two t o t h r e e  anticipated  these  visual  to sug-  adjust-  a l s o be reminded of an ex-  months b e f o r e  h e a l i n g has  taken  p l a c e , and the f i n a l v i s u a l c o r r e c t i o n p r o v i d e d . Several  authors  advocate  l a r g e p r i n t , as an a d j u n c t ten  material  their aid  authors  hospital  hospital  discharge  admission  (Low,  (Shanahan & Pelham,  1978;  adherence  A discharge  i n t h i s study may be found Community their  homes  Kidger,  These  r e p o r t t h a t t h e names o f the p a t i e n t ' s m e d i c a t i o n s ,  the p a t i e n t ' s p. 11).  Kidger,  1978).  dosage I n s t r u c t i o n s , a r e w r i t t e n on the i n f o r m a t i o n  1978,  1.  to v e r b a l i n s t r u c t i o n s , and p r o v i d e t h i s w r i t -  v a r i o u s l y before  1977), and b e f o r e latter  t h e p r o v i s i o n of w r i t t e n i n f o r m a t i o n , i n  nurses  undertake  who  to the p r e s c r i p t i o n s "  instruction  sheet  pamphlet " t o  (Shanahan  provided  with  & Pelham,  f o r most p a t i e n t s  i n Appendix E . care  f o r postoperative  cataract patients i n  the f o l l o w i n g r e s p o n s i b i l i t i e s  (Berkoben,  1978;  patients  and/or  1977):  Perform family  p r e s c r i b e d eye care members w h i l e  they  procedures,  perform  supervise  procedures,  and t e a c h  skills i f  necessary. 2.  Monitor  both  t h e p a t i e n t ' s g e n e r a l p h y s i c a l c o n d i t i o n , and the s t a -  tus o f the operated eye, and r e p o r t any c o m p l i c a t i o n s t o the a t t e n d ing physician. 3.  R e i t e r a t e recommended p r e c a u t i o n s , and ensure t h a t p a t i e n t s and family  members know them and understand  their  importance.  A s s i s t pa-  18  tlents  and f a m i l y members t o r e c o g n i z e and remove p o t e n t i a l  hazards  i n the home. 4.  Answer  q u e s t i o n s , and p r o v i d e i n f o r m a t i o n t o f a c i l i t a t e  self-care  and reduce c o n c e r n s . 5.  A s c e r t a i n the a b i l i t y o f p a t i e n t s t o p r o v i d e f o r d a i l y l i v i n g  neces-  s i t i e s , and r e f e r t o o t h e r a g e n c i e s i f n e c e s s a r y .  P e r s o n a l and E n v i r o n m e n t a l F a c t o r s That I n f l u e n c e S e l f - C a r e Since  no s t u d i e s  specifically  were  located  that  reported s e l f - c a r e  behaviours  of p o s t s u r g i c a l c a t a r a c t p a t i e n t s , general f a c t o r s  fluence patient's and  literature  the  terms  s e l f - c a r e were i d e n t i f i e d  related  t o the e l d e r l y .  "compliance"  and "adherence"  d e f i n e d a s " . . . the e x t e n t t o which  i n the compliance  F o r t h e purposes a r e used  that i n literature  of t h i s  synonymously,  patients follow  paper  and a r e  the i n s t r u c t i o n s  -  p r o s c r i p t i o n s and p r e s c r i p t i o n s - o f t h e i r p h y s i c i a n s or o t h e r p r o v i d e r s " (Hulka, 1979, p. 3 ) . personal  factors,  The d i s c u s s i o n  illness  i s p r e s e n t e d under  and treatment  factors,  t h r e e headings;  and i n t e r p e r s o n a l  fac-  tors.  Personal Factors In  extensive  reviews  (1973), Haynes (1978, graphic  variables  of  the l i t e r a t u r e  p . 49-62) and Marston  such  on compliance,  (1970), conclude  as age, sex^ socio-economic  status,  Blackwell that  demo-  education,  r e l i g i o n , and r a c e , when examined i n i s o l a t i o n from o t h e r v a r i a b l e s , a r e seldom ations.  found  t o be s i g n i f i c a n t l y  related  Some e x c e p t i o n s a r e noted  t o compliance  with  recommend-  i n the p r e v e n t i v e h e a l t h  literature  where Rosenstock preventive likely  (1974) found  actions,  that  and persons  t o take p r e v e n t i v e  women were more l i k e l y  o f low socio-economic  t o engage i n  groups were  less  a c t i o n s t h a t e n t a i l e d c o s t t o themselves.  In t h e ophthalmology l i t e r a t u r e  there a r e a l s o i n c o n s i s t e n c i e s .  In  s t u d i e s of eyedrop adherence of glaucoma p a t i e n t s , women were found t o be more compliant Vincent,  than men ( B l o c h ,  R o s e n t h a l , Friedman, & C a l d a r o l l a , 1977;  1973), and i n d i v i d u a l s over 65 y e a r s o f age were r e p o r t e d  more compliant  than t h e i r younger c o u n t e r p a r t s  (Vincent,  1973).  t o be Spaeth  (1970) found no d i f f e r e n c e s i n these v a r i a b l e s . M a r i t a l s t a t u s and l i v i n g i n many s t u d i e s . family 1973)  Divorce,  instability, contribute  (1970), h e a l t h reactions  situations are associated  separation  compliance  & Z e i t z , 1964),  alone  t o Davis  (Blackwell,  (1968) and Green  r e l a t e d b e h a v i o u r s a r e i n f l u e n c e d by the e x p e c t a n c i e s and  of o t h e r s .  (1976) r e p o r t e d support  and l i v i n g  According  Peer groups and f a m i l i e s can e x e r t  ence i n e i t h e r a p o s i t i v e o r n e g a t i v e  by  (Schwartz, Henley  unemployment, p o v e r t y ,  t o non-compliance.  with  from  direction.  a strong  Caplan and A s s o c i a t e s  t h a t adherence t o a regimen f o r h y p e r t e n s i o n physicians  and spouses,  and Donabedian  (1964) noted t h a t adherence o f c h r o n i c a l l y i l l regimen was c o r r e l a t e d support and i n t e r e s t .  t o t h e degree  t o which  influ-  patients family  was enhanced and  Rosenfeld  to t h e i r members  medical provided  In a d d i t i o n , s o c i a l i s o l a t i o n has been  associated  w i t h an i n c r e a s e i n m e d i c a t i o n e r r o r s among the e l d e r l y (Neely  & Patrick,  1968). Patient  personality  (1968b) r e p o r t s late  variables  have  been  investigated,  t h a t p a t i e n t s who a r e c o - o p e r a t i v e ,  a r e more compliant  and  Davis  g r a t e f u l and a r t i c u -  than those who a r e demanding, a u t h o r i t a t i v e and  20  overbearing; dence  in  or  s u b m i s s i v e and  one's . a b i l i t y  to  dependent.  follow  High s e l f - e s t e e m ,  recommendations  are  and  also  confi-  associated  p o s i t i v e l y w i t h adherence ( C a p l a n et a l , 1976). Many p a t i e n t v a l u e s , and of  the the  patient's  perception  physician's  factor  in  beliefs of  assessment  adherence  (Gillum  the  of &  and  a t t i t u d e s are s e v e r i t y of  an  no  illness  benefit  Barsky,  1974).  ules  ( G i l l u m & Barsky, 1974), b e l i e v e d  (Spaeth,  1970), or  were unimportant  compliance a r e  (Bloch  exemplified  considered et  i n Davis'  subjects  i n d i c a t e d that  l o w i n g the  doctor's  instruction.  of  the  prescriptions  that  a l . , 1977).  defaulting  percent  perceived  the a c t u a l or p o t e n -  that  the  regular  treatment was  sched-  attitudes  toward  Patient  any  written  by  physicians  percent  i n t e n t i o n of three  are  processing  and  the  i s disagreement whether t h e r e  ity.  Botwinick  (1978, p.  "when s u f f i c i e n t  278)  never  filled 1964).  of  younger p e o p l e . "  more disadvantaged  influ-  of c o n t r o v e r s y  in  Most s t u d i e s agree t h a t the speed of  i s a decline i n actual learning  summarized  time f o r a  ance of e l d e r l y p e o p l e i s o n l y  fol-  r a t e of r e s p o n d i n g d e c l i n e s w i t h age,  there  of  to seven  Hammell & W i l l i a m s ,  i s a subject  of  medication  l e a r n i n g a b i l i t y of o l d e r a d u l t s i s a p o t e n t i a l f a c t o r of  information  that  Non-compliers  Other authors note t h a t  the psychology l i t e r a t u r e on a g i n g .  to  important  by,  be  than  the  they never had  ence i n adherence t o recommendations, and  cludes,  to  adherence  rather  (1968b) study, where 40  (Boyd, Covington, Stanaszek, & C o u s i n s , 1974; The  illness,  i t , i s considered  themselves as l e s s s u s c e p t i b l e t o , or threatened tial  r e l a t e d to  a  number  of  studies  response i s a v a i l a b l e , the  slightly  inferior  or not  than younger a d u l t s a r e :  1) when t h e r e  abil-  and  con-  perform-  inferior  Some s i t u a t i o n s i n which o l d e r  but  at a l l  adults  are  is irrelevant  21  or  redundant  information  2) when p a c i n g is  an  of i n f o r m a t i o n  i n a p p r o p r i a t e l y high  (Powell, task  included  rather  learning  task  (Rabbitt,  1965);  i s r a p i d ( C a n e s t r a r i , 1963); 3) when  l e v e l of autonomic nervous system  E i s d o r f e r , Bogdonoff  i s abstract  i n the  & Durham, 1964); and  than  concrete  (Arenberg,  stimulation  4) when the 1968).  there  learning  Decreased  re-  sponse time or o m i t t e d responses i n the o l d e r a d u l t were a l s o a t t r i b u t e d to worry about making an e r r o r ( P o t a s h & Jones, 1977). Sensory d e f i c i t s , and  attitudes  ability Etten,  to  ing  the  studies are  the  comprehend  1978,  Few  about  p.  deficits  i n manual d e x t e r i t y , p h y s i c a l  ability  to  i n s t r u c t i o n s and  s t u d i e s make any regimen) and  distinction  compliance  In the P a r k i n  acute m e d i c a l wards were s t u d i e d  The  mean age  percent  of  understand  not  follow  factor  manual  older  skills  adult's (Saxon  &  two  percent  in this in  Common sources of e r r o r were:  prescribed  The  from p r e s c r i b e d  Therefore,  non-compliance  from  years.  15  patients discharged  weeks f o l l o w i n g d i s c h a r g e ,  66  regimens;  two  from  was  their  However,  s t u d y , 130  of  deviated  regimen).  1962)  deviation  subjects  the  (understand-  Schwartz, Wang, Z e i t z & Goss,  for  them.  than  the  between comprehension  responsible  subjects  not  perform  (following  ( P a r k i n , Brown & Monk, 1976;  factors  affect  158-166).  noted e x c e p t i o n s .  tify  learn also  diseases,  treatment  knew the  from  the  iden-  treatment.  results indicated  that  35  because they  did  i n s t r u c t i o n s but  did  study n e s c i e n c e was  deviation  drug  to  a more p o w e r f u l  prescribed  u s i n g dosages t h a t were o p e r a t i v e  regimen. prior  to  h o s p i t a l admission, r e v e r s i o n to o l d p r e s c r i p t i o n s ( P a r k i n et a l . , 1976), adding ones,  medications and  using  a  prescribed spouse's  by  a  previous  medication  both  physician knowingly  to and  the  current  unknowingly  (Schwartz factor that  a l . , 1962).  i n nescience.  i n one  general 54  et  study,  Ley  50  (Ley,  of  the  his  information  forgotten.  be  an  research given  f o r g o t t e n i n f i v e minutes.  of m a t e r i a l was  or i n t e l l i g e n c e , but  i n s t r u c t i o n s may  (1980) summarized  percent  p r a c t i t i o n e r was  percent  Forgetting  and  reported  to p a t i e n t s  In other  F o r g e t t i n g was  important  not  trials  a  37  -  r e l a t e d to  a c u r v i l i n e a r r e l a t i o n s h i p w i t h a n x i e t y was  age  reported  1980). The  aforementioned knowledge of expected b e h a v i o u r s , and  the  ability  to p e r f o r m them, i s d i f f e r e n t from f a c t u a l knowledge about d i s e a s e t i e s and  medications.  type  knowledge  of  Jongh, 1970; or  by  has  no  The  increases  Hulka, 1979; effect  Haynes et a l . , 1976,  l i t e r a t u r e i s d i v i d e d over whether t h i s  at  adherence  (Caldwell,  Cobb,  P r a t t , Seligmann & Reader, 1957;  a l l (Bergman p. 69-82).  &  Werner,  Close  1963;  &  de  Spaeth, 1970),  Boyd  not  latter  Dowling  et  al.,  s c r u t i n y of three glaucoma  would suggest t h a t a l t h o u g h knowledge of f a c t s was  enti-  1974;  studies  sufficient  to i n -  f l u e n c e adherence i n these s t u d i e s , an u n d e r s t a n d i n g and  appreciation  the r e l a t i o n s h i p between i n c r e a s e i n i n t r a o c u l a r p r e s s u r e  and  visual loss  did  et  al.,  d i f f e r e n t i a t e compilers  Spaeth, 1970; standing  and  Vincent,  and  1973).  appreciation,  non-compliers  (Bloch  Perhaps i t i s the h i g h e r  rather  l e v e l of  than f a c t u a l knowledge, t h a t  of  1977; under-  i s impor-  t a n t to adherence to recommendations. Although knowledge about the m e d i c a l c o n d i t i o n may correlate with ways  of  coping  L a z a r u s , 1979,  adherence, in  information  situations  p. 217-254).  by g a i n i n g i n f o r m a t i o n  that  are  seeking new  or  For example, J a n i s  i s one pose  not of  a  consistently  the threat  (1958) has  most  basic  (Cohen  suggested  &  that  about what to expect, p a t i e n t s can develop ways of  23  c o p i n g w i t h the t h r e a t s of s u r g e r y . that the  satisfaction medical  ever,  with  h e a l t h care  condition i s provided  the amount  of  T h i s concept  information  may  e x p l a i n the  finding  i s i n c r e a s e d when i n f o r m a t i o n (Hulka,  desired  1979;  Svarstad,  i s very  about  1976).  individual.  How-  Some  pa-  t i e n t s are i n s a t i a b l e i n t h e i r s e a r c h of i n f o r m a t i o n , whereas o t h e r s fer  to p l a c e themselves i n the hands of someone they can t r u s t ,  t h a t "ignorance  I l l n e s s and  is bliss"  (Cohen and L a z a r u s ,  This  are more l i k e l y  is particularly  when the  treatment  t r u e when  fects  of  and where the  the m e d i c a t i o n , treatment  percent  subjects with  than  244).  i n acute  delayed  is little  or  be  i s no  asymptomatic,  when the  conseFor  ex-  p a i n or  immediate  from u n p l e a s a n t  side ef-  reinforcement In B i g g e r ' s  asymptomatic e l e v a t i o n of  to c o n t i n u e  with  (1976) study,  intraocular  37  pressure  most w i t h i n a month of the i n i t i a l d i a g n o s i s .  symptoms are p r e s e n t , recommendations t h a t attempt to r e l i e v e  discomforts are u s u a l l y followed c a r e f u l l y  (Haynes, 1976), but  et a l . , 1972).  Bigger  though no s t a t i s t i c a l s t u d i e s r e p o r t compliance c o n d i t i o n s , most o p h t h a l m o l o g i s t s  (1967) comments i n acute  the  disappear-  ance of the symptoms f r e q u e n t l y l e a d to premature t e r m i n a t i o n of the s c r i b e d regimen (Becker  in  illnesses.  ( B l a c k w e l l , 1973).  there  symptoms may  lapses  s h o r t term  p r o p h y l a c t i c , or  glaucoma, where only  therapy,  condition i s mild or  be  i s prolonged  ( R i f f e n b u r g h , 1966).  dropped out of treatment, If  may  there  prescribed of  the  i s suppressive  i n c h r o n i c simple  disability,  there  to occur  quences of s k i p p i n g treatment ample,  p.  believing  Treatment F a c t o r s  In c h r o n i c c o n d i t i o n s where compliance  1979,  pre-  pre-  that a l -  ophthalmological  a r e aware t h a t p a t i e n t s w i t h  conjunc-  24  tivitis and  are l i k e l y to discontinue  many c o n t a c t  l e n s wearers d i s c o n t i n u e  once they have a c h i e v e d The  amount  t h e i r eyedrops once the symptoms c l e a r , r e g u l a r f o l l o w up appointments  s u c c e s s f u l wear.  of change i n h a b i t s  follow  the  recommendations  1976),  and  the  amount  of  or l i f e  (McAlister,  Farquhar,  interference  with  (Tagliacozzo  & Ima, 1970) a f f e c t adherence.  known  t o be  s e l e c t i v e i n adhering  those  aspects  (Davis  cited  Akingbehin, et  require  daily  &  living  In a d d i t i o n ,  adjustment  of the regimen and the number  by a number  of authors  to  Maccoby,  activities  patients are  complying  i n their  way  1980; F r a n c i s , Korsch  questioned (Blackwell, The (Haynes,  of  with life  & Morris,  side  1979, p. 60), however,  effects  both  Bloch  1969; Hulka,  few s t u d i e s  on adherence  have  (Davidson  &  1979; Schwartz  of doses p e r day has been  on  compliance  is  and A s s o c i a t e s ,  (1966) c i t e u n p l e a s a n t and i n c o n v e n i e n t  sons t h a t p a t i e n t s w i t h glaucoma d i s c o n t i n u e The  prescribed  1973).  e f f e c t of m e d i c a t i o n  Riffenburgh  of drugs  as a f f e c t i n g adherence  a l . , 1964), but the e f f e c t of the number  tions  Thoresen  t o recommendations,  the l e a s t  i s required  & E i c h h o r n e , 1963).  Complexity been  that  s t y l e that  their  equivocal  (1977) and  s i d e e f f e c t s as  rea-  eyedrops.  t h a t have i n v e s t i g a t e d the e f f e c t of c o s t of medicaproduce  conflicting  results  (Haynes,  1979, p. 60);  however, the c o s t of eyedrops was a f a c t o r i n non-compliance i n V i n c e n t ' s (1973) glaucoma study. Dispensing  factors are implicated  i n adherence t o m e d i c a t i o n  Mazzulo, L'asagna & G r i n e r  (1974) r e p o r t  that  taking  in  several studies.  there  is  a wide v a r i a t i o n i n p a t i e n t s ' i n t e r p r e t a t i o n s of l a b e l l e d i n s t r u c t i o n s  25  on  medication  plicit; culty  and  bottles,  particularly  Hermann (1973) n o t e s  Safety  lock containers  & Harris,  1971;  was  noted  that  off  once they had  p a t i e n t s have c o n s i d e r a b l e  i n two  elderly patients  Akingbehin  of  eye,"  Interpersonal The  frequently  1977).  left  the  Bergner  Furthermore, i t  tops  of  containers  (1980) comment  that  l a b e l s are  frequently  (1973, p.  218)  eyedrops were  reports  indicated stated,  reading  ability  that d i f f i c u l t i e s with as "My  factors  in  are  self-  non-compliance  hand t r e m b l e s , " " I t ' s h a r d  or " I waste too much."  Factors  r o l e of p a t i e n t s a t i s f a c t i o n w i t h m e d i c a l c a r e has  siderable  se-  reduced medi-  (Lane, B a r b a r i t e ,  Sathees & Lee,  a s m a l l number of s u b j e c t s who  to f i n d my  studies  f o r p a t i e n t s whose v i s u a l a c u i t y and  Vincent  administration  diffi-  been opened ( M c l n t i r e et a l . , 1977).  Davidson and  reduced, and  ex-  time i n t e r v a l s and  were a source of d i f f i c u l t y and  M c l n t i r e , Angle,  hard to d e c i p h e r  not  schedules.  c a t i o n consumption f o r s u b j e c t s  attention  (Aday,  s a t i s f a c t i o n w i t h the has  that  i n s t r u c t i o n s were  i n e s t a b l i s h i n g f o r themselves a p p r o p r i a t e  quences f o r m e d i c a t i o n  for  when the  Andersen  &  Fleming,  received  1980),  i n t e r a c t i o n between themselves and  and  their  con-  patient physician  been found t o be p o s i t i v e l y r e l a t e d to subsequent adherence to recom-  mendations Svarstad,  (Aday  et  1976).  tween p h y s i c i a n s  a l . , 1980;  Hulka,  A l t h o u g h most of and  patients,  the  the  1979; studies  Korsch are  p r i n c i p l e s apply  &  Negrete,  of r e l a t i o n s h i p s equally  to  From the p a t i e n t ' s p e r s p e c t i v e ,  s a t i s f a c t i o n i s enchanced when:  tors  w i t h what  pay  attention  to  and  deal  the  1972;  patient  perceives  be-  nurses. 1) as  docthe  26  main concern f o r the v i s i t ; m e d i c a l aspects  2) a d o c t o r  shows a f r i e n d l y i n t e r e s t i n non-  of a p a t i e n t ' s l i f e (Aday et a l . , 1980;  1972); 3)  expectations  1974); 4)  explana-  t i o n s and  i n f o r m a t i o n are g i v e n about the m e d i c a l d i a g n o s i s , and  justifi-  cations an the  for a v i s i t  are  met  (Stimson,  K o r s c h & Negrete,  f o r s p e c i f i c p r e s c r i p t i o n s are p r o v i d e d  opportunity doctor,  i s provided asking  t o p a r t i c i p a t e i n an  questions  and  (Svarstad,  1976); and  a c t i v e interchange  validating  impressions  5)  with  (Korsch  &  Negrete, 1972). The ception  communication of i n s t r u c t i o n s of p a t i e n t s , and of  (1979) and  these i n s t r u c t i o n s has Svarstad  (1976).  regimen,  resulted  in  the  subject  of  studies  by  In both these s t u d i e s , d i s c r e p a n c i e s  what the p h y s i c i a n s a i d was the  been  the p a t i e n t ' s  p r e s c r i b e d , and medication  Hulka  between  what the p a t i e n t r e p o r t e d  errors  re-  as  of  dosage,  scheduling,  and  that  reduced  s u c c e s s f u l com-  d u r a t i o n of treatment. Svarstad  identified  munication as: t h a t was the as and  not  extent  physician  1) incomplete  u n d e r s t o o d by  of  the  unwillingness  or ambiguous i n s t r u c t i o n s , 2)  the  p a t i e n t , and  p a t i e n t ' s knowledge. to  confusion.  factors  ask  Patients  for  Patient  clarification,  who  provided  s t r u c t i o n from the p h y s i c i a n , and  3)  such  or  terminology  f a u l t y assumptions about f a c t o r s were to  indicate  feedback  identified uncertainty  received  i n c r e a s e d the a c c u r a c y  more i n -  of. t h e i r  percep-  quantity,  quality  tions . In and  principle  content  tients  of  there  the  researchers.  be  l i t t l e doubt  provider/patient  conduct t h e i r own  i n t e r a c t i o n a r e few,  can  and  just  the  interaction influences  s e l f - c a r e , but are  that  s t u d i e s of  beginning  the  to a t t r a c t  the  way  components of the  pathe  a t t e n t i o n of  27  In t h e f i n a l s e c t i o n o f t h i s review, s t u d i e s of c a t a r a c t p a t i e n t s a t home a r e d i s c u s s e d .  Cataract  Studies  A l t h o u g h there a r e many s t u d i e s i n the m e d i c a l l i t e r a t u r e t h a t exami n e types and r a t e s of c o m p l i c a t i o n s , r a c t surgery, lives  and v i s u a l r e s u l t s f o l l o w i n g  there a r e few t h a t examine the impact of the s u r g e r y  of p a t i e n t s  and t h e i r  f a m i l i e s , and few t h a t  cataon the  describe  self-care  (1977), an ophthalmic nurse  specialist  practices. I n a paper w r i t t e n by K i d g e r in  England,  a home v i s i t i n g  i s described. period, in  procedures,  were  referred  wound, a t r o p i n e had  to postsurgical cataract  patients  One hundred and n i n e p a t i e n t s were v i s i t e d over a one y e a r  drops were i n s t i l l e d ,  eye care  tients  programme  p a t i e n t s and f a m i l y members were  and the o p e r a t e d  back  to t h e i r  sensitivity, i r i t i s ,  supervised  eye was examined.  opthalmologist and hyphema.  Seven p a -  because  of  Problems t h a t  leaking patients  a f t e r they got home from h o s p i t a l prompted t h e development of an i n -  formation  pamphlet, p r i n t e d i n l a r g e  t i e n t s before  h o s p i t a l admission.  type,  that  i s now sent  to a l l pa-  The author does not r e p o r t  the s p e c i f -  i c problems t h a t were encountered by the p a t i e n t s a t home. In another study i n the U n i t e d  Kingdom, H i l b o u r n e  (1975) v i s i t e d  e l d e r l y p o s t s u r g i c a l c a t a r a c t p a t i e n t s i n t h e i r homes t o a s c e r t a i n level  of functioning  f o l l o w i n g surgery,  and t h e i r  very  reactions  t o the s u r g e r y .  few p a t i e n t s had i n c r e a s e d  44  their  Three months  the number of a c t i v i -  t i e s they were a b l e t o do, many were h a v i n g d i f f i c u l t y a d j u s t i n g t o t h e i r spectacles,  and many were d i s a p p o i n t e d  with  the outcome of the s u r g e r y .  The key determinant ual acuity in  i n performance  i n the unoperated  the unoperated  eye  and s a t i s f a c t i o n was  eye;  better  subjects with corrected v i s u a l  than  20/100 were d i s s a t i s f i e d  w i t h l e s s than 20/100 were p l e a s e d w i t h t h e i r Finally,  Crawford  the l e v e l of  vis-  acuity  while  those  results.  (1980) i n an u n p u b l i s h e d master's  thesis, reports  on the needs of t e n e l d e r l y p o s t s u r g i c a l c a t a r a c t p a t i e n t s r e f e r r e d visiting  nurse  agency.  members, neighbours s i o n of eye c a r e . housekeeping  Patients i n this  study r e l i e d  Other needs f r e q u e n t l y i d e n t i f i e d were a s s i s t a n c e w i t h  i o n i n the unoperated  S u b j e c t s over 80 y e a r s of age, w i t h poor  eye,  living  were i d e n t i f i e d as most l i k e l y  a l o n e and  with  little  study  which  s m a l l sample s i z e  depended  on  support  vis-  system,  t o need Home H e a l t h S e r v i c e s f o r a l o n g e r  p e r i o d of time than the t h r e e days which are reimbursed The  h e a v i l y on f a m i l y  and f r i e n d s , as w e l l as the v i s i t i n g nurse f o r p r o v i -  and shopping.  c a r e System.  to a  recall  of  and  by the U.S.  the r e t r o s p e c t i v e  events  that  nature  o c c u r r e d up  Mediof  to one  the year  p r e v i o u s l y , a r e l i m i t a t i o n s of t h i s r e s e a r c h p r o j e c t . In  summary,  approach affect  t h e o r y supports  t o h e a l t h c a r e , and  patients'  both  the  need  s e l f - c a r e behaviours.  the u s e f u l n e s s of a to recognize that  collaborative many  variables  N u r s i n g and m e d i c a l a s p e c t s of a  p a t i e n t ' s c a r e f o l l o w i n g c a t a r a c t s u r g e r y a r e documented, but the al  and  environmental  o n l y be surmised cated  that  cataract  from  factors  that  influence  and  concerns  that  No  hospital  of  d i s c h a r g e , and  are e x p e r i e n c e d .  