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.

Notice for Google Chrome users:
If you are having trouble viewing or searching the PDF with Google Chrome, please download it here instead.

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.Sc, The University of 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 i n THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept t h i s thesis as conforming to the required standards THE UNIVERSITY OF BRITISH COLUMBIA March 1982 © Shelagh Jacqueline Smith, 1982 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y of B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e head of my d e p a r t m e n t or by h i s or h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . S h e l a g h J . Smith Department The U n i v e r s i t y of B r i t i s h C o l u m b i a 2075 Wesbrook P l a c e V a n c o u v e r , Canada V6T 1W5 Date 7* i i ABSTRACT The purpose of t h i s d e s c r i p t i v e exploratory study was to describe s p e c i f i c s e l f - c a r e behaviours re l a t e d to the pr o v i s i o n of eye care and performance of d a i l y l i v i n g a c t i v i t i e s , of p o s t s u r g i c a l cataract patients during t h e i r f i r s t few weeks at home following cataract e x t r a c t i o n . The twenty subjects who comprised the study sample were a l l over s i x t y years of age, were English speaking, had a best corrected v i s u a l acuity i n the unoperated eye of 20/50 or l e s s , and had undergone uncomplicated u n i l a t -e r a l standard cataract surgery without lens implant. Subjects were interviewed i n t h e i r homes on two occasions. D i f f i -c u l t i e s that were experienced and concerns that were expressed by sub-jects and family members i n the performance of eye care procedures, and management of d a i l y l i v i n g routines were recorded; and factors which i n -fluenced the a b i l i t y of subjects to manage t h e i r care at home were iden-t i f i e d . Observations 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 protective eye s h i e l d , and the status of the operated eye. The findings suggest a high degree of adherence to the prescribed medication regime, and to the precautionary measures that were to be f o l -lowed. D i f f i c u l t i e s were reported or observed i n several areas such as administering eyedrops, applying the eye s h i e l d , reading i n s t r u c t i o n s , opening eyedrop containers, and obtaining pr e s c r i p t i o n s or supplies. The majority of concerns expressed were rel a t e d to the performance of eye care procedures, and to the prospective v i s u a l outcome of the surgery. i i i Examples of factors i d e n t i f i e d as a f f e c t i n g home s e l f - c a r e were: the a-v a i l a b i l i t y of d i r e c t assistance and emotional support from family and community resources; the understanding of the s u r g i c a l procedure and r e -covery process; the knowledge, and the timing of the receipt of know-ledge, of expected behaviours; and the possession of adequate manual s k i l l s to perform the eye care procedures with competence and confidence. Implications for nursing, medical, and pharmacist's practice are discussed, and areas for further research are i d e n t i f i e d . i v TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES v i i LIST OF FIGURES v i i i ACKNOWLEDGEMENTS i x CHAPTER I 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 of Terms 6 Limitations 8 Assumptions 8 II REVIEW OF THE LITERATURE 9 Theoretical and Organizational Framework 9 Medical Practice Related to Patients with Cataracts 11 Nursing Practice Related to Patients with Cataracts 15 Personal and Environmental Factors that Influence Self-Care 18 Cataract Studies 27 II I METHODOLOGY 29 Selection 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 Analysis 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 Care A c t i v i t i e s 40 Administration of Medications as Prescribed 40 Protection of Eye from Injury 50 Maintenance of Cleanliness of the Eye 54 Provision of Comfort Measures when Necessary 55 Recognition and Reporting of S i g n i f i c a n t Indicators of Complication 56 Status of the Operated Eye 57 Continued Medical Supervision 57 General Concerns Related to the Eye 58 Daily L i v i n g A c t i v i t i e s 59 Li v i n g Arrangements 60 U t i l i z a t i o n of Community Services . . . . 61 Home Maintenance A c t i v i t i e s . 62 Self-Maintenance A c t i v i t i e s 62 Leisure A c t i v i t i e s and Exercise 63 Personal and Environmental Factors that Influence Behaviours, D i f f i c u l t i e s and Concerns 64 Requisite Knowledge and S k i l l s f o r Home Eye Care 65 Understanding of Cataracts and Cataract Surgery 67 Support Systems 69 Length of Hospital Stay 70 Demographic Factors 70 v i Discussion 71 The Sample 71 Adherence 72 Performance of Requisite S k i l l s f o r Home Eye Care 75 Safety 78 Knowledge and Understanding of Cataracts/ Cataract Surgery 79 Demographic Variables 80 V SUMMARY, CONCLUSION, IMPLICATIONS AND RECOMMENDATIONS 81 Summary 81 Conclusions 84 Implications 85 Recommendations f or Further Research 91 BIBLIOGRAPHY 92 APPENDICES A. Information f o r Prospective Subjects 100 B. Subject Consent Form 103 C. Letter of Agreement f or Eyedrop Administration 106 D. Interview Guide 108 E. Discharge Instruction Handout 124 F. Results of Eye Status Observations 126 G. Results of Analysis f o r Association Among Selected Variables Using Fisher Exact Test . . . . 128 H. Patient Suggestions kthat F a c i l i t a t e Compliance with Recommendations 131 v i i LIST OF TABLES 1. Examples of Expected Eye Care Behaviours: Adherence, Comprehension, D i f f i c u l t i e s , Concerns, Questions 41 2. Delegation of R e s p o n s i b i l i t y for Eyedrop I n s t i l l a t i o n , F i r s t and Second V i s i t . . . . 43 3. Summary of Reported D i f f i c u l t i e s , by Type, Frequency, and Person 49 4. Eye Shield D i f f i c u l t i e s by Type and Frequency 51 5. Discomforts by Frequency, Severity and Comfort Measures 55 6. Indicators of Possible Complications and Subject's Perception of Need to Report 57 7. Methods of Transport to Medical Appointments by Type and Frequency 58 8. Liv i n g Arrangements Postsurgery by Change and Sex 60 9. U t i l i z a t i o n of Community Services Pre and Postsurgery 61 10. Eyedrop I n s t i l l a t i o n : Demonstration by Previous Experience 66 11. Subject's Comprehension of Cataracts and Cataract Surgery 68 12. Results of Eye Status Observations 127 13. Two-tailed Significance Levels of Fisher Exact Tests of Association Among Selected Eye Care and Demographic Variables 130 LIST OF FIGURES v i i i 1. An In t e r a c t i o n a l Model of Health Care 11 2. Age and Sex D i s t r i b u t i o n s of Subjects 37 3. Selected Health Related C h a r a c t e r i s t i c s of Subjects 39 4. Observations of Home Administration of Prescribed Eyedrops 45 5. Patient Adherence to Eye Cleansing Instructions 54 i x ACKNOWLEDGEMENT S There are a number of people who contributed to the execution of th i s research project whose assistance I wish to acknowledge. I wish es-p e c i a l l y to thank the members of my thesis committee, Sheila Stanton, Ann Hi l t o n and Stephen Drance f o r t h e i r support, guidance and constructive c r i t i c i s m . Appreciation i s also extended to Mark Starr f o r h i s help with coding techniques and computer use. I am g r a t e f u l f o r the assistance and i n t e r e s t of the ophthalmic nurses and ophthalmologists who c r i t i q u e d the interview guide. P a r t i c u -l a r appreciation i s conveyed to the ophthalmologists who helped obtain the p a r t i c i p a n t s f o r the study, and whose i n t e r e s t and enthusiasm were a source of encouragement. I am also indebted to the study p a r t i c i p a n t s themselves, who generously 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 to my family for t h e i r co-operation, and f o r having confidence i n my a b i l i t y to succeed i n academic endeav-ours. A very s p e c i a l recognition i s saved f o r my husband E r i c , who a l -ways had time to l i s t e n . 1 CHAPTER ONE INTRODUCTION . Cataract surgery for the removal of an opaque lens i n the eye i s documented as early as 1000 B.C. i n Sanskrit writings (Shock, 1978). At the present time between 400,000 and 500,000 cataract extractions are performed each year i n the United States ( J a f f e , 1978; Shock, 1978), and about ten percent of that number are performed i n Canada (Kwitko, 1978). A cataract i s defined as "a loss of transparency of the c r y s t a l l i n e lens of the eye, or of i t s capsule" (Stedman, 1972, p. 214). The precise mechanism of cataract formation i s not w e l l understood, but cataracts develop when the lens p r o t e i n undergoes a change i n molecular structure that r e s u l t s i n gradual development of opacity. Radiation, t o x i c chemi-c a l s , trauma, genetic f a c t o r s , and some systemic diseases are associated with cataract formation, but the most common form of cataract, s e n i l e cataract, appears to occur as a natural part of the aging process (Kwitko, 1978; Gardener, 1979). It i s reported that by 80 years of age, approximately 85 percent of a l l people have some degree of clouding of the lens. Cataracts are recognized as the most common cause of blindness i n older persons (Shafer, Sawyer, McCluskey, Beck, & Phipps, 1975). Senile cataracts c h a r a c t e r i s t i c a l l y e f f e c t both eyes, but the rate of cataract development i s unpredictable, and often the cataract i n one eye i s considerably worse than the other. In a recent study, C o t l i e r (1981) reports that a c e t y l s a l i c y l i c a c i d retards the development of cataracts. However, once the lens i s opaque, s u r g i c a l removal i s the only treatment. 2 Teaching patients and family members the knowledge and s k i l l s that w i l l enable them to manage t h e i r own care at home following cataract surgery, and arranging f o r assistance from community services to f a c i l i -tate home s e l f - c a r e , i s an important component of nursing p r a c t i c e . Two trends evident i n the recent 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 caring f o r patients undergoing cataract surgery; f i r s t l y , the numbers of cataract extractions performed on persons over 65 years of age i s i n -creasing (Nadler & Schwartz, 1980), and secondly, the length of h o s p i t a l stay i s decreasing (Galin, Baras., Barasch, & Boniuk, 1974; Kidger, 1977; Williamson, 1978). In the United States, during the years 1968 to 1976; the number of intracapsular cataract extractions f o r i n d i v i d u a l s over 65 years of age increased at a rate of 4.9 percent per year. This fi g u r e was age con-t r o l l e d so that i t r e f l e c t s an excess over the rate of age s h i f t i n the population during the same period (Nadler & Schwartz, 1980). Canadian s t a t i s t i c s i n d i c a t e a s i m i l a r trend ( S t a t i s t i c s Canada, 1969, 1977). Improved technology that enables more e l d e r l y persons to to l e r a t e sur-gery, and an increased demand on the part of the e l d e r l y f o r fun c t i o n a l v i s i o n , are suggested as factors i n f l u e n c i n g the increase i n rate of intracapsular cataract extractions (Nadler & Schwartz, 1980). Available data i n d i c a t e that 70 percent of cataract procedures i n -volve persons over 65 years of age ( S t a t i s t i c s Canada, 1977; Nadler & Schwartz, 1980). This p a r t i c u l a r population has, during the past decade, increased by 23 percent while the under 65 age group increased by only 6.3 percent. Within t h i s e l d e r l y group, 38 percent are over 75 years of age, and the 85-and-over-group are assuming increasing proportions (Brody, 1980). 3 This population s h i f t , concomitant with the increased incidence of cataract extractions among the e l d e r l y , s i g n i f i e s an increase i n numbers of e l d e r l y people that w i l l need care. Many of these e l d e r l y people l i v e alone or with an equally e l d e r l y spouse (Brody, 1980), and many are de-veloping p h y s i c a l handicaps that make s e l f - c a r e d i f f i c u l t . Performance of the necessary eye care procedures and routine l i v i n g a c t i v i t i e s at home following h o s p i t a l discharge may present problems. The second trend, that of reduced h o s p i t a l stay, i s a subject of current i n t e r e s t . Nadler and Schwartz (1980) report a decrease i n aver-age length f o r h o s p i t a l stay of intracapsular cataract e x t r a c t i o n from 7.6 days i n 1968 to 4.8 days i n 1976. In a s i m i l a r time period, the average h o s p i t a l stay i n Canada f o r intracapsular e x t r a c t i o n changed from 12.3 days to 7.9 days ( S t a t i s t i c s Canada, 1969, 1976). This trend i s also reported i n the United Kingdom (Ingram, Banerjee, Traynar, & Thompson, 1980; Kidger, 1977). Improvements i n s u r g i c a l techniques, development of f i n e r i n s t r u -ments and sutures, and the use of an operating microscope have reduced both the intraoperative and postoperative r i s k of complication so that stringent r e s t r i c t i o n s of a c t i v i t y are no longer considered necessary (Boyd-Monk, 1977). These f a c t o r s , plus the obvious economic benefits i n -curred with reduced h o s p i t a l stay, have influenced medical p r a c t i c e . Several authors report p r a c t i c e s wherein patients undergo cataract sur-gery on an outpatient ambulatory basis (Williamson, 1978; Vukcevich, 1979; Low, 1978), or are admitted as day cases and are discharged a few hours following surgery ( G a l i n et a l . , 1974; Ingram et a l . , 1980). These authors claim that there i s no s i g n i f i c a n t difference i n the rate of 4 complications or i n the v i s u a l outcome rel a t e d to the decreased h o s p i t a l stay. However, these c r i t e r i a do not consider "the extra e f f o r t made by r e l a t i v e s and friends of the patients i n caring for them i n the immediate postoperative phase" (Strachan & Bowell, 1972, p. 629), nor the f a c t that the decreased h o s p i t a l stay w i l l give nurses less time to provide the teaching and discharge planning aspects of nursing care. Postsurgical cataract patients are expected to perform eye care pro-cedures and follow a prescribed medical regimen at home, the d e t a i l s of which are presented i n the following chapter. According to Davies (1976), e f f e c t i v e teaching of patients and family members should include not only the necessary knowledge and s k i l l s , but the teaching must be based on an understanding of the patient's environment and what i s impor-tant to him. An understanding of the experiences that p o s t s u r g i c a l pa-t i e n t s have at home following h o s p i t a l discharge i s therefore important for nurses, so that they can make t h e i r teaching relevant and approp-r i a t e . Discharge planning i s contingent on matching a v a i l a b l e resources with patient needs. In B r i t i s h Columbia there i s a government financed Home Care Programme which provides, among other services, nursing v i s i t s , homemaker v i s i t s , meals on wheels, and transportation (McClelland, 1976). This service i s a v a i l a b l e to 80% of the residents of B r i t i s h Columbia ( B r i t i s h Columbia M i n i s t r y of Health Annual Report, 1980, p. 70). Nurses are instrumental i n ordering Home Care services i f the need i s perceived. Few studies describe the way p o s t s u r g i c a l cataract patients manage t h e i r s e l f - c a r e at home following h o s p i t a l discharge. L i t t l e i s known 5 about the changes i n l i v i n g patterns the surgery may necessitate, or the concerns and d i f f i c u l t i e s these patients and t h e i r f a m i l i e s may exper-ience. With more knowledge of the home component of p o s t s u r g i c a l c a t -aract care, h o s p i t a l nurses would be better able to f u l f i l l t h e i r r o l e s of teaching and a s s i s t i n g with discharge planning, and community nurses would be as 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 i n which nursing care should be provided. In summary, the trends of decreasing length of h o s p i t a l stay f o r an increasing number of e l d e r l y patients undergoing cataract surgery accen-tuate the importance of the teaching and discharge planning aspects of nursing care of po s t s u r g i c a l cataract p a t i e n t s . Knowledge of what happ-ens to patients a f t e r they go home from h o s p i t a l i s e s s e n t i a l i f d i s -charge teaching and planning are to be e f f e c t i v e . The dearth of i n f o r -mation a v a i l a b l e regarding home s e l f - c a r e of cataract patients stimulated t h i s study. Purpose of the Study The purpose of t h i s study was to describe s p e c i f i c s e l f - c a r e behav-iours of i n d i v i d u a l s over 60 years of age during the f i r s t two to three weeks at home following uncomplicated intracapsular or extracapsular c a t -aract extraction; to i d e n t i f y d i f f i c u l t i e s and concerns experienced by these patients and family members; and to describe personal and environ-mental factors that affected the behaviours, d i f f i c u l t i e s or concerns. 6 S p e c i f i c Objectives The s i x objectives of the study were as follows: 1. To describe selected behaviours r e l a t e d to the provision of eye care i n the following categories: a) Administration of medications as prescribed. b) Protection of the eye from i n j u r y . c) Maintenance of clea n l i n e s s of the eye. d) Provision of comfort measures when necessary. e) A b i l i t y to recognize and report s i g n i f i c a n t i n d i c a t o r s of possible complications. f) Arrangement f o r continued medical supervision. 2. To assess provisions f o r accomplishment of a c t i v i t i e s of d a i l y l i v -ing. 3. To describe d i f f i c u l t i e s i d e n t i f i e d by patients or family members i n the provision of eye care or i n the accomplishment of a c t i v i t i e s of d a i l y l i v i n g . 4. To describe concerns expressed by patients and family members. 5. To i d e n t i f y personal and environmental factors that influenced the se l f - c a r e behaviours, d i f f i c u l t i e s or concerns. 6. To assess the status of the operated eye and report any signs i n d i -c a tive of possible complications. D e f i n i t i o n of Terms  S p e c i f i c s e l f - c a r e behaviours: Actions taken by the patient to carry out eye care procedures and to provide f o r the e s s e n t i a l requirements of d a i l y l i v i n g . 