l i t e r a t u r e d i r e c t s the f o c u s of the p r e s e n t study.  can  s t u d i e s have been l o -  the s e l f - c a r e behaviours  p a t i e n t s a t home f o l l o w i n g  difficulties  the p a t i e n t ' s behaviour  the g e n e r a l l i t e r a t u r e .  examine s p e c i f i c a l l y  person-  postsurgical few  report  This deficiency  i n the  29  CHAPTER  III  METHODOLOGY  T h i s study was conducted t o d e s c r i b e  s e l e c t e d eye c a r e and s e l f - c a r e  behaviours of p o s t s u r g i c a l c a t a r a c t p a t i e n t s d u r i n g a t home f o l l o w i n g h o s p i t a l d i s c h a r g e , have i n f l u e n c e d  those  behaviours.  purpose.  the o p p o r t u n i t y The July  An e x p l o r a t o r y  descriptive  t o observe changes i n t h e same s u b j e c t s over a three  31, of 1981, i n a l a r g e  month p e r i o d  metropolitan  provided  over time.  between May 1st and  Canadian  twenty s u b j e c t s who had r e c e n t l y undergone c a t a r a c t chapter d e s c r i b e s  research  method t o a c h i e v e t h e s t a t e d  The l o n g i t u d i n a l p a n e l d e s i g n of the p r o j e c t  study took p l a c e  This  few weeks  and t o i d e n t i f y f a c t o r s which might  d e s i g n was s e l e c t e d as t h e most a p p r o p r i a t e research  their f i r s t  city,  and i n v o l v e d  surgery.  the methods used t o conduct  the study:  se-  l e c t i o n of p a r t i c i p a n t s , development of the i n s t r u m e n t , c o l l e c t i o n of the d a t a , and a n a l y s i s of the d a t a .  S e l e c t i o n of P a r t i c i p a n t s A  convenience  sample  of twenty  met  the f o l l o w i n g e l i g i b i l i t y  1.  Age was over 60 y e a r s .  2.  Present s u r g e r y was the f i r s t  3.  Procedure was an i n t r a c a p s u l a r  4.  lens  implant.  Best  corrected  less.  visual  postsurgical  cataract  patients  who  c r i t e r i a were admitted t o t h e s t u d y :  acuity  cataract  extraction.  or extracapsular  extraction  i n t h e unoperated  eye was  without  20/50 o r  5.  S u r g i c a l procedure  and  postoperative  h o s p i t a l stay  were  uncompli-  cated. 6.  Were d i s c h a r g e d own  to  a p r i v a t e residence  Were a b l e to speak, understand and  8.  Lived i n a geographical area city The  t h a t was  gical  was  selected  because  of c a t a r a c t o p e r a t i o n s (Statistics  procedure,  to l i m i t  the sample. who  The  t e r v i e w data c o l l e c t i o n contact  ophthalmologist, s u b j e c t s expressed the  study  was  who  ask.  Canadian s t a t i s t i c s i n d i c a t e t h a t  70  The  requirements of the first  c a r e , and  year  specific  cataract surgery, l e n s implants  sur-  minimum  reflect  the communication  verbal interaction  requirements  subjects  specificaof  the i n -  technique. p o t e n t i a l subjects  explained  the  was  purpose and  made by scope of  the the  attending study.  an i n t e r e s t i n p a r t i c i p a t i n g , a w r i t t e n e x p l a n a t i o n  provided  an  i n c r e a s e the homogeneity of  requirements were s e l e c t e d to o b t a i n  the  with  d i s c u s s the study w i t h l i k e to  major  The of  the number of v a r i a b l e s and residence  the  briefly. group  the e x c l u s i o n of persons w i t h  made because of  Initial  i s discussed  i t represents  complications,  were r e s p o n s i b l e f o r t h e i r own  t i o n was  the  are performed on i n d i v i d u a l s over 65  Canada, 1977).  l a c k of  v i s u a l a c u i t y , and attempt  w i t h i n a one hour d r i v e of  r a t i o n a l e f o r the s e l e c t i o n c r i t e r i a  p e o p l e undergoing c a t a r a c t s u r g e r y .  of age  communicate i n E n g l i s h .  centre.  requirement  percent  to make  arrangements f o r s e r v i c e s ) .  7.  age  (where p a t i e n t had  (See  Appendix  A).  f a m i l y members, and  Subjects  were encouraged  t h i n k of q u e s t i o n s  they  If of to  would  31  The  investigator  visited  interested  subjects while  they were  still  i n h o s p i t a l , answered q u e s t i o n s , and o b t a i n e d a consent f o r p a r t i c i p a t i o n in  t h e study  (See Appendix B ) .  home v i s i t was made, a t a time t h a t was m u t u a l l y convenient  A tentative  appointment  f o r the f i r s t  on the day f o l l o w i n g h o s p i t a l  discharge,  t o t h e s u b j e c t and the r e s e a r c h e r .  A busi-  ness c a r d n o t i n g the i n v e s t i g a t o r ' s name, telephone number and u n i v e r s i t y a f f i l i a t i o n was l e f t w i t h the s u b j e c t . Both large  the i n f o r m a t i o n m a t e r i a l and the consent  print,  h i g h c o n t r a s t format  vision subjects. ability form.  t o maximize l e g i b i l i t y  I n s p i t e of these s p e c i a l e f f o r t s  of m a t e r i a l s , four  subjects  In these i n s t a n c e s , t o ensure  signing,  a f a m i l y member was asked  form were p r o v i d e d i n  were that  unable  f o r these low  t o improve the r e a d t o read  t h e consent  s u b j e c t s knew what  they  were  t o r e a d the i n f o r m a t i o n sheet and the  consent form t o the s u b j e c t , and c o - s i g n the agreement t o p a r t i c i p a t e . AH  s u b j e c t s who met t h e e l i g i b i l i t y c r i t e r i a  agreed  to p a r t i c i p a t e  i n the s t u d y .  Development o f the Instrument A  three f a c e t e d data c o l l e c t i o n  s e a r c h e r f o r t h i s study record  instrument was designed  (See Appendix D).  demographic d a t a .  by the r e -  A f a c e sheet was compiled t o  An i n t e r v i e w schedule was c o n s t r u c t e d u s i n g a  s e l e c t i o n on both open and closed-ended  q u e s t i o n s , a combination  h i g h l y recommended by P o l i t  (1978, p. 330) t o a t t a i n the a d -  vantages  and o f f s e t  and Hungler  the weaknesses o f each  type o f q u e s t i o n .  c h e c k l i s t was d e v i s e d t o r e c o r d o b s e r v a t i o n s of eyedrop plication eye.  of a p r o t e c t i v e  eye s h i e l d ,  that i s  Finally, a  i n s t i l l a t i o n , ap-  and the c o n d i t i o n  of the o p e r a t e d  32  Content areas were d i r e c t e d by t h e c o n c e p t u a l from  three  main s o u r c e s :  nursing care the  from  the l i t e r a t u r e  on p o s t o p e r a t i v e  of c a t a r a c t p a t i e n t s , h e a l t h care needs of the e l d e r l y , and  compliance  gists,  firstly  framework, and d e r i v e d  literature;  secondly  from  ophthalmic nurses and home care  discussions  nurses;  with  ophthalmolo-  and t h i r d l y  through  v e r s a t i o n w i t h i n d i v i d u a l s who themselves had undergone c a t a r a c t The and  interview  clarity  nursing  schedule  was c r i t i c a l l y  by two ophthalmic  research  head  reviewed f o r content  nurses,  surgery. validity  ophthalmologists,  a  committee two o f whose members had o p h t h a l m o l o g i c a l ex-  perience,  and by a f a c u l t y member e x p e r i e n c e d  interview  schedules.  the  three  con-  Revisions  i n c o n s t r u c t i n g and coding  were made t o i n c o r p o r a t e  suggestions  of  consultants. Reliability  schedule  i s s u e s were a d d r e s s e d by t h e u t i l i z a t i o n  of a  standard  f o r each s u b j e c t , by tape r e c o r d i n g i n t e r v i e w s , and by r e c o r d i n g  observations  immediately  f o l l o w i n g the interview.  of p a t i e n t responses i n c r e a s e d  confidence  Internal  consistency  i n the r e l i a b i l i t y  of t h e i n -  strument . A pilot ment.  study  was conducted w i t h  At t h e completion  of t h r e e  wording and sequence i n o r d e r  s i x subjects  to c l a r i f y  ambiguities  group t h a t had c o s t s of m e d i c a t i o n s  and  tape  covered  s u b j e c t s deemed o t h e r  t o be i n s i g n i f i c a n t  i n cost.  and i n t r o d u c e ,  to the subjects.  on c o s t of s u p p l i e s was d e l e t e d as most of t h e study  Insurance, and p i l o t  the i n s t r u -  i n t e r v i e w s , minor changes were made i n  l i e r i n t h e i n t e r v i e w , items of major r e l e v a n c e  age  to test  ear-  An i t e m  s u b j e c t s were i n an  by P r o v i n c i a l  Pharmacare  s u p p l i e s such as c o t t o n  The r e v i s e d schedule  w i t h t h r e e more s u b j e c t s and was found t o be s a t i s f a c t o r y .  balls  was t e s t e d  Two committee members and a f a c u l t y r e s e a r c h a s s o c i a t e reviewed recorded  interviews  and concomitant  data  coding  procedures.  Both  tape fea-  t u r e s were judged t o be a c c e p t a b l e . Confidentiality d a t a coding s h e e t s . i n a separate Written of  was  maintained  The l i s t  confidential permission  by u s i n g  code numbers  of p a t i e n t names was kept  and  by the r e s e a r c h e r  file.  was  obtained  from the a t t e n d i n g  each s u b j e c t f o r an e x t r a p r e s c r i b e d eyedrop  researcher's v i s i t  on tapes  ophthalmologist  to be i n s t i l l e d  d i d not c o i n c i d e w i t h a r e g u l a r m e d i c a t i o n  i f the  administra-  t i o n time (See Appendix C ) .  C o l l e c t i o n of Data Data were c o l l e c t e d from t h r e e s o u r c e s :  personal interviews, d i r e c t  o b s e r v a t i o n s , and the s u b j e c t ' s h o s p i t a l c h a r t .  Interviews  t i o n s took p l a c e d u r i n g the course of the two home v i s i t s to  each s u b j e c t .  discharge,  The f i r s t  of v i s i t s  hour.  Times of v i s i t s  t h e planned All  option  took p l a c e  averaged  40 minutes;  were r e c o n f i r m e d  no  observa-  which were made  the day f o l l o w i n g h o s p i t a l  the second between t h e 13th and 16th p o s t o p e r a t i v e  length  ing  visit  and  visit  lasted  by telephone  day.  The  than  one  more  the evening  preced-  visit.  i n t e r v i e w s were tape r e c o r d e d ,  of r e f u s i n g the tape,  turning  and although  a l l s u b j e c t s had the  i t o f f during  the i n t e r v i e w ,  or  e r a s i n g segments, none e x e r c i s e d the o p t i o n . The  manner  i n which  the i n t e r v i e w s were  conducted  merits  S i n c e the r e s e a r c h i n t e r v i e w i s an i n t e r a c t i v e p r o c e s s , w i t h both terviewer  and respondent  c o n t r i b u t i n g t o the communication,  comment. the i n -  i t becomes  the  responsibility  maximize tion.  the  At  the  interviewer  completeness  the  be m a i n t a i n e d tude,  of  and  veracity  same time a f o c u s (Kahn & C a n n e l l ,  warmth,  and  to c r e a t e the  on  the  1957,  p.  i n t e r e s t were used  open communication.  The  initial  o b t a i n a consent p r o v i d e d  an  that by the time of the f i r s t  of  the  49-64). by  the  t o p i c s , but  i f they were  opportunity  f o r rapport  home v i s i t and  judged  not  to  interview,  use  interviewer contact  were empathetic,  and  developed,  trust  and  so  mutual  influence  subsequent  interview  of the i n t e r v i e w i f i t was  any  Responses to  dif-  i n t e r v e n t i o n s were  de-  the advantages of e n a b l i n g  the  interview.  of the tape r e c o r d e r p r o v i d e d to observe and  respond  t o n o n - v e r b a l cues, and  maintain  eye  t o h o l d the a t t e n t i o n of e l d e r l y s u b j e c t s .  Observations of eye end  facilitate  Questions were answered as  but  The  to  to be  ficulties  of the  i n t e r v i e w must  interviewer  compromised.  f e r r e d to the end  communica-  A non-judgemental a t t i -  thought p a r t i c i p a n t s ' responses would be concerns  will  h o s p i t a l v i s i t to e x p l a i n the study  answers were postponed t o the end  and  that  respondent's  o b j e c t i v e s of the  i n t e r e s t were found to have been e s t a b l i s h e d . they came up  conditions  of home v i s i t s  i t y with  eye  s t a t u s were made at  i n the hope t h a t r a p p o r t would be b u i l t ,  the o b s e r v e r  observation  c a r e procedures and  would minimize the d i s t o r t i o n  s i t u a t i o n s (Fox,  on the c h e c k l i s t s as  1970,  p.  213).  and  that occurs  O b s e r v a t i o n s were  soon as p o s s i b l e a f t e r the r e s e a r c h e r  left  the  familiari n known recorded the  sub-  j e c t 's home. P h y s i o l o g i c a l and tained the  from  subject.  the  demographic data  h o s p i t a l chart  required  a f t e r permission  f o r the had  study were  been o b t a i n e d  obfrom  35  A n a l y s i s of the Data Data Finite  from  taped  i n t e r v i e w s were  answers were coded and  Data were then Descriptive  organized  statistics  t r a l tendency,  and  into  replies content  transferred  to  recording  to open ended q u e s t i o n s areas  such as f r e q u e n c y  related  to  the  sheets.  recorded.  objectives.  d i s t r i b u t i o n s , measures of  measures of v a r i a b i l i t y were used  to a n a l y z e and  cendis-  play data. In  addition,  the F i s h e r Exact  T e s t ^ was  bles to t e s t f o r p o s s i b l e a s s o c i a t i o n s . t a i l e d , was age,  a p p l i e d to s e l e c t e d  A l e v e l of p = .05 or l e s s ,  selected to i n d i c a t e a s i g n i f i c a n t a s s o c i a t i o n .  two  For example,  sex, manual d e x t e r i t y were t e s t e d f o r a s s o c i a t i o n w i t h d i f f i c u l t y i n  eyedrop a d m i n i s t r a t i o n .  Continuous  variables  such  mized by u s i n g the median as the d i v i d i n g p o i n t . Socio-economic life-time  s t a t u s was  occupation.  husband's o c c u p a t i o n was to  varia-  a  rank  For  of socio-economic  The  i n descending  (See Appendix G).  women w i t h  no  work  s t a t e d o c c u p a t i o n was  s t a t u s , u s i n g B l i s h e n and  s c a l e where f i v e hundred o c c u p a t i o n s ranked  were d i c h o t o -  o b t a i n e d by a s k i n g f o r the s u b j e c t ' s major  married  used.  as age  experience, then  converted  McRobert's  (1976)  of Canadian workers a r e indexed  o r d e r of s t a t u s on a s c a l e of one  the  and  t o f i v e hundred.  F i n d i n g s a r e p r e s e n t e d and d i s c u s s e d i n the f o l l o w i n g c h a p t e r .  The U n i v e r s i t y of B r i t i s h Columbia S t a t i s t i c a l Package f o r the SoS c i e n c e s , V e r s i o n 8, "CROSSTABS," ( K i t a 1980) was used t o perform test.  l  cial this  36  CHAPTER IV PRESENTATION AND DISCUSSION OF FINDINGS  The  study  findings  are, p r e s e n t e d  and d i s c u s s e d i n t h i s  five  sections.  The f i r s t  section  ple,  the second  and t h i r d  s e c t i o n s present  activities  and d a i l y  describes c h a r a c t e r i s t i c s  living activities  and  f a m i l y members  routine fifth  activities  Difficulties  factors  and concerns  i n the performance are described  of the sam-  related  t o eye care  r e s p e c t i v e l y , and the f o u r t h  t i o n d e s c r i b e s p e r s o n a l and e n v i r o n m e n t a l s e l f - c a r e behaviours.  findings  chapter i n  that i n f l u e n c e d p a t i e n t experienced  by p a t i e n t s  of eye care procedures  i n their  sec-  and d a i l y  relevant sections.  In the  s e c t i o n a d i s c u s s i o n and i n t e r p r e t a t i o n of the aforementioned  find-  ings i s presented.  SAMPLE CHARACTERISTICS The  study  operative  cataract  eligibility sonal  sample was a convenience  one, r e p r e s e n t i n g a l l the p o s t -  p a t i e n t s (N = 20) i n one h o s p i t a l  who met the study  c r i t e r i a d u r i n g the t h r e e month d a t a c o l l e c t i o n p e r i o d .  characteristics  and m e d i c a l  parameters  a s s o c i a t e d with  Per-  the study  p a r t i c i p a n t s a r e p r e s e n t e d i n t h i s s e c t i o n , and a r e summarized i n f i g u r e s 2 and 3. The  sample was composed of t h i r t e e n  who ranged  i n age from  h o s p i t a l admission, w i t h a b l e spouses;  63 t o 83 y e a r s  and seven  (median 71 y e a r s ) .  t e n of the respondents one woman l i v e d  female  Prior  to this  ( f o u r women and s i x men) l i v e d  w i t h h e r daughter;  ( e i g h t women and one man) l i v e d a l o n e .  male p a t i e n t s  and n i n e s u b j e c t s  A l l were C a u c a s i a n , of B r i t i s h or  37  European d e s c e n t . ed.  A wide range of  S i x t y percent  t i o n or h i g h e r .  socio-economic  of the s u b j e c t s had  The  range was  s t a t u s was  represent-  the e q u i v a l e n t of grade 12  seven years  of s c h o o l i n g to f i v e years  university.  Male  Female  Years  (4)  (1)  [  (2)  (6)  (2)  F i g u r e 2.  Age  and  80 -  84  75 -  79  70 -  74  65 - 69  (3)  (1)  c  ]  educa-  (1)  60 -  Sex D i s t r i b u t i o n s of S u b j e c t s  64  (N =  20)  of  A review  of the m e d i c a l h i s t o r y on the s u b j e c t ' s h o s p i t a l c h a r t i n -  d i c a t e d t h a t t h i s sample was r e p r e s e n t a t i v e i n m e d i c a l s t a t u s of the general  population  of a s i m i l a r  p o r t e d f o r 16, o r 80 percent ditions  were  jects).  hypertension  age.  Chronic  medical  of the s u b j e c t s . (eight  subjects)  c o n d i t i o n s were r e -  The m a j o r i t y of these  con-  and  sub-  Other m e d i c a l problems such as angina,  arthritis  (five  chronic o b s t r u c t i v e lung  d i s e a s e , and m i t r a l i n s u f f i c i e n c y were a l s o r e c o r d e d .  F i v e s u b j e c t s had  previously  cataract  had eye s u r g e r y  unrelated  to the p r e s e n t  F i v e were b e i n g t r e a t e d f o r glaucoma. in  the s u b j e c t ' s unoperated  and  surgery.  The best c o r r e c t e d v i s u a l  eye ranged  from  20/50  actuity  t o no u s e f u l  vision,  f o r one s u b j e c t , the operated eye was an o n l y eye. Impairments  jects,  i n fine  and a h e a r i n g  motor c o - o r d i n a t i o n were  l o s s was  noted  i n seven.  observed  i n 12  sub-  None r e q u i r e d a h e a r i n g  aid. All acute care  subjects  care  on an ophthalmology  cations  on  their  cataract  teaching h o s p i t a l ,  j e c t s had s t a n d a r d  stay.  had  surgery  in a  and r e c e i v e d t h e i r  unit.  Chart  review  c a t a r a c t s u r g e r y without  large  p r e and  metropolitan postoperative  e s t a b l i s h e d t h a t a l l sub-  lens implant,  and no  o c c u r r e d d u r i n g the s u r g e r y or d u r i n g the p o s t o p e r a t i v e One o p h t h a l m o l o g i s t  operated  t h r e e each, and t h e r e m a i n i n g  remaining  seven o p h t h a l m o l o g i s t s .  thetic, s i x a l o c a l anaesthetic.  hospital  on seven of the p a t i e n t s , two  seven p a t i e n t s were o p e r a t e d  others  on by the  F o u r t e e n p a t i e n t s had a g e n e r a l anaesF o l l o w i n g s u r g e r y , the l e n g t h of h o s p i -  t a l s t a y ranged from t h r e e t o s i x days; the mean was f o u r days.  compli-  4.2 days,  the mode  39  -20  100-  P E R C E N T A G E 0 F  90-1  U-18  80_|  U6 N .14 U M B E .12 R  70_|  60-1  Uio  50-1  S U 4 CM B J E C 30_| T S  u  20 50 20  |2001 20-J  VV 20 80  0 R 20 100  10-1  L E S S  Visual Acuity unoperated eye  F i g u r e 3.  N I M P A I R E D  I M P A I R E D  Hearing  U N I M P A I R E D  I M P A I R E D  F i n e Motor Dexterity  Concomitant medical conditions  U  8  U  6  U  2  Previous eye surgery  S e l e c t e d H e a l t h R e l a t e d C h a r a c t e r i s t i c s of S u b j e c t s  (N =  20)  40  EYE An  overview  of  sion, d i f f i c u l t i e s ally  i n Table  1.  expected  CARE ACTIVITIES eye  care  behaviours,  e x p e r i e n c e d and concerns As may  be  observed,  patients'  expressed,  i s presented  However, many p a t i e n t s and  bers e x p e r i e n c e d d i f f i c u l t i e s  concerns  the  instructions.  Detailed  p r e s e n t e d under headings  visu-  the m a j o r i t y of s u b j e c t s f o l l o w e d  the recommended m e d i c a l regimen. and  comprehen-  accounts  of  f a m i l y mem-  i n the course of c a r r y i n g  specific  eye  care  r e l a t e d t o the s p e c i f i c study  out  findings  are  purposes.  A d m i n i s t r a t i o n of M e d i c a t i o n s as P r e s c r i b e d Complete adherence t o the p r e s c r i b e d m e d i c a t i o n regime, t i o n s were o b t a i n e d , was Of  the two  remaining  r e p o r t e d by  s u b j e c t s , one  t i o n i n the two week p e r i o d , and quency of i n s t i l l a t i o n s aches to  18,  o m i t t e d o n l y one  of the s u b j e c t s .  eyedrop  administra-  the o t h e r o c c a s i o n a l l y a l t e r e d  of an eyedrop  t h a t were e x p e r i e n c e d .  or 90 p e r c e n t  once medica-  a c c o r d i n g t o the s e v e r i t y  A l l subjects considered c a r e f u l  the  fre-  of headadherence  the m e d i c a t i o n r o u t i n e s to be an important p a t i e n t r e s p o n s i b i l i t y ,  p e r c e i v e d t h i s adherence to be a f a c t o r visual  outcome.  Data  related  to  the  that  c o n t r i b u t e d to a  filling  s c r i p t i o n s ; e s t a b l i s h i n g a p p r o p r i a t e r o u t i n e s ; and i n s t i l l i n g  All scribed.  successful  a d m i n i s t r a t i o n of m e d i c a t i o n s  r e p o r t e d i n the f o l l o w i n g s e c t i o n under t h r e e headings:  Filling  and  are  the p r e -  eyedrops.  Prescriptions s u b j e c t s had  a minimum of  two  different  kinds  of eyedrops  In a d d i t i o n , t h r e e s u b j e c t s had s y s t e m i c m e d i c a t i o n  mide) o r d e r e d .  Frequencies  f o u r times a day.  No  of a d m i n i s t r a t i o n v a r i e d  ointments were p r e s c r i b e d .  from  pre-  (acetazola-  once a day  to  TABLE 1 Examples of Expected  Eye Care Behaviours:  Adherence, Comprehension, D i f f i c u l t i e s ,  Knew E x p e c t a t i o n s Adhered Not Adhered  Instilled  eyedrops  18  Took systemic medication  3(b)  Unaware o f Expectations  Concerns,  Incurred Difficulties  16(a)  Questions  Concerns or Questions  2  0  16  0  0  0  3  Wore p r o t e c t i v e g l a s s e s d u r i n g day  19  1  0  0  0  Wore p r o t e c t i v e s h i e l d a t n i g h t  19  1  0  14  8  2  0  0  0  1  11  0  6  2  0  0  0  14 16  4 3  0 0  0 0  0 0  0 0  0 0  18 19  0 0  0 0  R e s t r i c t e d bending,  lifting,  s t r a i n i n g , housework, gardening R e s t r i c t e d reading Avoided  8  t o u c h i n g eye  Washed hands before V i s i t 1(c) V i s i t 2(d)  18 treatments  Washed hands f o l l o w i n g treatments V i s i t 1(c) V i s i t 2(d)  (a) (b) (c) (d)  18  D i f f i c u l t i e s i n c l u d e g e t t i n g drops i n t o eye; t o u c h i n g l i d s , l a s h e s o r eye; m a n i p u l a t i n g agitating bottle. Only three persons had p a r e n t e r a l medications ordered. F i r s t home v i s i t - 18 o b s e r v a t i o n s made. Second home v i s i t - 19 o b s e r v a t i o n s made.  dropper,  42  The  p r e s c r i b e d medications  were o b t a i n e d by a l l s u b j e c t s .  However,  i n i t i a l d e l a y s i n p r e s c r i p t i o n d i s p e n s i n g , r a n g i n g from f o u r t o 24 hours, were  experienced  scheduled ficulty and  by  medication  i n locating  t o the l a c k  echothiophate  four  subjects,  times.  These  of a v a i l a b i l i t y  c h l o r i d e (Neosynephrine),  were  over  attributable  of two  specific  missing  to a  medications,  dif-  namely,  I o d i d e ) , and 2.5% p h e n y l e p h r i n e  i n s m a l l neighbourhood drug  hydro-  stores.  or f r i e n d s o b t a i n e d the p r e s c r i p t i o n s f o r the m a j o r i t y of  subjects  ( 1 6 ) , w h i l e pharmacists  stances.  One s u b j e c t o b t a i n e d  the h o s p i t a l  delays  concern  a neighbourhood pharmacy t h a t was open on a Sunday,  i o d i d e (Phospholine  Relatives  engendering  to a l o c a l  delivered  the medications  h i s own m e d i c a t i o n s ,  pharmacy,  i n three i n -  taking a taxi  and a bus the remainder  from  of the way  home.  E s t a b l i s h i n g Appropriate The  establishment  bering medication ticipants.  Routines  of a p p r o p r i a t e r o u t i n e s f o r sequencing  times was accomplished  D e c i s i o n s were f r e q u e n t l y based  used by nurses i n the h o s p i t a l . and  without  difficulty  on s c h e d u l e s  and rememby a l l p a r -  t h a t had been  D a i l y r o u t i n e s such as a r i s i n g ,  mealtimes p r o v i d e d f o c a l p o i n t s f o r remembering m e d i c i n e s .  ject,  who was r e c e i v i n g  c a t a r a c t drops,  drops  retiring One sub-  f o r glaucoma as w e l l as the p o s t o p e r a t i v e  s e t an a l a r m c l o c k f o r each s u c c e s s i v e m e d i c a t i o n  admin-  i s t r a t i o n time i n an endeavour t o m a i n t a i n constant l e v e l s of m e d i c a t i o n . It subjects  was noted  that the simpler  the r o u t i n e , the e a s i e r  t o sequence and remember m e d i c a t i o n  times.  i t was f o r  F o r example, when  two k i n d s of drops were ordered a t the same i n t e r v a l s , remembering admin-  i s t r a t i o n times was s i m p l i f i e d ,  and t h e need t o d i f f e r e n t i a t e  medications  was negated.  Instilling A  Eyedrops  variety  of arrangements  Table 2 i l l u s t r a t e s t i o n a t t h e time  were  made  f o r eyedrop  administration.  the d e l e g a t i o n of r e s p o n s i b i l i t y of eyedrop  of each of the two home v i s i t s .  E s p e c i a l l y notable are  the o b s e r v a t i o n s t h a t by t h e time of t h e second home v i s i t , s u b j e c t s who a d m i n i s t e r e d  their  instilla-  the number of  own drops had i n c r e a s e d by a f a c t o r of  t h r e e , and t h e home c a r e nurse v i s i t s had t e r m i n a t e d .  Table 2 D e l e g a t i o n of R e s p o n s i b i l i t y f o r Eyedrop Instillation, First  and Second V i s i t  (N = 20)  Person R e s p o n s i b l e f o r Eyedrop I n s t i l l a t i o n  Visit  One*  Visit  Two+  Subject  3  9  Spouse  9  8  Relatives  5  3  Friend  1  0  • 2  0  Home Care Nurse * Day f o l l o w i n g h o s p i t a l d i s c h a r g e + P o s t o p e r a t i v e day 13 - 16  Observations (Two  subjects  of i n s t i l l a t i o n  had home  t h e r e f o r e not observed.  care  of eyedrops were made i n 37 i n s t a n c e s .  nurses  for initial  One of these  A  graphic  p o r t r a y a l of observed  i n Figure  difficulties  difficulty  eyedrop  4, where t h e reader  observe  At the time of the f i r s t v i s i t ,  technique  that  is  a number of  s i x f a m i l y members had  g e t t i n g the drops i n t o the p a t i e n t ' s eye. Two f a c t o r s c o n t r i -  buted t o t t h e s e d i f f i c u l t i e s ; enough back t o p r o v i d e could  reluctant  not h o l d  e i t h e r the s u b j e c t ' s head was not t i l t e d f a r  an adequate a n g l e  t o , or d i d n o t know t o p u l l that  f o r a d m i n i s t r a t i o n , o r the sub-  h i s eye open v o l u n t a r i l y  creates  a pocket  and the f a m i l y member was  down the s u b j e c t ' s  to receive  need t o b l i n k o r squeeze the eye s h u t ) . ficult  will  instillation  were i n c u r r e d by s u b j e c t s o r f a m i l y members i n the a d m i n i s -  t r a t i o n of drops.  maneuver  from the a n a l y s i s f o r  techniques).  presented  ject  and were  s u b j e c t s r e f u s e d t o be observed i n -  s t i l l i n g drops on the second v i s i t and i s excluded observed  instillation  the drop,  lower  l i d (a  and overcomes the  P a t i e n t s had a p a r t i c u l a r l y  time k e e p i n g t h e i r eye open v o l u n t a r i l y d u r i n g  dif-  the a d m i n i s t r a t i o n  of t h e second of two d r o p s . Contamination  of the dropper or b o t t l e t i p was another  and  most f r e q u e n t l y o c c u r r e d  the  lashes  or l i d s .  None o f these  s t i l l a t i o n that provided of  when a f a m i l y member  support  the hand o f the s u b j e c t ' s  that  dispenser  directly  touched of i n -  f o r t h e i r hand, such as r e s t i n g the h e e l  brow o r temporal bone.  on t h e i n n e r  the drop went i n t o the eye.  difficulty  inadvertently  p a r t i c i p a n t s used a technique  were s e l f - a d m i n i s t e r i n g drops, contaminated the  difficulty,  Three s u b j e c t s  the b o t t l e when they  canthus or on the s c l e r a  With t h i s  technique  subjects  i n j u d g i n g how many drops had been i n s t i l l e d .  who  placed  t o ensure reported  45 Q  |  f  6  f  10  12  If  16  18  2"  Number of respondents  Washed hands b e f o r e procedure  Assumed a s a f e position  R e c l i n e d head to f a c i l i t a t e eyedrop instillation  A g i t a t e d suspension type drops  I n s t i l l e d correct medication  W/////A  Drop went i n t o eye f i r s t attempt  Avoided contaminating b o t t l e of drops  'A F i g u r e 4.  Observations of Home A d m i n i s t r a t i o n  Performed  ]//'I'/[ |  Not performed  | Not a p p l i c a b l e  Visit  1:  Visit  2:  Washed hands upon completion of procedure  of Prescribed  Eyedrops  N = 18 (3 s u b j e c t s , 15 r e l a t i v e s or f r i e n d s ) N = 19 (8 s u b j e c t s , 11 r e l a t i v e s )  Sixteen these  s u b j e c t s had  a  suspension  type  drop p r e s c r i b e d .  d i d not know of the n e c e s s i t y to a g i t a t e the  istering  the drops,  and  neglected  to do  so.  bottle  manufacturer's  directions  the typed pharmacist's The  on  the  bottle  and  admin-  covered  i n no  case  pendix E) r e c e i v e d by  who  stood  drops, drops. rim  by  were hands washed  s u b j e c t s was  the p o t e n t i a l hazard  unsupported  in  became unsteady  was  neglected In s i x  f o l l o w i n g treatments,  when  of the bathtub, was  As may served  the  be observed  during  the  s a f e t y of  have on  she  tilted  One  while her  a  82  year  relative  head on  back  (Ap-  admin-  old subject, instilled  to  the  receive  the  a f o l d e d towel on  the  jeopardy when he  i n F i g u r e 4,  leaned back to f a c i l -  participants  the  difficulties  the second v i s i t ,  results  Firstly,  j e o p a r d i z e d , the  to have the  support had  By  of  were  ob-  participants  overcome many of the i n i t i a l d i f f i c u l t i e s .  three items.  r o u t i n e would be  most  i n f l u e n c e d the  s u b j e c t s was  where t h e r e would be visit,  bathroom  f i r s t home v i s i t .  r e s e a r c h e r may  safer  al-  instillation.  second home v i s i t the  of a f a l l .  i n similar  had become more adept and had The  jeopardized during medication  Another s u b j e c t , p r e c a r i o u s l y balanced  i t a t e drop  by  17, or 85 p e r c e n t of the s u b j e c t s .  s a f e t y of two  istration  on  label.  though these i n s t r u c t i o n s were on a p r i n t e d d i s c h a r g e handout sheet  The  of  i n three instances  were c o m p l e t e l y  i n s t r u c t i o n t o wash hands b e f o r e treatments  instances,  before  F o r some, the d i r e c t i o n s  the b o t t l e to "shake w e l l " were too s m a l l , to read, and the  Eight  of  observations  i n the  two  r e s e a r c h e r suggested  s u b j e c t p o s i t i o n e d on  this  suggestion.  the  i n s t a n c e s where  d u r i n g eyedrop i n s t i l l a t i o n .  instigated  for  a  bed On  that a or  sofa  the second  Secondly,  in  the  eight  instances that  were t o l d  of t h i s  necessity.  members were h a v i n g subject  was  suspension  great  apprehensive  s e a r c h e r demonstrated  type  Finally,  difficulty of  drops  having  were not  agitated,  i n t h r e e i n s t a n c e s where f a m i l y  with the  eyedrop  bottle  instillation  and  the  the  re-  t h a t supported  the  touch  a t e c h n i q u e of drop i n s t i l l a t i o n  hand h o l d i n g the dropper.  subjects  the  eye,  T h i s i n t e r v e n t i o n f o l l o w e d the o b s e r v a t i o n of  the f a m i l y member's i n s t i l l a t i o n  o f drops, and was  done a t  participants'  request.  Concerns R e l a t e d to M e d i c a t i o n s The most f r e q u e n t l y s t a t e d c o n c e r n r e l a t e d t o m e d i c a t i o n a d m i n i s t r a t i o n was eyedrop tle  the worry of i n a d v e r t e n t l y instillation.  too hard and  quent  A second  Systemic  one  drop.  of s q u e e z i n g  the b o t -  Some examples  of  "Does i t matter which drop goes i n f i r s t ? "  I w a i t a few minutes between d r o p s ? "  w e l l as the new  damaging the eye d u r i n g  common concern was  i n s t i l l i n g more than  q u e s t i o n s were:  p l a c e d ? " "Should  t o u c h i n g and  I was  " W i l l the drops always be  medications  were a l s o  "Should  "Where on the eye s h o u l d the drop  I c o n t i n u e w i t h the drops ones?"  fre-  be  u s i n g b e f o r e s u r g e r y as necessary?"  the s u b j e c t of q u e s t i o n s .  While  in  h o s p i t a l , some s u b j e c t s had changes made i n s c h e d u l e s or dosages of medications prescribed prior  t o the s u r g e r y by f a m i l y d o c t o r s , and o c c a s i o n -  a l l y new  m e d i c a t i o n s had been added.  The q u e s t i o n was,  follow?  A l l t h r e e of the s u b j e c t s t a k i n g a c e t a z o l a m i d e  which s c h e d u l e to (Diamox) q u e r i e d  whether or not they s h o u l d have t h i s p r e s c r i p t i o n renewed. In  addition  t o p r e v i o u s l y mentioned d i f f i c u l t i e s ,  p o r t e d the f o l l o w i n g  problems:  participants  re-  48  1.  C o n t a i n e r s were collars  around  left  attached  top.  Eyedrop  initially the b o t t l e  2.  secure  sealing  t o remove, and when  replacement  of the b o t t l e tubes  and once opened, tops were f r e q u e n t l y  left  o r the c o n t a i n e r was n o t used a t a l l . on b o t t l e s , and the typed pharmacist's l a -  were t o o s m a l l f o r many s u b j e c t s t o r e a d .  friends,  colour,  help  Physical characteristics  shape, s i z e and p l a c e of s t o r a g e were used  tions apart.  from  dropper  bottles  p r e s s u r e needed t o emit  were  stiff  such as  to t e l l  In s e v e r a l i n s t a n c e s , d i f f e r e n t i a t i o n was  as drops were o r d e r e d a t simultaneous Plastic  Initial  r e l a t i v e s and home c a r e nurses enabled s u b j e c t s t o d i f f e r -  e n t i a t e and o r g a n i z e m e d i c a t i o n s .  3.  The p l a s t i c  b o t t l e s dispensed i n s i d e c h i l d - r e s i s t a n t p l a s t i c  The p r i n t e d i n s t r u c t i o n s bel  t o open.  t o p s were d i f f i c u l t  t o cap, p r e v e n t e d  a l s o p r e s e n t e d problems, off,  difficult  medica-  unnecessary  intervals. t o squeeze,  and the amount o f  j u s t one drop was d i f f i c u l t  t o judge.  Sub-  j e c t s w o r r i e d t h a t s e v e r a l drops would s p u r t out at one t i m e . 4.  R e p l a c i n g droppers  i n glass  c r e a s e d depth p e r c e p t i o n . dispensed over  i n glass  the b o t t l e  medicine  bottles  was  difficult  Two of t h e f o u r bottles  with  when they were a t t e m p t i n g  because  of de-  s u b j e c t s who had drops  s e p a r a t e droppers  tipped  t o r e p l a c e the dropper.  These s u b j e c t s l e a r n e d t o l o c a t e the b o t t l e c a r e f u l l y by touch, h o l d it  s e c u r e l y and f e e l f o r the opening t o r e p l a c e the dropper.  ulating  t h e s m a l l rubber b u l b on t h e g l a s s  t h e r e were enough drops for  t h r e e o f these f o u r  sucked up i n t o participants.  dropper,  the dropper,  Manip-  and j u d g i n g i f posed  problems  5.  Subjects  who  instilled  their  own  drops  reported  difficulties  j u d g i n g the a n g l e a t which they were h o l d i n g the dropper and  i n j u d g i n g the d i s t a n c e the d i s p e n s e r was from  s u b j e c t s , who had been i n s t i l l i n g s e v e r a l years difficulty  prior  to this  presented  their  own drops  c a t a r a c t surgery,  by t h e i r  inability  in  or b o t t l e ,  the eye.  Three  f o r glaucoma f o r  commented on the new  t o see the p o s i t i o n  of the  bottle. Difficulties  r e p o r t e d by p a r t i c i p a n t s  and the frequency  of t h e i r  occur-  rence a r e summarized i n T a b l e 3.  Table 3 Summary o f Reported  Difficulties  by Type, Frequency, and Person  Number of P a r t i c i p a n t s Patient alone  Family member  Total number  %  1.  Opening c o n t a i n e r  4  5  9  45  2.  Reading l a b e l s  8  -  8  40  3.  Squeezing  3  5  8  40  4.  Obtaining p r e s c r i p t i o n ( d e l a y > 6 hours)  -  2  2  10  5.  Spilling  2  -  2  50*  6.  Manipulating separate dropper  2  1  3  75*  bottle  eyedrops  * Only f o u r s u b j e c t s s e p a r a t e dropper.  had  eyedrops  dispensed  i n glass  bottles  with  a  50 P r o t e c t i o n o f the Eye from I n j u r y  Use  o f Eye G l a s s e s , P r o t e c t i v e Eye S h i e l d The  majority  scription  of s u b j e c t s  glasses  during  (19) used  dark g l a s s e s  or their  own  pre-  the day and t h e metal p r o t e c t i v e eye s h i e l d a t  n i g h t , t o p r o t e c t the eye from i n a d v e r t e n t  rubbing  or bumping.  One sub-  j e c t d i d not own p r e s c r i p t i o n g l a s s e s , and found the h o s p i t a l i s s u e d dark g l a s s e s were u n c o m f o r t a b l e t o wear a l l day. wear the dark g l a s s e s o u t d o o r s . g l a s s e s reduced t h e i r a b i l i t y difficult buying  t o get around.  clip-on plastic  have covered One  d i d , however,  Several subjects reported  t h a t the dark  the unoperated eye and made i t  One c r e a t i v e i n d i v i d u a l s o l v e d t h i s problem by  dark g l a s s e s  and c u t t i n g o f f the s i d e t h a t would  the unoperated e y e .  subject  discontinued  subject  t o see w i t h  This  d i d n o t understand  i t s use on the t h i r d  the need  f o r the m e t a l  day home from h o s p i t a l .  used the s h i e l d and an eye pad f o r e x t r a p e r i o d s as  at night,  curity  stating  and comfort.  indication  to this  that  t h e pad and s h i e l d  These f o u r behaviour,  subjects  subjects  the  shield;  of  difficulties,  Table 4.  reported  subjects  the day as w e l l  were n o t aware of any c o n t r a of i n c r e a s i n g the  environment.  any i n t e r f e r e n c e w i t h  however, many had d i f f i c u l t i e s and the frequency  Four  gave them a f e e l i n g of s e -  such as the p o s s i b i l i t y  r i s k of i n f e c t i o n w i t h i n an e n c l o s e d No  during  s h i e l d , and  with  their  sleep  because of  i t s application.  of occurrence  Types  are i l l u s t r a t e d i n  51 Table 4 Eye  Shield D i f f i c u l t i e s  by Type and Frequency  Number of Participants  Difficulty  %  Observed 1.  2.  P o s i t i o n i n g s h i e l d : n a s a l o r temporal p o r t i o n of eye l e f t exposed, o r s h i e l d r e s t e d on s o f t p o r t i o n of eye  8  40  11  55  M a n i p u l a t i n g tape: s h i e l d s l i p p e d out of p l a c e when p a r t i c i p a n t reached f o r r o l l of tape  Reported 1.  Tape i r r i t a t i n g t o s k i n  5  25  2.  Tape d i d n o t s t i c k w e l l  5  25  Successful  applications  1) p l a c i n g a s t r i p the  patient  tape.  hold  of  the eye s h i e l d  were  of tape on the s h i e l d b e f o r e a p p l y i n g the s h i e l d i n p l a c e  while  a family  I t s h o u l d be noted t h a t , w h i l e i n most i n s t a n c e s  r e l a t e d t o l a c k of f a c i l i t y , i n two i n s t a n c e s c o n f i g u r a t i o n o f the p a t i e n t ' s were s o l v e d  when s u b j e c t s  face.  changed  accomplished  by:  i t , or 2) h a v i n g  member  a p p l i e d the  d i f f i c u l t i e s were  the s h i e l d d i d not f i t the  Problems r e l a t e d t o the tape i t s e l f  to transparent  mending  tape,  masking  tape, or dermapore/micropore t a p e s . Questions t h a t p a r t i c i p a n t s f r e q u e n t l y  asked the r e s e a r c h e r  were:  1.  Is there  a s i d e t h a t i s supposed t o go next t o the nose?  2.  A t what a n g l e s h o u l d the s h i e l d be  3.  Should the s h i e l d be s t e r i l i z e d  4.  Is i t a l l r i g h t t o use a f o l d e d Kleenex under the s h i e l d at n i g h t ?  positioned?  each day?  52  R e s t r i c t i o n of The  discharge  proscribes directed work.  Activity  a c t i o n s which  by  As  instruction  the  doctor,  sheet  i n v o l v e bending,  the reader w i l l  have noted  p l i e d w i t h the recommendations. e t y of s t r a t e g i e s to comply. tongs  counter  to  level.  pick  to p a t i e n t s i n t h i s  lifting,  straining;  r e a d i n g , housework, gardening,  t i o n of the r e a d i n g p r o s c r i p t i o n ,  salad  provided  up  these  and  until  r e t u r n i n g to  1 (p. 41), w i t h the excep-  or 90 percent  of the s u b j e c t s com-  S u b j e c t s r e p o r t e d t h a t they used a  F o r example, they bent  fallen  None of  18,  i n Table  and  study  o b j e c t s , and subjects  kept  reported  vari-  t h e i r knees or used  items that  they the  needed  at  restrictions  p r e s e n t e d any d i f f i c u l t y o t h e r than remembering about them. Both of the s u b j e c t s who ing  activities,  them.  One  although  r e p o r t e d non-compliance  they  d i d have  other  people  resumed  housekeep-  available  to  help  s u b j e c t w i t h i n two weeks of s u r g e r y hoed the garden, vacuumed  the house, and  carried  two  l a r g e bags of g r o c e r i e s f i v e b l o c k s home from  the s t o r e . The  s a n c t i o n on  r e a d i n g was  stimulated questions it  r e g a r d i n g how  should be r e s t r i c t e d .  the  least  much would be  eye was  P r e c a u t i o n s to A v o i d F a l l i n g and Bumping the  railings  subjects on  stairs,  said  they  steadying  the home, and w a l k i n g  restriction,  t o l e r a b l e and  how  and long  S e v e r a l s u b j e c t s c o n j e c t u r e d t h a t r e a d i n g would  be a c c e p t a b l e as l o n g as the o p e r a t e d  All  understood  took  covered.  Eye  precautions  against  themselves when necessary  carefully  outdoors  j e c t s r e p o r t e d t h a t s i n c e the s u r g e r y  falling on  on uneven ground.  i t was  more d i f f i c u l t  by  using  furniture  in  S e v e r a l subto judge  the  53  speed and d i s t a n c e of c a r s . traffic  lights  to  blocks  further.  Complicated ticed  by  the  cross  They, t h e r e f o r e , now  busy  furniture  streets  even  arrangements  researcher i n s i x of  or  used i n t e r s e c t i o n s w i t h  i f I t meant  loose  scatter  the homes, but  walking  rugs  a  few  were  no-  subjects stated  they  were f a m i l i a r w i t h these and d i d not p e r c e i v e them as a h a z a r d . Walking  sticks  were u n a c c e p t a b l e  an a s s o c i a t i o n w i t h b e i n g o l d . the r e p l i e s When I get  One  of o t h e r s u b j e c t s w i t h old I will  use  t o 18  s u b j e c t s , mostly  seventy-one  year o l d s u b j e c t t y p i f i e d  the comment, "I am  a cane."  because of  Another,  not an o l d woman.  eighty-two  years  of  s t a t e d she might f i n d a r o l l e d up u m b r e l l a a c c e p t a b l e but a w a l k i n g would g i v e the appearance of o l d age, Five ry.  Two  so she would not use  subjects described incidents  that  had  s u b j e c t s f e l l when they got out of bed  u n f a m i l i a r s u r r o u n d i n g s of a daughter's  home.  potential  age, stick  one. f o r eye  inju-  d u r i n g the n i g h t i n the  Another  bumped her head on  a bookcase near her bed, and one had a p a i n f u l j a r when she climbed up the r i m of a bathtub to  the f l o o r .  as he was  The  t o hang up  l a u n d r y and misjudged  f i f t h poked h i s eye w i t h  p u t t i n g them on.  Few  the d i s t a n c e down  the e a r p i e c e of h i s g l a s s e s  people (seven) were aware of a p r e c a u t i o n  when p u t t i n g on s p e c t a c l e s , of h o l d i n g them by the ear t i p s an a c c i d e n t . to  None of these i n c i d e n t s was  check-up  visit.  to a v o i d such  deemed s e r i o u s enough to r e p o r t  the o p h t h a l m o l o g i s t , and i n d e e d no eye problem was  quent  on  noted on the  subse-  54  Maintenance o f C l e a n l i n e s s o f the Eye "Bathe your cotton  eyes w i t h  as n e c e s s a r y ,  b a l l s which may be purchased a t the d r u g s t o r e "  on t h e p r i n t e d d i s c h a r g e i n any of the drug t o purchase them. locate  warm t a p water  a drug  sheet.  stores  Sterile  that  i s an i n s t r u c t i o n  i n which p a r t i c i p a n t s i n t h i s  carried  sterile  study  considerable  cotton  balls  use.  These persons were concerned  cotton  balls  as i n s t r u c t e d .  cotton  and p u l l e d o f f p o r t i o n s  they a l r e a d y had on hand. the  words,  "as n e c e s s a r y . "  that  and f i n a l l y  as necessary,  sterile  sterile  and s i x used c o t t o n  Two s u b j e c t s q u e r i e d  the frequency  5 illustrates  pur-  or f i r s t -  they were not u s i n g  Two p a r t i c i p a n t s purchased  Figure  attempted  time t r y i n g t o  chased n o n - s t e r i l e c o t t o n o r rayon b a l l s packaged f o r cosmetic aid  sterile  c o t t o n b a l l s were n o t a v a i l a b l e  Some f a m i l y members spent  store  using  rolled balls  implied i n  eye c l e a n s i n g  behav-  iours.  14 c l e a n s e d eye w i t h warm water and c o t t o n b a l l s as necessary  F i g u r e 5.  3 not n e c e s s a r y no mucus or crusts  3 unaware of i n s t r u c t i o n s : used d r y c o t t o n b a l l s or f a c e c l o t h t o wipe eye  I l l u s t r a t i o n of P a t i e n t Adherence t o Eye Cleansing Instructions  55  P r o v i s i o n of Comfort  Measures When Necessary  T h i r t e e n s u b j e c t s r e p o r t e d m i l d d i s c o m f o r t i n t h e i r eye, u s u a l l y scribing plained  the of  feeling  as  browache.  A  troublesome edy,  "itchy" total  of  " s c r a t c h y , " and  eight  s i x p a t i e n t s deemed  p a t i e n t s com-  their  discomfort  enough to o c c a s i o n a l l y take an o v e r - t h e - c o u n t e r headache rem-  a measure which, w i t h  discomfort at a l l . trated  or  de-  i n Table  5.  one  e x c e p t i o n was  effective.  Seven had  D i s c o m f o r t s and measures f o r t h e i r r e l i e f A l l subjects with  provements by the second home  initial  are  no  illus-  discomforts reported  im-  visit.  Table 5 D i s c o m f o r t s by Frequency,  Discomforts 1.  2.  3.  Browache  Number of subjects reporting 7 1*  Eye i t c h y , scratchy  Photophobia  13  S e v e r i t y and Comfort  Severity  Comfort  measures  mild-mod. severe  used o v e r - t h e - c o u n t e r headache remedy  mild  c l e a n s e d eye l a y down and r e s t e d eye put on pad and s h i e l d used o v e r - t h e - c o u n t e r headache remedy  -11  Measures  mild  drew drapes — wore dark g l a s s e s  4.  5.  C i g a r e t t e smoke irritating  3+  Eyedrops  3  * One  stung  — avoided  smoky areas  F  4 5 4 4 2 4 11  3  mild  subject experienced i n c r e a s i n g l y severe headaches which were u n r e l i e v e d by home remedies. The o p h t h a l m o l o g i s t was n o t i f i e d , and frequency of e c h o t h i o p h a t e iodide ( P h o s p h o l i n e I o d i d e ) drops were reduced. + These s u b j e c t s were a l l non-smokers themselves.  56 R e c o g n i t i o n and R e p o r t i n g o f S i g n i f i c a n t I n d i c a t o r s of C o m p l i c a t i o n Specific follows: from  signs  and symptoms deemed r e p o r t a b l e by s u b j e c t s were as  severe p a i n i n the eye; onset  t h e eye; i n c r e a s e d  redness;  of nausea or v o m i t i n g ;  severe  headache;  change  discharge  i n vision;  swelling. T a b l e 6 i n d i c a t e s the number of s u b j e c t s who c o n s i d e r e d each s i g n or symptom r e p o r t a b l e . terview  schedule  A f r e e response  item:  was t h e spontaneous r e p l y t o the i n -  "When p a t i e n t s l e a v e h o s p i t a l  they  are u s u a l l y  i n s t r u c t e d t o phone t h e i r d o c t o r i f they have undue d i s c o m f o r t a  change  i n t h e c o n d i t i o n of t h e i r  think required a c a l l the  spontaneous  eye.  What s p e c i f i c  t o your eye d o c t o r ? "  response,  they  s i g n s would you  When s u b j e c t s had completed  were prompted  by t h e q u e s t i o n ,  t h i n k you would c a l l your eye d o c t o r i f you n o t i c e d : t a b l e were s u b j e c t t o a prompting except  or n o t i c e  "Do y o u  A l l items  i n the  " s w e l l i n g , " which was not o f f e r -  ed. All  s u b j e c t s s t a t e d t h a t they would have had no h e s i t a t i o n i n phon0  ing  t h e i r eye d o c t o r i f t h e r e was any concern  about  one  s u b j e c t would have been r e l u c t a n t t o c a l l  on a weekend.  the  s u b j e c t s , the ophthalmologist  consulted. reassurance;  The remaining  seven had secondary  family doctor,  bours or r e l a t i v e s who were Six first  home c a r e  office  nurse,  person  sources  eye, a l t h o u g h  they  F o r 13 o f would  have  f o r i n f o r m a t i o n or  hospital  eye ward,  neigh-  nurses.  s u b j e c t s made phone c a l l s  postoperative  was the o n l y  their  t o the o p h t h a l m o l o g i s t  check-up;  one c a l l  was  before  to r e p o r t  a  headache, and f i v e were r e q u e s t s f o r c l a r i f i c a t i o n of i n s t r u c t i o n s .  their severe  57  Table 6 I n d i c a t o r s of P o s s i b l e C o m p l i c a t i o n  and S u b j e c t ' s  P e r c e p t i o n o f Need t o Report Number o f s u b j e c t s who would r e p o r t Free response Prompted Total  S i g n o r sympton  17  3  20  Onset of nausea o r v o m i t i n g  1  19  20  Discharge  from the eye  8  11  19  Increased  redness+  5  13  18  Severe headache  1*  15  16  Change i n v i s i o n  3  8  11  Swelling  4  -  4  Severe p a i n i n t h e eye  + Two persons l i v i n g a l o n e s t a t e d they c o u l d n o t seew e l l enough to n o t i c e a change i n t h e amount of redness * Reported  S t a t u s o f the Operated Eye On nea,  each of the two home v i s i t s  observations  were made of l i d s ,  c o n j u n c t i v a , a n t e r i o r chamber, p u p i l and i r i s .  