7 Uncomplicated Intracapsular or Extracapsular Cataract Extraction a) Uncomplicated: No unusual or untoward happenings ei t h e r during the s u r g i c a l procedure or during the h o s p i t a l stay, e.g. expulsive hem-orrhage, major loss of vitreous, endophthalmitis, severe i r i t i s , wound rupture, serious medical event. b) Intracapsular cataract extraction: Removal of the cataractous lens i n i t s capsule, i e . without planned or acci d e n t a l rupture of the lens capsule. c) Extracapsular cataract e x t r a c t i o n : Removal of the nuclear and c o r t -i c a l material, leaving the posterior capsule i n place. Concern: A s i t u a t i o n that was perceived by patients or family members as s t r e s s f u l , causing worry, or that stimulated a question. D i f f i c u l t y : A circumstance that was perceived by the patient or family member as hard to do, understand or surmount; that posed a problem or obstacle. Personal and Environmental Factors a) Personal f a c t o r s : Examples were manual dexterity, p h y s i c a l func-t i o n i n g , knowledge and s k i l l s r e l a t e d to home care of the eye, v i s -u a l acuity, hearing, perceptions of the s u r g i c a l experience, f e e l -ings of confidence, education l e v e l , ethnic background, health s t a -tus, previous experience with eye surgery or i n s t i l l a t i o n of eye drops. b) Environmental f a c t o r s : Examples were family, s o c i a l and community support groups, smoking status, housing, neighbourhood environment, length of stay i n h o s p i t a l , transportation, proximity of stores and other services, socio-economic status, season of the year. 8 A c t i v i t i e s of Daily L i v i n g : Actions that are undertaken on a regular basis to provide f o r basic needs of r e s t , exercise, n u t r i t i o n , e lim-i n a t i o n , safety, sh e l t e r and companionship. Signs Indicative of Possible Complications: Swollen l i d s , unduly red conjunctiva, hazy cornea, shallow anterior chamber, unusual discharge, crusting of the eye lashes, severe headache, browache, nausea, pain i n the eye, change i n v i s i o n . Limitations Caution must be used i n gen e r a l i z i n g r e s u l t s of t h i s study because of the small sample s i z e (N = 20), and the convenience method of sample s e l e c t i o n . The data c o l l e c t i o n method which used open-ended questions and observations i n ad d i t i o n to structured items, introduced the r i s k of bias both i n the i n t e r p r e t a t i o n of subject's responses to open-ended items, and i n the accurate recording of patient behaviours. Assumptions For t h i s study i t was assumed that behaviour of patients, and per-sonal and environmental factors are important components of the health care process, i n t e r a c t i n g with medical and nursing p r a c t i c e to influence the outcome of health care. 9 CHAPTER II REVIEW OF THE LITERATURE This l i t e r a t u r e review provides a perspective for the study of post-s u r g i c a l cataract patients' s e l f - c a r e behaviours. The review i s presented i n f i v e sections: 1) t h e o r e t i c a l and organizational framework; 2) medical p r a c t i c e r e l a t e d to patients with cataracts; 3) nursing prac-t i c e r e l a t e d to patients with cataracts; 4) personal and environmental factors that influence patient's s e l f - c a r e behaviours; and 5) studies of p o s t s u r g i c a l cataract patients i n t h e i r homes. Theoretical and Organizational Framework Psychological theories of behaviour may be divided i n t o two main categories, f i r s t l y those that contend that there i s a d i r e c t connection between the stimulus and the response, minimizing mediating v a r i a b l e s , and secondly those that view the mediating variables as important factors i n a behavioral response. Examples of t h e o r i s t s i n the f i r s t mentioned category are Thorndike, Pavlov, Watson and Skinner, and uses of t h e i r work i n the health care f i e l d may be seen i n behaviour modification tech-niques and programmed learning. The second group of psychologists, who contend that mediating f a c -tors govern the reception of s t i m u l i , t h e i r reorganization, and the r e -sponse, are the G e s t a l t i s t s , such as Kohler and Koffka; f i e l d t h e o r i s t s , such as Lewin and Tolman; phenomenologists, such as Combs and Snygg; and personality t h e o r i s t s , such as Freud and Maslow (Clayton, 1965, p. 46-77). 10 Theories of t h i s second group of psychologists are appealing to many health professionals because they provide a r a t i o n a l e f o r understanding behaviour, and a focus f o r intervening to modify behaviours i n a d i r e c -t i o n that w i l l f o s t e r p o s i t i v e health outcomes. The major concepts inherent i n the work of Lewin (1951), Tolman (1958), and Combs and Snygg (1959), are: 1) that a v a r i e t y of f a c t o r s , both i n t e r n a l and external to the i n d i v i d u a l , influence behaviour; and 2) that the i n d i v i d u a l ' s perception 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. These concepts have become a c e n t r a l theme of many nursing models (Campbell, Cruise & Murakami, 1976; King, 1968; Neuman, 1974; Roy, 1974). The importance of considering the patient's viewpoint i s recognized, and act i v e patient p a r t i c i p a t i o n i n the health care pro-cess i s encouraged. The r o l e of the health provider, p a r t i c u l a r l y the nurse, i s changing from one of doing things f o r or to the patient, to a more co 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 patient i s helped to assume h i s own s e l f - c a r e ( K i n l e i n , 1977; Norris, 1979). An organizational framework which incorporates the concepts of medi-ating factors i n behaviour, and the c o l l a b o r a t i v e patient/provider r e l a -t i onship, has been adapted f o r t h i s study from a health services research model proposed by S t a r f i e l d (1973). Figure 1 i l l u s t r a t e s t h i s adapted model wherein patients, nurses and doctors are seen as co-providers of health care. The outcome of such care i s the r e s u l t of the i n t e r a c t i o n of patient behaviour, personal and environmental f a c t o r s , and medical and nursing p r a c t i c e . The various aspects of th i s i n t e r a c t i o n a l model w i l l now be discussed. 11 ]////\ Outcome Figure 1. An I n t e r a c t i o n a l Model of Health Care Medl c a l Practice Related to Patients with Cataracts The medical p r a c t i c e component of the model i s well documented i n the l i t e r a t u r e . Many authors describe v a r i a t i o n s i n s u r g i c a l procedures, new instruments and suture materials, v a r i a t i o n s i n h o s p i t a l and postsur-g i c a l management, prevention and c o n t r o l of complications, and resultant v i s u a l outcomes. However, the discussion i n t h i s section w i l l be l i m i t -12 ed to aspects that have relevance to the s e l f - c a r e behaviours of post-s u r g i c a l cataract p a t i e n t s . Cataract surgery Is us u a l l y an e l e c t i v e procedure, and the decision to operate i s customarily made when the v i s u a l acuity i n the patient's better eye had decreased to the point where normal a c t i v i t i e s cannot be performed ( J a f f e , 1978). The surgery may be performed under l o c a l or general anaesthetic, depending upon the surgeon/patient preference and the patient's medical status. There are two basic techniques f o r cataract removal; the intracap-sular technique which removes the lens and i t s capsule, and the extracap-sular technique i n which the capsule i s ruptured, the cortex and nucleus removed, and the pos t e r i o r capsule l e f t i n place. Customarily i n these standard procedures the lens i s removed through an 11 - 18 mm. i n c i s i o n which i s made superio r l y at the c o r n e a l - s c l e r a l junction. The i n c i s i o n i s closed with e i t h e r d i r e c t or running multiple f i n e sutures. The de-gree of reaction and discomfort postoperatively depends to some extent on the s i z e and type of suture material used, and whether knots are l e f t ex-posed or are buried (Troutman, 1971). Complications re l a t e d to the surgery are rare (Gardener, 1979; Weinstock, 1978), and v i s u a l improvement i s achieved i n 95 percent of cases of standard cataract surgery when combined with c o r r e c t i v e r e f r a c -t i o n (Luckman & Sorensen, 1980, p. 1992). Occasionally the following complications may occur: i n f e c t i o n , hemorrhage, wound disr u p t i o n , v i t r e -ous l o s s , r e t i n a l detachment, u v e i t i s , or glaucoma (Havener, Saunders, Keith, & Prescott, 1974, chap. 11; Johnson, 1978; Smith & Nachazel, 1980, chap. 5). Postoperatively, patients are taught precautionary measures 13 designed to reduce the occurrence of complications. A more d e t a i l e d d i s -cussion of patient teaching i s presented i n the ensuing section on nurs-ing p r a c t i c e . Mydriatic, anti-inflammatory, and a n t i b i o t i c eyedrops and/or o i n t -ments may be prescribed to be used f o r several weeks following standard cataract surgery to reduce the r i s k of complications, and to increase comfort (Smith & Nachazel, 1980). As the lens normally contributes about one-quarter of the focusing power of the eye (Smith & Nachazel, 1980), i t s function must be replaced by some form of o p t i c a l c o r r e c t i o n such as spectacles, contact lenses or an i n t r a o c u l a r lens implant. The advantages and disadvantages of each of these corrective measures are important f o r patients to consider. Cataract spectacles create many d i f f i c u l t i e s . Objects are magnified approximately 30 percent, p e r i p h e r a l images are d i s t o r t e d , and the f i e l d of v i s i o n i s reduced. The weight of thick lenses i s uncomfortable, and the cosmetic appearances are objectionable to a number of people ( J a f f e , 1978). Some amelioration of these problems may be obtained with p l a s t i c lenses which are l i g h t e r i n weight than glass lenses, and with new manu-fa c t u r i n g techniques which reduce peripheral d i s t o r t i o n . * The s p a t i a l d i s o r i e n t a t i o n associated with cataract spectacles requires major adjust-ments and i s d i f f i c u l t f o r many people. In addition, i f surgery has been performed In only one eye, the discrepancy i n s i z e of images precludes binocular v i s i o n ( J a f f e , 1978). Richard Stewart; Dispensing Optician; personal communication, June 1981. 14 A contact lens produces less d i s t o r t i o n and permits adequate periph-e r a l v i s i o n . Objects are magnified by only f i v e to ten percent, so b i n -ocular v i s i o n can be achieved i n instances when only one eye i s aphakic. However, management of contact lenses requires a high degree of manual dexterity, which older persons often lack. The p e r f e c t i o n of extended wear lenses, ones which may be worn f o r several months without removal, may o f f e r a v i able option to those persons who are unable to manage the d a i l y i n s e r t i o n and removal of a contact lens (Luckman & Sorensen, 1980, p. 1992-96). Permanent c o r r e c t i o n with glasses or contact lenses i s u s u a l l y de-layed u n t i l changes i n r e f r a c t i o n due to the healing process have s t a b i -l i z e d - a period commonly e n t a i l i n g two to three months. Occasionally temporary spectacles with r e f r a c t i v e power approximating the permanent co r r e c t i o n are provided. The implantation of a p l a s t i c lens, with o p t i c a l power s i m i l a r to that of the patient's natural lens, i s a method of o p t i c a l c o r r e c t i o n gaining i n popularity. According to J a f f e (1978), at the time of his w r i t i n g approximately one-quarter of the cataract operations peformed i n the United States involved a lens i n p l a n t . The advantages of the i n t r a -ocular lens are namely: that the magnification produced i s only one to three percent, there i s no s p a t i a l d i s o r i e n t a t i o n or abnormal peripheral v i s i o n , and patients have u s e f u l v i s i o n almost immediately. The implant-ed lens does not have the a b i l i t y to accommodate, so reading glasses need to be worn for close work (Luckman & Sorensen, 1980, p. 1992-96). Ac-cording to J a f f e (1976), short term r e s u l t s of the i n t r a o c u l a r lens are good, but there are as yet no well documented long term studies. For a 15 young i n d i v i d u a l there i s a question of long term i n t r a o c u l a r tolerance, but f o r older, dextrously impaired persons, the i n t r a o c u l a r lens o f f e r s many advantages. Nursing Practice Related to Patients with Cataracts Because t h i s study i s concerned with p o s t s u r g i c a l cataract patients at home, the discussion of nursing care w i l l be l i m i t e d to those measures that help patients and family 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 following h o s p i t a l discharge. Widely accepted recommendations that are pertinent to home eye care f o r postoperative cataract patients have been selected from nursing texts (Luckman & Sorensen, 1980, p. 1992-96; Shafer et a l . , 1975, chap. 31; Smith & Nachazel, 1980, chap. 5), and journal a r t i c l e s (Berkoben, 1978; Boyd-Monk, 1977; Shanahan & Pelham, 1978), and have been summarized by t h i s w r i t e r . Since i t i s customary for eyedrops to be prescribed f o r several weeks following surgery, i t i s necessary to teach patients and/or a r e -sponsible family member how to i n s t i l l the drops appropriately. Other eye care procedures such as i n s t i l l a t i o n of ointment, a p p l i c a t i o n of a protective s h i e l d at night, and cleansing the eye of mucus or crusts may be recommended, and therefore require i n s t r u c t i o n . A number of a c t i v i t y r e s t r i c t i o n s and precautionary measures are advocated i n an endeavour to reduce the r i s k of postoperative compli-cations. The following l i s t summarizes major recommendations that nurses convey to patients. 1. Avoid actions such as coughing, sneezing, bending, l i f t i n g , and s t r a i n i n g during bowel movements, that may increase i n t r a o c u l a r pressure and place s t r a i n on the suture l i n e . 16 2. Avoid sudden movements, j a r r i n g , bumping, squeezing, or rubbing the eye, that might contribute to wound rupture, i r i s prolapse, hemor-rhage, or r e t i n a l detachment. 3. Wear dark glasses or p r e s c r i p t i o n glasses during the day, and a pro-t e c t i v e eye s h i e l d at night to prevent accidental rubbing or i n j u r y . 4. Wash hands before treatments, and r e f r a i n from touching the eye with fingers or other unclean materials, to avoid i n f e c t i o n . 5. Be cautious on s t a i r s , uneven ground, curbs, crossing busy s t r e e t s , and pouring hot l i q u i d s , as there may be d i f f i c u l t i e s with depth perception that influence the a b i l i t y to judge distances. 6. Be aware of, and report any signs or symptoms of possible complica-tions to the doctor immediately. S i g n i f i c a n t signs and symptoms are pain i n the eye, headache or browache that i s unrelieved by a usual headache remedy, nausea or vomiting, unusual discharge or crusting, change i n v i s i o n , f l a s h i n g l i g h t s . 7. Use a walking s t i c k f o r s t a b i l i t y , and f o r judging heights and edges of curbs and s t a i r s . Shanahan and Pelham (1978) describe a p r a c t i c e wherein a responsible family member i s included i n home care i n s t r u c t i o n s . Nurses demonstrate necessary s k i l l s , and a s c e r t a i n before h o s p i t a l discharge that the pa-t i e n t or the family member i s capable of adequately performing the pre-scribed procedures. In c o l l a b o r a t i o n with family members, nurses make r e f e r r a l s to community agencies i f home care assistance i s required. In a d d i t i o n to teaching manual s k i l l s and precautionary measures, the nurse has a r e s p o n s i b i l i t y to prepare patients and family members for s i t u a t i o n s that may a r i s e during the postoperative recovery period. The 17 p o s s i b i l i t y of experiencing minor eye discomforts and s e n s i t i v i t y to bright l i g h t should be discussed, and methods of a l l e v i a t i n g these sug-gested. If temporary glasses are provided, anticipated v i s u a l adjust-ments need to be discussed. Patients should also be reminded of an ex-pected waiting period of two to three months before healing has taken place, and the f i n a l v i s u a l c o r r e c t i o n provided. Several authors advocate the pr o v i s i o n of written information, i n large p r i n t , as an adjunct to verbal i n s t r u c t i o n s , and provide t h i s w r i t -ten material variously before h o s p i t a l admission (Low, 1978; Kidger, 1977), and before h o s p i t a l discharge (Shanahan & Pelham, 1978). These l a t t e r authors report that the names of the patient's medications, with t h e i r dosage Instructions, are written on the information pamphlet "to a i d the patient's adherence to the p r e s c r i p t i o n s " (Shanahan & Pelham, 1978, p. 11). A discharge i n s t r u c t i o n sheet provided f o r most patients i n t h i s study may be found i n Appendix E. Community nurses who care f o r postoperative cataract patients i n t h e i r homes undertake the following r e s p o n s i b i l i t i e s (Berkoben, 1978; Kidger, 1977): 1. Perform prescribed eye care procedures, supervise patients and/or family members while they perform procedures, and teach s k i l l s i f necessary. 2. Monitor both the patient's general p h y s i c a l condition, and the s t a -tus of the operated eye, and report any complications to the attend-ing physician. 3. Reiterate recommended precautions, and ensure that patients and fam-i l y members know them and understand t h e i r importance. A s s i s t pa-18 t l e n t s and family members to recognize and remove p o t e n t i a l hazards i n the home. 4. Answer questions, and provide information to f a c i l i t a t e s e l f - c a r e and reduce concerns. 