In no i n s t a n c e was a  s i g n o r symptom o f a p o s s i b l e c o m p l i c a t i o n noted t h a t m e r i t e d the  opthalmologist.  Detailed  eye s t a t u s  cor-  observations  a report to  may be found i n  Appendix F.  Continued M e d i c a l  Supervision  A l l s u b j e c t s made and kept appointments f o r continued vision.  T r a n s p o r t a t i o n t o the doctor's  s u b j e c t and a v o l u n t e e r to s o l v e  this  problem.  o f f i c e was d i f f i c u l t  d r i v e r was arranged Table  by s u b j e c t s t o a t t e n d m e d i c a l  medical  7 illustrates appointments.  super-  f o r o n l y one  through the l o c a l h e a l t h u n i t t r a n s p o r t a t i o n methods used  58  Table Methods of T r a n s p o r t  7  to M e d i c a l Appointments  by Type and  Frequency  Number of s u b j e c t s  1.  D r i v e n by a r e l a t i v e or f r i e n d  2.  D r i v e n by community v o l u n t e e r  1  3.  Bus,  accompanied by r e l a t i v e o r f r i e n d  6  4.  Bus,  unaccompanied  1  5.  Taxi  1  General For not  the m a j o r i t y of  stressful.  Of  the  Concerns R e l a t e d to the s u b j e c t s (70%)  12  s u b j e c t s who  w i t h which to make a comparison, "minor;"  11  "easier;"  "not  10  as p a i n f u l "  perceived  as  extremely  t h e i r behaviour  and  a l l the  important  concerns.  had  felt as  p a e d i c , p r o s t a t i c or glaucoma s u r g e r y . come from the s u r g e r y , w i t h  the  Eye  c a t a r a c t surgery experienced  that  their  the  itself  previous  abdominal,  resultant  t o a l l these  anticipated  P a t i e n t s commented t h a t i n s p i t e of a gen-  tical  examples  f r i e n d s and  relatives,  success,  and  of  statis-  s u c c e s s f u l outcomes among  they a l l had an u n d e r l y i n g p e r v a s i v e concern  the improvement i n v i s i o n they would o b t a i n . a t r i a l l e n s was  p r e s e n t e d , and  was  influenced  by c o n f i d e n c e i n t h e i r d o c t o r ,  of  out-  benefits,  s u b j e c t s , and  was  ortho-  However, a s u c c e s s f u l v i s u a l  e r a l o p t i m i s t i c o u t l o o k , generated probability  surgery  c a t a r a c t surgery  previous  was  The  about  f i r s t o c c a s i o n on which  s u b j e c t s c o u l d read l e t t e r s on the c h a r t ,  59  o r c l e a r l y see o b j e c t s i n t h e room, was both a r e l i e f citement.  As one s u b j e c t s u c c i n c t l y put i t , "That r e a l l y bucked me up."  Only one s u b j e c t gery. and  and a moment of ex-  had severe  concerns about  the outcome of the s u r -  T h i s s u b j e c t , and spouse had expected improved v i s i o n  immediately,  p e r c e i v e d the presence of s t i t c h e s t o be i n d i c a t i v e of a c o m p l i c a t i o n  i n the s u r g e r y .  T h e i r concern was e v i d e n t  pressions;  their  lack  "We  thought  spouse's just  and  remark,  one day . . . you know  but i t wasn't t h a t a t a l l . " nothing  yet!  of  i n t h e i r f a c i a l and v o c a l ex-  understanding  i t was  just  . . . they  was  exemplified  a cataract  lift  removal,  by the which i s  i t o f f and send you home -  The s u b j e c t a n x i o u s l y r e p o r t e d ,  " I can't see  I'm b l i n d i n t h a t eye!"  DAILY LIVING ACTIVITIES At the time of h o s p i t a l d i s c h a r g e ,  16, or 80 percent  of the s u b j e c t s  were v e r y c o n f i d e n t t h a t they c o u l d manage t h e i r p e r s o n a l c a r e and household tasks with munity s e r v i c e s . pated  decreased  their ability  the h e l p  they  had a v a i l a b l e from f a m i l y members and com-  The remaining visual  f o u r s u b j e c t s were concerned t h a t  acuity,  t o manage a t home.  or decreased  energy  These s u b j e c t s  level  reported  would  anticiaffect  t h a t they were  p l e a s a n t l y s u r p r i s e d , once they were home," a t how w e l l they were a b l e t o cope. E x p l i c i t behaviours,  d i f f i c u l t i e s and concerns r e l a t e d to d a i l y  ing a c t i v i t i e s are reported i n the f o l l o w i n g s e c t i o n .  liv-  60  L i v i n g Arrangements P r i o r t o t h i s s u r g e r y , 10 s u b j e c t s l i v e d w i t h a b l e spouses, a  daughter,  and  nine  lived  alone.  Following surgery,  temporary changes i n l i v i n g arrangements. rangements and a s s o c i a t e d sex  Table  five  one  with  people  made  8 illustrates  distributions.  Table  8  L i v i n g Arrangements P o s t s u r g e r y by Change and  Sex  Number of s u b j e c t s M F  L i v i n g arrangements  Change  Moved i n w i t h  daughter  3  Moved i n w i t h  sister*  1  Daughter moved i n w i t h s u b j e c t  1  No Change  L i v e d w i t h a b l e spouse Lived with Lived  6  daughter  alone  * Permanent r e s i d e n c e out of town  3 1  1  4  these  ar-  61  U t i l i z a t i o n o f Community S e r v i c e s Homemaker s e r v i c e , Home Care n u r s i n g s e r v i c e , and a v o l u n t e e r t r a n s p o r t a t i o n s e r v i c e were used by f i v e s u b j e c t s . Table  D e t a i l s are i l l u s t r a t e d i n  9.  Table 9 U t i l i z a t i o n of Community S e r v i c e s Pre and P o s t s u r g e r y L i v i n g arrangements Subject code #  Sex  5  F  6  Age  Community s e r v i c e s used  Presurg.  Postsurg.  Presurg.  Postsurg.  77  Alone  Alone  Homemaker  Homemaker  F  82  Alone  Alone  Homemaker  Nurse and homemaker  7  F  72  Alone  With daughter  Homemaker  Nurse (supervisory v i s i t only)  8  F  83  Alone  With daughter  None  Volunteer transportation  9  F  71  Alone  Alone  None  Nurse and homemaker*  * S u b j e c t d i s c o n t i n u e d homemaker a f t e r one week; no l o n g e r  Homemaker s e r v i c e s were u s u a l l y p r o v i d e d ever,  one s u b j e c t ' s  homemaker was  ordered  f o u r hours p e r week; how-  f o r two hours p e r day.  amount of h e l p was p e r c e i v e d as more than necessary by the s u b j e c t a f t e r one week. s u b j e c t s , and taught nursing v i s i t s proximately own  treatments.  administration.  and i n c l u d e d a f o l l o w - u p  one week a f t e r  This  and was d i s c o n t i n u e d  A home care nurse i n s t i l l e d drops f o r two  independent  was f i v e ,  necessary  The average  number of  supervisory v i s i t  s u b j e c t s had assumed r e s p o n s i b i l i t y  ap-  for their  62  Home Maintenance  Activities  Most s u b j e c t s (19) arranged f o r another person, e i t h e r spouse, tive, dry No  f r i e n d or homemaker t o do the heavy h o u s e c l e a n i n g , gardening, l a u n -  and  grocery  shopping  during  the  first  few  weeks f o l l o w i n g  surgery.  d i f f i c u l t i e s or concerns were e x p r e s s e d .  Self-Maintenance Daily a c t i v i t i e s ing,  Activities  such as meal p r e p a r a t i o n , b a t h i n g , d r e s s i n g , s l e e p -  and e l i m i n a t i o n , were a s s e s s e d and were r e p o r t e d t o present no  lem.  Even the  s u b j e c t s who  meal p r e p a r a t i o n , and  by  lived  the time  grocery  shopping  f o r themselves.  quality  of  s l e e p was  their  greatly  a l o n e were a b l e of  the second  Many  The E) was  instruction,  "You  may  now  on that  the  had  fact  own  resumed that  the  they were back i n  home.  have your h a i r washed and  i n t e r p r e t e d i n d i v i d u a l l y t o produce  set"  (Appendix  a wide range i n behaviour,  g i n n i n g a t one end of the s c a l e w i t h an i n d i v i d u a l who pooed on p o s t s u r g e r y day f i v e ,  prob-  to manage t h e i r  home v i s i t ,  commented  improved  the f a m i l i a r surroundings of t h e i r own  at  rela-  to an i n d i v i d u a l who  showered and  planned  to w a i t  be-  shamuntil  l e a s t f o u r weeks p o s t s u r g e r y b e f o r e h a v i n g a p r o f e s s i o n a l shampoo  and  set.  The t i m i n g o f , method o f , and s a f e t y of h a i r shampoo was  q u e r i e d by  over  50  activity  percent  of  the  s u b j e c t s , but  none  considered  this  a  problem. A v a r i e t y of a d a p t a t i o n s were made i n r o u t i n e a c t i v i t i e s  i n order to  comply w i t h p r e c a u t i o n a r y measures, these a r e l i s t e d i n Appendix  H.  63 L e i s u r e A c t i v i t i e s and E x e r c i s e All  subjects reported that  they were l e s s  surgery,  a situation attributed  t o compliance  active  their  discharge, f i v e  own  s u b j e c t s went out  neighbourhoods.  By  14  days p o s t s u r g e r y ,  summer weather d u r i n g the time  outdoor  seem t o be as  subjects their  unaccompanied, i n  the m a j o r i t y of  s i x m i l e s a day.  study was  conducted  the  eye  good as with  opinion, either  Temporary  ous  the the  or  i t was  b e f o r e s u r g e r y , even though f o r these  least  vision  vision  i n the  had  r e c e i v e d the  "good" eye had  surgery.  In  deteriorated  or  the  image and  g l a s s e s enabled  activities,  future visual  and  two  five  had  no  s u b j e c t s remarked distorted  them t o f u n c t i o n  were a source  of  vision  on,  peripheral  of a but  as  previquickly  vision.  more i n d e p e n d e n t l y  of encouragement  at a l l  The  in  their  a harbinger  of  ability.  Most s u b j e c t s spent t h e i r time v i s i t i n g w i t h or c h a t t i n g on the ephone w i t h f r i e n d s and r e l a t i v e s , watching  television,  sic,  out  doing  the  A l l of these had v i -  no u s e f u l v i s i o n as a r e s u l t  These  magnified  subjects.  of 20/100 or l e s s ;  detachment).  to  temporary daily  eye  monocular, and one had  retinal  eye.  " p r a c t i c e " g l a s s e s which were an a p p r o x i m a t i o n  i n the unoperated  adjusted  Pleas-  t o see t o perform u s u a l a c t i v i t i e s d i d  r e q u i r e d p r e s c r i p t i o n were g i v e n t o f i v e  (one was  pa-  facilitated  the operated eye i n t e r f e r e d w i t h the v i s u a l a b i l i t y i n the best  sion  of  exercise.  F o r 11 s u b j e c t s , the a b i l i t y not  this  their  restrictions  On the day  f o r walks,  t i e n t s (18) had been out f o r walks, one averaged ant  before  with a c t i v i t y  or t o poor v i s u a l a c u i t y , r a t h e r than l a c k of energy. hospital  than  light  household  j o b s , and  going  listening  shopping.  to  telmu-  Six subjects  64 complained  t h a t time dragged and  content  t o accept  who  been employed p r i o r  had  and  abide  by  they were v e r y bored, the  temporary  restrictions.  to s u r g e r y , were anxious  S e v e r a l s u b j e c t s mentioned t h a t i t was s u r g e r y because t h e r e was  the remainder were  easy  no bandage, l i t t l e  Three  men,  to r e t u r n to work.  t o f o r g e t they  had  d i s c o m f o r t , and  even  they f e l t  had so  well. Two lowing Both  s u b j e c t s r e p o r t e d t h a t they were unable surgery,  had  even w i t h  spouses who  when they were l e f t  a  magnifying  d i d the  alone.  dialing  lens,  to  to see w e l l enough f o l dial  f o r them, but  N e i t h e r phone had  their  they  telephone.  felt  a large print  stranded  dial  attach-  ment, and n e i t h e r f a m i l y knew of the f r e e s e r v i c e a v a i l a b l e t o low customers whereby the o p e r a t o r w i l l the  connection.  l o o k up any  requested  Other s u b j e c t s used m a g n i f y i n g  r a c t g l a s s e s , and  large print  dials  number and make  l e n s e s , temporary  to f a c i l i t a t e  vision  independent use  cataof  the  telephone.  PERSONAL AND  ENVIRONMENTAL FACTORS THAT INFLUENCED  BEHAVIOURS, DIFFICULTIES, AND A  number of p e r s o n a l and  performance of eye ready  tial, ing  c a r e procedures  been mentioned  behaviours.  environmental  i n the  course  Additional factors  and of  daily  CONCERNS  factors living  perceptions  reported  ness of support  of c a t a r a c t s and  systems i s p r e s e n t e d  activities  r e p o r t i n g data by  have a l -  p e r t i n e n t to  subjects  such as a c q u i s i t i o n of r e q u i s i t e knowledge and  and  t h a t i n f l u e n c e d the  as  being  skills,  c a t a r a c t surgery,  and  those  influen-  understandthe  i n the f o l l o w i n g s e c t i o n .  helpful-  65  R e q u i s i t e Knowledge and  S k i l l s f o r Home Eye  Care  P r i o r t o h o s p i t a l d i s c h a r g e , a l l s u b j e c t s r e c e i v e d some i n s t r u c t i o n s pertaining  t o home eye  measures.  Major  care procedures  sources  of  ( r e c e i v e d by  17  the recommended p r e c a u t i o n a r y  i n f o r m a t i o n were  (mentioned by 18 s u b j e c t s ) , and by nurses  and  reported  as:  the  the d i s c h a r g e i n s t r u c t i o n sheet  subjects).  r e s i d e n t d o c t o r , home care nurse,  Other sources  were:  presented  the  f r i e n d s and r e l a t i v e s who  doctor  hospital  had had  cata-  instruction  sheet  which  could  r a c t s u r g e r y , and o t h e r p a t i e n t s I n the h o s p i t a l room. Patients  and  helpful,  and  refer.  However,  s h e e t ; two  were  f a m i l y members glad  to  seven  have  found printed  patients  of these l i v e d a l o n e .  the  were I t was  discharge  material  unable  to  to read  that  scribed  they  activities  liked so  to know that  they  the  principles  could  or  sion All  of home care  management  of these s u b j e c t s and  discussed  Several subjects  reasons  behind  pro-  judge the s a f e t y of a v a r i e t y  o t h e r a c t i v i t i e s not s p e c i f i c a l l y mentioned i n the F a m i l y members were p r e s e n t , and  instruction  h e l p f u l when the nurse  the i n s t r u c t i o n s , e l a b o r a t i n g on or c l a r i f y i n g p o i n t s . stated  the  they  of  instructions.  a b l e to p a r t i c i p a t e i n the d i s c u s -  precedures,  i n nine  of  the  twenty  f a m i l y members r e p o r t e d t h a t i t was  have a second person aware of the i n s t r u c t i o n s , f o r i t was or m i s i n t e r p r e t p o i n t s , e s p e c i a l l y d u r i n g the excitement  easy  cases.  h e l p f u l to to f o r g e t  of g e t t i n g ready  to go home. The  t i m i n g of i n f o r m a t i o n r e g a r d i n g home care e x p e c t a t i o n s was  an important  factor.  p i t a l admission  The  e i g h t s u b j e c t s who  had  knowledge p r i o r  r e p o r t e d t h i s advance i n f o r m a t i o n enabled  f o r a s s i s t a n c e from r e l a t i v e s ,  put  t h e i r house and  them t o  also  to h o s arrange  garden i n o r d e r ,  and  66  s t o c k up on s t a p l e food items so t h a t these f a c t o r s would not be a source of  c o n c e r n immediately  additional  a f t e r h o s p i t a l discharge.  f o u r who r e p o r t e d they  received  These s u b j e c t s , and an  i n f o r m a t i o n on s e v e r a l  occa-  s i o n s d u r i n g t h e i r h o s p i t a l s t a y , had time t o t h i n k of q u e s t i o n s and a s s i m i l a t e the i n f o r m a t i o n . ceived  home eye c a r e i n f o r m a t i o n o n l y  charge. ficult prior  E i g h t p a r t i c i p a n t s p e r c e i v e d t h a t they had r e -  Three  on the morning  o f these s u b j e c t s v o l u n t a r i l y  to concentrate  on i n s t r u c t i o n s  that  commented were  of h o s p i t a l  dis-  that  i t was d i f -  provided  Immediately  t o g o i n g home, when t h e i r thoughts were on h o s p i t a l d i s c h a r g e r o u -  t i n e s and w a i t i n g r e l a t i v e s . A demonstration o f eyedrop  i n s t i l l a t i o n was p r o v i d e d f o r seven  j e c t s ; v e r b a l i n s t r u c t i o n s were g i v e n t o o t h e r s . demonstration initiated  to four  relatives  who r e q u e s t e d  H o s p i t a l nurses gave a  the a s s i s t a n c e ,  a doctor  one demonstration f o r a spouse, and home c a r e nurses taught the  procedure t o two s u b j e c t s i n t h e i r homes. of  sub-  eyedrop  T a b l e 10 r e l a t e s  demonstration  i n s t i l l a t i o n w i t h p r e v i o u s e x p e r i e n c e i n i n s t i l l i n g eyedrops.  T a b l e 10 Eyedrop  Instillation:  Demonstration  by P r e v i o u s E x p e r i e n c e Demonstration Yes No  Previous Experience with  Yes  2*  11  Eyedrop  No  5+  2  Instillation  *1 f r i e n d and 1 spouse +2 s u b j e c t s , 2 daughters, 1  spouse  All  of the s u b j e c t s who  r e c e i v e d a demonstration  h e l p f u l , f i v e o t h e r s would have l i k e d to  instill  necessary for  the drops. as they  their  performed  children.  Of  the procedure  these  a demonstration  eyedrops on p r e v i o u s eight with  without  i t was  very  t o have had someone show them  E i g h t p a r t i c i p a n t s thought  had i n s t i l l e d  thought  difficulty  how  was  un-  occasions, u s u a l l y  previous, e x p e r i e n c e , or concern  only  two  once they were a t  home. With the e x c e p t i o n  of the s u b j e c t s v i s i t e d  by home care  nurses,  no  p a t i e n t nor f a m i l y member had the o p p o r t u n i t y t o be a s s e s s e d i n the a b i l ity  t o manage eyedrop i n s t i l l a t i o n  r e c e i v e reassurance  or c o r r e c t i o n  or application i f necessary.  of the eye s h i e l d I t was  and  noticeable that  the s u b j e c t s who had home nurse v i s i t s were c o n f i d e n t i n t h e i r a b i l i t y t o manage t h e i r own c a r e , and had no unanswered q u e s t i o n s . pants,  who  helpfulness  recognized of having  the  researchers  a nurse  questions, r e c e i v e reassurance cedures  nursing  role,  Several p a r t i c i commented  come t o t h e i r home so t h a t they about l i t t l e  concerns,  on  c o u l d ask  have eye care  of C a t a r a c t and C a t a r a c t  S u b j e c t s s t a t e d t h a t knowledge and u n d e r s t a n d i n g  Surgery of c a t a r a c t , c a t a -  r a c t s u r g e r y , and p o s t o p e r a t i v e e x p e c t a t i o n s was h e l p f u l i n a l l a y i n g i e t y and r e d u c i n g  ing,  the response  the number of c o n c e r n s .  T h i s concept  of one s u b j e c t , " I f you r e a l l y understand  was  anx-  exemplified  what i s happen-  you a r e more r e l a x e d about the whole p r o c e s s . " A variety  of answers were  g i v e n by s u b j e c t s to the q u e s t i o n s  what a c a t a r a c t i s , and the s u r g i c a l and r e c o v e r y p r o c e s s . of  pro-  s u p e r v i s e d , and have the o p e r a t e d eye examined.  Understanding  in  the  s u b j e c t ' s comments were:  about  Some examples  68 " I presume i t i s a f i l m over the eye and they s t r i p the f i l m o f f . They gave me a paper i n the h o s p i t a l but I haven't s t u d i e d i t p a r t i c u l a r l y . . . ! t h i n k I may t r y c o n t a c t l e n s e s . I c e r t a i n l y don't want t o wear those t h i c k heavy g l a s s e s . I don't l i k e the looks of them! ...The d o c t o r says I w i l l have to wait a month or so b e f o r e I get them." "Dr. ( h o s p i t a l resident) explained everything. He used a model t h a t comes a p a r t t o show me the i n s i d e s of an eye...and t h e c l o u d y l e n s t h a t i s taken o u t . . . . I t was very i n t e r e s t i n g and very r e assuring. . . . L a t e r on I w i l l get g l a s s e s . I am used t o g l a s s e s . " " I know I have the s e n i l e type of c a t a r a c t where the l e n s g r a d u a l l y becomes opaque and has t o be removed. ...The l e n s i s behind the aqueous humour so an i n c i s i o n i s made above the cornea and the l e n s i s taken o u t . Then you need t o r e p l a c e t h a t l e n s . . . . I am p l a n n i n g t o have c o n t a c t l e n s e s i n about t h r e e months...or whenever the eye i s healed. They g i v e b e t t e r p e r i p h e r a l v i s i o n , but I w i l l have c a t a r a c t g l a s s e s as w e l l so t h a t I won't be e n t i r e l y dependent on the c o n t a c t l e n s . I might drop i t sometime and not be a b l e to f i n d i t . " The content  of s u b j e c t ' s responses was summarized and c a t e g o r i z e d .  11 r e p r e s e n t s  the author's  i n t e r p r e t a t i o n of s u b j e c t ' s  Table  Table  responses.  11  S u b j e c t s ' Comprehension of C a t a r a c t s and C a t a r a c t  Surgery  No. of S u b j e c t s  1.  A c a t a r a c t i s an o p a c i t y or c l o u d i n g of the l e n s  2.  The surgery e n t a i l s e n t r y i n t o the eye and closure with  3.  c o r r e c t i v e l e n s e s c o u l d be  fitted  15*  A c a t a r a c t i s a f i l m over the eye t h a t would be peeled o f f during  5.  15  A w a i t i n g p e r i o d i s expected p o s t o p e r a t i v e l y before  4.  sutures  15  surgery  No concept of a c a t a r a c t  * Two  4 1  of these persons were s u r p r i s e d a t the l e n g t h of the w a i t i n g  period  On  the whole, study  p a r t i c i p a n t s reported  w i t h the amount of knowledge they ously  discussed,  surgery, had  where a  because of  little  "ignorance  lack  couple  had. was  that  There was  very  they were  one  concerned  of u n d e r s t a n d i n g .  The  exception,  over  other  "the  d o c t o r knows what to do,"  the  few  or i n a c c u r a t e i n f o r m a t i o n were q u i t e c o n t e n t , is bliss,"  satisfied previ-  outcome of  subjects  who  commenting t h a t  and  "I take  things  as they come." Sources of i n f o r m a t i o n about c a t a r a c t s and p o r t e d as: ract  surgery;  pamphlets at  eye d o c t o r ; r e s i d e n t ; r e l a t i v e s and  the  a t e l e v i s i o n programme on eye  obtained  Pacific  c a t a r a c t s u r g e r y were r e f r i e n d s who  surgery;  newspaper  from Canadian N a t i o n a l I n s t i t u t e  National Exhibition,  and  answering an advertisement  cata-  articles;  f o r the B l i n d  d i s c u s s i o n with  n i n g the booth; d i c t i o n a r y ; l i b r a r y books; and  had had  booth  the person  man-  i n f o r m a t i o n r e c e i v e d from  i n a U n i t e d S t a t e s magazine.  Support Systems A l l s u b j e c t s i n t h i s study had who  at l e a s t one  c l o s e r e l a t i v e or  c o u l d be i n s t r u m e n t a l i n p r o v i d i n g d i r e c t a s s i s t a n c e and/or  support.  In a d d i t i o n , many s u b j e c t s had  bours and  church  group  f r i e n d s who  p r o v i d i n g companionship, o u t i n g s and  took  interest  diversions.  was  and  medication  both expressed  by  times.  Although  s u b j e c t s and  a strong  observed  p o r t of i n t e r e s t e d f r i e n d s and r e l a t i v e s was  by  in  their  neigh-  welfare,  F a m i l y members were r e -  p o r t e d t o have been p a r t i c u l a r l y h e l p f u l i n reminding tions  emotional  l a r g e extended f a m i l i e s , an  friend  s u b j e c t s of  desire for the  independence  researcher,  welcomed and  precau-  the  sup-  appreciated.  70  Length of H o s p i t a l S a t i s f a c t i o n with jority  (17)  of  days f o l l o w i n g managed One  at  length  subjects.  home sooner,  p a t i e n t , discharged  of h o s p i t a l s t a y was  Two  s u r g e r y , and  Stay  of  one  these  expressed by  subjects,  one  s i x days, remarked  i f that  had  been  p o s t s u r g e r y day  the  discharged  that  p i t a l been l o n g e r .  Two  subjects,  discharged  gery thought they might have b e n e f i t e d expectations  of these  ences of f r i e n d s who  latter had  two  stayed  by  f i v e and  a few  were i n p a r t  three have  recommendation.  developed s e v e r e  aches, thought the headaches might have been a v o i d e d had  ma-  they c o u l d  doctor's  f o u r , who  the  head-  the s t a y i n hos-  s i x days a f t e r  sur-  more h o s p i t a l days.  The  influenced  by  the  experi-  i n h o s p i t a l f o r a week f o l l o w i n g  cataract  surgery.  Demographic The tingency tween  F i s h e r Exact T e s t tables  was  demographic  economic s t a t u s ,  used  of A s s o c i a t i o n , C&2 to  examine  variables length  Factors  of  such  as  the  possibility  age,  h o s p i t a l stay,  a c u i t y , w i t h performance v a r i a b l e s  - «05 u s i n g  such as  sex,  of  manual  level  of  of  years,  concern.  The  s i g n i f i c a n c e was  and  only a  association  relationship  of  the  small  sample  f r e q u e n c y of o c c u r r e n c e s u f f i c i e n t  size  few  con-  in  and  visual  administering  comprehension,  age  greater  ex-  the  .05  than  71  ophthalmologist.  performance  variables  had  to p e r f o r m a t e s t of a s s o c i a t i o n ,  drawn from r e s u l t s of v a r i a b l e s  be-  socio-  p o s i t i v e at  concerns as evidenced by phone c a l l s to the  Because  conclusions  t h a t was  two  level,  dexterity,  difficulties  between  by  association  education  eyedrops, c o n f i d e n c e i n managing eyedrop i n s t i l l a t i o n , pression  two  t h a t were t e s t e d  must be  a and in-  71  terpreted may  with  caution.  Tested  be found i n Appendix  v a r i a b l e s and  their  significance levels  G.  