5. Ascertain the a b i l i t y of patients to provide 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 to other agencies i f necessary. Personal and Environmental Factors That Influence Self-Care Since no studies were located that reported s e l f - c a r e behaviours s p e c i f i c a l l y of p o s t s u r g i c a l cataract patients, general factors that i n -fluence patient's s e l f - c a r e were i d e n t i f i e d i n the compliance l i t e r a t u r e and l i t e r a t u r e r e l a t e d to the e l d e r l y . For the purposes of t h i s paper the terms "compliance" and "adherence" are used synonymously, and are defined as". . . the extent to which patients follow the i n s t r u c t i o n s -prosc r i p t i o n s and p r e s c r i p t i o n s - of t h e i r physicians or other providers" (Hulka, 1979, p. 3). The discussion i s presented under three headings; personal f a c t o r s , i l l n e s s and treatment f a c t o r s , and interpersonal f a c -t o r s . Personal Factors In extensive reviews of the l i t e r a t u r e on compliance, Blackwell (1973), Haynes (1978, p. 49-62) and Marston (1970), conclude that demo-graphic variables such as age, sex^ socio-economic status, education, r e l i g i o n , and race, when examined i n i s o l a t i o n from other v a r i a b l e s , are seldom found to be s i g n i f i c a n t l y r e l a t e d to compliance with recommend-ations. Some exceptions are noted i n the preventive health l i t e r a t u r e where Rosenstock (1974) found that women were more l i k e l y to engage i n preventive actions, and persons of low socio-economic groups were les s l i k e l y to take preventive actions that e n t a i l e d cost to themselves. In the ophthalmology l i t e r a t u r e there are also i n c o n s i s t e n c i e s . In studies of eyedrop adherence of glaucoma patients, women were found to be more compliant than men (Bloch, Rosenthal, Friedman, & C a l d a r o l l a , 1977; Vincent, 1973), and i n d i v i d u a l s over 65 years of age were reported to be more compliant than t h e i r younger counterparts (Vincent, 1973). Spaeth (1970) found no differences i n these v a r i a b l e s . M a r i t a l status and l i v i n g s i t u a t i o n s are associated with compliance i n many studies. Divorce, separation (Schwartz, Henley & Z e i t z , 1964), family i n s t a b i l i t y , unemployment, poverty, and l i v i n g alone (Blackwell, 1973) contribute to non-compliance. According to Davis (1968) and Green (1970), health r e l a t e d behaviours are influenced by the expectancies and reactions of others. Peer groups and f a m i l i e s can exert a strong i n f l u -ence i n eit h e r a p o s i t i v e or negative d i r e c t i o n . Caplan and Associates (1976) reported that adherence to a regimen for hypertension was enhanced by support from physicians and spouses, and Donabedian and Rosenfeld (1964) noted that adherence of c h r o n i c a l l y i l l patients to t h e i r medical regimen was correlated to the degree to which family members provided support and i n t e r e s t . In add i t i o n , s o c i a l i s o l a t i o n has been associated with an increase i n medication errors among the e l d e r l y (Neely & Patrick, 1968). Patient personality variables have been investigated, and Davis (1968b) reports that patients who are co-operative, g r a t e f u l and a r t i c u -l a t e are more compliant than those who are demanding, a u t h o r i t a t i v e and 20 overbearing; or submissive and dependent. High self-esteem, and c o n f i -dence i n one's . a b i l i t y to follow recommendations are also associated p o s i t i v e l y with adherence (Caplan et a l , 1976). Many patient values, b e l i e f s and attitudes are r e l a t e d to adherence and the patient's perception of the s e v e r i t y of an i l l n e s s , rather than of the physician's assessment of i t , i s considered to be the important f a c t o r i n adherence (Gillum & Barsky, 1974). Non-compliers perceived themselves as l e s s susceptible to, or threatened by, the a c t u a l or poten-t i a l i l l n e s s (Gillum & Barsky, 1974), believed that the treatment was of no benefit (Spaeth, 1970), or considered that regular medication sched-ules were unimportant (Bloch et a l . , 1977). Patient a t t i t u d e s toward compliance are exemplified i n Davis' (1968b) study, where 40 percent of defaulting subjects indicated that they never had any i n t e n t i o n of f o l -lowing the doctor's i n s t r u c t i o n . Other authors note that three to seven percent of the p r e s c r i p t i o n s written by physicians are never f i l l e d (Boyd, Covington, Stanaszek, & Cousins, 1974; Hammell & Williams, 1964). The learning a b i l i t y of older adults i s a p o t e n t i a l factor of i n f l u -ence i n adherence to recommendations, and i s a subject of controversy i n the psychology l i t e r a t u r e on aging. Most studies agree that the speed of information processing and the rate of responding declines with age, but there i s disagreement whether there i s a decline i n actual learning a b i l -i t y . Botwinick (1978, p. 278) summarized a number of studies and con-cludes, "when s u f f i c i e n t time f o r a response i s a v a i l a b l e , the perform-ance of e l d e r l y people i s only s l i g h t l y i n f e r i o r or not i n f e r i o r at a l l to that of younger people." Some si t u a t i o n s i n which older adults are more disadvantaged than younger adults are: 1) when there i s i r r e l e v a n t 21 or redundant information included i n the learning task (Rabbitt, 1965); 2) when pacing of information i s rapid (Canestrari, 1963); 3) when there i s an inappropriately high l e v e l of autonomic nervous system stimulation (Powell, E i s d o r f e r , Bogdonoff & Durham, 1964); and 4) when the learning task i s abstract rather than concrete (Arenberg, 1968). Decreased r e -sponse time or omitted responses i n the older adult were also a t t r i b u t e d to worry about making an error (Potash & Jones, 1977). Sensory d e f i c i t s , d e f i c i t s i n manual dexterity, p h y s i c a l diseases, and attitudes about the a b i l i t y to learn also a f f e c t the older adult's a b i l i t y to comprehend i n s t r u c t i o n s and perform manual s k i l l s (Saxon & Etten, 1978, p. 158-166). Few studies make any d i s t i n c t i o n between comprehension (understand-ing the regimen) and compliance (following the regimen). However, two studies (Parkin, Brown & Monk, 1976; Schwartz, Wang, Zeitz & Goss, 1962) are noted exceptions. In the Parkin study, 130 patients discharged from acute medical wards were studied two weeks following discharge, to iden-t i f y factors responsible f o r deviation from prescribed drug treatment. The mean age of subjects was 66 years. The r e s u l t s indicated that 35 percent of subjects deviated from prescribed treatment because they did not understand t h e i r regimens; 15 percent knew the i n s t r u c t i o n s but did not follow them. Therefore, i n t h i s study nescience was a more powerful fa c t o r than non-compliance i n deviation from the prescribed regimen. Common sources of error were: using dosages that were operative p r i o r to h o s p i t a l admission, reversion to old p r e s c r i p t i o n s (Parkin et a l . , 1976), adding medications prescribed by a previous physician to the current ones, and using a spouse's medication both knowingly and unknowingly (Schwartz et a l . , 1962). Forgetting i n s t r u c t i o n s may be an important f a c t o r i n nescience. Ley (1980) summarized his research and reported that i n one study, 50 percent of the information given to patients by a general p r a c t i t i o n e r was forgotten i n f i v e minutes. In other t r i a l s 37 -54 percent of material was forgotten. Forgetting was not r e l a t e d to age or i n t e l l i g e n c e , but a c u r v i l i n e a r r e l a t i o n s h i p with anxiety was reported (Ley, 1980). The aforementioned knowledge of expected behaviours, and the a b i l i t y to perform them, i s d i f f e r e n t from f a c t u a l knowledge about disease e n t i -t i e s and medications. The l i t e r a t u r e i s divided over whether t h i s l a t t e r type of knowledge increases adherence (Caldwell, Cobb, Dowling & de Jongh, 1970; Hulka, 1979; Pratt, Seligmann & Reader, 1957; Spaeth, 1970), or has no e f f e c t at a l l (Bergman & Werner, 1963; Boyd et a l . , 1974; Haynes et a l . , 1976, p. 69-82). Close scrutiny of three glaucoma studies would suggest that although knowledge of f a c t s was not s u f f i c i e n t to i n -fluence adherence i n these studies, an understanding and appreciation of the r e l a t i o n s h i p between increase i n i n t r a o c u l a r pressure and v i s u a l loss did d i f f e r e n t i a t e compilers and non-compliers (Bloch et a l . , 1977; Spaeth, 1970; Vincent, 1973). Perhaps i t i s the higher l e v e l of under-standing and appreciation, rather than f a c t u a l knowledge, that i s impor-tant to adherence to recommendations. Although knowledge about the medical condition may not c o n s i s t e n t l y c o r r e l a t e with adherence, information seeking i s one of the most basic ways of coping i n s i t u a t i o n s that are new or pose a threat (Cohen & Lazarus, 1979, p. 217-254). For example, Janis (1958) has suggested that by gaining information about what to expect, patients can develop ways of 23 coping with the threats of surgery. This concept may explain the f i n d i n g that s a t i s f a c t i o n with health care i s increased when information about the medical condition i s provided (Hulka, 1979; Svarstad, 1976). How-ever, the amount of information desired i s very i n d i v i d u a l . 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 search of information, whereas others pre-f e r to place themselves i n the hands of someone they can t r u s t , b e l i e v i n g that "ignorance i s b l i s s " (Cohen and Lazarus, 1979, p. 244). I l l n e s s and Treatment Factors In chronic conditions where there i s prolonged therapy, lapses i n compliance are more l i k e l y to occur than i n acute short term i l l n e s s e s . This i s p a r t i c u l a r l y true when the condition i s mild or asymptomatic, when the treatment i s suppressive or prophylactic, or when the conse-quences of skipping treatment may be delayed (Blackwell, 1973). For ex-ample, i n chronic simple glaucoma, where there i s no pain or immediate d i s a b i l i t y , and where the only symptoms may be from unpleasant side e f -f e c t s of the medication, there i s l i t t l e reinforcement to continue with prescribed treatment (Riffenburgh, 1966). In Bigger's (1976) study, 37 percent of subjects with asymptomatic elevation of i n t r a o c u l a r pressure dropped out of treatment, most within a month of the i n i t i a l diagnosis. If symptoms are present, recommendations that attempt to r e l i e v e the discomforts are u s u a l l y followed c a r e f u l l y (Haynes, 1976), but disappear-ance of the symptoms frequently lead to premature termination of the pre-scribed regimen (Becker et a l . , 1972). Bigger (1967) comments that a l -though no s t a t i s t i c a l studies report compliance i n acute ophthalmological conditions, most ophthalmologists are aware that patients with conjunc-24 t i v i t i s are l i k e l y to discontinue t h e i r eyedrops once the symptoms c l e a r , and many contact lens wearers discontinue regular follow up appointments once they have achieved successful wear. The amount of change i n habits or l i f e s t y l e that i s required to follow the recommendations (McAlister, Farquhar, Thoresen & Maccoby, 1976), and the amount of interference with d a i l y l i v i n g a c t i v i t i e s (Tagliacozzo & Ima, 1970) a f f e c t adherence. In addition, patients are known to be s e l e c t i v e i n adhering to recommendations, complying with those aspects that require the l e a s t adjustment i n t h e i r way of l i f e (Davis & Eichhorne, 1963). Complexity of the regimen and the number of drugs prescribed have been c i t e d by a number of authors as a f f e c t i n g adherence (Davidson & Akingbehin, 1980; Francis, Korsch & Morris, 1969; Hulka, 1979; Schwartz et a l . , 1964), but the e f f e c t of the number of doses per day has been questioned (Blackwell, 1973). The e f f e c t of medication side e f f e c t s on compliance i s equivocal (Haynes, 1979, p. 60), however, both Bloch and Associates, (1977) and Riffenburgh (1966) c i t e unpleasant and inconvenient side e f f e c t s as rea-sons that patients with glaucoma discontinue t h e i r eyedrops. The few studies that have investigated the e f f e c t of cost of medica-tions on adherence produce c o n f l i c t i n g r e s u l t s (Haynes, 1979, p. 60); however, the cost of eyedrops was a f a c t o r i n non-compliance i n Vincent's (1973) glaucoma study. Dispensing factors are implicated i n adherence to medication taking i n several studies. Mazzulo, L'asagna & Griner (1974) report that there i s a wide v a r i a t i o n i n patients' 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 b o t t l e s , p a r t i c u l a r l y when the i n s t r u c t i o n s were not ex-p l i c i t ; and Hermann (1973) notes that patients have considerable d i f f i -c u l t y i n e s t a b l i s h i n g for themselves appropriate time i n t e r v a l s and se-quences f o r medication schedules. Safety lock containers were a source of d i f f i c u l t y and reduced medi-cation consumption f o r subjects i n two studies (Lane, Barbarite, Bergner & H a r r i s , 1971; Mclntire, Angle, Sathees & Lee, 1977). Furthermore, i t was noted that e l d e r l y patients frequently l e f t the tops of containers off once they had been opened (Mclntire et a l . , 1977). Davidson and Akingbehin (1980) comment that labels are frequently hard to decipher for patients whose v i s u a l acuity and reading a b i l i t y are reduced, and Vincent (1973, p. 218) reports that d i f f i c u l t i e s with s e l f -administration of eyedrops were indicated as factors i n non-compliance f o r a small number of subjects who stated, "My hand trembles," "It's hard to f i n d my eye," or "I waste too much." Interpersonal Factors The r o l e of patient s a t i s f a c t i o n with medical care has received con-siderable attention (Aday, Andersen & Fleming, 1980), and patient s a t i s f a c t i o n with the i n t e r a c t i o n between themselves and t h e i r physician has been found to be p o s i t i v e l y r e l a t e d to subsequent adherence to recom-mendations (Aday et a l . , 1980; Hulka, 1979; Korsch & Negrete, 1972; Svarstad, 1976). Although most of the studies are of r e l a t i o n s h i p s be-tween physicians and patients, the p r i n c i p l e s apply equally to nurses. From the patient's perspective, s a t i s f a c t i o n i s enchanced when: 1) doc-tors pay attention to and deal with what the patient perceives as the 26 main concern for the v i s i t ; 2) a doctor shows a f r i e n d l y i n t e r e s t i n non-medical aspects of a patient's l i f e (Aday et a l . , 1980; Korsch & Negrete, 1972); 3) expectations for a v i s i t are met (Stimson, 1974); 4) explana-tions and information are given about the medical diagnosis, and j u s t i f i -cations for s p e c i f i c p r e s c r i p t i o n s are provided (Svarstad, 1976); and 5) an opportunity i s provided to p a r t i c i p a t e i n an a c t i v e interchange with the doctor, asking questions and v a l i d a t i n g impressions (Korsch & Negrete, 1972). The communication of i n s t r u c t i o n s of patients, and the patient's r e -ception of these i n s t r u c t i o n s has been the subject of studies by Hulka (1979) and Svarstad (1976). In both these studies, discrepancies between what the physician said was prescribed, and what the patient reported as the regimen, resulted i n medication errors of dosage, scheduling, and duration of treatment. Svarstad i d e n t i f i e d physician factors that reduced successful com-munication as: 1) incomplete or ambiguous i n s t r u c t i o n s , 2) terminology that was not understood by the patient, and 3) f a u l t y assumptions about the extent of the patient's knowledge. Patient factors were i d e n t i f i e d as unwillingness to ask for c l a r i f i c a t i o n , or to i n d i c a t e uncertainty and confusion. Patients who provided such feedback received more i n -s t r u c t i o n from the physician, and increased the accuracy of. t h e i r percep-tions . In p r i n c i p l e there can be l i t t l e doubt that the quantity, q u a l i t y and content of the provider/patient i n t e r a c t i o n influences the way pa-t i e n t s conduct t h e i r own s e l f - c a r e , but studies of the components of the i n t e r a c t i o n are few, and are just beginning to a t t r a c t the attention of researchers. 27 In the f i n a l section of t h i s review, studies of cataract patients at home are discussed. Cataract Studies Although there are many studies i n the medical l i t e r a t u r e that exam-ine types and rates of complications, and v i s u a l r e s u l t s following c a t a -ract surgery, there are few that examine the impact of the surgery on the l i v e s of patients and t h e i r f a m i l i e s , and few that describe s e l f - c a r e p r a c t i c e s . In a paper w r i t t e n by Kidger (1977), an ophthalmic nurse s p e c i a l i s t i n England, a home v i s i t i n g programme to pos t s u r g i c a l cataract patients i s described. One hundred and nine patients were v i s i t e d over a one year period, drops were i n s t i l l e d , patients and family members were supervised i n eye care procedures, and the operated eye was examined. Seven pa-t i e n t s were referred back to t h e i r opthalmologist because of leaking wound, atropine s e n s i t i v i t y , i r i t i s , and hyphema. Problems that patients had a f t e r they got home from h o s p i t a l prompted the development of an i n -formation pamphlet, printed i n large type, that i s now sent to a l l pa-ti e n t s before h o s p i t a l admission. The author does not report the s p e c i f -i c problems that were encountered by the patients at home. In another study i n the United Kingdom, Hilbourne (1975) v i s i t e d 44 e l d e r l y p o s t s u r g i c a l cataract patients i n t h e i r homes to as c e r t a i n t h e i r l e v e l of functioning and t h e i r reactions to the surgery. Three months following surgery, very few patients had increased the number of a c t i v i -t i e s they were able to do, many were having d i f f i c u l t y adjusting to t h e i r spectacles, and many were disappointed with the outcome of the surgery. The key determinant i n performance and s a t i s f a c t i o n was the l e v e l of v i s -u a l acuity i n the unoperated eye; subjects with corrected v i s u a l acuity i n the unoperated eye better than 20/100 were d i s s a t i s f i e d while those with less than 20/100 were pleased with t h e i r r e s u l t s . F i n a l l y , Crawford (1980) i n an unpublished master's t h e s i s , reports on the needs of ten e l d e r l y p o s t s u r g i c a l cataract patients referred to a v i s i t i n g nurse agency. Patients i n t h i s study r e l i e d heavily on family members, neighbours and f r i e n d s , as well as the v i s i t i n g nurse f o r p r o v i -sion of eye care. Other needs frequently i d e n t i f i e d were assistance with housekeeping and shopping. Subjects over 80 years of age, with poor v i s -ion i n the unoperated eye, l i v i n g alone and with l i t t l e support system, were i d e n t i f i e d as most l i k e l y to need Home Health Services f o r a longer period of time than the three days which are reimbursed by the U.S. Medi-care System. The small sample s i z e and the retrospective nature of the study which depended on r e c a l l of events that occurred up to one year previously, are l i m i t a t i o n s of t h i s research project. In summary, theory supports both the usefulness of a c o l l a b o r a t i v e approach to health care, and the need to recognize that many var i a b l e s a f f e c t patients' s e l f - c a r e behaviours. Nursing and medical aspects of a patient's care following cataract surgery are documented, but the person-a l and environmental factors that influence the patient's behaviour can only be surmised from the general l i t e r a t u r e . No studies have been l o -cated that examine s p e c i f i c a l l y the s e l f - c a r e behaviours of p o s t s u r g i c a l cataract patients at home following h o s p i t a l discharge, and few report d i f f i c u l t i e s and concerns that are experienced. This deficiency i n the l i t e r a t u r e d i r e c t s the focus of the present study. 