DISCUSSION The The  subjects  i n this  study  are  group i n the g e n e r a l p o p u l a t i o n these  subjects  lived  alone  Sample fairly  although  than  medical  conditions  a s l i g h t l y higher  i s generally  community s e r v i c e s f o r a s s i s t a n c e , and al  representative  reported.  of  their  proportion  of  Utilization  of  the presence of concomitant  i s also consistent  (Brody,  1980).  age  The  gener-  relatively  l a r g e p r o p o r t i o n of s u b j e c t s w i t h glaucoma as an a d d i t i o n a l d i a g n o s i s  may  reflect  but  may  the  patterns  also reflect  the  cataract formation sence  in  mellitus be  the  of  a s s o c i a t i o n of  some k i n d s  of m i o t i c eyedrops  sample  of  surprising.  patients  with  the  p.  816-823).  diagnosis  Although such i n d i v i d u a l s are  of  ated  M a u s o l f , 1975,  (Cotlier,  diabetic  study's The  1981).  patients  Therefore,  p. 200)  at  subjects  On an  the  average, c a t a r a c t s u r g e r y  of  the  Schwartz, 1980).  continuing Age  d i d not  than  would  in  tend  requirement was  stay  than the average s t a y r e p o r t e d reflect  age  diabetes  sample, f o r whom the age average l e n g t h  ab-  diabetes  recognized  to  1969,  the p r o g r e s s i o n of the o p a c i t y i s a c c e l e r -  earlier  with  with  The  p a r t i c u l a r l y prone to the development of c a t a r a c t s (Duke-Elder,  p. 166;  may  c o n t r i b u t i n g ophthalmologists,  (Nurses's Guide to Drugs, 1980,  study  i s not  p r a c t i c e of  of  5.2  days  of  decreased  appear to be  to  general be  population.  younger  over 60  (4.2  i n Canada i n 1977  trend  the  i s indicated i n  than  this  years.  postsurgery)  was  lower  ( S t a t i s t i c s Canada) and h o s p i t a l stay  (Nadler  a f a c t o r r e l a t e d to l e n g t h  & of  72  hospital  stay,  for  t h i r d postoperative  an  80  day,  and  and  an  two  83  year  71 year  old  subject  of  length  chronic  of  stay,  medical f o r the  concomitant m e d i c a l  conditions subject  condition.  did  with  not  the  S i m i l a r l y , the  appear  longest  I t would appear  to  be  s t a y had  that  related no  i n this  Because  of  people were not  on  preto  diagnosed small  sam-  p l e , the l e n g t h of h o s p i t a l s t a y most l i k e l y r e f l e c t s the customary t i c e of the a t t e n d i n g  the  o l d s u b j e c t s were d i s c h a r g e d  the f i f t h and s i x t h p o s t o p e r a t i v e days r e s p e c t i v e l y . sence  went home on  prac-  ophthalmologist.  selection criteria represented  for  i n the  the  sample.  study,  non-English  speaking  However, i t would be  reason-  a b l e t o p o s t u l a t e t h a t such a s u b j e c t would i n c u r even more d i f f i c u l t i e s and  concerns,  especially  those  that are  r e l a t e d to communication  of i n -  structions.  Adherence The h i g h r a t e of adherence (90%) in  this  study  when compared w i t h  viewed by B l a c k w e l l to 50  percent,  the  or w i t h  reports  from the  a non-compliance  1977)  (Vincent,  compliance.  percent  general  regimen was  compliance  notable  literature  re-  (1973), where the non-compliance r a t e ranged from  most s t u d i e s r e p o r t t o 58  to the m e d i c a l  A finding  1971)  ophthalomology l i t e r a t u r e  rate  of  28  depending on  congruent w i t h  this  study  percent the  25  where  (Bloch  et a l . ,  definition  of non-  is a  recent  report  by  Worthen (1979) t h a t i n d i c a t e s a compliance r a t e of 95 percent  to t i m o l o l  maleate ( T i m o p t i c ) , a l o n g a c t i n g glaucoma drug t h a t r e q u i r e s  administra-  t i o n o n l y once or twice a Factors  day.  c o n t r i b u t i n g to the f a v o u r a b l e  j e c t s i n t h i s study  r a t e of adherence among  c o u l d be p o s t u l a t e d as f o l l o w s :  sub-  73  1.  A s u c c e s s f u l v i s u a l outcome was of g r e a t importance and  complete  adherence  as a s i g n i f i c a n t  to medication  recommendations was p e r c e i v e d  f a c t o r i n a t t a i n i n g v i s u a l improvement.  r e t i c a l framework (Lewin, 2.  1951) supports t h i s  The c o n d i t i o n i s acute and o f r e l a t i v e l y ance  problems  t o the s u b j e c t s ,  associated with  long  term  The t h e o -  premise.  s h o r t d u r a t i o n , so c o m p l i medication administration  ( B l a c k w e l l , 1973) have not developed. 3.  S u b j e c t s i n t h e age group  of those  i n this  study  f r e q u e n t l y have  o t h e r m e d i c a l c o n d i t i o n s f o r which they have e s t a b l i s h e d schedules.  I n c o r p o r a t i n g eye m e d i c a t i o n s  into  medication  an a l r e a d y  existing  schedule d i d n o t n e c e s s i t a t e a major change i n h a b i t s or l i f e a factor  identified  by a number of authors  as a f f e c t i n g  style,  compliance  (Davis & E i c h h o r n , 1963; M c A l i s t e r e t a l . , 1976; T a g l i a c o z z o & Ima, 1970). ic  V i n c e n t (1971) r e p o r t s t h a t p a t i e n t s on system-  m e d i c a t i o n were more l i k e l y  drop 4.  Furthermore,  t o comply w i t h  recommended  glaucoma  schedules.  Medication  schedules  were u s u a l l y  uncomplicated  ber, a f a c t o r a s s o c i a t e d w i t h compliance  and easy  t o remem-  i n e l d e r l y people  (Neely &  P a t r i c k , 1968; P a r k i n e t a l . , 1976; Schwartz e t a l . , 1964). 5.  The o c c u r r e n c e o f u n p l e a s a n t  s i d e e f f e c t s was minimal,  and many p a -  t i e n t s r e p o r t e d the drops made t h e i r eye more c o m f o r t a b l e . 6.  The i n t e r a c t i o n tory.  was h i g h l y  T h i s c o n t e n t i o n i s supported by the f a c t s  knowledgeable their  between p h y s i c i a n and p a t i e n t  concerns  about  medication  instructions,  satisfac-  t h a t p a t i e n t s were  felt  free  to d i s c u s s  and v a l i d a t e p e r c e p t i o n s , had no r e l u c t a n c e t o phone  t h e i r d o c t o r i f a n y t h i n g w o r r i e d them, f e l t  their  d o c t o r was h i g h l y  74  competent, f e l t b e i n g , and had  t h e i r d o c t o r took a p e r s o n a l i n t e r e s t i n t h e i r  were mostly  about  their  satisfied  condition.  with  A l l of  well-  the amount of knowledge  these  facets  of p o s i t i v e  they  inter-  a c t i o n have been i d e n t i f i e d i n o t h e r s t u d i e s to be r e l a t e d to a d h e r ence  to  recommendations  (Hulka,  1979;  Korsch  &  Negret,  1972;  S v a r s t a d , 1976). Problems noted  i n this  study  such  as  reading l a b e l s ,  opening  child  r e s i s t a n t c o n t a i n e r s , and o b t a i n i n g eyedrops at community pharmacies have been  substantiated variously  1980;  Hammell & W i l l i a m s , 1964; In  contrast  with  other  i n other  studies  (Davidson  &  Akingbehin,  Lane et a l . , 1971). studies  (Boyd  et  W i l l i a m s , 1964), a l l p a t i e n t s i n t h i s study had  a l . , 1974;  Hammell  their prescriptions  &  fill-  ed. O r g a n i z i n g and s c h e d u l i n g m e d i c a t i o n at a p p r o p r i a t e i n t e r v a l s d u r i n g the day was  not a problem as i t was  i n Hermann's (1973) study.  q u e s t i o n s were r a i s e d r e g a r d i n g which of two t e r v a l s s h o u l d be  instilled  w a i t e d between i n s t i l l i n g It  i s Interesting  drops  ordered a t s i m i l a r i n -  f i r s t , and whether a time i n t e r v a l s h o u l d  two  different  types of  that p a t i e n t s should  Baum (1981) s t a t e s t h a t the average  .25 t o .4 ml and sac'  The  one,  so may  suggests  s m a l l e r drop  larger  stimulates  than  identify  this  eyedrop ranges  problem,  as  tear formation there i s l e s s  i n size  than  unnecessary.  t h a t two  drops  from  conjunctival the  larger  dilution.  t h a t f i v e minutes s h o u l d be a l l o w e d between i n s t i l l a t i o n t o a v o i d wash-out, and  be-  i n the l i t e r -  .25 ml o v e r f l o w the  less  a c t u a l l y d e l i v e r more drug  types of drops t i o n are  t h a t drops  be  drops.  cause i t i s o n l y r e c e n t l y t h a t the t o p i c has been addressed ature.  However,  Baum of  two  of the same medica-  75  The  activity  restrictions  were w e l l known and  adhered  t o , whereas the  l e s s w e l l known, understood, were f a m i l i a r w i t h  t h a t i n v o l v e d bending, l i f t i n g ,  or  followed.  p r o s c r i p t i o n on  straining  reading  was  I t i s p o s s i b l e that patients  the former i n s t r u c t i o n s because they were p a r t of  pre-  o p e r a t i v e t e a c h i n g and were r e i n f o r c e d throughout the h o s p i t a l s t a y .  The  i n s t r u c t i o n about r e a d i n g was  p a r t of the  the day  and  of h o s p i t a l d i s c h a r g e  to l e a v i n g the h o s p i t a l .  The  was  timing  discharge  teaching provided  u s u a l l y provided of  this  teaching  immediately may  not  be  on  prior appro-  priate for effective learning. In a d d i t i o n , nurses who may  not have been c o n v i n c e d  were d i s c u s s i n g i n s t r u c t i o n s w i t h  of the n e c e s s i t y of the r e a d i n g p r o s c r i p t i o n  as t h e r e i s a d i v e r s i t y of o p i n i o n among o p h t h a l m o l o g i s t s erature  (Smith  & Nachazel,  patients  1980)  regarding  this  subject.  and  i n the  lit-  C e r t a i n l y , pa-  t i e n t s were not aware of the reasons f o r the r e a d i n g p r o s c r i p t i o n . Finally, ficult  discharge  handout  f o r many s u b j e c t s and  ories. ledge  the  itself  was  i n small  treatments.  Performance of R e q u i s i t e S k i l l s f o r Home Eye  eye  i n this  c a r e procedures without  instances ficulty,  deficits but  i n fine  i n many cases  dif-  a l s o have c o n t r i b u t e d to the l a c k of know-  of the i n s t r u c t i o n to wash hands f o l l o w i n g  subjects  and  f a m i l y members t o read to r e f r e s h t h e i r mem-  T h i s l a t t e r p o i n t may  Only two  print  study  were a b l e  to perform the  some k i n d of d i f f i c u l t y motor the  co-ordination  difficulties  Care necessary  or concern.  contributed  to  were r e l a t e d to  t e c h n i c a l s k i l l s , a f a c t o r which might have been amenable to  In some  a  the  dif-  lack  teaching.  of  76  Redman (1972) d e s c r i b e d t h r e e f a c t o r s that a r e important i n l e a r n i n g a manual s k i l l ; formed,  development  of a mental  opportunity to practice  image of how  the s k i l l  the s k i l l  and r e c e i v e  i s per-  corrective  back, and the o p p o r t u n i t y to develop a p o s i t i v e a t t i t u d e toward  feed-  the p r o -  cedure ( p . 77-79). Five subjects i n this stillation  ( t h e mental  study r e c e i v e d a demonstration of eyedrop i n -  image),  b e f o r e they  left  hospital.  A l l of these  persons deemed the demonstration h e l p f u l ; however, two s t i l l difficulties home.  when  they  came  to perform  the procedure  An o p p o r t u n i t y t o p r a c t i c e and r e c e i v e  experienced  by themselves  corrective  feedback  at  might  have h e l p e d these s u b j e c t s . Redman a l s o notes t h a t the o p p o r t u n i t y t o p r a c t i c e i n a s e t t i n g approximates  as c l o s e l y  procedure w i l l  as p o s s i b l e  be performed,  the a c t u a l  facilitates  learning  j e c t s who had h e l p from home c a r e nurses the o p p o r t u n i t y t o p r a c t i c e still  had some d i f f i c u l t y  (the p o s i t i v e  (p. 79).  because  i n which the The two sub-  had both the demonstration and  i n the home s e t t i n g .  a b l e t o perform the procedure performance  situation  of poor  Although  manual  these  dexterity,  eyedrops  tions. for  and  to perform  the s k i l l  a  situa-  d i d not t u r n out t o be t r u e i n the p r e s e n t study,  o r some concern  when  i s not s u r p r i s i n g  decrease  were  instillation  i n ensuing  the 13 s u b j e c t s who r e p o r t e d p r e v i o u s e x p e r i e n c e , e i g h t  finding  they  attitude).  the a b i l i t y  T h i s assumption  difficulty This  assures  people  i n d e p e n d e n t l y , and were c o n f i d e n t i n t h e i r  It i s f r e q u e n t l y presumed t h a t p r e v i o u s e x p e r i e n c e w i t h of  that  i n manual  they  attempted  the procedure  when one c o n s i d e r s that  dexterity  that  often  (60%) had a a t home.  both  forgetting  accompanies  increasing  age,  contribute  skill.  Further  t o d e t e r i o r a t i o n i n performance of a p r e v i o u s l y c o n s i d e r a t i o n s a r e t h a t the s k i l l  been l e a r n e d adequately, i n which the p r e v i o u s ported mal  experience  experience gery.  a false  was a c q u i r e d .  a drop  i n one's  drop i n a n o r -  f o r i t i s quite  i n an eye t h a t has j u s t  As w e l l , p u t t i n g drops  children's  prompted an a f f i r m a t i v e response t o " p r e v i o u s drops," but that s k i l l  F o r example, s u b j e c t s r e -  anti-inflammatory  sense of c o n f i d e n c e ,  instilling  may not have i n i t i a l l y  or t h i s new s i t u a t i o n may be d i f f e r e n t from t h a t  t h a t p u t t i n g an o v e r - t h e - c o u n t e r  eye g i v e s  learned  a  different  had c a t a r a c t  eyes  experience  i s q u i t e d i f f e r e n t from i n s t i l l i n g  many  sur-  years  instilling  ago eye-  one's own drops  i n an aphakic e y e . There a r e many techniques omology l i t e r a t u r e p r o v i d e s cy of v a r i o u s methods. individuals dexterity support  little  d i r e c t i o n as t o the m e r i t s and e f f i c a -  i n the o l d e r age group, many of whom have d e f i c i t s  and v i s u a l  a c u i t y , a p r e f e r r e d technique  t o the hand t h a t i s i n s t i l l i n g  allay  eyedrops, but the o p h t h a l -  However, i t i s the o p i n i o n of the author t h a t f o r  reduce the number of i n s t a n c e s might  for Instilling  the concern  the drop.  of t o u c h i n g  of persons w i t h  lashes  i s one t h a t  i n manual provides  Such a technique  might  o r the eye i t s e l f , and  shaky hands about  damaging the  r e c e n t l y operated eye. It  i s noteworthy t o r e p o r t t h a t a f r e q u e n t l y recommended  whereby the s u b j e c t i s i n s t r u c t e d t o stand p o s i t i o n t h e dropper and i n s t i l l in  this  study,  in  a mirror  tration.  a mirror  t o see how t o  t h e drop, was o f no h e l p t o i n d i v i d u a l s  whose v i s i o n w i t h o u t  a b l e t o see i n a m i r r o r .  before  technique,  g l a s s e s was n o t good  enough  t o be  Furthermore, the p o s i t i o n assumed when l o o k i n g  does n o t p r o v i d e  an a n g l e  that f a c i l i t a t e s  eyedrop  adminis-  78  A p p l i c a t i o n of the p r o t e c t i v e eye s h i e l d was another s k i l l sented d i f f i c u l t i e s a t home f o r many s u b j e c t s  and f a m i l y members.  i n s t r u c t i o n s were s u f f i c i e n t f o r some p e o p l e , but o t h e r s f i t e d by the o p p o r t u n i t y The  t o p r a c t i c e the s k i l l under  ophthalmic nurse s p e c i a l i s t  that  home v i s i t i n g  pre-  Verbal  might have bene-  supervision. programme r e p o r t e d  by  Kidger (1977) r e f l e c t s an approach t o f a c i l i t a t i n g home s e l f - c a r e t h a t i s of  interest.  Kidger  following discharge. nities  to teach  visits This  referred patients  s e r v i c e provides  and s u p e r v i s e  would appear t o t h i s w r i t e r  patients  c o n t i n u i t y of c a r e ,  i n their  to offer possible  problems and concerns i d e n t i f i e d i n t h i s  i n h o s p i t a l , and a t home opportu-  own home s i t u a t i o n and  solutions  t o a number of  study.  Safety Throughout  this  study  there  has been mention  when the s a f e t y of s u b j e c t s was j e o p a r d i z e d . an  eye w i t h  Several  ear pieces  factors  most s u b j e c t s relative  when  may  of s p e c t a c l e s  contribute  of various  instances  Two f a l l s and one poking o f  a r e examples  of a c t u a l  to unsafe p r a c t i c e s .  accidents.  Firstly,  although  s t a t e d they used hand r a i l s on s t a i r s and took the arm of a outdoors  ( i f accompanied),  they  d i d not p e r c e i v e  loose  s c a t t e r rugs, f o o t s t o o l s o r c o f f e e t a b l e s i n f r e q u e n t l y t r a v e l l e d a r e a s , book cases or t a b l e s c l o s e t o the s i d e o f the bed, or s t a n d i n g  on c h a i r s  or the r i m of the bath tub t o r e a c h something, as a hazard even when commented on by the i n v e s t i g a t o r . are  difficult  people  were  or inconvenient just  not used  C e r t a i n l y , those who stood  Perhaps these a r e examples of h a b i t s t o change,  or i t i s possible  t o a n t i c i p a t i n g and p r e v e n t i n g  that  that these  accidents.  i n the bathroom o r s a t on the edge of the tub  79  t o have t h e i r eyedrops i n s t i l l e d were not ly,  unfamiliar  surroundings  e l d e r l y female s u b j e c t s who  may  have  t h i n k i n g about s a f e t y .  contributed  abil-  would  either  not  the  any  relative  t o remind s u b j e c t s  subjects  need,  comfort of  of  the  not  use  not  willing  the  eye  postoperatively  restrictions  to  a  or  activity  the  decrements i n p h y s i c a l  Even  most  of  there  ity.  Finally,  falls  Thirdly,  and  perceiving  the  moved i n t o a daughter's home.  appears to be a d e n i a l of i n c r e a s i n g age temporarily,  to  Second-  be  walking seen  using  provided  designed  stick, one. little  to prevent  eye  complications.  Knowledge and The  Understanding of C a t a r a c t s / C a t a r a c t  premise t h a t knowledge and (Janis,  u n d e r s t a n d i n g of a s u r g i c a l procedure  reduced  anxiety  study.  Many s u b j e c t s were s u r p r i s i n g l y knowledgeable about c a t a r a c t s  c a t a r a c t surgery,  and  1958)  Surgery  had  would  appear  used a v a r i e t y of  to  to l e a r n about the  tient  the  standing among  of  the  these  wherein  86  who  had  condition.  subjects percent  f r o n t of the The  study  of  The  contrasts subjects  condition.  greatest  anxiety  relatively  high  with  the  thought  a  substantiated  had level  findings cataract  of was  The  the of  one  as pa-  understanding  Hilbourne a  and  l e a s t under-  film  (1975)  over  as major c o n t r i b u t o r s  t i e n t knowledge i s a l s o documented by Marram (1973) and suggest t h a t t h e i r f i n d i n g s may  r o l e may  this  the  eye.  f a c t t h a t nurses were not p e r c e i v e d  of t e a c h i n g  in  community sources as w e l l  discussions with t h e i r doctor i n this  be  as  a nursing  have been p r e s e n t  to  pa-  White (1972)  who  be based on p a t i e n t ' s l a c k of  function.  recognition  A s i m i l a r o r i e n t a t i o n to the  among s u b j e c t s  i n the p r e s e n t  study.  nurse's  80  Demographic V a r i a b l e s It from  i s acknowledged  statistical  that  analysis  with are  questionable,  found i n t h i s study between age not  surprising.  tions,  majority  and  concise  sample, i n f e r e n c e s however,  phone c a l l s  the  association  to the o p h t h a l m o l o g i s t  is  the  point  i n s t r u c t i o n s provided  that  in a  elderly patients  non-stressful  need  environment,  need to have i n s t r u c t i o n s r e p e a t e d . An  between  explanation demographic  procedures  would  variety  persons,  of  be  t h a t c o u l d be e n t e r t a i n e d variables that and  variables - f o r instance The  and  the were  predictive  or  difficulties  difficulties related  to  e f f e c t i v e n e s s of  d e s c r i p t i v e n a t u r e of  this  causative  f o r the l a c k of a s s o c i a t i o n in  were  performing  experienced  something  other  eye by  study  and  the  statements.  small  personal  sample  and  m e d i c a l p r a c t i c e i s concerned w i t h i n d i v i d u a l s as w e l l  size  However, s i n c e as  In  the  following  t i o n s f o r h e a l t h care p r o f e s s i o n a l s , and  chapter  conclusions,  recommendations w i l l be  do  nursing  groups  p e o p l e , f i n d i n g s t h a t r e l a t e to h e a l t h care outcomes of even a few consideration.  wide  teaching.  permit  deserve  care  a  than  not  ed.  drawn  of the phone c a l l s were to c l a r i f y i n s t r u c -  a f i n d i n g which a c c e n t u a t e s  explicit, and  The  such a s m a l l  of  people  implicapresent-  81  CHAPTER V SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS Summary  The o b s e r v a t i o n t h a t ract is  the number of e l d e r l y persons undergoing  cata-  s u r g e r y i s i n c r e a s i n g each y e a r , and t h e l e n g t h of s t a y i n h o s p i t a l  d e c r e a s i n g , has i m p l i c a t i o n s  f o r patient  care.  Nurses  i n hospitals  who  teach p o s t s u r g i c a l c a t a r a c t p a t i e n t s and f a m i l y members the knowledge  and  skills  necessary  f o r home s e l f - c a r e  will  be d e a l i n g w i t h  a greater  number o f o l d e r people, many of whom l i v e a l o n e or w i t h an e q u a l l y e l d e r ly  spouse.  Many w i l l have concomitant  manual d e x t e r i t y .  In a d d i t i o n ,  m e d i c a l c o n d i t i o n s and d i m i n i s h e d  there w i l l  be l e s s  time i n which t o p e r -  form these t e a c h i n g and d i s c h a r g e p l a n n i n g f u n c t i o n s .  In o r d e r t o make  the t e a c h i n g and p l a n n i n g r e l e v a n t and e f f e c t i v e , i t i s n e c e s s a r y t o consider  the e x p e r i e n c e s p a t i e n t s and t h e i r  home f o l l o w i n g c a t a r a c t  families  are l i k e l y  t o have a t  surgery.  The purpose of t h i s study was t o d e s c r i b e s p e c i f i c behaviours ed  t o eye care and d a i l y  of age d u r i n g t h e f i r s t  living  activities  of i n d i v i d u a l s  over  two t o t h r e e weeks a t home f o l l o w i n g  ed c a t a r a c t e x t r a c t i o n ; t o i d e n t i f y d i f f i c u l t i e s and concerns  relat-  60 years  uncomplicatexperienced  by these p a t i e n t s and f a m i l y members; and t o d e s c r i b e p e r s o n a l and e n v i ronmental f a c t o r s t h a t a f f e c t e d t h e b e h a v i o u r s , d i f f i c u l t i e s o r c o n c e r n s . An e x p l o r a t o r y d e s c r i p t i v e study was c a r r i e d out u s i n g a s e m i - s t r u c tured  i n t e r v i e w schedule  d u r i n g two home v i s i t s lies.  developed  by t h e i n v e s t i g a t o r ,  t o gather  t o p o s t s u r g i c a l c a t a r a c t p a t i e n t s and t h e i r  data fami-  Twenty s u b j e c t s were i n t e r v i e w e d i n t h e i r homes the day f o l l o w i n g  82  t h e i r h o s p i t a l d i s c h a r g e , and tive  day.  Observations of  The  s u b j e c t s , t h i r t e e n females  63 t o 83 y e a r s . s u r g e r y , and  and  16th  protective shield,  and  the  and  s t a t u s of  homemaker s e r v i c e s and  seven males, ranged i n age  from  to h o s p i t a l the day  Findings  were a l o n e , t h r e e had  two  indicated  high  degree  of  factor  i n obtaining a  i n s t a n c e s when expected  adherence  washing f o l l o w i n g treatments, ledge was  as  to  nurse.  the  recommended  outcome.  In  the  reading  were e x p e r i e n c e d  instillation  of  eyedrops,  ing  l a b e l s and i n s t r u c t i o n s .  ing  and  proscriptions),  few  l a c k of know-  reporting significant  i n the and  performance  application  as s t e r i l e  of  of  a  manual  difficulties  were  reported  in  and  i n read-  personal  and  keeping  problem. care  such  b a t h i n g , d r e s s i n g , meal p r e p a r a t i o n , e l i m i n a t i o n , e x e r c i s e and r e s t . s i s t a n c e w i t h heavy household the f i r s t  c l e a n i n g and gardening was  f o u r to s i x weeks p o s t s u r g e r y ,  privately  hired  labour,  and  and was  community  eye  such as r e c o g n i z -  complications,  managing  skills  protective  cotton b a l l s ;  Other eye care behaviours indicators  of  appointments f o r c o n t i n u e d m e d i c a l s u p e r v i s i o n , presented no  bers,  an  were not performed ( f o r example, hand  s h i e l d , i n o b t a i n i n g s u p p l i e s such  No  lived  a major c o n t r i b u t i n g f a c t o r .  Difficulties such  and  sub-  p e r c e i v e d adherence as  successful visual  behaviours  five  to  a s s i s t a n c e from community  p o s t s u r g i c a l regimen by study p a r t i c i p a n t s , who important  prior  Fifteen  had a s s i s t a n c e from a home care  a  apeye.  remained t h r e e to s i x days f o l l o w i n g s u r g e r y .  Of these f i v e who  the  operated  A l l s u b j e c t s were admitted  the  j e c t s l i v e d w i t h f a m i l y members a f t e r h o s p i t a l d i s c h a r g e , and alone.  postopera-  were a l s o made of eyedrop i n s t i l l a t i o n ,  plication study  a  a g a i n between the 13th  necessary  as As-  during  p r o v i d e d by f a m i l y mem-  homemaker  service.  