29 CHAPTER III METHODOLOGY This study was conducted to describe selected eye care and s e l f - c a r e behaviours of po s t s u r g i c a l cataract patients during t h e i r f i r s t few weeks at home following h o s p i t a l discharge, and to i d e n t i f y factors which might have influenced those behaviours. An exploratory d e s c r i p t i v e research design was selected as the most appropriate method to achieve the stated research purpose. The l o n g i t u d i n a l panel design of the project provided the opportunity to observe changes i n the same subjects over time. The study took place over a three month period between May 1st and July 31, of 1981, i n a large metropolitan Canadian c i t y , and involved twenty subjects who had recently undergone cataract surgery. This chapter describes the methods used to 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 instrument, c o l l e c t i o n of the data, and analysis of the data. Selection of Participants A convenience sample of twenty p o s t s u r g i c a l cataract patients who met the following e l i g i b i l i t y c r i t e r i a were admitted to the study: 1. Age was over 60 years. 2. Present surgery was the f i r s t cataract e x t r a c t i o n . 3. Procedure was an intracapsular or extracapsular extraction without lens implant. 4. Best corrected v i s u a l acuity i n the unoperated eye was 20/50 or l e s s . 5. Surgical procedure and postoperative h o s p i t a l stay were uncompli-cated. 6. Were discharged to a p r i v a t e residence (where patient had to make own arrangements f o r s e r v i c e s ) . 7. Were able to speak, understand and communicate i n E n g l i s h . 8. Lived i n a geographical area that was within a one hour drive of the c i t y centre. The 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 i s discussed b r i e f l y . The age requirement was selected because i t represents the major group of people undergoing cataract surgery. Canadian s t a t i s t i c s i n d i c a t e that 70 percent of cataract operations are performed on i n d i v i d u a l s over 65 year of age ( S t a t i s t i c s Canada, 1977). The requirements of the s p e c i f i c sur-g i c a l procedure, lack of complications, f i r s t cataract surgery, minimum v i s u a l acuity, and the exclusion of persons with lens implants r e f l e c t an attempt to l i m i t the number of variables and increase the homogeneity of the sample. The residence requirements were selected to obtain subjects who were responsible for t h e i r own care, and the communication s p e c i f i c a -t i o n was made because of the verbal i n t e r a c t i o n requirements of the i n -terview data c o l l e c t i o n technique. I n i t i a l contact with p o t e n t i a l subjects was made by the attending ophthalmologist, who explained the purpose and scope of the study. If subjects expressed 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 written explanation of the study was provided (See Appendix A). Subjects were encouraged to discuss the study with family members, and think of questions they would l i k e to ask. 31 The investigator v i s i t e d i n t e r e s t e d subjects while they were s t i l l i n h o s p i t a l , answered questions, and obtained a consent f o r p a r t i c i p a t i o n i n the study (See Appendix B). A tentative appointment f o r the f i r s t home v i s i t was made, at a time on the day following h o s p i t a l discharge, that was mutually convenient to the subject and the researcher. A b u s i -ness card noting the inve 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 with the subject. Both the information material and the consent form were provided i n large p r i n t , high contrast format to maximize l e g i b i l i t y for these low v i s i o n subjects. In sp i t e of these s p e c i a l e f f o r t s to improve the read-a b i l i t y of materials, four subjects were unable to read the consent form. In these instances, to ensure that subjects knew what they were signing, a family member was asked to read the information sheet and the consent form to the subject, and co-sign the agreement to p a r t i c i p a t e . A H subjects who met the 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 study. Development of the Instrument A three faceted data c o l l e c t i o n instrument was designed by the r e -searcher f o r t h i s study (See Appendix D). A face sheet was compiled to record demographic data. An interview schedule was constructed using a s e l e c t i o n on both open and closed-ended questions, a combination that i s highly recommended by P o l i t and Hungler (1978, p. 330) to a t t a i n the ad-vantages and o f f s e t the weaknesses of each type of question. F i n a l l y , a c h e c k l i s t was devised to record observations of eyedrop i n s t i l l a t i o n , ap-p l i c a t i o n of a protective eye s h i e l d , and the condition of the operated eye. 32 Content areas were directed by the conceptual framework, and derived from three main sources: f i r s t l y from the l i t e r a t u r e on postoperative nursing care of cataract patients, health care needs of the e l d e r l y , and the compliance l i t e r a t u r e ; secondly from discussions with ophthalmolo-g i s t s , ophthalmic nurses and home care nurses; and t h i r d l y through con-versation with i n d i v i d u a l s who themselves had undergone cataract surgery. The interview schedule was c r i t i c a l l y reviewed f o r content v a l i d i t y and c l a r i t y by two ophthalmic head nurses, three ophthalmologists, a nursing research committee two of whose members had ophthalmological ex-perience, and by a f a c u l t y member experienced i n constructing and coding interview schedules. Revisions were made to incorporate suggestions of the consultants. R e l i a b i l i t y issues were addressed by the u t i l i z a t i o n of a standard schedule f o r each subject, by tape recording interviews, and by recording observations immediately following the interview. Internal consistency of patient responses increased confidence i n the r e l i a b i l i t y of the i n -strument . A p i l o t study was conducted with s i x subjects to tes t the i n s t r u -ment. At the completion of three interviews, minor changes were made i n wording and sequence i n order to c l a r i f y ambiguities and introduce, ear-l i e r i n the interview, items of major relevance to the subjects. An item on cost of supplies was deleted as most of the study subjects were i n an age group that had costs of medications covered by P r o v i n c i a l Pharmacare Insurance, and p i l o t subjects deemed other supplies such as cotton b a l l s and tape to be i n s i g n i f i c a n t i n cost. The revised schedule was tested with three more subjects and was found to be s a t i s f a c t o r y . Two committee members and a f a c u l t y research associate reviewed tape recorded interviews and concomitant data coding procedures. Both f e a -tures were judged to be acceptable. C o n f i d e n t i a l i t y was maintained by using code numbers on tapes and data coding sheets. The l i s t of patient names was kept by the researcher i n a separate c o n f i d e n t i a l f i l e . Written permission was obtained from the attending ophthalmologist of each subject f o r an extra prescribed eyedrop to be i n s t i l l e d i f the researcher's v i s i t did not coincide with a regular medication 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 three sources: personal interviews, d i r e c t observations, and the subject's h o s p i t a l chart. Interviews and observa-tions took place during the course of the two home v i s i t s which were made to each subject. The f i r s t v i s i t took place the day following h o s p i t a l discharge, the second between the 13th and 16th postoperative day. The length of v i s i t s averaged 40 minutes; no v i s i t lasted more than one hour. Times of v i s i t s were reconfirmed by telephone the evening preced-ing the planned v i s i t . A l l interviews were tape recorded, and although a l l subjects had the option of refusing the tape, turning i t off during the interview, or erasing segments, none exercised the option. The manner i n which the interviews were conducted merits comment. Since the research interview i s an i n t e r a c t i v e process, with both the i n -terviewer and respondent contributing to the communication, i t becomes the r e s p o n s i b i l i t y of the interviewer to create the conditions that w i l l maximize the completeness and v e r a c i t y of the respondent's communica-t i o n . At the same time a focus on the objectives of the interview must be maintained (Kahn & Cannell, 1957, p. 49-64). A non-judgemental a t t i -tude, warmth, and i n t e r e s t were used by the interviewer to f a c i l i t a t e open communication. The i n i t i a l h o s p i t a l v i s i t to explain the study and obtain a consent provided an opportunity for rapport to be developed, so that by the time of the f i r s t home v i s i t and interview, t r u s t and mutual i n t e r e s t were found to have been established. Questions were answered as they came up i f they were judged not to influence subsequent interview t o p i c s , but answers were postponed to the end of the interview i f i t was thought p a r t i c i p a n t s ' responses would be compromised. Responses to d i f -f i c u l t i e s and concerns were empathetic, but any interventions were de-f e r r e d to the end of the interview. The use of the tape recorder provided the advantages of enabling the interviewer to observe and respond to non-verbal cues, and maintain eye contact to hold the a t t e n t i o n of e l d e r l y subjects. Observations of eye care procedures and eye status were made at the end of home v i s i t s i n the hope that rapport would be b u i l t , and f a m i l i a r -i t y with the observer would minimize the d i s t o r t i o n that occurs i n known observation s i t u a t i o n s (Fox, 1970, p. 213). Observations were recorded on the c h e c k l i s t s as soon as possible a f t e r the researcher l e f t the sub-jec t 's home. Phys i o l o g i c a l and demographic data required f o r the study were ob-tained from the h o s p i t a l chart a f t e r permission had been obtained from the subject. 35 Analysis of the Data Data from taped interviews were transferred to recording sheets. F i n i t e answers were coded and r e p l i e s to open ended questions recorded. Data were then organized i n t o content areas re l a t e d to the objectives. Descriptive s t a t i s t i c s such as frequency d i s t r i b u t i o n s , measures of cen-t r a l tendency, and measures of v a r i a b i l i t y were used to analyze and d i s -play data. In addition, the Fisher Exact Test^ was applied to selected v a r i a -bles to test f o r possible a s s o c i a t i o n s . A l e v e l of p = .05 or l e s s , two t a i l e d , was 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 . For example, age, sex, manual dexterity were tested for as s o c i a t i o n with d i f f i c u l t y i n eyedrop administration. Continuous v a r i a b l e s such as age were dichoto-mized by using the median as the d i v i d i n g point. (See Appendix G). Socio-economic status was obtained by asking f o r the subject's major l i f e - t i m e occupation. For married women with no work experience, the husband's occupation was used. The stated occupation was then converted to a rank of socio-economic status, using Blishen and McRobert's (1976) scale where f i v e hundred occupations of Canadian workers are indexed and ranked i n descending order of status on a scale of one to f i v e hundred. Findings are presented and discussed i n the following chapter. lThe University 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 So-c i a l Sciences, Version 8, "CROSSTABS," ( K i t a 1980) was used to perform t h i s t e s t . 36 CHAPTER IV PRESENTATION AND DISCUSSION OF FINDINGS The study findings are, presented and discussed i n t h i s chapter i n f i v e sections. The f i r s t section describes c h a r a c t e r i s t i c s of the sam-ple, the second and t h i r d sections present findings related to eye care a c t i v i t i e s and d a i l y l i v i n g a c t i v i t i e s r e spectively, and the fourth sec-t i o n describes personal and environmental factors that influenced patient s e l f - c a r e behaviours. D i f f i c u l t i e s and concerns experienced by patients and family members i n the performance of eye care procedures and d a i l y routine a c t i v i t i e s are described i n t h e i r relevant sections. In the f i f t h section a discussion and i n t e r p r e t a t i o n of the aforementioned f i n d -ings i s presented. SAMPLE CHARACTERISTICS The study sample was a convenience one, representing a l l the post-operative cataract patients (N = 20) i n one h o s p i t a l who met the study e l i g i b i l i t y c r i t e r i a during the three month data c o l l e c t i o n period. Per-sonal c h a r a c t e r i s t i c s and medical parameters associated with the study pa r t i c i p a n t s are presented i n t h i s section, and are summarized i n figures 2 and 3. The sample was composed of th i r t e e n female and seven male patients who ranged i n age from 63 to 83 years (median 71 years). Prior to this h o s p i t a l admission, ten of the respondents (four women and s i x men) l i v e d with able spouses; one woman l i v e d with her daughter; and nine subjects (eight women and one man) l i v e d alone. A l l were Caucasian, of B r i t i s h or 37 European descent. A wide range of socio-economic status was represent-ed. Sixty percent of the subjects had the equivalent of grade 12 educa-t i o n or higher. The range was seven years of schooling to f i v e years of u n i v e r s i t y . Male Female Years (4) 80 - 84 (1) [ (2) 75 - 79 (2) (6) 70 - 74 (3) 65 - 69 (1) c ] (1) 60 - 64 Figure 2. Age and Sex D i s t r i b u t i o n s of Subjects (N = 20) A review of the medical h i s t o r y on the subject's h o s p i t a l chart i n -dicated that this sample was representative i n medical status of the gen-e r a l population of a s i m i l a r age. Chronic medical conditions were r e -ported f o r 16, or 80 percent of the subjects. The majority of these con-d i t i o n s were hypertension (eight subjects) and a r t h r i t i s ( f i v e sub-j e c t s ) . Other medical problems such as angina, chronic obstructive lung disease, and m i t r a l i n s u f f i c i e n c y were also recorded. Five subjects had previously had eye surgery unrelated to the present cataract surgery. Five were being treated f o r glaucoma. The best corrected v i s u a l a c t u i t y i n the subject's unoperated eye ranged from 20/50 to no u s e f u l v i s i o n , and f o r one subject, the operated eye was an only eye. Impairments i n f i n e motor co-ordination were observed i n 12 sub-j e c t s , and a hearing l o s s was noted i n seven. None required a hearing a i d . A l l subjects had t h e i r cataract surgery i n a large metropolitan acute care teaching h o s p i t a l , and received t h e i r pre and postoperative care on an ophthalmology u n i t . Chart review established that a l l sub-jects had standard cataract surgery without lens implant, and no compli-cations occurred during the surgery or during the postoperative h o s p i t a l stay. One ophthalmologist operated on seven of the patients, two others on three each, and the remaining seven patients were operated on by the remaining seven ophthalmologists. Fourteen patients had a general anaes-t h e t i c , s i x a l o c a l anaesthetic. Following surgery, the length of hospi-t a l stay ranged from three to s i x days; the mean was 4.2 days, the mode four days. 39 100- -20 90-1 U-18 80_| P E R C 70_| E N T A 60-1 G E 0 50-1 F S U 4 C M B J E C 30_| T S 20-J 10-1 U 6 20 50 VV 20 80 20 |2001 0 R 20 100 L E S S u N I M P A I R E D I M P A I R E D U N I M P A I R E D I M P A I R E D N .14 U M B E .12 R Uio U 8 U 6 U 2 V i s u a l Acuity Hearing Fine Motor Concomitant Previous unoperated eye Dexterity medical eye conditions surgery Figure 3. Selected Health Related C h a r a c t e r i s t i c s of Subjects (N = 20) 40 EYE CARE ACTIVITIES An overview of expected eye care behaviours, patients' comprehen-sion, d i f f i c u l t i e s experienced and concerns expressed, i s presented v i s u -a l l y i n Table 1. As may be observed, the majority of subjects followed the recommended medical regimen. However, many patients and family mem-bers experienced d i f f i c u l t i e s and concerns i n the course of carrying out the i n s t r u c t i o n s . Detailed accounts of s p e c i f i c eye care findings are presented under headings re l a t e d to the s p e c i f i c study purposes. Administration of Medications as Prescribed Complete adherence to the prescribed medication regime, once medica-tions were obtained, was reported by 18, or 90 percent of the subjects. Of the two remaining subjects, one omitted only one eyedrop administra-t i o n i n the two week period, and the other occasionally a l t e r e d the f r e -quency of i n s t i l l a t i o n s of an eyedrop according to the se v e r i t y of head-aches that were experienced. A l l subjects considered c a r e f u l adherence to the medication routines to be an important patient r e s p o n s i b i l i t y , and perceived t h i s adherence to be a f a c t o r that contributed to a successful v i s u a l outcome. Data re l a t e d to the administration of medications are reported i n the following section under three headings: f i l l i n g the pre-s c r i p t i o n s ; e s t a b l i s h i n g appropriate routines; and i n s t i l l i n g eyedrops. F i l l i n g Prescriptions A l l subjects had a minimum of two d i f f e r e n t kinds of eyedrops pre-scribed. In addition, three subjects had systemic medication (acetazola-mide) ordered. Frequencies of administration varied from once a day to four times a day. No ointments were prescribed. TABLE 1 Examples of Expected Eye Care Behaviours: Adherence, Comprehension, D i f f i c u l t i e s , Concerns, Questions Knew Expectations Unaware of Incurred Concerns Adhered Not Adhered Expectations D i f f i c u l t i e s or Questions I n s t i l l e d eyedrops 18 Took systemic medication 3(b) Wore protective glasses during day 19 Wore protective s h i e l d at night 19 Restric t e d bending, l i f t i n g , s t r a i n i n g , housework, gardening 18 Res t r i c t e d reading 8 Avoided touching eye 18 Washed hands before treatments V i s i t 1(c) 14 V i s i t 2(d) 16 Washed hands following treatments V i s i t 1(c) 0 V i s i t 2(d) 0 2 0 1 1 2 1 2 4 3 0 0 0 0 0 0 0 11 0 0 0 18 19 16(a) 0 0 14 0 0 0 0 0 0 0 16 3 0 8 0 6 0 0 0 0 0 (a) D i f f i c u l t i e s include getting drops into eye; touching l i d s , lashes or eye; manipulating dropper, a g i t a t i n g bottle. (b) Only three persons had parenteral medications ordered. (c) F i r s t home v i s i t - 18 observations made. (d) Second home v i s i t - 19 observations made. 42 The prescribed medications were obtained by a l l subjects. However, i n i t i a l delays i n p r e s c r i p t i o n dispensing, ranging from four to 24 hours, were experienced by four subjects, engendering concern over missing scheduled medication times. These delays were a t t r i b u t a b l e to a d i f -f i c u l t y i n lo c a t i n g a neighbourhood pharmacy that was open on a Sunday, and to the lack of a v a i l a b i l i t y of two s p e c i f i c medications, namely, echothiophate iodide (Phospholine Iodide), and 2.5% phenylephrine hydro-chloride (Neosynephrine), i n small neighbourhood drug stores. Relatives or friends obtained the pres c r i p t i o n s f o r the majority of subjects (16), while pharmacists delivered the medications i n three i n -stances. One subject obtained h i s own medications, taking a t a x i from the h o s p i t a l to a l o c a l pharmacy, and a bus the remainder of the way home. Est a b l i s h i n g Appropriate Routines The establishment of appropriate routines f o r sequencing and remem-bering medication times was accomplished without d i f f i c u l t y by a l l par-t i c i p a n t s . Decisions were frequently based on schedules that had been used by nurses i n the h o s p i t a l . Daily routines such as a r i s i n g , r e t i r i n g and mealtimes provided f o c a l points f o r remembering medicines. One sub-j e c t , who was receiving drops f o r glaucoma as well as the postoperative cataract drops, set an alarm clock f o r each successive medication admin-i s t r a t i o n time i n an endeavour to maintain constant l e v e l s of medication. It was noted that the simpler the routine, the easier i t was f o r subjects to sequence and remember medication times. For example, when two kinds of drops were ordered at 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 the need to d i f f e r e n t i a t e medications was negated. I n s t i l l i n g Eyedrops A v a r i e t y of arrangements were made for eyedrop administration. Table 2 i l l u s t r a t e s the delegation of r e s p o n s i b i l i t y of eyedrop i n s t i l l a -t i o n at the time 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 observations that by the time of the second home v i s i t , the number of subjects who administered t h e i r own drops had increased by a factor of three, and the home care nurse v i s i t s had terminated. Table 2 Delegation of R e s p o n s i b i l i t y for Eyedrop I n s t i l l a t i o n , F i r s t and Second V i s i t (N = 20) Person Responsible f o r Eyedrop I n s t i l l a t i o n V i s i t One* V i s i t Two+ Subject 3 9 Spouse 9 8 Relatives 5 3 Friend 1 0 Home Care Nurse • 2 0 * Day following h o s p i t a l discharge + Postoperative day 13 - 16 Observations of i n s t i l l a t i o n of eyedrops were made i n 37 instances. (Two subjects had home care nurses f o r i n i t i a l i n s t i l l a t i o n and were therefore not observed. One of these subjects refused to 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 from the analysis f o r observed techniques). A graphic p o r t r a y a l of observed eyedrop i n s t i l l a t i o n technique i s presented i n Figure 4, where the reader w i l l observe that a number of d i f f i c u l t i e s were incurred by subjects or family members i n the adminis-t r a t i o n of drops. At the time of the f i r s t v i s i t , s i x family members had d i f f i c u l t y getting the drops i n t o the patient's eye. Two factors c o n t r i -buted totthese d i f f i c u l t i e s ; e i t h e r the subject's head was not t i l t e d f a r enough back to provide an adequate angle f o r administration, or the sub-ject could not hold h i s eye open v o l u n t a r i l y and the family member was reluctant to, or did not know to p u l l down the subject's lower l i d (a maneuver that creates a pocket to receive the drop, and overcomes the need to b l i n k or squeeze the eye shut). Patients had a p a r t i c u l a r l y d i f -f i c u l t time keeping t h e i r eye open v o l u n t a r i l y during the administration of the second of two drops. Contamination of the dropper or b o t t l e t i p was another d i f f i c u l t y , and most frequently occurred when a family member inadvertently touched the lashes or l i d s . None of these p a r t i c i p a n t s used a technique of i n -s t i l l a t i o n that provided support f o r t h e i r hand, such as r e s t i n g the heel of the hand of the subject's brow or temporal bone. Three subjects who were self-administering drops, contaminated the b o t t l e when they placed the dispenser d i r e c t l y on the inner canthus or on the s c l e r a to ensure that the drop went i n t o the eye. With t h i s technique subjects reported d i f f i c u l t y i n judging how many drops had been i n s t i l l e d . 45 Q | f 6 f 10 12 If 16 18 2" Number of respondents W/////A 'A Washed hands before procedure Assumed a safe p o s i t i o n Reclined head to f a c i l i t a t e eyedrop i n s t i l l a t i o n Agitated suspension type drops I n s t i l l e d correct medication Drop went into eye f i r s t attempt Avoided contaminating b o t t l e of drops Washed hands upon completion of procedure Figure 4. Observations of Home Administration of Prescribed Eyedrops Performed ]//'I'/[ Not performed | | Not applicable V i s i t 1: N = 18 (3 subjects, 15 r e l a t i v e s or friends) V i s i t 2: N = 19 (8 subjects, 11 r e l a t i v e s ) Sixteen subjects had a suspension type drop prescribed. Eight of these did not know of the necessity to a g i t a t e the b o t t l e before admin-i s t e r i n g the drops, and neglected to do so. For some, the d i r e c t i o n s on the b o t t l e to "shake w e l l " were too small, to read, and i n three instances the manufacturer's d i r e c t i o n s on the b o t t l e were completely covered by the typed pharmacist's l a b e l . The i n s t r u c t i o n to wash hands before treatments was neglected In s i x instances, and i n no case were hands washed following treatments, a l -though these i n s t r u c t i o n s were on a printed discharge handout sheet (Ap-pendix E) received by 17, or 85 percent of the subjects. The safety of two subjects was jeopardized during medication admin-i s t r a t i o n by the p o t e n t i a l hazard of a f a l l . One 82 year o l d subject, who stood unsupported i n the bathroom while a r e l a t i v e i n s t i l l e d the drops, became unsteady when she t i l t e d her head back to receive the drops. Another subject, precariously balanced on a folded towel on the rim of the bathtub, was i n s i m i l a r jeopardy when he leaned back to f a c i l -i t a t e drop i n s t i l l a t i o n . As may be observed i n Figure 4, most of the d i f f i c u l t i e s were ob-served during the f i r s t home v i s i t . By the second v i s i t , p a r t i c i p a n t s had become more adept and had overcome many of the i n i t i a l d i f f i c u l t i e s . The researcher may have influenced the r e s u l t s of observations for the second home v i s i t on three items. F i r s t l y , i n the two instances where the safety of subjects was jeopardized, the researcher suggested that a safer routine would be to have the subject positioned on a bed or sofa where there would be support during eyedrop i n s t i l l a t i o n . On the second v i s i t , p a r t i c i p a n t s had i n s t i g a t e d t h i s suggestion. Secondly, i n the eight instances that suspension type drops were not agitated, subjects were t o l d of t h i s necessity. F i n a l l y , i n three instances where family members were having great d i f f i c u l t y with eyedrop i n s t i l l a t i o n and the subject was apprehensive of having the b o t t l e touch the eye, the r e -searcher demonstrated a technique of drop i n s t i l l a t i o n that supported the hand holding the dropper. This intervention followed the observation of the family member's i n s t i l l a t i o n of drops, and was done at p a r t i c i p a n t s ' request. Concerns Related to Medications The most frequently stated concern r e l a t e d to medication administra-t i o n was the worry of inadvertently touching and damaging the eye during eyedrop i n s t i l l a t i o n . A second common concern was of squeezing the bot-t l e too hard and i n s t i l l i n g more than one drop. Some examples of f r e -quent questions were: "Does i t matter which drop goes i n f i r s t ? " "Should I wait a few minutes between drops?" "Where on the eye should the drop be placed?" "Should I continue with the drops I was using before surgery as well as the new ones?" " W i l l the drops always be necessary?" Systemic medications were a l s o the subject of questions. While i n h o s p i t a l , some subjects had changes made i n schedules or dosages of medi-cations prescribed p r i o r to the surgery by family doctors, and occasion-a l l y new medications had been added. The question was, which schedule to follow? A l l three of the subjects taking acetazolamide (Diamox) queried whether or not they should have t h i s p r e s c r i p t i o n renewed. In addition to previously mentioned d i f f i c u l t i e s , p a r t i c i p a n t s r e -ported the following problems: 48 1. Containers were i n i t i a l l y d i f f i c u l t to open. The p l a s t i c s e a l i n g c o l l a r s around the b o t t l e tops were d i f f i c u l t to remove, and when l e f t attached to cap, prevented secure replacement of the bo t t l e top. Eyedrop bottles 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 tubes also presented problems, and once opened, tops were frequently l e f t o f f , or the container was not used at a l l . 2. The printed i n s t r u c t i o n s on b o t t l e s , and the typed pharmacist's l a -be l were too small f o r many subjects to read. I n i t i a l help from f r i e n d s , r e l a t i v e s and home care nurses enabled subjects to d i f f e r -e ntiate and organize medications. Physical c h a r a c t e r i s t i c s such as colour, shape, s i z e and place of storage were used to t e l l medica-tions apart. In several instances, d i f f e r e n t i a t i o n was unnecessary as drops were ordered at simultaneous i n t e r v a l s . 3. P l a s t i c dropper b o t t l e s were s t i f f to squeeze, and the amount of pressure needed to emit just one drop was d i f f i c u l t to judge. Sub-ject s worried that several drops would spurt out at one time. 4. Replacing droppers i n glass bottles was d i f f i c u l t because of de-creased depth perception. Two of the four subjects who had drops dispensed i n glass medicine bottles with separate droppers tipped over the b o t t l e when they were attempting to replace the dropper. These subjects learned to locate the b o t t l e c a r e f u l l y by touch, hold i t securely and f e e l f o r the opening to replace the dropper. Manip-u l a t i n g the small rubber bulb on the glass dropper, and judging i f there were enough drops sucked up i n t o the dropper, posed problems fo r three of these four p a r t i c i p a n t s . 5. Subjects who i n s t i l l e d t h e i r own drops reported d i f f i c u l t i e s i n judging the angle at which they were holding the dropper or b o t t l e , and i n judging the distance the dispenser was from the eye. Three subjects, who had been i n s t i l l i n g t h e i r own drops f o r glaucoma f o r several years p r i o r to t h i s cataract surgery, commented on the new d i f f i c u l t y presented by t h e i r i n a b i l i t y to see the p o s i t i o n of the b o t t l e . D i f f i c u l t i e s reported by p a r t i c i p a n t s and the frequency of t h e i r occur-rence are summarized i n Table 3. Table 3 Summary of Reported D i f f i c u l t i e s by Type, Frequency, and Person Number of Par t i c i p a n t s Patient Family T o t a l alone member number % 1. Opening container 4 5 9 45 2. Reading la b e l s 8 - 8 40 3. Squeezing b o t t l e 3 5 8 40 4. Obtaining p r e s c r i p t i o n (delay > 6 hours) - 2 2 10 5. S p i l l i n g eyedrops 2 - 2 50* 6. Manipulating separate dropper 2 1 3 75* * Only four subjects had eyedrops dispensed i n glass bottles with a separate dropper. 50 Protection of the Eye from Injury Use of Eye Glasses, Protective Eye Shield The majority of subjects (19) used dark glasses or t h e i r own pre-s c r i p t i o n glasses during the day and the metal protective eye s h i e l d at night, to protect the eye from inadvertent rubbing or bumping. One sub-jec t did not own p r e s c r i p t i o n glasses, and found the h o s p i t a l issued dark glasses were uncomfortable to wear a l l day. This subject did, however, wear the dark glasses outdoors. Several subjects reported that the dark glasses reduced t h e i r a b i l i t y to see with the unoperated eye and made i t d i f f i c u l t to get around. One creative i n d i v i d u a l solved t h i s problem by buying c l i p - o n p l a s t i c dark glasses and cu t t i n g o f f the side that would have covered the unoperated eye. One subject did not understand the need f o r the metal s h i e l d , and discontinued i t s use on the t h i r d day home from h o s p i t a l . Four subjects used the s h i e l d and an eye pad f o r extra periods during the day as we l l as at night, s t a t i n g that the pad and s h i e l d gave them a f e e l i n g of se-c u r i t y and comfort. These four subjects were not aware of any contra-i n d i c a t i o n to t h i s behaviour, such as the p o s s i b i l i t y of increasing the r i s k of i n f e c t i o n within an enclosed environment. No subjects reported any interference with t h e i r sleep because of the s h i e l d ; however, many had d i f f i c u l t i e s with i t s a p p l i c a t i o n . Types of d i f f i c u l t i e s , and the frequency of occurrence are i l l u s t r a t e d i n Table 4. 51 Table 4 Eye Shield D i f f i c u l t i e s by Type and Frequency Number of D i f f i c u l t y P a r t i c i p a n t s % Observed 1. Positioning s h i e l d : nasal or temporal portion of eye l e f t exposed, or s h i e l d rested on s o f t portion of eye 8 40 2. Manipulating tape: s h i e l d slipped out of place when p a r t i c i p a n t reached f o r r o l l of tape 11 55 Reported 1. Tape i r r i t a t i n g to skin 5 25 2. Tape did not s t i c k w e l l 5 25 Successful applications of the eye s h i e l d were accomplished by: 1) placing a s t r i p of tape on the s h i e l d before applying i t , or 2) having the patient hold the s h i e l d i n place while a family member applied the tape. I t should be noted that, while i n most instances d i f f i c u l t i e s were rela t e d to lack of f a c i l i t y , i n two instances the s h i e l d did not f i t the configuration of the patient's face. Problems rel a t e d to the tape i t s e l f were solved when subjects changed to transparent mending tape, masking tape, or dermapore/micropore tapes. Questions that p a r t i c i p a n t s frequently asked the researcher were: 1. Is there a side that i s supposed to go next to the nose? 2. At what angle should the s h i e l d be positioned? 3. Should the s h i e l d be s t e r i l i z e d each day? 4. Is i t a l l r i g h t to use a folded Kleenex under the s h i e l d at night? 52 R e s t r i c t i o n of A c t i v i t y The discharge i n s t r u c t i o n sheet provided to patients i n t h i s study proscribes actions which involve bending, l i f t i n g , s t r a i n i n g ; and u n t i l d irected by the doctor, reading, housework, gardening, and returning to work. As the reader w i l l have noted i n Table 1 (p. 41), with the excep-t i o n of the reading p r o s c r i p t i o n , 18, or 90 percent of the subjects com-p l i e d with the recommendations. Subjects reported that they used a v a r i -ety of strategies to comply. For example, they bent t h e i r knees or used salad tongs to pick up f a l l e n objects, and kept items they needed at counter l e v e l . None of these subjects reported that the r e s t r i c t i o n s presented any d i f f i c u l t y other than remembering about them. Both of the subjects who reported non-compliance resumed housekeep-ing a c t i v i t i e s , although they did have other people a v a i l a b l e to help them. One subject within two weeks of surgery hoed the garden, vacuumed the house, and c a r r i e d two large bags of groceries f i v e blocks home from the store. The sanction on reading was the l e a s t understood r e s t r i c t i o n , and stimulated questions regarding how much would be t o l e r a b l e and how long i t should be r e s t r i c t e d . Several subjects conjectured that reading would be acceptable as long as the operated eye was covered. Precautions to Avoid F a l l i n g and Bumping the Eye A l l subjects s a i d they took precautions against f a l l i n g by using r a i l i n g s on s t a i r s , steadying themselves when necessary on f u r n i t u r e i n the home, and walking c a r e f u l l y outdoors on uneven ground. Several sub-jec t s reported that since the surgery i t was more d i f f i c u l t to judge the 53 speed and distance of cars. They, therefore, now used i n t e r s e c t i o n s with t r a f f i c l i g h t s to cross busy str e e t s even i f I t meant walking a few blocks further. Complicated f u r n i t u r e arrangements or loose s c a t t e r rugs were no-t i c e d by the researcher i n s i x of the homes, but subjects stated they were f a m i l i a r with these and did not perceive them as a hazard. Walking s t i c k s were unacceptable to 18 subjects, mostly because of an a s s o c i a t i o n with being o l d . One seventy-one year old subject t y p i f i e d the r e p l i e s of other subjects with the comment, "I am not an old woman. When I get o l d I w i l l use a cane." Another, eighty-two years of age, stated she might f i n d a r o l l e d up umbrella acceptable but a walking s t i c k would give the appearance of old age, so she would not use one. Five subjects described incidents that had p o t e n t i a l for eye i n j u -ry. Two subjects f e l l when they got out of bed during the night i n the unfamiliar surroundings of a daughter's home. 