Assis-  83 tance  with  grocery  shopping  f o r approximately  weeks a t home was a l s o  required.  deference  proscriptions  to a c t i v i t y  r a t h e r than l a c k of energy.  the f i r s t  Leisure a c t i v i t i e s or because  10 days  to two  were r e s t r i c t e d i n  of poor  visual  Independent use of t h e t e l e p h o n e  acuity  presented  problems f o r two s u b j e c t s . Concerns and q u e s t i o n s were  largely  related  t o t h e performance  of  eye c a r e procedures, and a n t i c i p a t e d v i s u a l outcome. A number of f a c t o r s were i d e n t i f i e d by s u b j e c t s as b e i n g i n f a c i l i t a t i n g s e l f - c a r e and i n a l l e v i a t i n g c o n c e r n s . f a c t o r s were: pectations,  influential  Examples of these  adequate u n d e r s t a n d i n g of the s u r g e r y and p o s t s u r g i c a l e x -  c o n f i d e n c e i n t h e d o c t o r and t h e o p p o r t u n i t y t o d i s c u s s op-  t i o n s and concerns, i n c l u s i o n of f a m i l y members i n i n f o r m a t i o n s e s s i o n s , t e a c h i n g and s u p e r v i s i o n from support  systems b o t h  home care n u r s e s ,  f o r direct  a s s i s t a n c e and e m o t i o n a l  those s u b j e c t s who had v e r y poor v i s i o n sion  at a l l ,  temporary  cataract  v i s i o n t o cope w i t h d a i l y Factors  that  were  and t h e a v a i l a b i l i t y of  i n t h e unoperated  g l a s s e s were h e l p f u l  support.  For  eye, o r no v i -  to provide  enough  routines.  identified  as c o n t r i b u t i n g  concerns were l a c k of r e q u i s i t e knowledge and s k i l l s  to d i f f i c u l t i e s to follow  and  recommen-  d a t i o n s w i t h competence and c o n f i d e n c e , and p e r c e i v e d r e d u c t i o n i n v i s u a l a c u i t y i n t h e unoperated e y e . S t a t i s t i c a l analysis  of s e l e c t e d p a t i e n t  demographic v a r i a b l e s  duced o n l y one a s s o c i a t i o n a t t h e .05 l e v e l o f s i g n i f i c a n c e — a n t i o n between concerns, as e v i d e n c e d by number of phone c a l l s t h a l m o l o g i s t , and age g r e a t e r than 71 y e a r s . size,  few v a r i a b l e s  nalysis.  o c c u r r e d w i t h frequency  pro-  associa-  t o the oph-  Because of the s m a l l sample sufficient  t o perform  Any i n t e r p r e t a t i o n s must be t r e a t e d w i t h c a u t i o n .  an a -  84  Conclusions The 1.  f i n d i n g s of t h i s study suggest the f o l l o w i n g  P o s t s u r g i c a l c a t a r a c t p a t i e n t s a r e h i g h l y m o t i v a t e d t o f o l l o w recommendations  assiduously,  and become very  a r i s e that i n t e r f e r e with t h e i r a b i l i t y 2.  Patients  manage r o u t i n e  sistance  s i m i l a r to that  extra  temporary  Cataract  surgery,  postoperative  activities  concerned  with  when  situations  t o comply.  a t home extremely w e l l  which was r e q u i r e d  assistance  g a r d e n i n g and g r o c e r y 3.  conclusions:  with a s -  p r i o r to surgery  heavy household  maintenance  plus tasks,  shopping.  without  complications,  c o u r s e , and few p a t i e n t s  has a r e l a t i v e l y  find  painless  the s u r g i c a l e x p e r i e n c e  enervating. 4.  S u p p o r t i v e f a m i l y members and f r i e n d s c o n t r i b u t e important remembering  and  interpreting  instructions,  and  services;  providing  direct  c a r e , companionship, and e m o t i o n a l s u p p o r t . 5.  Concerns a r e reduced when p a t i e n t s cient The  6.  understanding  of cataract  surgery  amount and k i n d o f knowledge r e q u i r e d  Self-administration vision  o f eyedrops  i n the unoperated  concerns. variety  Patients  of s t r a t e g i e s  Difficulties formance  develop,  to i n s t i l l  their  and s u p e r v i s e  dent about t h e i r a b i l i t y  members  have  and t h e r e c o v e r y  suffiprocess.  i s highly i n d i v i d u a l .  f o r a p h a k i c p a t i e n t s who have poor  eye p r e s e n t s  eventually  home care nurses teach  7.  and f a m i l y  difficulties through t r i a l own  drops.  and engenders and e r r o r , a Those  eye care procedures f e l t  who had confi-  t o manage s e l f - c a r e .  and concerns e x p e r i e n c e d by f a m i l y members i n the p e r -  of eye c a r e  p r o c e d u r e s were r e l a t e d  to diminished  manual  dexterity,  the use of an i n e f f e c t i v e technique,  and nervousness  about damaging the eye. 8.  Patients were unaware of the p o t e n t i a l hazard of many of their actions, and of many elements i n their environment.  9.  There were a number  of d i f f i c u l t i e s  experienced  by patients and  family members i n the I n i t i a l stages of obtaining supplies and opening containers that could be ameliorated.  Implications Although this study's l i m i t a t i o n s of design and sample size r e s t r i c t the a b i l i t y  to generalize  implications f o r nursing  the findings, some factors emerged that have p r a c t i c e , medical practice, pharmacist's  prac-  t i c e , and patient self-care behaviour.  Nursing Practice The d i f f i c u l t i e s  that patients and family members had with the per-  formance of eyedrop i n s t i l l a t i o n serves attention. recognized  and application of the eye s h i e l d de-  Since teaching r e q u i s i t e s k i l l s f o r home eye care i s a  nursing r e s p o n s i b i l i t y , i t would be desirable to examine cur-  rent teaching practices to see how they might be changed to increase patient competence i n home eye care procedures.  Some d i r e c t i o n regarding  the a c q u i s i t i o n of manual s k i l l s could be taken from the education erature,  which advocates a demonstration followed  practice under supervision, dence.  I t i s also recognized  i n order  by an opportunity to  to a t t a i n competence  that readiness  lit-  and c o n f i -  to learn and even the recog-  n i t i o n of the need to learn, i s highly i n d i v i d u a l , and influences the ap-  p r o p r i a t e time f o r t e a c h i n g . skills  I t may be found t o be a p p r o p r i a t e t o teach  b e f o r e s u r g e r y , d u r i n g the h o s p i t a l s t a y , f o l l o w i n g h o s p i t a l  charge i n the home environment, In a d d i t i o n patients  learn  o r a combination of a l l t h r e e .  t o f o r m a l t e a c h i n g , i t i s important  from,  and make d e c i s i o n s  nurses d u r i n g t h e p r o c e s s o f p a t i e n t  based  care.  q u e n t l y heard was, " t h a t was the way  i t i s important  want p a t i e n t s t o f o l l o w l a t e r . tients  to wait  five  minutes  to recognize  that  on behaviours modelled by  F o r example, a comment  fre-  the nurses d i d i t i n the h o s p i t a l ,  so I j u s t t r i e d t o do i t the same way." comment i s t h a t  dis-  An i m p l i c a t i o n  f o r nurses  inherent i n this  t o model b e h a v i o u r s t h a t  they  F o r i n s t a n c e , i f i t i s important f o r p a between  the i n s t i l l a t i o n  of two  different  k i n d s of drops, then the same behaviour must be modelled by n u r s e s . Problems  related  t o the d i s c h a r g e i n s t r u c t i o n  f i c u l t y i n r e a d i n g the s m a l l s i z e d p r i n t , e r a l items, suggests t h a t sentation  of t h i s  as  sterile  sheet  merit  the eye w i t h s t e r i l e  cotton  balls  "cotton  balls"  rather  comprehension  consideration.  cotton balls  a r e not r e a d i l y  as  dif-  of s e v -  a change i n wording than  sterile  ones,  The i t e m r e -  s h o u l d be  available  S i n c e the eye c l e a n s i n g r o u t i n e i n the p a t i e n t ' s o n l y a c l e a n procedure,  such  r e v i s i o n s i n format, c o n t e n t , and time of p r e -  instruction  garding cleansing  and poor  sheet  i n the community.  own home may need t o be  of the i n s t r u c t i o n would  reviewed,  remove  caused t r o u b l e and concern t o a number o f p a r t i c i p a n t s .  a  t o read  factor  that  The i t e m on hand  washing a f t e r t r e a t m e n t s , and t h e Item p r o s c r i b i n g r e a d i n g were not widely  comprehended, and i f these a r e c o n s i d e r e d t o be important  a change i n method o f p r e s e n t a t i o n i s i n d i c a t e d . frequently  asked  questions  noted  i n this  study  behaviours,  I n c l u s i o n of answers t o might  s t r e n g t h e n the  printed  handout.  Other  nurse-patient-family instructions, tivities,  content  discussion are:  could  1) p r i n c i p l e s  and 3) a v a i l a b l e community r e s o u r c e s  s e r v i c e to medical  be  considered f o r  and reasons  behind  and nonrecommended a c -  such as f r e e telephone a s -  attachments, and v o l u n t e e r t r a n s p o r t a t i o n  appointments.  optimum time f o r t h e p r o v i s i o n of i n f o r m a t i o n f o r home eye care  i s an a d d i t i o n a l c o n s i d e r a t i o n . the d i s c h a r g e ing  station  One  effective  A p r a c t i c e d e s c r i b e d by s u b j e c t s w h e r e i n  i n s t r u c t i o n sheet  immediately  admission,  was p r e s e n t e d  prior  practice  might be c o n s i d e r e d , pital  which  2) s p e c i f i c examples of p e r m i s s a b l e  s i s t a n c e , l a r g e p r i n t telephone  The  areas  and d i s c u s s e d  to h o s p i t a l discharge  reported  i n another  i s to mail  centre  out i n f o r m a t i o n  has  at the nursdisadvantages.  (Kidger,  1977) t h a t  pamphlets p r i o r  and r e i n f o r c e t h e i n s t r u c t i o n s a t subsequent  to hosintervals  both d u r i n g t h e h o s p i t a l s t a y , and a t home f o l l o w i n g d i s c h a r g e . The  f i n d i n g s r e l a t e d t o p a r t i c i p a n t ' s knowledge and s k i l l s  plications  f o r nursing  education  n u r s i n g s c h o o l s , students in  a r e taught  p a t i e n t s ' eyes, and t h i s  members.  However,  little  and n u r s i n g  administration.  how t o i n s t i l l  same s k i l l  has imIn most  eyedrops and ointment  i s a p p l i c a b l e i n teaching  attention i s paid  to helping  students  family learn  s t r a t e g i e s that a r e e f f e c t i v e f o r p a t i e n t s e l f - a d m i n i s t r a t i o n , a teaching problem o f a d i f f e r e n t o r d e r .  Graduate nurses who work w i t h p a t i e n t s who  have eye problems might a l s o b e n e f i t from e d u c a t i o n cused on how t o teach selves.  Within  patients  programmes  that f o -  t o p e r f o r m eye care procedures f o r them-  the domain of n u r s i n g  a d m i n i s t r a t i o n , a l t e r n a t e methods  of n u r s i n g care d e l i v e r y might be c o n s i d e r e d .  F o r i n s t a n c e , a nurse w i t h  e x p e r t i s e i n t e a c h i n g eye c a r e t o p a t i e n t s and f a m i l i e s might be a s s i g n e d  88  t h i s p a r t i c u l a r r o l e , or h o s p i t a l nurses c o u l d extend t h e i r work i n t o t h e community, making home v i s i t s satisfactory The on  them e s t a b l i s h a  f i n d i n g t h a t a l a r g e number o f p a t i e n t s c o u l d not read l a b e l s , or t h e r e g u l a r  s h e e t , and t h e f i n d i n g t h a t regarding  medication  t o ensure t h a t  accurately.  routines  on t h e d i s c h a r g e  f o r concomitant  planning.  the p a t i e n t  A significant  type  could  medical  that  administer  are able  i n s u l i n a c c u r a t e l y , e i t h e r by o b s e r v i n g  nurse t o v i s i t Finally,  conditions,  prescribed  medications  example would be a p a t i e n t who was an i n s u l i n  these p a t i e n t s  independently before  instruction  I t would appear t o be impor-  dependent d i a b e t i c , many of whom undergo c a t a r a c t s u r g e r y . ascertain  the p r i n t  s e v e r a l p a t i e n t s were unsure about i n s t r u c -  have i m p l i c a t i o n s f o r d i s c h a r g e tant  to help  routine.  medication  tions  to their patients  Nurses  should  t o measure and a d m i n i s t e r  their  t h e p a t i e n t p e r f o r m t h e procedure  h o s p i t a l discharge,  o r by a r r a n g i n g  f o r a home  care  i n t h e home. the i d e n t i f i e d  need  f o r assistance  a t home  with  heavy  household maintenance, gardening and shopping a c t i v i t i e s has i m p l i c a t i o n s f o r discharge identify  planning.  specific  areas  Discussions  w i t h p a t i e n t s and f a m i l y members can  where h e l p  i s required,  and community  services  can be arranged t o supplement f a m i l y support systems.  Medical The  Practice high  with various association  degree o f s a t i s f a c t i o n e x p r e s s e d by p a t i e n t s  study  components of t h e i r i n t e r a c t i o n w i t h the p h y s i c i a n , and t h e of this  satisfaction  with  i m p l i e s t h a t t h e time taken t o d i s c u s s is well  i n this  spent.  subsequent t h e surgery  reduction  of a n x i e t y ,  and l i s t e n t o concerns  89 Although bottles with  o n l y a few s u b j e c t s had problems m a n i p u l a t i n g s m a l l g l a s s separate  droppers,  they  r e p r e s e n t 50 p e r c e n t  f o r whom t h i s k i n d o f d i s p e n s e r was p r o v i d e d . were  viable  options  f o r the same  generic  of the group  I f p l a s t i c dropper  drug,  bottles  c o n s i d e r a t i o n might  be  g i v e n t o o r d e r i n g t h i s l a t t e r d i s p e n s e r , e x p e c i a l l y f o r p a t i e n t s or f a m i l y members who have d i m i n i s h e d manual d e x t e r i t y . ation  f o r prescribing  practices  i s suggested  An a d d i t i o n a l c o n s i d e r -  by the f i n d i n g  that  drops  o r d e r e d a t s i m i l a r i n t e r v a l s reduced concerns a s s o c i a t e d w i t h remembering s c h e d u l e s and d i f f e r e n t i a t i n g I t was noted  that  medications.  once p a t i e n t s had g i v e n t h e p r e s c r i p t i o n  to the  pharmacist, they no l o n g e r had a r e c o r d o f the p h y s i c i a n ' s m e d i c a t i o n i n structions f o r reference. be:  P r e c a u t i o n s t o prevent p o t e n t i a l e r r o r s  could  1) t o g i v e p a t i e n t s w r i t t e n i n s t r u c t i o n s of m e d i c a t i o n s and times of  administration  f o r their  own  r e f e r e n c e , and  b r i n g m e d i c a t i o n s w i t h them t o o f f i c e v i s i t s r a c y of m e d i c a t i o n s b e i n g  2) encourage  patients to  t o a s s e s s c u r r e n c y and a c c u -  used.  I n i t i a l d i f f i c u l t i e s i n o b t a i n i n g m e d i c a t i o n s might be a l l e v i a t e d by p r o v i d i n g s t a r t e r samples of m e d i c a t i o n s . ed w i t h a l i s t  o f pharmacies  that:  P a t i e n t s c o u l d a l s o be p r o v i d -  1) c a r r y i n f r e q u e n t l y p r e s c r i b e d eye  m e d i c a t i o n s , and 2) a r e open on Sundays and H o l i d a y s .  Pharmacist's  Practice  Several  findings  pharmacists. bels  Study  have  implications  p a r t i c i p a n t s were noted t o have problems r e a d i n g l a -  typed i n r e g u l a r p r i n t ,  tirely  by glued-on  f o r the d i s p e n s i n g p r a c t i c e s of  typed  reading i n s t r u c t i o n s  labels,  opening  caps  that were covered en-  of eyedrops,  and  opening  90  child  resistant  which these tients, tops,  problems might  pharmacists  could  print,  containers.  design  especially  be a l l e v i a t e d .  could some  Consideration  remove method  could  be  given  For instance,  the p l a s t i c  collars  f o r providing  t o ways i n  f o r older pa-  around  the b o t t l e  instructions  i n larger  "shake w e l l " i n s t r u c t i o n s , and c o u l d review the n e c e s -  s i t y of d i s p e n s i n g eyedrops i n c h i l d r e s i s t a n t  containers.  P a t i e n t S e l f - C a r e Behaviour Implications the  findings.  bility  f o r p a t i e n t s e l f - c a r e behaviours  Since  accurate  understanding  t o perform the n e c e s s a r y  self-care,  a r e a l s o generated by  of e x p e c t a t i o n s ,  and the a -  procedures i s e s s e n t i a l f o r managing home  p a t i e n t s and f a m i l y members should  i n s t r u c t i o n s and f e e l c o n f i d e n t i n p e r f o r m i n g  make sure  they  understand  procedures b e f o r e  they have  to do them a l o n e . Knowledge about c a t a r a c t s , the s u r g e r y and the r e c o v e r y factor need  i n alleviating  to a v a i l  nurses, In hospital  concerns.  themselves  Therefore,  of o p p o r t u n i t i e s  h o s p i t a l r e s i d e n t d o c t o r s , and t h e i r order  to f a c i l i t a t e  discharge,  s t a p l e food  accomplishment  process  p a t i e n t s and f a m i l y to discuss  isa  members  the s u b j e c t  with  ophthalmologist. of d a i l y  routines  p a t i e n t s who a r e aware of e x p e c t a t i o n s  following  could  stock  s u p p l i e s , and p l a n f o r a n t i c i p a t e d needed a s s i s t a n c e w e l l i n  advance of s u r g e r y . Finally,  s i n c e s a f e t y was an i s s u e i n t h i s study,  l y members s h o u l d  examine the home environment, and a c t i o n s they  a r i l y perform, f o r p o t e n t i a l s a f e t y h a z a r d s . patients help.  to stay  p a t i e n t s and f a m i -  i n their  custom-  I t may be s a f e r f o r e l d e r l y  own homes, and have  others  come  t o them t o  91  Recommendations f o r F u r t h e r  Research  Based on the f i n d i n g s of t h i s study, the f o l l o w i n g areas of are 1.  suggested: That t h i s study be r e p l i c a t e d w i t h a l a r g e sample to i n c r e a s e dence i n the r e l i a b i l i t y of the f i n d i n g s and to generalize statistical  the  results.  analysis  of  That a s i m i l a r study be  variables,  possibly  finding  the  ability  associations  practice.  conducted w i t h a s l i g h t l y  f o r example, younger p a t i e n t s , lens implants,  to i n c r e a s e  confi-  A l a r g e r sample would a l s o permit w i d e r  t h a t would g i v e d i r e c t i o n to n u r s i n g 2.  research  or p a t i e n t s who  to compare s i m i l a r i t i e s and  d i f f e r e n t sample,  have had  intraocular  differences with  patients  i n t h i s present study. 3.  That  a v a r i e t y of  teaching  bers be developed and 4.  That for  a study be teaching  knowledge and  strategies  skills.  and  f a m i l y mem-  tested for e f f i c a c y .  undertaken t o  patients  for patients  and  determine  family  the  members  optimum time and  place  r e q u i s i t e home s e l f - c a r e  92 BIBLIOGRAPHY  Aday, L., Anderson, R., & Fleming, G. H e a l t h c a r e i n the U n i t e d S t a t e s . Beverly H i l l s : Sage Pub. Co., 1980. Arenberg, D. Concept problem s o l v i n g i n young and o l d a d u l t s . of Gerontology, 1968, 23, 279-282. Baum, J . L . O c u l a r a n t i b i o t i c a d m i n i s t r a t i o n . June 4, 1981, 19, ( 1 1 ) . (Tape)  Audio-Digest  Journal  Ophthalmology,  Becker, M.H., Drachman, R.H., K i r s c h t , J.P. P r e d i c t i n g mother's compliance w i t h p e d i a t r i c m e d i c a l regimens. J o u r n a l of P e d i a t r i c s , 1972, 81, 843-854. Bergman, A.B., & Werner, R.J. F a i l u r e of c h i l d r e n t o r e c e i v e p e n i c i l l i n by mouth. New England J o u r n a l of M e d i c i n e , 1963, 268, 1334-1338. Berkoben, R. The v i t a l l i n k . Home c a r e f o r the p a t i e n t a f t e r surgery. Q u a l i t y Review B u l l e t i n , 1978, 4_ ( 5 ) , 11-12.  cataract  B i g g e r , J.F. A comparison of p a t i e n t compliance i n t r e a t e d v s . u n t r e a t e d o c u l a r h y p e r t e n s i o n . T r a n s a c t i o n s of the American Academy of Ophthalmology and O t o l a r y n g o l o g y , 1976, 81_, 277-285. B l a c k w e l l , B. P a t i e n t compliance. 1973, 289, 249-252.  New  England J o u r n a l of M e d i c i n e ,  B l i s h e n , B.R., & McRoberts, H.A. A r e v i s e d socioeconomic i n d e x f o r o c c u p a t i o n s i n Canada. Canadian Review of S o c i o l o g y and A n t h r o p o l o g y , 1976, 13 ( 1 ) , 71-79. B l o c h , S., R o s e n t h a l , A.R., Friedman, L., & C a l d a r o l l a , P. Patient compliance i n glaucoma. B r i t i s h J o u r n a l of Ophthalmology, 1977, 531-534. B o t w i n i c k , J . Aging and behaviour (2nd e d . ) . Co., 1978.  New  York:  61,  S p r i n g e r Pub.  Boyd, J . , C o v i n g t o n , T., Stanaszek, W., & C o u s i n s , R. Drug d e f a u l t i n g . P a r t I I : A n a l y s i s of noncompliance p a t t e r n s . American J o u r n a l of H o s p i t a l Pharmacy, 1974, 31_, 485-494. Boyd-Monk, H.  Cataract surgery.  Nursing 77, June 1977, _7, 56-61.  B r i t i s h Columbia M i n i s t r y of H e a l t h . 1980.  Annual Report.  Victoria,  B.C,  93 Brody, S.J. 123.  The  graying  of America.  Hospitals,  1980,  _54 (10),  63-66;  C a l d w e l l , J . , Cobb, S., Dowling, M.D., & de Jongh, D.D. The dropout problem i n a n t i h y p e r t e n s i v e t h e r a p y . J o u r n a l of C h r o n i c D i s e a s e s , 1970, 22, 579-592. Campbell, M., C r u i s e , M., & Murakami, T.R. A model f o r n u r s i n g : U n i v e r s i t y of B r i t i s h Columbia S c h o o l of N u r s i n g . N u r s i n g Papers, 1976, 8 ( 2 ) , 5-9. C a n e s t r a r i , R. Paced and s e l f - p a c e d l e a r n i n g i n young and adults. J o u r n a l of Gerontology, 1963, _18, 165-168. Caplan, R., Robinson, E., F r e n c h , J . , C a l d w e l l , Adhering to m e d i c a l regimens. Ann A r b o r : Research, U n i v e r s i t y of M i c h i g a n , 1976.  elderly  J . , & Shinn, M. Institute for Social  C l a y t o n , T. Teaching and l e a r n i n g ; a p s y c h o l o g i c a l Englewood C l i f f s : Prentice Hall, 1965.  perspective,  Cohen, F., & L a z a r u s , R. Coping w i t h the s t r e s s e s of i l l n e s s . In G. Stone, F. Cohen, N. A d l e r , & A s s o c i a t e s ( E d s . ) , H e a l t h p s y c h o l o g y ; A handbook. San F r a n c i s c o : Jossie-Bass, 1979. Combs, A., & Snygg, D. I n d i v i d u a l b e h a v i o u r , a p e r c e p t u a l approach to behaviour (Rev. e d . ) . New York: Harper & Row, 1959. C o t l i e r , E. Senile cataract: evidence f o r a c c e l e r a t i o n by d i a b e t e s d e c e l e r a t i o n by s a l i c y l a t e . Canadian J o u r n a l of Ophthalmology, 1981, 16 ( 3 ) , 113-118.  and  Crawford, C.I. Medicare's d e f i n i t i o n of s k i l l e d n u r s i n g c a r e : impact on home h e a l t h s e r v i c e s f o r c a t a r a c t p a t i e n t s . Unpublished master's t h e s i s , Yale U n i v e r s i t y , 1980. Davidson, S.I., & A k i n g b e h i n , T. Compliance i n ophthalmology. T r a n s a c t i o n s of the O p h t h a l m o l o g i c a l S o c i e t y of the U n i t e d 1980, 100, 286-290.  Kingdom,  Davies, J . Impact of the system on the p a t i e n t - p r a c t i t i o n e r r e l a t i o n s h i p , p. 137-144. In J.W. C u l l i n , B.H. Fox, & R.N. Isom ( E d s . ) , Cancer: The b e h a v i o u r a l dimension . New York: Raven P r e s s , 1976. D a v i s , M. V a r i a t i o n s i n p a t i e n t s ' compliance w i t h d o c t o r s ' a d v i c e : an e m p i r i c a l a n a l y s i s of p a t t e r n s of communication. American J o u r n a l of P u b l i c H e a l t h , 1968, 58 ( 2 ) , 274-288. (a) D a v i s , M. P h y s i o l o g i c , p s y c h o l o g i c a l and demographic f a c t o r s i n p a t i e n t compliance w i t h d o c t o r s ' o r d e r s . M e d i c a l Care, 1968, 6 ( 2 ) , 115-120. (b)  94 D a v i s , M.S., study.  & E i c h h o r n , R. Compliance w i t h m e d i c a l regimens: A p a n e l J o u r n a l of H e a l t h and Human Behaviour, 1963, 4_, 240-249.  Donabedian, A., & R o s e n f e l d , L. F o l l o w up study of c h r o n i c a l l y i l l p a t i e n t s d i s c h a r g e d from h o s p i t a l . J o u r n a l of Chronic Deseases, 1964, 17, 847-862. Duke-Elder, S i r Stewart ( E d . ) . System of ophthalmology: l e n s and v i t r e o u s ; glaucoma and hypotony ( V o l . X I ) . Kimpton, 1969.  D i s e a s e s of the London: Henry  Fox,  York:  D. Fundamentals of n u r s i n g r e s e a r c h (2nd e d . ) . Appleton-Century-Crofts, 1970.  F r a n c i s , V., Korsch, B., communication. New  New  & M o r r i s , M. Gaps i n d o c t o r - p a t i e n t England J o u r n a l of M e d i c i n e , 1969, 280,  535-540.  G a l i n , M.A., Baras, I . , Barasch, K., & Boniuk, V. Immediate ambulation and d i s c h a r g e a f t e r c a t a r a c t e x t r a c t i o n . T r a n s a c t i o n s of the Amercian Academy of Ophthalmology and O t o l a r y n g o l o g y , 1974, 78, OP43. Gardener, P.A. A.B.C. of ophthalmology: J o u r n a l , 1979, I, 36-38.  cataracts.  British  Medical  G i l l u m , F.R., & Barsky, A . J . D i a g n o s i s and management of p a t i e n t noncompliance. J o u r n a l of the American M e d i c a l A s s o c i a t i o n , 228, 1563-1567.  1974,  Green, L.W. Should h e a l t h e d u c a t i o n abandon a t t i t u d e change s t r a t e g i e s ? P e r s p e c t i v e s from r e c e n t r e s e a r c h . H e a l t h E d u c a t i o n Monograph, 1970, 30, 25-48. Hammell, R.W., & W i l l i a m s , P.O. Do p a t i e n t s r e c e i v e p r e s c r i b e d medications? American P h a r m a c e u t i c a l A s s o c i a t i o n J o u r n a l , 4-, 331-334.  