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 on the rim of a bathtub to hang up laundry and misjudged the distance down to the f l o o r . The f i f t h poked his eye with the earpiece of his glasses as he was putting them on. Few people (seven) were aware of a precaution when putting on spectacles, of holding them by the ear t i p s to avoid such an accident. None of these incidents was deemed serious enough to report to the ophthalmologist, and indeed no eye problem was noted on the subse-quent check-up v i s i t . 54 Maintenance of Cleanliness of the Eye "Bathe your eyes with warm tap water as necessary, using s t e r i l e cotton b a l l s which may be purchased at the drugstore" i s an i n s t r u c t i o n on the printed discharge sheet. S t e r i l e cotton b a l l s were not a v a i l a b l e i n any of the drug stores i n which p a r t i c i p a n t s i n t h i s study attempted to purchase them. Some family members spent considerable time t r y i n g to locate a drug store that c a r r i e d s t e r i l e cotton b a l l s and f i n a l l y pur-chased n o n - s t e r i l e cotton or rayon b a l l s packaged f o r cosmetic or f i r s t -a i d use. These persons were concerned that they were not using s t e r i l e cotton b a l l s as i n s t r u c t e d . Two p a r t i c i p a n t s purchased s t e r i l e r o l l e d cotton and pul l e d o f f portions as necessary, and s i x used cotton b a l l s they already had on hand. Two subjects queried the frequency implied i n the words, "as necessary." Figure 5 i l l u s t r a t e s eye cleansing behav-i o u r s . 14 3 3 cleansed eye with warm water and cotton b a l l s as necessary not necessary no mucus or crusts unaware of i n s t r u c t i o n s : used dry cotton b a l l s or face c l o t h to wipe eye Figure 5. I l l u s t r a t i o n of Patient Adherence to Eye Cleansing Instructions 55 Provision of Comfort Measures When Necessary Thirteen subjects reported mild discomfort i n t h e i r eye, usually de-s c r i b i n g the f e e l i n g as " i t c h y " or "scratchy," and eight patients com-plained of browache. A t o t a l of s i x patients deemed t h e i r discomfort troublesome enough to occasionally take an over-the-counter headache rem-edy, a measure which, with one exception was e f f e c t i v e . Seven had no discomfort at a l l . Discomforts and measures for t h e i r r e l i e f are i l l u s -t rated i n Table 5. A l l subjects with i n i t i a l discomforts reported im-provements by the second home v i s i t . Table 5 Discomforts by Frequency, Severity and Comfort Measures Discomforts Number of subjects reporting Severity Comfort measures F 1. Browache 7 mild-mod. used over-the-counter 1* severe headache remedy 4 2. Eye i t c h y , 13 mild cleansed eye 5 scratchy - lay down and rested eye 4 - put on pad and s h i e l d 4 - used over-the-counter headache remedy 2 3. Photophobia 11 mild drew drapes 4 — wore dark glasses 11 4. Cigarette smoke i r r i t a t i n g 3+ — avoided smoky areas 3 5. Eyedrops stung 3 mild * One subject experienced i n c r e a s i n g l y severe headaches which were unrelieved by home remedies. The ophthalmologist was n o t i f i e d , and frequency of echothiophate iodide (Phospholine Iodide) drops were reduced. + These subjects were a l l non-smokers themselves. 56 Recognition and Reporting of S i g n i f i c a n t  Indicators of Complication S p e c i f i c signs and symptoms deemed reportable by subjects were as follows: severe pain i n the eye; onset of nausea or vomiting; discharge from the eye; increased redness; severe headache; change i n v i s i o n ; swelling. Table 6 indicates the number of subjects who considered each sign or symptom reportable. A free response was the spontaneous reply to the i n -terview schedule item: "When patients leave h o s p i t a l they are usually i n s t r u c t e d to phone t h e i r doctor i f they have undue discomfort or notice a change i n the condition of t h e i r eye. What s p e c i f i c signs would you think required a c a l l to your eye doctor?" When subjects had completed the spontaneous response, they were prompted by the question, "Do you think you would c a l l your eye doctor i f you noticed:- A l l items i n the table were subject to a prompting except "swelling," which was not o f f e r -ed. A l l subjects stated that they would have had no h e s i t a t i o n i n phon-0 ing t h e i r eye doctor i f there was any concern about t h e i r eye, although one subject would have been reluctant to c a l l on a weekend. For 13 of the subjects, the ophthalmologist was the only person they would have consulted. The remaining seven had secondary sources f o r information or reassurance; family doctor, home care nurse, h o s p i t a l eye ward, neigh-bours or r e l a t i v e s who were nurses. Six subjects made phone c a l l s to the ophthalmologist before t h e i r f i r s t postoperative o f f i c e check-up; one c a l l was to report a severe headache, and f i v e were requests 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 . 57 Table 6 Indicators of Possible Complication and Subject's Perception of Need to Report Number of subjects who would report Sign or sympton Free response Prompted Total Severe pain i n the eye 17 3 20 Onset of nausea or vomiting 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 + Two persons l i v i n g alone stated notice a change i n the amount of * Reported they could not see redness w e l l enough to Status of the Operated Eye On each of the two home v i s i t s observations were made of l i d s , cor-nea, conjunctiva, anterior chamber, p u p i l and i r i s . In no instance was a sign or symptom of a possible complication noted that merited a report to the opthalmologist. Detailed eye status observations may be found i n Appendix F. Continued Medical Supervision A l l subjects made and kept appointments f o r continued medical super-v i s i o n . Transportation to the doctor's o f f i c e was d i f f i c u l t f o r only one subject and a volunteer d r i v e r was arranged through the l o c a l health u n i t to solve t h i s problem. Table 7 i l l u s t r a t e s transportation methods used by subjects to attend medical appointments. 58 Table 7 Methods of Transport to Medical Appointments by Type and Frequency Number of subjects 1. Driven by a r e l a t i v e or f r i e n d 11 2. Driven by community volunteer 1 3. Bus, accompanied by r e l a t i v e or f r i e n d 6 4. Bus, unaccompanied 1 5. Taxi 1 General Concerns Related to the Eye For the majority of subjects (70%) the cataract surgery i t s e l f was not s t r e s s f u l . Of the 12 subjects who had experienced previous surgery with which to make a comparison, 10 f e l t that the cataract surgery was "minor;" "easier;" "not as p a i n f u l " as t h e i r previous abdominal, ortho-paedic, p r o s t a t i c or glaucoma surgery. However, a successful v i s u a l out-come from the surgery, with a l l the resultant anticipated b e n e f i t s , was perceived as extremely important to a l l these subjects, and influenced t h e i r behaviour and concerns. Patients commented that i n s p i t e of a gen-e r a l o p t i m i s t i c outlook, generated by confidence i n t h e i r doctor, s t a t i s -t i c a l p r o b a b i l i t y of success, and examples of successful outcomes among friends and r e l a t i v e s , they a l l had an underlying pervasive concern about the improvement i n v i s i o n they would obtain. The f i r s t occasion on which a t r i a l lens was presented, and subjects could read l e t t e r s on the chart, 59 or c l e a r l y see objects i n the room, was both a r e l i e f and a moment of ex-citement. As one subject 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 subject had severe concerns about the outcome of the sur-gery. This subject, and spouse had expected improved v i s i o n immediately, and perceived the presence of s t i t c h e s to be i n d i c a t i v e of a complication i n the surgery. Their concern was evident i n t h e i r f a c i a l and vocal ex-pressions; and t h e i r lack of understanding was exemplified by the spouse's remark, "We thought i t was just a cataract removal, which i s just one day . . . you know . . . they l i f t i t off and send you home -but i t wasn't that at a l l . " The subject anxiously reported, "I can't see nothing yet! I'm b l i n d i n that eye!" DAILY LIVING ACTIVITIES At the time of h o s p i t a l discharge, 16, or 80 percent of the subjects were very confident that they could manage t h e i r personal care and house-hold tasks with the help they had a v a i l a b l e from family members and com-munity services. The remaining four subjects were concerned that a n t i c i -pated decreased v i s u a l acuity, or decreased energy l e v e l would a f f e c t t h e i r a b i l i t y to manage at home. These subjects reported that they were pleasantly surprised, once they were home," at how well they were able to 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 l i v -ing a c t i v i t i e s are reported i n the following s e c t i o n . 60 L i v i n g Arrangements P r i o r to t h i s surgery, 10 subjects l i v e d with able spouses, one with a daughter, and nine l i v e d alone. Following surgery, f i v e people made temporary changes i n l i v i n g arrangements. Table 8 i l l u s t r a t e s these a r -rangements and associated sex d i s t r i b u t i o n s . Table 8 Li v i n g Arrangements Postsurgery by Change and Sex L i v i n g arrangements Number of subjects M F Change Moved i n with daughter 3 Moved i n with s i s t e r * 1 Daughter moved i n with subject 1 No Change Lived with able spouse 6 3 Lived with daughter 1 Lived alone 1 4 * Permanent residence out of town 61 U t i l i z a t i o n of Community Services Homemaker ser v i c e , Home Care nursing service, and a volunteer trans-portation service were used by f i v e subjects. De t a i l s are i l l u s t r a t e d i n Table 9. Table 9 U t i l i z a t i o n of Community Services Pre and Postsurgery L i v i n g arrangements Community services used Subject code # Sex Age Presurg. Postsurg. Presurg. Postsurg. 5 F 77 Alone Alone Homemaker Homemaker 6 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* * Subject discontinued homemaker a f t e r one week; no longer necessary Homemaker services were usually provided four hours per week; how-ever, one subject's homemaker was ordered for two hours per day. This amount of help was perceived as more than necessary and was discontinued by the subject a f t e r one week. A home care nurse i n s t i l l e d drops f o r two subjects, and taught independent administration. The average number of nursing v i s i t s was f i v e , and included a follow-up supervisory v i s i t ap-proximately one week a f t e r subjects had assumed r e s p o n s i b i l i t y f o r t h e i r own treatments. 62 Home Maintenance A c t i v i t i e s Most subjects (19) arranged f o r another person, e i t h e r spouse, r e l a -t i v e , f r i e n d or homemaker to do the heavy housecleaning, gardening, laun-dry and grocery shopping during the f i r s t few weeks following surgery. No d i f f i c u l t i e s or concerns were expressed. Self-Maintenance A c t i v i t i e s Daily a c t i v i t i e s such as meal preparation, bathing, dressing, sleep-ing, and elimination, were assessed and were reported to present no prob-lem. Even the subjects who l i v e d alone were able to manage t h e i r own meal preparation, and by the time of the second home v i s i t , had resumed grocery shopping f o r themselves. Many commented on the f a c t that the q u a l i t y of t h e i r sleep was greatly improved now that they were back i n the f a m i l i a r surroundings of t h e i r own home. The i n s t r u c t i o n , "You may have your h a i r washed and set" (Appendix E) was interpreted i n d i v i d u a l l y to produce a wide range i n behaviour, be-ginning at one end of the scale with an i n d i v i d u a l who showered and sham-pooed on postsurgery day f i v e , to an i n d i v i d u a l who planned to wait u n t i l at l e a s t four weeks postsurgery before having a p r o f e s s i o n a l shampoo and set. The timing of, method of, and safety of h a i r shampoo was queried by over 50 percent of the subjects, but none considered t h i s a c t i v i t y a problem. A v a r i e t y of adaptations were made i n routine a c t i v i t i e s i n order to comply with precautionary measures, these are l i s t e d i n Appendix H. 63 Leisure A c t i v i t i e s and Exercise A l l subjects reported that they were less a c t i v e than before t h e i r surgery, a s i t u a t i o n a t t r i b u t e d to compliance with a c t i v i t y r e s t r i c t i o n s or to poor v i s u a l acuity, rather than lack of energy. On the day of h o s p i t a l discharge, f i v e subjects went out for walks, unaccompanied, i n t h e i r own neighbourhoods. By 14 days postsurgery, the majority of pa-t i e n t s (18) had been out for walks, one averaged s i x miles a day. Pleas-ant summer weather during the time t h i s study was conducted f a c i l i t a t e d outdoor exercise. For 11 subjects, the a b i l i t y to see to perform usual a c t i v i t i e s did not seem to be as good as i t was before surgery, even though for these subjects the eye with the l e a s t v i s i o n had received the surgery. In t h e i r opinion, e i t h e r the v i s i o n i n the "good" eye had deteriorated or the operated eye i n t e r f e r e d with the v i s u a l a b i l i t y i n the best eye. Temporary or " p r a c t i c e " glasses which were an approximation of the required p r e s c r i p t i o n were given to f i v e subjects. A l l of these had v i -sion i n the unoperated eye of 20/100 or l e s s ; two had no v i s i o n at a l l (one was monocular, and one had no u s e f u l v i s i o n as a r e s u l t of a p r e v i -ous r e t i n a l detachment). These f i v e subjects remarked on, but quickly adjusted to the magnified image and d i s t o r t e d peripheral v i s i o n . The temporary glasses enabled them to function more independently i n t h e i r d a i l y a c t i v i t i e s , and were a source of encouragement as a harbinger of future v i s u a l a b i l i t y . Most subjects spent t h e i r time v i s i t i n g with or chatting on the t e l -ephone with friends and r e l a t i v e s , watching t e l e v i s i o n , l i s t e n i n g to mu-s i c , doing l i g h t household jobs, and going out shopping. Six subjects 64 complained that time dragged and they were very bored, the remainder were content to accept and abide by the temporary r e s t r i c t i o n s . Three men, who had been employed p r i o r to surgery, were anxious to return to work. Several subjects mentioned that i t was easy to forget they had even had surgery because there was no bandage, l i t t l e discomfort, and they f e l t so w e l l . Two subjects reported that they were unable to see w e l l enough f o l -lowing surgery, even with a magnifying lens, to d i a l t h e i r telephone. Both had spouses who did the d i a l i n g f o r them, but they f e l t stranded when they were l e f t alone. Neither phone had a large p r i n t d i a l a ttach-ment, and neither family knew of the free service a v a i l a b l e to low v i s i o n customers whereby the operator w i l l look up any requested number and make the connection. Other subjects used magnifying lenses, temporary cata-ract glasses, and large p r i n t d i a l s to f a c i l i t a t e independent use of the telephone. PERSONAL AND ENVIRONMENTAL FACTORS THAT INFLUENCED BEHAVIOURS, DIFFICULTIES, AND CONCERNS A number of personal and environmental factors that influenced the performance of eye care procedures and d a i l y l i v i n g a c t i v i t i e s have a l -ready been mentioned i n the course of reporting data pertinent to those behaviours. Additional factors reported by subjects as being i n f l u e n -t i a l , 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 s k i l l s , understand-ing and perceptions of cataracts and cataract surgery, and the h e l p f u l -ness of support systems i s presented i n the following s e c t i o n . 65 Requisite Knowledge and S k i l l s f o r Home Eye Care P r i o r to h o s p i t a l discharge, a l l subjects received some i n s t r u c t i o n s pertaining to home eye care procedures and the recommended precautionary measures. Major sources of information were reported as: the doctor (mentioned by 18 subjects), and the discharge i n s t r u c t i o n sheet presented by nurses (received by 17 subjects). Other sources were: the h o s p i t a l resident doctor, home care nurse, friends and r e l a t i v e s who had had cata-ract surgery, and other patients In the h o s p i t a l room. Patients and family members found the discharge i n s t r u c t i o n sheet h e l p f u l , and were glad to have printed material to which they could r e f e r . However, seven patients were unable to read the i n s t r u c t i o n sheet; two of these l i v e d alone. It was h e l p f u l when the nurse discussed the i n s t r u c t i o n s , elaborating on or c l a r i f y i n g points. Several subjects stated that they l i k e d to know the p r i n c i p l e s or reasons behind pro-scribed a c t i v i t i e s so that they could judge the safety of a v a r i e t y of other 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 i n s t r u c t i o n s . Family members were present, and able to p a r t i c i p a t e i n the discus-sion of home care management precedures, i n nine of the twenty cases. A l l of these subjects and family members reported that i t was h e l p f u l to 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 easy to forget or misinterpret points, e s p e c i a l l y during the excitement of getting ready to go home. The timing of information regarding home care expectations was also an important f a c t o r . The eight subjects who had knowledge p r i o r to hos-p i t a l admission reported t h i s advance information enabled them to arrange f o r assistance from r e l a t i v e s , put t h e i r house and garden i n order, and 66 stock up on staple food items so that these factors would not be a source of concern immediately a f t e r h o s p i t a l discharge. These subjects, and an a d d i t i o n a l four who reported they received information on several occa-sions during t h e i r h o s p i t a l stay, had time to think of questions and as-si m i l a t e the information. Eight p a r t i c i p a n t s perceived that they had r e -ceived home eye care information only on the morning of h o s p i t a l d i s -charge. Three of these subjects v o l u n t a r i l y commented that i t was d i f -f i c u l t to concentrate on i n s t r u c t i o n s that were provided Immediately p r i o r to going home, when t h e i r thoughts were on h o s p i t a l discharge rou-tines and waiting r e l a t i v e s . A demonstration of eyedrop i n s t i l l a t i o n was provided f o r seven sub-j e c t s ; verbal i n s t r u c t i o n s were given to others. Hospital nurses gave a demonstration to four r e l a t i v e s who requested the assistance, a doctor i n i t i a t e d one demonstration f o r a spouse, and home care nurses taught the procedure to two subjects i n t h e