1964,  Havener, W., Saunders, W.H., K e i t h , C.F., & P r e s c o t t , A.W. Nursing i n eye, ear, nose and t h r o a t d i s o r d e r s ( 3 r d e d . ) . St. Louis: Mosby, 1974.  care  Haynes, R.B. A c r i t i c a l review of the "determinants" of p a t i e n t compliance w i t h t h e r a p e u t i c regimens. In D.C. Sackett & R.B. Haynes ( E d s . ) , Compliance w i t h t h e r a p e u t i c regimens. B a l t i m o r e : Johns Hopkins U n i v e r s i t y P r e s s , 1976. Haynes, R.B. Determinants of compliance: The d i s e a s e and the mechanics of treatment. In R.B. Haynes, D.W. T a y l o r , & D.L. S a c k e t t ( E d s . ) , Compliance i n h e a l t h c a r e . B a l t i m o r e : Johns Hopkins U n i v e r s i t y P r e s s , 1979.  95 Hermann, F. The o u t p a t i e n t p r e s c r i p t i o n l a b e l as a source of m e d i c a t i o n errors. American J o u r n a l of H o s p i t a l Pharmacy, 1973, 30, 155-159. H i l b o u r n e , J.F.H. S o c i a l and o t h e r a s p e c t s of adjustment t o s i n g l e eye c a t a r a c t e x t r a c t i o n i n e l d e r l y p a t i e n t s . T r a n s a c t i o n s of the O p h t h a l m o l o g i c a l S o c i e t y of the U n i t e d Kingdom, 1975, 95, 254-259. Hulka, B. P a t i e n t - c l i n i c i a n i n t e r a c t i o n s and compliance. In R.B. Haynes, D.W. T a y l o r , & D.L. S a c k e t t ( E d s . ) , Compliance i n h e a l t h c a r e . Baltimore: Johns Hopkins U n i v e r s i t y P r e s s , 1979. Ingram, R.M., Banerjee, D., T r a y n a r , J . J . , & Thompson, R.K. c a t a r a c t s u r g e r y . T r a n s a c t i o n s of the O p h t h a l m o l o g i c a l the U n i t e d Kingdom, 1980, 100, 205-209.  Day-case S o c i e t y of  J a f f e , N.S. I n t r a o c u l a r l e n s e s , i n d i c a t i o n s and c o n t r a i n d i c a t i o n s . T r a n s a c t i o n s of the American Academy of Ophthalmology and O t o l a r y n g o l o g y , 1976, 81, OP 93-96 J a f f e , N.S. C u r r e n t concepts i n ophthalmology; c a t a r a c t s u r g e r y . New England J o u r n a l of M e d i c i n e , 1978, 299, 235-238. J a n i s , I.L. P s y c h o l o g i c a l s t r e s s , p s y c h o l o g i c a l and b e h a v i o u r a l s t u d i e s of s u r g i c a l p a t i e n t s . New York: John W i l e y & Sons Inc., 1958. Johnson, J.D. One-day s t a y f o r h o s p i t a l J . A study on the q u a l i t y of care f o r p a t i e n t s b r i e f l y h o s p i t a l i z e d f o r c a t a r a c t s u r g e r y . Q u a l i t y Review B u l l e t i n , 1978, _4 ( 5 ) , 16-19. Kahn, R., & C a n n e l l , C. The dynamics of i n t e r v i e w i n g ; t h e o r y , and c a s e s . New York: W i l e y , 1957. K i d g e r , J . Home v i s i t i n g scheme f o r ophthalmic August 4, 1977, 1212-1214. K i n g , I.M. 1968,  patients.  Conceptual frame of r e f e r e n c e f o r n u r s i n g . 17_ ( 1 ) , 27-31.  K i n l e i n , M. A s e l f - c a r e concept. ( 4 ) , 598-601.  techniques  N u r s i n g Times,  Nursing  American J o u r n a l of N u r s i n g ,  Research,  1977, 77_  K i t a , S. S t a t i s t i c a l package f o r the s o c i a l s c i e n c e s ; v e r s i o n 8, CROSSTABS. Vancouver: The U n i v e r s i t y of B r i t i s h Columbia Computing Centre, 1980. Korsch, B., & Negrete, V. D o c t o r - p a t i e n t communication. American, 1972, 277 ( 2 ) , 66-76.  Scientific  Kwitko, M.L. A r t i f i c i a l lens implant. J o u r n a l of the A s s o c i a t i o n of O p e r a t i n g Room Nurses, 1978, 28, 47-53.  96 Lewin, K. S e l e c t e d t h e o r e t i c a l p a p e r s . In D. C a r t w r i g h t theory i n s o c i a l s c i e n c e . New York: Harper, 1951.  (Ed.),  Field  Ley,  P. The psychology of compliance. I n D. Oborne, M. Gruneberg, & J . E i s e n ( E d s . ) , Research i n Psychology and M e d i c i n e , ( V o l . 2 ) . New York: Academic P r e s s , 1980.  Low,  C.R. O u t p a t i e n t c a t a r a c t s u r g e r y . J o u r n a l o f the A s s o c i a t i o n o f Operating Room Nurses, 1978, 2_8 ( 1 ) , 35-40.  Luckman, J . , & Sorensen, K. M e d i c a l - s u r g i c a l n u r s i n g : A p s y c h o p h y s i o l o g i c a l approach (2nd e l d . ) . P h i l a d e l p h i a : W.B. Saunders, 1980. Marram. G. P a t i e n t s ' e v a l u a t i o n of n u r s i n g performance. 1973, 22 ( 2 ) , 153-157.  Nursing  Research,  Marston, M. Compliance w i t h m e d i c a l regimens: A review o f the literature. Nursing Research, 1970, 19_ ( 4 ) , 312-322. M a u s o l f , F.  The eye and systemic  disease.  St. Louis:  C V . Mosby, 1975.  M a z z u l l o , J . , L'asagna, L., & G r i n e r , P. V a r i a t i o n s i n i n t e r p r e t a t i o n of p r e s c r i p t i o n i n s t r u c t i o n s . J o u r n a l o f the American M e d i c a l A s s o c i a t i o n , 1974, 227, 929-931. M c A l i s t e r , A.L., Farquhar, J.W., Thoresen, C.E., & Maccoby, N. Behavioural s c i e n c e a p p l i e d t o c a r d i o v a s c u l a r h e a l t h : Progress and r e s e a r c h needs i n the m o d i f i c a t i o n of r i s k - t a k i n g h a b i t s i n a d u l t p o p u l a t i o n s . H e a l t h E d u c a t i o n Monographs, 1976, 4^ 45-74. M c C l e l l a n d , R.H. P r o v i n c i a l home c a r e program. J o u r n a l , 1976, 18 (10), 328-329.  B r i t i s h Columbia  Medical  M c l n t i r e , M., Angle, C , Sathees, K., & Lee, P. S a f e t y packaging - what does the p u b l i c t h i n k ? American J o u r n a l o f P u b l i c H e a l t h , 1977, 67, 169-171. Nadler, D.J., & Schwartz, B. C a t a r a c t s u r g e r y i n the U n i t e d S t a t e s , 1968-1976. A d e s c r i p t i v e e p i d e m i o l o g i c s t u d y . Ophthalmology, January, 1980, 87_ ( 1 ) , 10-18. Neely, E., & P a t r i c k , M. Problems of aged persons t a k i n g at home. Nursing Research, 1968, 1_7 ( 1 ) , 52-55.  medications  Neuman, B. The B e t t y Neuman h e a l t h care systems model: A t o t a l person approach t o p a t i e n t problems. I n J . R i e h l , & C. Roy ( E d s . ) , Conceptual models f o r n u r s i n g p r a c t i c e . New York: Appleton-CenturyC r o f t s , 1974.  97 N o r r i s , C. S e l f - c a r e . 486-489.  American J o u r n a l o f Nursing,  Nurses Guide t o Drugs. Nursing 80 Books. Intermed Communications I n c . , 1980.  Horsham,  1979, _9 ( 3 ) ,  Pennsylvania:  P a r k i n , D.M., Brown, G.W., & Monk, E.M. D e v i a t i o n from p r e s c r i b e d drug treatment a f t e r d i s c h a r g e from h o s p i t a l . B r i t i s h Medical Journal, 1976, 2_, 686-688. P o l i t , D., & Hungler, B. Nursing r e s e a r c h : New York: J.B. L i p p i n c o t t , 1978.  P r i n c i p l e s and methods.  Potash, M.A., & Jones, B. Aging and d e c i s i o n c r i t e r i a f o r the d e t e c t i o n of tones i n n o i s e . J o u r n a l o f Gerontology, 1977, 32, 436-440. P o w e l l , A.H., E i s d o r f e r , C , Bogdonoff, M., & Durham, N.C. P h y s i o l o g i c response p a t t e r n s observed i n a l e a r n i n g t a s k . A r c h i v e s o f General P s y c h i a t r y , 1964, 10, 192-195. P r a t t , L., Seligmann, A., & Reader, G. P h y s i c i a n s ' views on the l e v e l of m e d i c a l i n f o r m a t i o n among p a t i e n t s . American J o u r n a l o f P u b l i c H e a l t h , 1957, 47, 1277-1283. P u b l i c a t i o n Manual o f the American P s y c h o l o g i c a l A s s o c i a t i o n , (2nd ed.) Baltimore: Garamond/Pridemark P r e s s , I n c . , 1981 R a b b i t t , P. An age decrement i n the a b i l i t y t o i g n o r e i r r e l e v a n t i n f o r m a t i o n . J o u r n a l o f Gerontology, 1965, 20, 233-238. Redman, B.K. The process 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 . ) . S t . L o u i s : Mosby, 1972. R i f f e n b u r g h , R.S. D o c t o r - p a t i e n t r e l a t i o n s h i p i n glaucoma A r c h i v e s o f Ophthalmology, 1966, _ 5 , 204-206.  therapy.  Rosenstock, I.M. The h e a l t h b e l i e f model and p r e v e n t i v e h e a l t h behaviour. H e a l t h E d u c a t i o n Monographs, 1974, 2. ( 4 ) , 354-386. Roy,  C. The Roy a d a p t a t i o n model. In J . R i e h l , & C. Roy ( E d s . ) , Conceptual models f o r n u r s i n g p r a c t i c e . New York: AppletonC e n t u r y - C r o f t s , 1974.  Saxon, S., & E t t e n , M. P h y s i c a l change and a g i n g : A guide f o r the h e l p i n g p r o f e s s i o n s . New York: T i r e s i a s Press", 1978. Schwartz, D., Wang. M., Z e i t z , L., Goss, M. M e d i c a t i o n e r r o r s made by e l d e r l y c h r o n i c a l l y i l l p a t i e n t s . American J o u r n a l o f P u b l i c H e a l t h , 1962, 52, 2018-2019.  98 Schwartz, D., Henley, B., & Z e i t z , L. Nursing and p s y c h o l o g i c a l needs.  The New  e l d e r l y ambulatory p a t i e n t : York: M a c M i l l a n , 1964.  S h a f e r , K., Sawyer, J . , McCluskey, A., Beck, E., & Phipps, W. s u r g i c a l nursing (6th ed.). S t . L o u i s : Mosby, 1975.  Medical-  Shanahan, M., & Pelham, V. N u r s i n g e v a l u a t i o n of the care of p a t i e n t s w i t h c a t a r a c t s . Q u a l i t y Review B u l l e t i n , 1978, h_ ( 5 ) , 8-10. Shock, D. O p e r a t i v e management of c a t a r a c t s : I n t r o d u c t i o n . In H.E.J. K o l d e r ( E d . ) , C a t a r a c t s : Proceedings of the P a u l Boeder i n t e r n a t i o n a l symposium. I n t e r n a t i o n a l Ophthalmology C l i n i c s , Summer 1978, 1_8 ( 2 ) , 129-143. Boston: L i t t l e Brown & Company. Smith, J . , & Nachazel, D. Ophthalmologics! Brown & Company, 1980. Spaeth, G.L. tions.  nursing.  V i s u a l l o s s i n a glaucoma c l i n i c . I n v e s t i g a t i v e Ophthalmology, 1970,  Boston:  Little  Sociological considera9, 73-82.  S t a r f i e l d , B. H e a l t h s e r v i c e s r e s e a r c h : A working model. England J o u r n a l of M e d i c i n e , 1973, 289 ( 3 ) , 132-136.  The  New  S t a t i s t i c s Canada. S u r g i c a l procedures and treatments M i n i s t r y of I n d u s t r y , Trade & Commerce, 1969.  (p. 34).  Ottawa:  S t a t i s t i c s Canada. S u r g i c a l procedures and treatments M i n i s t r y of Supply and S e r v i c e s , 1977.  ( p . 52).  Ottawa:  Stedman's M e d i c a l D i c t i o n a r y (22nd ed., p. 214). W i l l i a m s , 1972.  Baltimore:  Williams  Stimson, G. Obeying d o c t o r s o r d e r s : A view from the o t h e r s i d e . S c i e n c e and M e d i c i n e , 1974, j}, 97-104.  &  Social  Strachan, I.M., & B o w e l l , R.E. 1972. Reduced i n - p a t i e n t s t a y f o l l o w i n g c a t a r a c t e x t r a c t i o n . T r a n s a c t i o n s of the O p h t h a l m o l o g i c a l S o c i e t y of the U n i t e d Kingdom, 1972, 92_, 629-636. S v a r s t a d , B. P h y s i c i a n - p a t i e n t communication and p a t i e n t c o n f o r m i t y w i t h medical advice. In D. Mechanic ( E d . ) , The growth of b u r e a u c r a t i c medicine. New York: W i l e y , 1976. T a g l i a c o z z o , D.M., & Ima, K. Knowledge of i l l n e s s as a p r e d i c t o r of p a t i e n t behaviour. J o u r n a l of C h r o n i c D i s e a s e s , 1970, 22_, 765-775. Tolman, E.C. B e h a v i o u r a l and p s y c h o l o g i c a l man ( p . 144-178; 241-264). Berkeley: U n i v e r s i t y of C a l i f o r n i a P r e s s , 1958. Troutman, R.C. Techniques i n s u r g e r y : and c a t a r a c t . E t h i c o n , 1971.  S u t u r i n g techniques  f o r cornea  99 V i n c e n t , P. F a c t o r s i n f l u e n c i n g p a t i e n t noncompliance: approach. Nursing Research, 1971, 20, 509-516. V i n c e n t , P. P a t i e n t ' s v i e w p o i n t of glaucoma therapy. Winter 1973, 42 ( 4 ) , 213-221.  A theoretical  S i g h t Saving Review,  V u k c e v i c h , W.M. O u t p a t i e n t c a t a r a c t s u r g e r y and l e n s i m p l a n t a t i o n . J o u r n a l o f the American I n t r a o c u l a r Implant S o c i e t y , 1979, _5 ( 4 ) , 324-325. Weinstock, F . J . What your a g i n g p a t i e n t may want t o know about G e r i a t r i c s , 1978, 33 ( 1 2 ) , 57-60; 64. White, M.B. Importance of s e l e c t e d n u r s i n g a c t i v i t i e s . Research, 1972, 21 ( 1 ) , 4-14.  cataracts.  Nursing  W i l l i a m s o n , D.E. O u t p a t i e n t c a t a r a c t - i m p l a n t s u r g e r y compared w i t h outpatient c a t a r a c t standard surgery. Annals o f Ophthalmology, 1978, 7, 957-965. Worthen, D.M. Timolol.  P a t i e n t compliance and the " u s e f u l n e s s p r o d u c t " o f Survey o f Ophthalmology, 1979, 23, 403-405.  APPENDIX A  I N F O R M A T I O N L E T T E R FOR PROSPECTIVE  SUBJECTS  INFORMATION REGARDING A RESEARCH STUDY RELATED TO POST-SURGICAL CATARACT PATIENTS INDIVIDUALS WHO HAVE RECENTLY HAD CATARACT OPERATIONS ARE BEING ASKED TO PARTICIPATE IN A RESEARCH STUDY. THE PURPOSE OF THE STUDY IS TO LEARN ABOUT THE EXPERIENCES THAT PATIENTS HAVE DURING THE FIRST FEW WEEKS THAT THEY ARE HOME FOLLOWING CATARACT SURGERY. IT IS HOPED THAT THE RESULTS OF THE STUDY WILL HELP NURSES BE OF MORE ASSISTANCE TO FUTURE CATARACT PATIENTS. * MRS. SHELAGH SMITH, A REGISTERED NURSE STUDYING FOR A MASTER'S DEGREE IN NURSING AT THE UNIVERSITY OF BRITISH COLUMBIA, IS CONDUCTING THE STUDY, AND WITH THE AGREEMENT OF YOUR DOCTOR, IS REQUESTING THAT YOU CONSIDER PARTICIPATING. IF YOU AGREE, TWO VISITS WOULD BE MADE BY MRS. SMITH TO YOU IN YOUR HOME AT A TIME THAT IS CONVENIENT TO YOU. THE FIRST VISIT WOULD BE THE DAY AFTER YOU LEAVE HOSPITAL. THE SECOND VISIT WOULD BE ABOUT TWO WEEKS AFTER YOUR SURGERY. THE DISCUSSION WOULD BE RELATED TO THE EXPERIENCES YOU HAVE IN MANAGING YOUR CARE AT HOME. OBSERVATIONS OF EYE CARE PROCEDURES SUCH AS INSTILLATION OF EYE DROPS WOULD BE MADE. IF A FAMILY MEMBER IS ASSISTING YOU IN THE CARE OF YOUR EYE, IT WOULD BE APPRECIATED IF THAT MEMBER COULD BE PRESENT FOR THE INTERVIEWS. EACH VISIT WILL BE LESS THAN ONE HOUR. ALL INFORMATION WILL BE CONFIDENTIAL. NO ASSOCIATION BETWEEN WRITTEN REPORTS OF THE STUDY AND YOU OR YOUR FAMILY WILL BE ABLE TO BE MADE. UNDER SPECIAL CIRCUMSTANCES, AND WITH YOUR AGREEMENT, IF A CONDITION OF CONCERN RELATED TO YOUR EYE WAS NOTICED, MRS. SMITH WOULD NOTIFY YOUR DOCTOR.  102  IN ORDER THAT CONVERSATION IS NOT INTERRUPTED BY TAKING NOTES, FIRS. SMITH WOULD LIKE TO USE A TAPE RECORDER DURING THE VISITS. THE TAPE WILL BE ERASED AS SOON AS THE STUDY IS FINISHED. IF YOU AGREE TO PARTICIPATE, YOU ARE FREE TO WITHDRAW AT ANY TIME WITHOUT .AFFECTING YOUR FUTURE MEDICAL OR NURSING CARE. YOU ARE WELCOME TO HAVE A SUMMARY OF THE RESULTS IF YOU REQUEST IT. THE PURPOSE OF THIS LETTER IS TO PROVIDE A GENERAL DESCRIPTION OF THE STUDY. IF YOU ARE WILLING TO CONSIDER PARTICIPATING IN THE STUDY, MRS. SMITH WILL CONTACT YOU SOMETIME DURING YOUR HOSPITAL STAY TO DESCRIBE THE STUDY IN MORE DETAIL, ANSWER ANY QUESTIONS YOU MIGHT HAVE, AND OBTAIN YOUR CONSENT.  APPENDIX B SUBJECT CONSENT FORM  CONSENT FORM I AGREE TO TAKE PART IN A PROJECT THAT IS DESIGNED TO STUDY THE EXPERIENCES OF CATARACT PATIENTS AFTER THEY RETURN HOME FROM HOSPITAL. I AGREE THAT TWO HOME VISITS MAY BE MADE BY MRS. SHELAGH SMITH FROM THE UNIVERSITY OF BRITISH COLUMBIA TO DISCUSS HOW I AM MANAGING AT HOME, AND TO OBSERVE EYE CARE PROCEDURES SUCH AS THE INSTILLATION OF EYE DROPS AND APPLICATION OF PROTECTIVE EYE SHIELD. EACH VISIT WILL BE SHORTER THAN ONE HOUR. I UNDERSTAND THAT ALL INFORMATION WILL BE KEPT CONFIDENTIAL. UNDER SPECIAL CIRCUMSTANCES, AND WITH MY AGREEMENT, MRS. SMITH MAY DISCUSS MY CONDITION WITH MY DOCTOR. INFORMATION OBTAINED IN THE STUDY WILL BE WRITTEN IN A PAPER AND SHARED WITH OTHER NURSES, BUT MY NAME WILL NOT APPEAR IN ANY PLACE. I UNDERSTAND THAT I MAY WITHDRAW FROM THE STUDY AT ANY TIME WITHOUT AFFECTING MY FUTURE MEDICAL OR NURSING CARE, AND  105  THAT I MAY RECEIVE INFORMATION ABOUT THE RESULTS OF THE STUDY IF I SO REQUEST. INTERVIEWS WILL BE TAPE-RECORDED, AND THE TAPES WILL BE ERASED WHEN THE STUDY IS COMPLETED. I ALSO GIVE PERMISSION TO SHELAGH"SMITH TO READ MY HOSPITAL CHART TO OBTAIN INFORMATION NECESSARY FOR THE STUDY. ALL MY QUESTIONS ABOUT THE STUDY HAVE BEEN ANSWERED BY SHELAGH SMITH. SIGNATURE: WHERE APPLICABLE A MEMBER OF MY FAMILY MAY BE ASKED TO PARTICIPATE IN THE INTERVIEWS. SIGNATURE:  APPENDIX C  LETTER OF AGREEMENT FOR EYE DROP ADMINISTRATION  107 U n i v e r s i t y of B r i t i s h School o f N u r s i n g 2075 Wesbrook M a l l Vancouver, B.C. V6T 1W5  Dear Doctor  :  Thank you f o r a g r e e i n g research  Columbia  t o a s s i s t me i n c o n t a c t i n g  subjects  study on p o s t s u r g i c a l c a t a r a c t p a t i e n t s d u r i n g  weeks a t home f o l l o w i n g h o s p i t a l I am r e q u e s t i n g  f o r my  t h e i r f i r s t few  discharge.  w r i t t e n permission  that i t i s acceptable  f o r your  p a t i e n t t o r e c e i v e one e x t r a drop o f p r e s c r i b e d eye m e d i c a t i o n on the day I make a home v i s i t  i f I am unable t o c o i n c i d e my v i s i t w i t h a r e g u l a r  medication administration I would a p p r e c i a t e  time.  i t i f you would s i g n t h e p e r m i s s i o n  noted below.  Thank You,  Shelagh Smith  I agree t h a t t h e p o s t s u r g i c a l c a t a r a c t p a t i e n t s under my c a r e who are v i s i t e d by Shelagh Smith f o r a r e s e a r c h  study may r e c e i v e f o r reasons  of t h e study, one e x t r a a p p l i c a t i o n of a p r e s c r i b e d eye m e d i c a t i o n on t h e day  of h e r v i s i t .  detrimental  In my o p i n i o n t h i s e x t r a m e d i c a t i o n would i n no way be  to the p a t i e n t .  Signature:  APPENDIX D  INTERVIEW  GUIDE  INTERVIEW GUIDE POST-SURGICAL PATIENTS PROFILE SHEET  1. 2. _*3. _ 4.  5. *6.  P a t i e n t Number Doctor Number P a t i e n t Age i n Years Sex [M] [F] 1 2  +14.  Manual D e x t e r i t y of F a m i l y Member ( i f applicable) L e v e l of P h y s i c a l Functioning: 1. Independent w i t h no r e g u l a r household or gardening h e l p .  E t h n i c Background Type of A n a e s t h e t i c 1. G e n e r a l 2. L o c a l  2.  Independent, but employs r e g u l a r household or gardening h e l p to facilitate daily living.  3.  Requires a s s i s t a n c e with routine household or gardening a c t i v i t i e s one-half day per week or l e s s f r e q u e n t l y .  4.  Requires a s s i s t a n c e with routine household or gardening a c t i v i t i e s more than one-half day per week.  *Length of H o s p i t a l Stay i n Days 7. 8. 9.  B e f o r e Surgery A f t e r Surgery Total  *10.  Other m e d i c a l problems List:  *11.  M e d i c a t i o n s p r e s c r i b e d on d i s c h a r g e from h o s p i t a l . List: Frequency & Route of Name Dosage Admin. 15. 16. 17.  *12.  +13.  Vision: Best c o r r e c t e d v i s u a l a c u i t y unoperated eye  Manual D e x t e r i t y ( f i n e motor c o - o r d i n a t i o n ) 1. No impairment 2. Some impairment 3. Impaired  +18.  C l i e n t Pre-op L e v e l C l i e n t Post-op L e v e l Spouse/Family Member ( i f applicable) Hearing 1. No apparent impairment 2.  M i l d impairment (needs o c c a s i o n a l repetitions, i n c r e a s e d volume).  3.  Moderate impairment repetitions).  19.  Smoking 1. 2.  20.  Status  29.  Furniture 1. 2.  Non-smoker Smoker  Arrangement  C l e a r passageways Complicated arrangement  E d u c a t i o n L e v e l i n Years 30.  S c a t t e r Rugs  [Y]  +Neighbourhood 21.  Occupation 31.  +22.  1. 2. 3. 4. 5. 23.  Traffic  Housing: 1. 2. 3.  House Apartment Room F a c i l i t y (without nursing care) Other ( s p e c i f y )  32.  33. 1. 2. 3. 4. 5. 6.  Curbs 1. 2. 3.  Household Composition Pre-surgery L i v e s : Alone With a b l e spouse With dependent spouse With o t h e r f a m i l y member ( s p e c i f y ) With f r i e n d Other  Outside s t a i r s Handrails Inside s t a i r s Handrails Adequate l i g h t i n g  [Y]  [N]  [Y] [Y] [Y] [Y]  [N] [N] [N] [N]  None A little A lot  P r o x i m i t y of u s u a l shopping f a c i l i t i e s .  + P h y s i c a l Environment 24. 25. 26. 27. 28.  None Few Many  Rough T e r r a i n 1. 2. 3.  34.  Light Moderate Heavy  * Data from h o s p i t a l c h a r t + Observations  Ill  FIRST HOME VISIT INTERVIEW GUIDE  General  I n t r o d u c t o r y Remarks  E x p l a i n f o c u s of the study a g a i n , and r e i t e r a t e o p t i o n of s u b j e c t t o have tape stopped o r p o r t i o n s e r a s e d . To b e g i n , t e l l me how you have g o t t e n a l o n g s i n c e you came home from h o s p i t a l yesterday. (Ask about a n y t h i n g unexpected t h a t happened, a n y t h i n g f o r which s u b j e c t or f a m i l y were unprepared, any v i s i t s from a home c a r e nurse, any phone c a l l s r e q u e s t i n g i n f o r m a t i o n or a s s i s t a n c e r e l a t e d t o eye care)  35.  I would now l i k e t o ask a few q u e s t i o n s about your eye. Since you got home from h o s p i t a l , have you had any p a i n or d i s c o m f o r t i n your eye?  38.  1. cue  1.  2. _36.  cue  _37.  cue  Yes - E l a b o r a t e . E l i c i t description, duration, severity, frequency, comfort measures (Items 36-43). No - Go t o 44.  I n which of t h e f o l l o w i n g words would you d e s c r i b e the way your eye f e e l s ? 1. 2. 3. 4. 5. 6.  Itchy Scratchy Smarting Aching Throbbing Sharp p a i n  Would you d e s c r i b e t h e discomfort as: 1.' 2. 3.  Mild Moderate Severe  How f r e q u e n t l y has the f e e l i n g of discomfort occurred?  2. 3.  Once or twice ( v e r y occasionally) Three t o f i v e times (occasionally) More than f i v e times  39.  Does the d i s c o m f o r t  cue  1. 2. 3.  40.  cue  42.  A few minutes S e v e r a l hours A l l day  Did you take any medication f o r the p a i n , discomfort? 1. 2.  41.  last:  Yes (what?) No  Did t h i s medicine your d i s c o m f o r t ? 1. 2. 3.  relieve  Completely Some Not a t a l l  Did you use any o t h e r measure t o make your eye more comfortable? 1. 2.  Yes ( s p e c i f y ) No  112  43.  Have you n o t i c e d a n y t h i n g i n p a r t i c u l a r t h a t you t h i n k causes your eye t o be uncomfortable? Free response:  56.  1. 2.  Probe f o r 1. Photophobia 2. C i g a r e t t e smoke 57. Now, I would l i k e t o ask about some g e n e r a l problems t h a t people sometimes have. S i n c e you got home from have you had any: 44. ""45. "46. ~47. "48. "49. ~50.  Slept w e l l Awake a l o t of the time  How does t h i s compare w i t h your u s u a l s l e e p i n g pattern? 1. 2.  Same Different  hospital,  Nausea Vomiting Coughing Sneezing Headache Sore t h r o a t Other d i s c o m f o r t s (specify)  51.  If a f f i r m a t i v e f o r s o r e throat, e l i c i t severity.  52.  If a f f i r m a t i v e f o r headache, e l i c i t s e v e r i t y (52) and l o c a t i o n ( 5 3 ) .  58.  I f d i f f e r e n t or awake a l o t of the time, e l i c i t any reasons f o r t h e difference.  59.  Did you take a s l e e p i n g p i l l , o r use a home remedy to h e l p you s l e e p ? 1. 2. 3.  60.  54.  E l i c i t comfort measures employed f o r above.  55.  E l i c i t success of any comfort measures: R e l i e v e d 1. Completely 2. M o d e r a t e l y well 3. Not a t a l l  Sleeping p i l l Home remedy Nothing  Is i t u s u a l f o r you t o take something t o h e l p you sleep? 1. 2.  53.  cue  How w e l l d i d you s l e e p l a s t night? Free response, then v a l i d a t e w i t h cues:  Yes No  Now I would l i k e t o ask a few q u e s t i o n s about your m e d i c a t i o n s and t r e a t m e n t s . 61.  When you l e f t h o s p i t a l you were g i v e n a p r e s c r i p t i o n f o r eye m e d i c i n e s . How d i d you o b t a i n these medications? 1. 2. 3.  D e l i v e r e d by pharmacy P i c k e d up by r e l a t i v e or f r i e n d P i c k e d up by s e l f  4.  Other  (specify)  113  Interviewer: Check m e d i c a t i o n s against discharge orders. 62.  Was t h e r e any d i f f i c u l t y i n o b t a i n i n g the medicines? 1. 2.  63.  68.  Yes ( s p e c i f y ) No  How l o n g a f t e r you r e t u r n e d home from h o s p i t a l d i d you r e c e i v e your f i r s t a p p l i c a t i o n o f eye medication? 1. 2.  I n t e r v i e w e r : D i r e c t the next s i x q u e s t i o n s t o person i n s t i l l i n g drops.  1. 2. 69.  Scheduled time Discrepancy elaborate cue  _64.  Were t h e r e any o t h e r s u p p l i e s r e l a t e d t o the c a r e of your eye t h a t you needed t o purchase? 1. 2. 3.  65.  1. 2. _66.  67.  1. 2. 3. 4. 5. 6.  72.  Self Spouse Relative F r i e n d , neighbour Home care nurse Other ( s p e c i f y )  Confident A l i t t l e nervous Very nervous  Have you ever i n s t i l l e d eyedrops b e f o r e ? Yes ( d e s c r i b e circumstances) No  Would a demonstration been h e l p f u l t o you? 1. 2.  Yes ( l i s t ) No  Who puts the drops i n your eyei  1. 2. 3.  2. 71.  Yes - e l a b o r a t e No  How do you f e e l about p u t t i n g i n t h e eyedrops? Free response. Then cue:  1.  Yes ( s p e c i f y ) No  Are t h e r e any o t h e r m e d i c a t i o n s t h a t you take regularly? 1. 2.  70.  Cotton b a l l s Tape Other ( s p e c i f y )  Were t h e r e any problems i n obtaining the supplies?  How d i d you manage w i t h the f i r s t few applications? D i d you e x p e r i e n c e any difficulties? (Ask about opening b o t t l e s ) .  have  Yes No  Would an o p p o r t u n i t y t o p r a c t i c e have been helpful? 1. 2.  Yes No  Do you have any s p e c i a l methods t o d i f f e r e n t i a t e the m e d i c a t i o n s ? 73. 74. 75. 