i r homes. Table 10 re l a t e s demonstration of eyedrop i n s t i l l a t i o n with previous experience i n i n s t i l l i n g eyedrops. Table 10 Eyedrop I n s t i l l a t i o n : Demonstration by Previous Experience Demonstration Yes No Previous Experience with Yes 2* 11 Eyedrop I n s t i l l a t i o n No 5+ 2 *1 f r i e n d and 1 spouse +2 subjects, 2 daughters, 1 spouse A l l of the subjects who received a demonstration thought i t was very h e l p f u l , f i v e others would have l i k e d to have had someone show them how to i n s t i l l the drops. Eight p a r t i c i p a n t s thought a demonstration was un-necessary as they had i n s t i l l e d eyedrops on previous occasions, u s u a l l y fo r t h e i r c h i l d r e n . Of these eight with previous, experience, only two performed the procedure without d i f f i c u l t y or concern once they were at home. With the exception of the subjects v i s i t e d by home care nurses, no patient nor family member had the opportunity to be assessed i n the a b i l -i t y to manage eyedrop i n s t i l l a t i o n or a p p l i c a t i o n of the eye s h i e l d and receive reassurance or co r r e c t i o n i f necessary. It was noticeable that the subjects who had home nurse v i s i t s were confident i n t h e i r a b i l i t y to manage t h e i r own care, and had no unanswered questions. Several p a r t i c i -pants, who recognized the researchers nursing r o l e , commented on the helpfulness of having a nurse come to t h e i r home so that they could ask questions, receive reassurance about l i t t l e concerns, have eye care pro-cedures supervised, and have the operated eye examined. Understanding of Cataract and Cataract Surgery Subjects stated that knowledge and understanding of cataract, cata-ract surgery, and postoperative expectations was h e l p f u l i n a l l a y i n g anx-i e t y and reducing the number of concerns. This concept was exemplified i n the response of one subject, "If you r e a l l y understand what i s happen-ing, you are more relaxed about the whole process." A v a r i e t y of answers were given by subjects to the questions about what a cataract i s , and the s u r g i c a l and recovery process. Some examples of subject's comments were: 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 studied i t par-t i c u l a r l y . . . ! think I may t r y contact lenses. I c e r t a i n l y don't want to wear those thick heavy glasses. I don't l i k e the looks of them! ...The doctor says I w i l l have to wait a month or so before I get them." "Dr. ( h o s p i t a l resident) explained everything. He used a model that comes apart to show me the insides of an eye...and the cloudy lens that i s taken out. . . . I t was very i n t e r e s t i n g and very r e -assuring. ...Later on I w i l l get glasses. I am used to glasses." "I know I have the s e n i l e type of cataract where the lens gradually becomes opaque and has to be removed. ...The lens i s behind the aqueous humour so an i n c i s i o n i s made above the cornea and the lens i s taken out. Then you need to replace that lens. ...I am planning to have contact lenses i n about three months...or whenever the eye i s healed. They give better peripheral v i s i o n , but I w i l l have ca-taract glasses as well so that I won't be e n t i r e l y dependent on the contact lens. I might drop i t sometime and not be able to f i n d i t . " The content of subject's responses was summarized and categorized. Table 11 represents the author's i n t e r p r e t a t i o n of subject's responses. Table 11 Subjects' Comprehension of Cataracts and Cataract Surgery No. of Subjects 1. A cataract i s an opacity or clouding of the lens 2. The surgery e n t a i l s entry i n t o the eye and 15 closure with sutures 15 3. A waiting period i s expected postoperatively before c o r r e c t i v e lenses could be f i t t e d 4. A cataract i s a f i l m over the eye that would be peeled o f f during surgery 15* 4 5. No concept of a cataract 1 * Two of these persons were surprised at the length of the waiting period On the whole, study p a r t i c i p a n t s reported that they were s a t i s f i e d with the amount of knowledge they had. There was one exception, p r e v i -ously discussed, where a couple was very concerned over the outcome of surgery, because of lack of understanding. The other few subjects who had l i t t l e or inaccurate information were quite content, commenting that "ignorance i s b l i s s , " "the doctor knows what to do," and "I take things as they come." Sources of information about cataracts and cataract surgery were r e -ported as: eye doctor; resident; r e l a t i v e s and friends who had had cata-ract surgery; a t e l e v i s i o n programme on eye surgery; newspaper a r t i c l e s ; pamphlets obtained from Canadian National I n s t i t u t e f or the B l i n d booth at the P a c i f i c National E x h i b i t i o n , and discussion with the person man-ning the booth; d i c t i o n a r y ; l i b r a r y books; and information received from answering an advertisement i n a United States magazine. Support Systems A l l subjects i n t h i s study had at l e a s t one close r e l a t i v e or f r i e n d who could be instrumental i n providing d i r e c t assistance and/or emotional support. In addition, many subjects had large extended f a m i l i e s , neigh-bours and church group friends who took an i n t e r e s t i n t h e i r welfare, providing companionship, outings and d i v e r s i o n s . Family members were re -ported to have been p a r t i c u l a r l y h e l p f u l i n reminding subjects of precau-tions and medication times. Although a strong desire for independence was both expressed by subjects and observed by the researcher, the sup-port of interested friends and r e l a t i v e s was welcomed and appreciated. 70 Length of Hospital Stay S a t i s f a c t i o n with length of h o s p i t a l stay was expressed by the ma-j o r i t y (17) of subjects. Two of these subjects, one discharged three days following surgery, and one s i x days, remarked that they could have managed at home sooner, i f that had been the doctor's recommendation. One patient, discharged postsurgery day four, who developed severe head-aches, thought the headaches might have been avoided had the stay i n hos-p i t a l been longer. Two subjects, discharged f i v e and s i x days a f t e r sur-gery thought they might have benefited by a few more h o s p i t a l days. The expectations of these l a t t e r two were i n part influenced by the e x p e r i -ences of friends who had stayed i n h o s p i t a l for a week following cataract surgery. Demographic Factors The Fisher Exact Test of Association, C&2 - «05 using two by two con-tingency tables was used to examine the p o s s i b i l i t y of a s s o c i a t i o n be-tween demographic variables such as age, sex, education l e v e l , socio-economic status, length of h o s p i t a l stay, manual dexterity, and v i s u a l acuity, with performance variables such as d i f f i c u l t i e s i n administering eyedrops, confidence i n managing eyedrop i n s t i l l a t i o n , comprehension, ex-pression of concern. The only a s s o c i a t i o n that was p o s i t i v e at the .05 l e v e l of s i g n i f i c a n c e was a r e l a t i o n s h i p between age greater than 71 years, and concerns as evidenced by phone c a l l s to the ophthalmologist. Because of the small sample s i z e few performance variables had a frequency of occurrence s u f f i c i e n t to perform a test of association, and conclusions drawn from r e s u l t s of variables that were tested must be i n -71 terpreted with caution. Tested variables and t h e i r s i g n i f i c a n c e l e v e l s may be found i n Appendix G. DISCUSSION The Sample The subjects i n t h i s study are f a i r l y representative of t h e i r age group i n the general population although a s l i g h t l y higher proportion of these subjects l i v e d alone than i s generally reported. U t i l i z a t i o n of community services f o r assistance, and the presence of concomitant gener-a l medical conditions i s also consistent (Brody, 1980). The r e l a t i v e l y large proportion of subjects with glaucoma as an a d d i t i o n a l diagnosis may r e f l e c t the patterns of p r a c t i c e of contributing ophthalmologists, but may also r e f l e c t the a s s o c i a t i o n of some kinds of miotic eyedrops with cataract formation (Nurses's Guide to Drugs, 1980, p. 816-823). The ab-sence i n the study sample of patients with the diagnosis of diabetes m e l l i t u s i s not s u r p r i s i n g . Although such i n d i v i d u a l s are recognized to be p a r t i c u l a r l y prone to the development of cataracts (Duke-Elder, 1969, p. 166; Mausolf, 1975, p. 200) the progression of the opacity i s a c c e l e r -ated ( C o t l i e r , 1981). On the average, cataract surgery i s indicated i n d i a b e t i c patients at an e a r l i e r age than i n the general population. Therefore, subjects with diabetes would tend to be younger than t h i s study's sample, f o r whom the age requirement was over 60 years. The average length of stay of 5.2 days (4.2 postsurgery) was lower than the average stay reported i n Canada i n 1977 ( S t a t i s t i c s Canada) and may r e f l e c t the continuing trend of decreased h o s p i t a l stay (Nadler & Schwartz, 1980). Age did not appear to be a f a c t o r r e l a t e d to length of 72 h o s p i t a l stay, for an 80 and an 83 year old subject went home on the t h i r d postoperative day, and two 71 year old subjects were discharged on the f i f t h and s i x t h postoperative days r e s p e c t i v e l y . S i m i l a r l y , the pre-sence of chronic medical conditions did not appear to be r e l a t e d to length of stay, for the subject with the longest stay had no diagnosed concomitant medical condition. It would appear that i n t h i s small sam-ple, the length of h o s p i t a l stay most l i k e l y r e f l e c t s the customary prac-t i c e of the attending ophthalmologist. Because of s e l e c t i o n c r i t e r i a f o r the study, non-English speaking people were not represented i n the sample. However, i t would be reason-able to postulate that such a subject would incur even more d i f f i c u l t i e s and concerns, e s p e c i a l l y those that are r e l a t e d to communication of i n -s t r u c t i o n s . Adherence The high rate of adherence (90%) to the medical regimen was notable i n t h i s study when compared with the general compliance l i t e r a t u r e r e -viewed by Blackwell (1973), where the non-compliance rate ranged from 25 to 50 percent, or with reports from the ophthalomology l i t e r a t u r e where most studies report a non-compliance rate of 28 percent (Bloch et a l . , 1977) to 58 percent (Vincent, 1971) depending on the d e f i n i t i o n of non-compliance. A f i n d i n g congruent with t h i s study i s a recent report by Worthen (1979) that indicates a compliance rate of 95 percent to t i m o l o l maleate (Timoptic), a long acting glaucoma drug that requires administra-t i o n only once or twice a day. Factors contributing to the favourable rate of adherence among sub-jects i n t h i s study could be postulated as follows: 73 1. A successful v i s u a l outcome was of great importance to the subjects, and complete adherence to medication recommendations was perceived as a s i g n i f i c a n t f a c t o r i n a t t a i n i n g v i s u a l improvement. The theo-r e t i c a l framework (Lewin, 1951) supports t h i s premise. 2. The condition i s acute and of r e l a t i v e l y short duration, so compli-ance problems associated with long term medication administration (Blackwell, 1973) have not developed. 3. Subjects i n the age group of those i n t h i s study frequently have other medical conditions f o r which they have established medication schedules. Incorporating eye medications i n t o an already e x i s t i n g schedule did not necessitate a major change i n habits or l i f e s t y l e , a f a c t o r i d e n t i f i e d by a number of authors as a f f e c t i n g compliance (Davis & Eichhorn, 1963; McAlister et a l . , 1976; Tagliacozzo & Ima, 1970). Furthermore, Vincent (1971) reports that patients on system-i c medication were more l i k e l y to comply with recommended glaucoma drop schedules. 4. Medication schedules were us u a l l y uncomplicated and easy to remem-ber, a fa c t o r associated with compliance i n e l d e r l y people (Neely & Patric k , 1968; Parkin et a l . , 1976; Schwartz et a l . , 1964). 5. The occurrence of unpleasant side e f f e c t s was minimal, and many pa-tie n t s reported the drops made t h e i r eye more comfortable. 6. The i n t e r a c t i o n between physician and patient was highly s a t i s f a c -tory. This contention i s supported by the facts that patients were knowledgeable about medication i n s t r u c t i o n s , f e l t free to discuss t h e i r concerns and v a l i d a t e perceptions, had no reluctance to phone t h e i r doctor i f anything worried them, f e l t t h e i r doctor was highly 74 competent, f e l t t h e i r doctor took a personal i n t e r e s t i n t h e i r w e l l -being, and were mostly s a t i s f i e d with the amount of knowledge they had about t h e i r condition. A l l of these facets of p o s i t i v e i n t e r -a c t i o n have been i d e n t i f i e d i n other studies to be related to adher-ence to recommendations (Hulka, 1979; Korsch & Negret, 1972; Svarstad, 1976). Problems noted i n t h i s study such as reading l a b e l s , opening c h i l d r e s i s t a n t containers, and obtaining eyedrops at community pharmacies have been substantiated v a r i o u s l y i n other studies (Davidson & Akingbehin, 1980; Hammell & Williams, 1964; Lane et a l . , 1971). In contrast with other studies (Boyd et a l . , 1974; Hammell & Williams, 1964), a l l patients i n t h i s study had t h e i r p r e s c r i p t i o n s f i l l -ed. Organizing and scheduling medication at appropriate i n t e r v a l s during the day was not a problem as i t was i n Hermann's (1973) study. However, questions were raised regarding which of two drops ordered at s i m i l a r i n -tervals should be i n s t i l l e d f i r s t , and whether a time i n t e r v a l should be waited between i n s t i l l i n g two d i f f e r e n t types of drops. It i s Interesting that patients should i d e n t i f y t h i s problem, be-cause i t i s only recently that the topi c has been addressed i n the l i t e r -ature. Baum (1981) states that the average eyedrop ranges i n s i z e from .25 to .4 ml and that drops larger than .25 ml overflow the conjunctival s a c ' The smaller drop stimulates less tear formation than the larger one, so may a c t u a l l y d e l i v e r more drug as there i s le s s d i l u t i o n . Baum suggests that f i v e minutes should be allowed between i n s t i l l a t i o n of two types of drops to avoid wash-out, and that two drops of the same medica-t i o n are unnecessary. 75 The a c t i v i t y r e s t r i c t i o n s that involved bending, l i f t i n g , s t r a i n i n g were w e l l known and adhered to, whereas the p r o s c r i p t i o n on reading was less w ell known, understood, or followed. It i s possible that patients were f a m i l i a r with the former i n s t r u c t i o n s because they were part of pre-operative teaching and were reinforced throughout the h o s p i t a l stay. The i n s t r u c t i o n about reading was part of the discharge teaching provided on the day of h o s p i t a l discharge and was u s u a l l y provided immediately p r i o r to leaving the h o s p i t a l . The timing of t h i s teaching may not be appro-p r i a t e f o r e f f e c t i v e learning. In addition, nurses who were discussing i n s t r u c t i o n s with patients may not have been convinced of the necessity of the reading p r o s c r i p t i o n as there i s a d i v e r s i t y of opinion among ophthalmologists and i n the l i t -erature (Smith & Nachazel, 1980) regarding t h i s subject. 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 reading p r o s c r i p t i o n . F i n a l l y , the discharge handout i t s e l f was i n small p r i n t and d i f -f i c u l t f o r many subjects and family members to read to refresh t h e i r mem-o r i e s . This l a t t e r point may also have contributed to the lack of know-ledge of the i n s t r u c t i o n to wash hands following treatments. Performance of Requisite S k i l l s f o r Home Eye Care Only two subjects i n t h i s study were able to perform the necessary eye care procedures without some kind of d i f f i c u l t y or concern. In some instances d e f i c i t s i n f i n e motor co-ordination contributed to the d i f -f i c u l t y , but i n many cases the d i f f i c u l t i e s were r e l a t e d to a lack of 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 teaching. 76 Redman (1972) described three factors that are important i n learning a manual s k i l l ; development of a mental image of how the s k i l l i s per-formed, opportunity to pr a c t i c e the s k i l l and receive c o r r e c t i v e feed-back, and the opportunity to develop a p o s i t i v e a t t i t u d e toward the pro-cedure (p. 77-79). Five subjects i n t h i s study received a demonstration of eyedrop i n -s t i l l a t i o n (the mental image), before they l e f t h o s p i t a l . A l l of these persons deemed the demonstration h e l p f u l ; however, two s t i l l experienced d i f f i c u l t i e s when they came to perform the procedure by themselves at home. An opportunity to p r a c t i c e and receive c o r r e c t i v e feedback might have helped these subjects. Redman also notes that the opportunity to pr a c t i c e i n a s e t t i n g that approximates as c l o s e l y as possible the actu a l s i t u a t i o n i n which the procedure w i l l be performed, f a c i l i t a t e s learning (p. 79). The two sub-jects who had help from home care nurses had both the demonstration and the opportunity to p r a c t i c e i n the home s e t t i n g . Although these people s t i l l had some d i f f i c u l t y because of poor manual dexterity, they were able to perform the procedure independently, and were confident i n t h e i r performance (the p o s i t i v e a t t i t u d e ) . It i s frequently presumed that previous experience with i n s t i l l a t i o n of eyedrops assures the a b i l i t y to perform the s k i l l i n ensuing s i t u a -t i o n s . This assumption did not turn out to be true i n the present study, fo r the 13 subjects who reported previous experience, eight (60%) had a d i f f i c u l t y or some concern when they attempted the procedure at home. This f i n d i n g i s not s u r p r i s i n g when one considers that both f o r g e t t i n g and a decrease i n manual dexterity that often accompanies increasing age, contribute to d e t e r i o r a t i o n i n performance of a previously learned s k i l l . Further considerations are that the s k i l l may not have i n i t i a l l y been learned adequately, 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 that i n which the previous experience was acquired. For example, subjects r e -ported that putting an over-the-counter anti-inflammatory drop i n a nor-mal eye gives a f a l s e sense of confidence, f o r i t i s quite a d i f f e r e n t experience i n s t i l l i n g a drop i n an eye that has just had cataract sur-gery. As we l l , putting drops i n one's children's eyes many years ago prompted an af f i r m a t i v e response to "previous experience i n s t i l l i n g eye-drops," but that s k i l l i s quite d i f f e r e n t from i n s t i l l i n g one's own drops i n an aphakic eye. There are many techniques f o r I n s t i l l i n g eyedrops, but the ophthal-omology l i t e r a t u r e provides l i t t l e d i r e c t i o n as to the merits and e f f i c a -cy of various methods. However, i t i s the opinion of the author that f o r in d i v i d u a l s i n the older age group, many of whom have d e f i c i t s i n manual dexterity and v i s u a l acuity, a preferred technique i s one that provides support to the hand that i s i n s t i l l i n g the drop. Such a technique might reduce the number of instances of touching lashes or the eye i t s e l f , and might a l l a y the concern of persons with shaky hands about damaging the recently operated eye. It i s noteworthy to report that a frequently recommended technique, whereby the subject i s i n s t r u c t e d to stand before a mirror to see how to p o s i t i o n the dropper and i n s t i l l the drop, was of no help to i n d i v i d u a l s i n t h i s study, whose v i s i o n without glasses was not good enough to be able to see i n a mirror. Furthermore, the p o s i t i o n assumed when looking i n a mirror does not provide an angle that f a c i l i t a t e s eyedrop adminis-t r a t i o n . 