76. "77.  Can read the l a b e l s C o l o u r of top S i z e or shape of c o n t a i n e r P l a c e of s t o r a g e Other ( s p e c i f y )  114  I would l i k e t o t a l k about some of the ways i n which you c a r e f o r your eye now that you a r e home from hospital. T e l l me what you do t o keep your eye c l e a n ? 78.  79. 80.  Cleanse eye w i t h s t e r i l e c o t t o n b a l l s and water as n e c e s s a r y t o remove c r u s t s and mucus Wash hands b e f o r e treatment Other - d e s c r i b e  Free Probe 1. Wear g l a s s e s d u r i n g the day 2. Wear eye shield at night ( e l i c i t success of first application) 3. Hold g l a s s e s by ear t i p s when p u t t i n g on 4. Other ( e n v i r onmental hazards, s t a i r s , use of cane or other support)  90.  91.  92.  93. T e l l me some of the a c t i o n s you a v o i d because you understand they may be h a r m f u l t o your e y e . F r e e response, then ask: D i d anyone mention? Free Probe 1. 2. 3. 4. 5. 6.  Bending Lifting Straining Rubbing eye Squeezing eye Sudden movements 7. Other (specify)  81. "82. "83. "84. "85. "86. 87.  88.  Do any of these r e s t r i c t i o n s present a d i f f i c u l t y f o r you? 1. 2.  89.  Who were the people t h a t p r o v i d e d you w i t h i n f o r m a t i o n about what would be expected o f you and what you c o u l d expect t o do once you were home from h o s p i t a l ? Free response, then probe: Free Probe 1. 2. 3. 4.  94. "95. "96. "97.  Yes - e l a b o r a t e No  How do you p i c k up something t h a t has f a l l e n t o the f l o o r ?  Are t h e r e any s p e c i a l p r e c a u t i o n s t h a t you take t o p r o t e c t your eye from i n j u r y ? Free response then probe f o r :  Nurses Doctors Interns Other ( o t h e r people who had had cataract surgery, other patients)  When d i d you r e c e i v e i n f o r m a t i o n about e x p e c t a t i o n s f o r home care? F r e e response, then probe: Free Probe 98.  1. B e f o r e admission t o hospital  115  99.  2. S e v e r a l times during h o s p i t a l stay 3. Day of discharge 4. Other (specify)  100. 101.  102.  When you l e f t h o s p i t a l , d i d you r e c e i v e a p r i n t e d sheet t h a t gave i n s t r u c t i o n s f o r home eye care? 1. 2.  103.  Yes-Ask items 102-106 No-Go t o i t e m 107  108.  1. 2. 109.  110.  111. 104.  D i d you f i n d t h i s helpful? 1. 2.  105.  106.  1.  Yes  2.  No  Could you read the p r i n t ? Yes No  Could a f a m i l y member read the p r i n t ? 1. 2.  Yes No  E l i c i t opinion family member ( i f p r e s e n t ) . 1. 2. 3.  Yes No  Were t h e r e any items you d i d not understand?  1. 2. 107.  sheet  Yes No  Would i t have been h e l p f u l f o r a f a m i l y member t o be present f o r i n s t r u c t i o n s ? 1. 2.  Yes No  Yes No  Was i t h e l p f u l t o have a f a m i l y member p r e s e n t f o r instructions? 1. 2.  D i d anyone d i s c u s s the i n s t r u c t i o n s w i t h you? 1. 2.  Was a f a m i l y member a b l e to be p r e s e n t t o r e c e i v e i n s t r u c t i o n s about home eye care?  4.  Helpful Not h e l p f u l Would have been helpful Not n e c e s s a r y  When p a t i e n t s l e a v e h o s p i t a l , they are u s u a l l y i n s t r u c t e d t o phone t h e i r d o c t o r i f they have undue d i s c o m f o r t or n o t i c e a change i n the c o n d i t i o n of t h e i r eye. What s p e c i f i c s i g n s would you t h i n k r e q u i r e d a c a l l t o your eye doctor? F r e e response. Then ask: Do you t h i n k you would c a l l your eye d o c t o r i f you n o t i c e d :  Yes No  Free Probe 112. 113. 114.  1. Severe p a i n i n the eye 2. I n c r e a s e d redness 3. Discharge from eye  116  129.  4. Severe headache 5. Onset of nausea or vomiting 6. Change i n vision 7. Other (specify)  115. 116.  117. 118.  1. 2. 130.  Is t h e r e anyone e l s e you would c a l l i f you needed some h e l p or i n f o r m a t i o n r e g a r d i n g your eye or i t s treatments? 119. ~120. "121. "122. ~123. 124.  -  Family doctor P u b l i c h e a l t h nurse H o s p i t a l nurse Neighbour Other  2.  Yes - e l i c i t reason) No  (who  132.  Lids  and  My next q u e s t i o n i s r e l a t e d t o support people t h a t are a v a i l a b l e to you.  125. 126. "127.  - F a m i l y members - Neighbours, good f r i e n d s - Other  128.  Has an appointment been made f o r you to see your eye d o c t o r f o r a check up? Yes No - What are your p l a n s about making an appointment?  134.  1.  Normal  2.  Abnormal ( d e s c r i b e )  Cornea Clear, lustrous Steamy, hazy  A n t e r i o r chamber 1. 2.  136.  No i n j e c t i o n Slight injection Moderate i n j e c t i o n Marked i n j e c t i o n  Incision  1. 2. 135.  Normal Swollen Ecchymosis  Conjunctiva 1. 2. 3. 4.  133.  1. 2.  Do you have any q u e s t i o n s t h a t you would l i k e t o ask . . . a n y t h i n g you have been wondering?  1. 2. 3.  Who do you have t h a t you can c a l l on i f you need t o have an e r r a n d done or want someone t o t a l k to?  Yes - e l a b o r a t e No  EYE STATUS OBSERVATIONS 131.  Have you c a l l e d your eye d o c t o r or any of these o t h e r people s i n c e you got home from h o s p i t a l ? 1.  Is t h e r e any problem associated with transportation?  Normal, formed Shallow, f l a t  Pupil 1. 2. 3. 4.  Round Irregular Keyhole Other  117  137.  Pupil 1. 2. 3.  138.  Absent Watery Mucus Purulent Other  APPLICATION OF EYE SHIELD 152. 153. 154.  Crusting 1. 2.  140.  Dilated Constricted Other  Discharge 1. 2. 3. 4. 5.  139.  Comments:  Absent Present  Comments:  Subject's r e p o r t of c r u s t i n g i n a.m. 1. 2.  Absent Present  OBSERVATION OF INSTILLATION OF EYEDROPS Code: 141. 142. 143.  144. 145. 146. 147.  148. 149. 150. 151.  1 = Yes  2 =  No  Washed hands b e f o r e procedure Assumed a s a f e p o s i t i o n R e c l i n e d head t o f a c i l i t a t e eyedrop administration A g i t a t e d medicine b o t t l e i f necessary Instilled correct medication I n s t i l l e d c o r r e c t amount Drop went i n t o eye on f i r s t attempt ( d e s c r i b e attempts i f more than one) M a i n t a i n e d c l e a n l i n e s s of b o t t l e of eyedrops Touched l i d s or l a s h e s Touched globe Washed hands upon c o m p l e t i o n of procedure  Applies s h i e l d securely Applies s h i e l d confidently Edges of s h i e l d r e s t on bone of o r b i t on a l l edges  118 SECOND HOME VISIT INTERVIEW GUIDE  General  I n t r o d u c t o r y Remarks  R e i t e r a t e tape r e c o r d i n g p o l i c i e s .  155.  How have you been g e t t i n g along since I l a s t v i s i t e d you?  156.  Has t h e r e been a n y t h i n g about your eye o r i t s treatments t h a t has w o r r i e d you, or t h a t you have wondered about?  157.  Have you n o t i c e d any d i f f e r e n c e i n your a b i l i t y to manage d a i l y r o u t i n e activities?  Today I have some q u e s t i o n s t h a t a r e s i m i l a r t o those I asked on my l a s t v i s i t , and some new ones t h a t a r e r e l a t e d t o the changes, i f any, you have made i n your d a i l y r o u t i n e s i n c e you had t h e s u r g e r y . 158.  159.  S i n c e I was here l a s t , how many v i s i t s have you made to your eye d o c t o r ' s office?  161.  1. 2. 3.  162.  160.  Have t h e r e been any changes made i n your t r e a t m e n t s , or any new instructions related to activity? 1. 2.  Yes - e l a b o r a t e No  Frequency 1. 2.  163.  164.  Occasionally Frequently  Duration 1. 2. 3.  Few minutes S e v e r a l hours A l l day  Severity 1. 2. 3.  165. Yes - e l a b o r a t e No  More c o m f o r t a b l e About the same Less c o m f o r t a b l e  If l e s s c o m f o r t a b l e , e l i c i t frequency, s e v e r i t y , d u r a t i o n and d e s c r i p t i o n of d i s c o m f o r t .  Did you encounter any d i f f i c u l t i e s related to k e e p i n g your appointment? 1. 2.  Compared w i t h my l a s t v i s i t , do you f e e l your eye i s :  Mild Moderate Severe  Description 1. 2. 3. 4. 5. 6.  Itchy Sandy, s c r a t c h y Smarting Aching Throbbing Sharp p a i n  E l i c i t comfort measures, success of comfort measures.  119  S i n c e my l a s t v i s i t have you had any: Code frequency 1 = Not a t a l l 2 = Occasionally 3 = Most of the time 166. "167. ~168. "169. "170. "171. "172.  Nausea Vomiting Coughing Sneezing Headache Sore t h r o a t Other d i s c o m f o r t s (specify)  175.  1. 2.  Since my l a s t v i s i t , i n a d d i t i o n t o the s c h e d u l e d v i s i t ( s ) t o your eye d o c t o r , have you c o n s u l t e d anyone or phoned anyone because you had a q u e s t i o n or a concern about your eye or i t s treatment? 1. 2.  176.  174.  How have you been managing w i t h the eye drops? Free response, then ask: Compared w i t h my l a s t v i s i t , do you f e e l : 1. 2. 3.  More c o n f i d e n t About the same Less c o n f i d e n t  How w e l l have you been a b l e t o have the drops put i n the p r e s c r i b e d number of times each day? Would you say: 1.  cue  2. 3.  177.  Yes No  If affirmative, describe concern, e l i c i t who was called.  Yes - e l a b o r a t e No  Probe f o r a s s o c i a t i o n w i t h meal times, o t h e r medication times.  If affirmative, e l i c i t severity, duration f r e q u e n c y , comfort measures and success of comfort measures. 173.  Do you have any s p e c i a l methods t h a t you use to h e l p you remember when each of the m e d i c a t i o n s i s due?  Always r e c e i v e d medications according to i n s t r u c t i o n s Sometimes missed a does O f t e n missed a dose  How have you managed w i t h the metal eye s h i e l d ? F r e e response, then ask: Does i t s t a y on a l l n i g h t ? 1. 2.  Yes No  _178.  How w e l l have you managed to a v o i d bending, l i f t i n g or s t r a i n i n g ?  _179.  D i d these r e s t r i c t i o n s present any d i f f i c u l t y to you i n the management of daily routine a c t i v i t i e s ? 1. 2.  Yes No  120  A c t i v i t i e s of D a i l y L i v i n g I am i n t e r e s t e d I n knowing what changes, i f any, you have made i n your r o u t i n e household and p e r s o n a l care a c t i v i t i e s s i n c e the surgery. 180.  Have you made any changes i n l i v i n g arrangements as a r e s u l t of the surgery? 1. 2.  181.  182.  189  194.  Were any of these d a i l y routine a c t i v i t i e s d i f f i c u l t f o r you t o do? Were they more d i f f i c u l t to do than they were b e f o r e your surgery?  195.  Have you developed any s p e c i a l methods f o r managing t h i n g s a t home t h a t might be u s e f u l f o r someone e l s e t o know about, and t h a t you would share?  196.  Can you t h i n k of any o t h e r k i n d o f h e l p o t h e r than what you had t h a t would have been u s e f u l t o you?  Yes No  Yes - e l a b o r a t e No  Have you made any changes i n your general routine i n regard t o :  183. 184. 185. 186. 187. 188.  Bathing Dressing H a i r shampoo Other  Have you made any changes i n the frequency o r type of a s s i s t a n c e you r e c e i v e ? 1. 2.  Code:  190. 191. 192. 193.  Yes No  Do you have r e g u l a r or p e r i o d i c household o r gardening help? 1. 2.  In r e l a t i o n t o p e r s o n a l c a r e a c t i v i t i e s , have you made any changes r e l a t e d t o :  1.  Yes - e l a b o r a t e  2.  No  Shopping Food p r e p a r a t i o n Housecleaning Laundry Transportation Use of the telephone ( a s k about any s p e c i a l a i d s t o f a c i l i t a t e telephone use i e . magnifying l e n s , l a r g e p r i n t attachment, o p e r a t o r assistance) Other home maintenance o r household management tasks  Nutrition 197.  Has there been any change i n your e a t i n g p a t t e r n since the operation? 1. 2.  Yes No  I f a f f i r m a t i v e , e l i c i t how i t has changed and i f anything i n p a r t i c u l a r prevented s u b j e c t from e a t i n g normal d i e t .  121  Elimination 198.  Have you had any d i f f i c u l t y with c o n s t i p a t i o n s i n c e you came home from h o s p i t a l ? 1. 2.  My l a s t group of q u e s t i o n s a r e r e l a t e d t o your u n d e r s t a n d i n g of re the c a t a r a c t s u r g e r y , and your f e e l i n g s about t h e whole experience. 208.  What i s your u n d e r s t a n d i n g of what a c a t a r a c t i s ?  209.  What i s your u n d e r s t a n d i n g of the o p e r a t i o n t h a t was done?  Yes No  I f a f f i r m a t i v e , e l i c i t any a c t i o n taken: 199. "200. 201. "202.  I f not f r e e l y o f f e r e d , ask: D i d you expect t h a t you would not be a b l e t o see out of the operated eye f o r s e v e r a l weeks? E l i c i t expectations r e g a r d i n g type of o p t i c a l c o r r e c t i o n and v i s u a l improvement. Elicit f e e l i n g s about w a i t i n g f o r optical correction.  Laxative D i e t a r y measure Other No a c t i o n  E x e r c i s e and r e l a x a t i o n 203.  T e l l me how you have spent your time d u r i n g a t y p i c a l day s i n c e your surgery?  204.  How does t h i s way of spending time compare w i t h a t y p i c a l day b e f o r e your surgery? 1. 2.  _210.  Same Different - elaborate: e l i c i t energy l e v e l , vision, activity r e s t r i c t i o n s as possible factors.  205.  Are t h e r e a c t i v i t i e s you would l i k e t o do t h a t you a r e unable t o do j u s t now?  206.  Do you a n t i c i p a t e t h a t you w i l l be a b l e t o do these t h i n g s l a t e r on?  207.  When you r e t u r n e d home from h o s p i t a l , how c o n f i d e n t d i d you f e e l about managing your p e r s o n a l c a r e , and household a c t i v i t i e s ?  1. 2.  211.  1. 2.  Confident Insecure - e l a b o r a t e  Was the amount of knowledge you had regarding the s u r g i c a l procedure, t h e w a i t i n g time a f t e r s u r g e r y f o r the eye t o h e a l , and t h e c h o i c e s you might have f o r visual correction:  _212.  S u f f i c i e n t to s a t i s f y you Not s u f f i c i e n t elaborate  Is t h e r e any i n f o r m a t i o n t h a t you would l i k e t o have had t h a t was not provided? How does t h i s eye s u r g i c a l e x p e r i e n c e compare w i t h previous h o s p i t a l admissions, or s u r g e r y you have had?  122  213.  214.  Some people say t h a t any surgery creates anxiety, but t h a t eye s u r g e r y i s particularly stressful. What i s your o p i n i o n r e g a r d i n g t h i s statement? Can you t h i n k of any f a c t o r s that i n f l u e n c e d your f e e l i n g s .  215.  Have you a r e l a t i v e or f r i e n d who has had c a t a r a c t surgery? Was t h e i r experience:  cue  1. 2.  216.  You were i n h o s p i t a l days a f t e r your s u r g e r y . What i s your o p i n i o n r e g a r d i n g the l e n g t h of your h o s p i t a l stay?  EYE 218.  217.  1. 2. 3.  219.  Can you t h i n k of a n y t h i n g more t h a t c o u l d have been done t o b e t t e r p r e p a r e you f o r the f i r s t few weeks at home f o l l o w i n g h o s p i t a l discharge?  Complete p r o f i l e sheet items t h a t have not been f i l l e d i n , i e . e d u c a t i o n l e v e l , e t h n i c background, o c c u p a t i o n , smoking s t a t u s . Terminate v i s i t w i t h e x a m i n a t i o n of o p e r a t e d eye, and o b s e r v a t i o n of eyedrop i n s t i l l a t i o n .  (describe)  Clear, lustrous Steamy, hazy  A n t e r i o r chamber 1. 2.  223.  Normal Abnormal  Cornea 1. 2.  222.  No i n j e c t i o n Slight injection Moderate i n j e c t i o n Marked i n j e c t i o n  Incision 1. 2.  221.  Normal Swollen Ecchymosis  Conjunctiva 1. 2. 3. 4.  Helpful Not h e l p f u l  Not l o n g enough About r i g h t Too l o n g  Lids 1. 2. 3.  220.  cue  STATUS OBSERVATIONS  Normal, formed Shallow, f l a t  Pupil 1. 2. 3. 4.  Round Irregular Keyhole Other  1. 2. 3.  Dilated Constricted Other  224.  225.  Discharge 1. 2. 3. 4. 5.  Absent Watery Mucus Purulent Other  226.  Crusting 1. 2.  227.  Absent Present  S u b j e c t ' s r e p o r t of c r u s t i n g i n a.m. 1. 2.  Absent Present  OBSERVATION OF INSTILLATION OF EYEDROPS Code: _228. _229. _230.  _231. _232. 233. _234.  _235. _236. _237. 238.  1 = Yes  2 = No  Washed hands b e f o r e procedure Assumed a s a f e p o s i t i o n R e c l i n e d head t o f a c i l i t a t e eyedrop administration A g i t a t e d medicine b o t t l e i f necessary I n s t i l l e d correct medication I n s t i l l e d c o r r e c t amount Drop went i n t o eye on f i r s t attempt ( d e s c r i b e attempts i f more than one) M a i n t a i n e d c l e a n l i n e s s of b o t t l e of eyedrops Touched l i d s or l a s h e s Touched globe Washed hands upon c o m p l e t i o n of procedure  Comments:  APPENDIX E  DISCHARGE I N S T R U C T I O N  HAND-OUT  125 INSTRUCTIONS FOR EYE PATIENTS ON DISCHARGE FROM HOSPITAL  1.  Make an appointment t o see your d o c t o r i n The phone number i s and the address i s  time.  2.  B e f o r e c a r r y i n g out any treatment t o your eye, wash hands t h o r o u g h l y and a g a i n upon c o m p l e t i o n .  3.  Have your p r e s c r i p t i o n s f i l l e d a t your d r u g s t o r e and you may have the p r e s c r i p t i o n r e f i l l e d by your p h a r m a c i s t s h o u l d t h i s be n e c e s s a r y . C a r e f u l l y f o l l o w the d i r e c t i o n s on the b o t t l e .  4.  Bathe your eyes w i t h warm tap water as n e c e s s a r y , u s i n g s t e r i l e b a l l s which may be purchased a t the d r u g s t o r e .  5.  I f your eye i s u n c o m f o r t a b l e you may f a v o r i t e headache remedy.  6.  Your eye may remain r e d f o r a month or so as p a r t of the normal h e a l i n g p r o c e s s . Moderate mucous d i s c h a r g e i s to be expected and your l i d s may be s w o l l e n . I f you have undue d i s c o m f o r t or n o t i c e a change of the c o n d i t i o n of your eye p l e a s e c a l l your d o c t o r ' s o f f i c e at once.  7.  Wear dark g l a s s e s d u r i n g the day e s p e c i a l l y when out of doors or i n any glare. At bedtime a p p l y the eye s h i e l d over your o p e r a t e d eye u s i n g s c o t c h tape t o h o l d i t i n p l a c e .  8.  Be v e r y c a r e f u l t o a v o i d j a r r i n g your head or bumping your eye. You must not bend, l i f t or s t r a i n . You may d r e s s y o u r s e l f , be up and about the house, walk o u t s i d e , watch t e l e v i s i o n and p r e p a r e l i g h t meals. You must not read, do housework, g a r d e n i n g or r e t u r n t o work u n t i l d i r e c t e d by your d o c t o r .  9.  You may brush your t e e t h , t a k e a tub b a t h , or shower. Men may shave. You may have y o u r h a i r washed and s e t . A v o i d s h a k i n g your head d u r i n g these a c t i v i t i e s  cotton  take one or two a s p i r i n s or your  10. Do not resume s p o r t s or strenuous a c t i v i t i e s u n t i l d i r e c t e d by your d o c t o r .  Special  Instructions:  APPENDIX F  RESULTS OF E Y E  STATUS OBSERVATIONS  127 TABLE 12 RESULTS OF EYE STATUS  Feature  Frequency Visit Visit 1 2  Lids :  OBSERVATIONS  A n t e r i o r Chamber: 20  20  0  0  Absent  11  15  12  18  Swollen  5  2  Shallow,  Ecchymosis  3  0  Discharge:  Normal  Normal, formed  Conjuctiva: No  Frequency Visit Visit 2 1  Feature  injection  Slight  injection  Moderate Marked  injection  injection  3  5  Watery  3  3  6  8  Mucus  6  2  8  5  Purulent  0  0  3*  2*  2  2  18  18  6  7  20  20  0  0  Crusting: Present  Cornea: 18  20  2  0  13  13  Round, s m a l l * * *  3  3  Ovoid,  1  1  Clear, lustrous Steamy, hazy  Absent Subject's r e p o r t of crusting i n a.m.  Pupil: Round,  flat  dilated**  Incision: Normal dilated**  Abnormal I r r e g u l a r , mod. dilated**  1  1  Keyhole,  2  2  dilated**  *  S u b j e c t s had s u b c o n j u n c t i v a l inje; c t i o n of a n t i b i o t i c (Garamycin) during surgery  **  A t r o p i n e drops  ***  Phospholine  ordered  I o d i d e o r T i m o l o l drops  ordered  APPENDIX G  RESULTS OF ANALYSIS FOR ASSOCIATION AMONG SELECTED VARIABLES USING FISHER EXACT TEST  METHOD OF DICHOTOMIZING  Age:  CONTINUOUS VARIABLES FOR FISHER EXACT TEST  1 = 71 y e a r s or l e s s ;  Length o f Stay:  1=4  2 = more than 71 y e a r s  days or l e s s ;  V i s u a l A c u i t y , Unoperated  Eye:  2 = more than 4 days  1 = 20/100 or b e t t e r ; 2 = 20/200 o r l e s s  L i v i n g Arrangements:  1 = with able r e l a t i v e ;  2 = alone  Education Level: Socio-economic  1 = 12 y e a r s s c h o o l o r l e s s ; 2 = more than 12 y e a r s Status: 1 = Rank l e s s than 250; 2 = Rank 250 o r g r e a t e r ( B l i s h e n & McRoberts, 1976)  Manual D e x t e r i t y :  1 = no impairment;  Understanding of C a t a r a c t Surgery:  2 = impaired  1 = knew l e n s became opaque, s u r g e r y was i n t r a o c u l a r 2 = thought c a t a r a c t was e x t e r n a l growth  130 TABLE 13 Two-tailed  Significance Levels  of F i s h e r Exact  Tests - o f 1  A s s o c i a t i o n Among S e l e c t e d E y e C a r e and D e m o g r a p h i c V a r i a b l e s  A G  S  E  E  E  X  D U C A T I 0 N A L L  E  S 0 C 1 0  S T A T S  M P A E N R U S A O S L N  E C 0 N 0 M I C  V  E  D  E X T  E R I T Y  L  I N S T I L L I N G  D R 0 P  U N D  E R S T A N D I N G 0 F  C A T A R A C T  .08  E V I 0 U S  S U R G  E  E  R 1  R Y  0 F Change i n l i v i n g arrangements  P R  X P  E E  W I T  H E Y  E  P R  E V I 0 U S  S U R G  E  E  R I  R Y  X P  E  w I T H  0 T H  E R  P R 0 B L  E  E Y  M  E  E  D R 0 P S  D I C A L  M S  V I S  u A L A C U I T Y  E  N C  N C  E  E  .09  Length of stay^ 1.0  .58  Phone c a l l s t o ophthalmologist  .05  .61  Understanding of cataract surgery  .30  1.0 .27  .61  Knowledge o f waiting period  1.0 .28  .53  1.0  Difficulty getting drop i n t o eye  .64  Manual dexterity  .17  .54  Difficulty squeezing b o t t l e  1.0  1.0  D i f f i c u l t y with b o t t l e opening  .  .28  Contamination of eyedrop b o t t l e  .62  Concern about touching eye w i t h d r o p p e r  1.0  .64  Difficulty reading labels  1.0  Feelings of confidence  1.0  1.0  1.0  1  The U n i v e r s i t y o f B r i t i s h C o l u m b i a S t a t i s t i c a l P a c k a g e f o r t h e S o c i a l S c i e n c e s , V e r s i o n 8, "CROSSTABS," ( K i t a , 1980) was u s e d t o p e r f o r m t h i s t e s t . Selected s i g n i f i c a n c e : cC 2 = .05.  2  The method u s e d t o d i c h o t o m i z e  continuous  variables i s provided  on t h e f a c i n g p a g e .  APPENDIX H  PATIENT  SUGGESTIONS THAT  COMPLIANCE W I T H  FACILITATE  RECOMMENDATIONS  132 PATIENT SUGGESTIONS THAT FACILITATE COMPLIANCE WITH RECOMMENDATIONS  Dressing: 1.  Bend knees o r use s a l a d tongs t o p i c k up o b j e c t s from the f l o o r .  2.  S e l e c t c l o t h i n g t h a t buttons down t h e f r o n t and does not need t o be p u l l e d on over the head.  3.  Hang up c l o t h e s immediately so they w i l l not end up on the f l o o r .  4.  L i f t f e e t t o put on shoes and s t o c k i n g s .  5.  Use l o n g shoe horn t o a s s i s t w i t h p u t t i n g on shoes.  6.  Use shoes without  7.  S t o r e shoes on c h a i r s , c h e s t s , or c l o s e t shoe bags so they w i l l be h i g h enough t o prevent the need t o bend.  laces.  Bathing: 8.  Turn one's back t o the shower s p r a y .  9.  Wear metal eye s h i e l d when t a k i n g a shower.  10.  Use sponge baths f o r the f i r s t w h i l e as a p r e c a u t i o n a g a i n s t f a l l i n g i n the tub.  Meal P r e p a r a t i o n : 11.  Keep k i t c h e n u t e n s i l s and f r e q u e n t l y used pots and pans a t counter level.  12.  Ask f a m i l y members t o put o b j e c t s back i n t h e i r u s u a l p l a c e s so they may be l o c a t e d e a s i l y and thereby permit p a t i e n t to be more independent.  Garden: 13.  S i t on a p i e c e of c a r p e t or mat t o " p u l l a few weeds."  133  Dark G l a s s e s ; 14.  Eye  Cut o f f s i d e of p l a s t i c c l i p - o n g l a s s e s to p r o v i d e r e l i e f from photophobia f o r the o p e r a t e d eye, but enough l i g h t f o r the o t h e r .  Shield:  15.  Bend edges of metal eye s h i e l d t o f i t i n d i v i d u a l configuration.  16.  P l a c e a p i e c e of tape on the s h i e l d f i r s t face.  17.  Have p a t i e n t h o l d the s h i e l d i n p l a c e w h i l e a f a m i l y member a p p l i e s the t a p e .  Eyedrops 18.  facial  and then a p p l y i t to the  - Family Member A d m i n i s t r a t i o n :  Have p a t i e n t h o l d down the lower l i d w h i l e f a m i l y member the drop.  instills  Eyedrops - S e l f - A d m i n i s t r a t i o n : 19.  P l a c e k n u c k l e of thumb on b r i d g e of nose and h o l d eye dropper between thumb and f o r e f i n g e r , t o e s t i m a t e c o r r e c t p o s i t i o n , of dropper.  20.  P l a c e thumb k n u c k l e on middle of eyebrow t o e s t i m a t e c o r r e c t p o s i t i o n of dropper.  21.  Use non-dominant f o r e f i n g e r t o p u l l down lower l i d , and use extended middle f i n g e r of t h i s hand to judge d i s t a n c e the dropper i s from the eye.  22.  L i e on bed w i t h a s m a l l p i l l o w or r o l l e d towel beneath the neck to hyperextend head and f a c i l i t a t e a n g l e f o r drop i n s t i l l a t i o n .  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0095286/manifest

Comment

Related Items