78 A p p l i c a t i o n of the protective eye s h i e l d was another s k i l l that pre-sented d i f f i c u l t i e s at home f o r many subjects and family members. Verbal 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 people, but others might have bene-f i t e d by the opportunity to p r a c t i c e the s k i l l under supervision. The ophthalmic nurse s p e c i a l i s t home v i s i t i n g programme reported by Kidger (1977) r e f l e c t s an approach to f a c i l i t a t i n g home s e l f - c a r e that i s of i n t e r e s t . Kidger v i s i t s r e f e r r e d patients i n h o s p i t a l , and at home following discharge. This service provides continuity of care, opportu-n i t i e s to teach and supervise patients i n t h e i r own home s i t u a t i o n and would appear to t h i s w r i t e r to o f f e r possible solutions to a number of problems and concerns i d e n t i f i e d i n t h i s study. Safety Throughout t h i s study there has been mention of various instances when the safety of subjects was jeopardized. Two f a l l s and one poking of an eye with ear pieces of spectacles are examples of act u a l accidents. Several factors may contribute to unsafe p r a c t i c e s . F i r s t l y , although most subjects stated they used hand r a i l s on s t a i r s and took the arm of a r e l a t i v e when outdoors ( i f accompanied), they did not perceive loose s c a t t e r rugs, foot stools or coffee tables i n frequently t r a v e l l e d areas, book cases or tables close to the side of the bed, or standing on chairs or the rim of the bath tub to reach something, as a hazard even when com-mented on by the i n v e s t i g a t o r . Perhaps these are examples of habits that are d i f f i c u l t or inconvenient to change, or i t i s possible that these people were just not used to a n t i c i p a t i n g and preventing accidents. C e r t a i n l y , those who stood i n the bathroom or sat on the edge of the tub 79 to have t h e i r eyedrops i n s t i l l e d were not thinking about safety. Second-l y , unfamiliar surroundings may have contributed to the f a l l s of the e l d e r l y female subjects who moved in t o a daughter's home. T h i r d l y , there appears to be a d e n i a l of increasing age and decrements i n p h y s i c a l a b i l -i t y . Even temporarily, most subjects would not use a walking s t i c k , e i t h e r not perceiving any need, or not w i l l i n g to be seen using one. F i n a l l y , the r e l a t i v e comfort of the eye postoperatively provided l i t t l e to remind subjects of the a c t i v i t y r e s t r i c t i o n s designed to prevent eye complications. Knowledge and Understanding of Cataracts/Cataract Surgery The premise that knowledge and understanding of a s u r g i c a l procedure reduced anxiety (Janis, 1958) would appear to be substantiated i n t h i s study. Many subjects were s u r p r i s i n g l y knowledgeable about cataracts and cataract surgery, and had used a v a r i e t y of community sources as w e l l as discussions with t h e i r doctor to l e a r n about the condition. The one pa-t i e n t i n t h i s study who had the greatest anxiety had the l e a s t under-standing of the condition. The r e l a t i v e l y high l e v e l of understanding among these subjects contrasts with the findings of Hilbourne (1975) wherein 86 percent of subjects thought a cataract was a f i l m over the front of the eye. The f a c t that nurses were not perceived as major contributors to pa-t i e n t knowledge i s also documented by Marram (1973) and White (1972) who suggest that t h e i r findings may be based on patient's lack of recognition of teaching as a nursing function. A s i m i l a r o r i e n t a t i o n to the nurse's r o l e may have been present among subjects i n the present study. 80 Demographic Variables It i s acknowledged that with such a small sample, inferences drawn from s t a t i s t i c a l analysis are questionable, however, the a s s o c i a t i o n found i n t h i s study between age and phone c a l l s to the ophthalmologist i s not s u r p r i s i n g . The majority of the phone c a l l s were to c l a r i f y i n s t r u c -t i o n s , a f i n d i n g which accentuates the point that e l d e r l y patients need e x p l i c i t , concise i n s t r u c t i o n s provided i n a non-stressful environment, and need to have i n s t r u c t i o n s repeated. An explanation that could be entertained for the lack of a s s o c i a t i o n between demographic variables and d i f f i c u l t i e s i n performing eye care procedures would be that the d i f f i c u l t i e s were experienced by a wide v a r i e t y of persons, and were r e l a t e d to something other than personal variables - f o r instance effectiveness of teaching. The d e s c r i p t i v e nature of t h i s study and the small sample s i z e do not permit p r e d i c t i v e or causative statements. However, since nursing and medical p r a c t i c e i s concerned with i n d i v i d u a l s as w e l l as groups of people, findings that r e l a t e to health care outcomes of even a few people deserve consideration. In the following chapter conclusions, i m p l i c a -tions f o r health care professionals, and recommendations w i l l be present-ed. 81 CHAPTER V SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS Summary The observation that the number of e l d e r l y persons undergoing cata-ract surgery i s increasing each year, and the length of stay i n h o s p i t a l i s decreasing, has implications f o r patient care. Nurses i n hos p i t a l s who teach p o s t s u r g i c a l cataract patients and family members the knowledge and s k i l l s necessary f o r home s e l f - c a r e w i l l be dealing with a greater number of older people, many of whom l i v e alone or with an equally e l d e r -l y spouse. Many w i l l have concomitant medical conditions and diminished manual dexterity. In addition, there w i l l be less time i n which to per-form these teaching and discharge planning functions. In order to make the teaching and planning relevant and e f f e c t i v e , i t i s necessary to con-s i d e r the experiences patients and t h e i r f a m i l i e s are l i k e l y to have at home following cataract surgery. The purpose of t h i s study was to describe s p e c i f i c behaviours r e l a t -ed to eye care and d a i l y l i v i n g a c t i v i t i e s of in d i v i d u a l s over 60 years of age during the f i r s t two to three weeks at home following uncomplicat-ed cataract extraction; to i d e n t i f y d i f f i c u l t i e s and concerns experienced by these patients and family members; and to describe personal and e n v i -ronmental factors that affected the behaviours, d i f f i c u l t i e s or concerns. An exploratory d e s c r i p t i v e study was c a r r i e d out using a semi-struc-tured interview schedule developed by the inv e s t i g a t o r , to gather data during two home v i s i t s to po s t s u r g i c a l cataract patients and t h e i r fami-l i e s . Twenty subjects were interviewed i n t h e i r homes the day following 82 t h e i r h o s p i t a l discharge, and again between the 13th and 16th postopera-t i v e day. Observations were also made of eyedrop i n s t i l l a t i o n , the ap-p l i c a t i o n of a protective s h i e l d , and the status of the operated eye. The study subjects, t h i r t e e n females and seven males, ranged i n age from 63 to 83 years. A l l subjects were admitted to h o s p i t a l the day p r i o r to surgery, and remained three to s i x days following surgery. F i f t e e n sub-jects l i v e d with family members a f t e r h o s p i t a l discharge, and f i v e l i v e d alone. Of these f i v e who were alone, three had assistance from community homemaker services and two had assistance from a home care nurse. Findings indicated a high degree of adherence to the recommended post s u r g i c a l regimen by study p a r t i c i p a n t s , who perceived adherence as an important f a c t o r i n obtaining a successful v i s u a l outcome. In the few instances when expected behaviours were not performed (for example, hand washing following treatments, and reading p r o s c r i p t i o n s ) , lack of know-ledge was a major contributing f a c t o r . D i f f i c u l t i e s were experienced i n the performance of manual s k i l l s such as i n s t i l l a t i o n of eyedrops, and a p p l i c a t i o n of a protective eye s h i e l d , i n obtaining supplies such as s t e r i l e cotton b a l l s ; and i n read-ing l a b e l s and i n s t r u c t i o n s . Other eye care behaviours such as recogniz-ing and reporting s i g n i f i c a n t i n d i c a t o r s of complications, and keeping appointments for continued medical supervision, presented no problem. No d i f f i c u l t i e s were reported i n managing personal care such as bathing, dressing, meal preparation, elimination, exercise and r e s t . As-sistance with heavy household cleaning and gardening was necessary during the f i r s t four to s i x weeks postsurgery, and was provided by family mem-bers, p r i v a t e l y hired labour, and community homemaker s e r v i c e . A s s i s -83 tance with grocery shopping f o r approximately the f i r s t 10 days to two weeks at home was also required. Leisure a c t i v i t i e s were r e s t r i c t e d i n deference to a c t i v i t y p r o s c r i p t i o n s or because of poor v i s u a l acuity rather than lack of energy. Independent use of the telephone presented problems for two subjects. Concerns and questions were l a r g e l y r e l a t e d to the performance of eye care procedures, and an t i c i p a t e d v i s u a l outcome. A number of factors were i d e n t i f i e d by subjects as being i n f l u e n t i a l 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 concerns. Examples of these factors were: adequate understanding of the surgery and po s t s u r g i c a l ex-pectations, confidence i n the doctor and the opportunity to discuss op-tions and concerns, i n c l u s i o n of family members i n information sessions, teaching and supervision from home care nurses, and the a v a i l a b i l i t y of support systems both f o r d i r e c t assistance and emotional support. For those subjects who had very poor v i s i o n i n the unoperated eye, or no v i -sion at a l l , temporary cataract glasses were h e l p f u l to provide enough v i s i o n to cope with d a i l y routines. Factors that were i d e n t i f i e d as contributing to d i f f i c u l t i e s and concerns were lack of r e q u i s i t e knowledge and s k i l l s to follow recommen-dations with competence and confidence, and perceived reduction i n v i s u a l a cuity i n the unoperated eye. S t a t i s t i c a l analysis of selected patient demographic variables pro-duced only one ass o c i a t i o n at the .05 l e v e l of s i g n i f i c a n c e — a n a s s o c i a -t i o n between concerns, as evidenced by number of phone c a l l s to the oph-thalmologist, and age greater than 71 years. Because of the small sample s i z e , few variables occurred with frequency s u f f i c i e n t to perform an a-n a l y s i s . Any interp r e t a t i o n s must be treated with caution. 84 Conclusions The findings of th i s study suggest the following conclusions: 1. Postsurgical cataract patients are highly motivated to follow recom-mendations assiduously, and become very concerned when s i t u a t i o n s 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 to comply. 2. Patients manage routine a c t i v i t i e s at home extremely w e l l with as-sistance s i m i l a r to that which was required p r i o r to surgery plus extra temporary assistance with heavy household maintenance tasks, gardening and grocery shopping. 3. Cataract surgery, without complications, has a r e l a t i v e l y painless postoperative course, and few patients f i n d the s u r g i c a l experience enervating. 4. Supportive family members and friends contribute important services; remembering and i n t e r p r e t i n g i n s t r u c t i o n s , and providing d i r e c t care, companionship, and emotional support. 5. Concerns are reduced when patients and family members have s u f f i -c i e n t understanding of cataract surgery and the recovery process. The amount and kind of knowledge required i s highly i n d i v i d u a l . 6. Self-administration of eyedrops f o r aphakic patients who have poor v i s i o n i n the unoperated eye presents d i f f i c u l t i e s and engenders concerns. Patients eventually develop, through t r i a l and error, a var i e t y of str a t e g i e s to i n s t i l l t h e i r own drops. Those who had home care nurses teach and supervise eye care procedures f e l t c o n f i -dent about t h e i r a b i l i t y to manage s e l f - c a r e . 7. D i f f i c u l t i e s and concerns experienced by family members i n the per-formance of eye care procedures were rel a t e d to diminished manual dexterity, the use of an ineffective technique, and nervousness about damaging the eye. 8. Patients were unaware of the potential hazard of many of their ac-tions, 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 open-ing containers that could be ameliorated. Implications Although this study's limitations of design and sample size restrict the a b i l i t y to generalize the findings, some factors emerged that have implications for nursing practice, medical practice, pharmacist's prac-tice, 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 and application of the eye shield de-serves attention. Since teaching requisite s k i l l s for home eye care is a recognized nursing responsibility, i t would be desirable to examine cur-rent teaching practices to see how they might be changed to increase pa-tient competence i n home eye care procedures. Some direction regarding the acquisition of manual s k i l l s could be taken from the education l i t -erature, which advocates a demonstration followed by an opportunity to practice under supervision, in order to attain competence and confi-dence. It is also recognized that readiness to learn and even the recog-nition of the need to learn, is highly individual, and influences the ap-propriate time f o r teaching. It may be found to be appropriate to teach s k i l l s before surgery, during the h o s p i t a l stay, following h o s p i t a l d i s -charge i n the home environment, or a combination of a l l three. In ad d i t i o n to formal teaching, i t i s important to recognize that patients learn from, and make decisions based on behaviours modelled by nurses during the process of patient care. For example, a comment f r e -quently heard was, "that was the way the nurses did i t i n the h o s p i t a l , so I just t r i e d to do i t the same way." An im p l i c a t i o n inherent i n t h i s comment i s that i t i s important f o r nurses to model behaviours that they want patients to follow l a t e r . For instance, i f i t i s important f o r pa-ti e n t s to wait f i v e minutes between the i n s t i l l a t i o n of two d i f f e r e n t kinds of drops, then the same behaviour must be modelled by nurses. Problems rel a t e d to the discharge i n s t r u c t i o n sheet such as d i f -f i c u l t y i n reading the small siz e d p r i n t , and poor comprehension of sev-e r a l items, suggests that revisions i n format, content, and time of pre-sentation of th i s i n s t r u c t i o n sheet merit consideration. The item r e -garding cleansing the eye with s t e r i l e cotton b a l l s should be reviewed, as s t e r i l e cotton b a l l s are not r e a d i l y a v a i l a b l e i n the community. Since the eye cleansing routine i n the patient's own home may need to be only a clean procedure, a change i n wording of the i n s t r u c t i o n to read "cotton b a l l s " rather than s t e r i l e ones, would remove a fa c t o r that caused trouble and concern to a number of p a r t i c i p a n t s . The item on hand washing a f t e r treatments, and the Item p r o s c r i b i n g reading were not wide-l y comprehended, and i f these are considered to be important behaviours, a change i n method of presentation i s indicated. Inclusion of answers to frequently asked questions noted i n t h i s study might strengthen the printed handout. Other content areas which could be considered f o r nurse-patient-family discussion are: 1) p r i n c i p l e s and reasons behind i n s t r u c t i o n s , 2) s p e c i f i c examples of permissable and nonrecommended ac-t i v i t i e s , and 3) av a i l a b l e community resources such as free telephone as-sistance, large p r i n t telephone attachments, and volunteer transportation service to medical appointments. The optimum time f o r the pro v i s i o n of information f o r home eye care i s an a d d i t i o n a l consideration. A pr a c t i c e described by subjects wherein the discharge i n s t r u c t i o n sheet was presented and discussed at the nurs-ing s t a t i o n immediately p r i o r to h o s p i t a l discharge has disadvantages. One e f f e c t i v e p r a c t i c e reported i n another centre (Kidger, 1977) that might be considered, i s to mail out information pamphlets p r i o r to hos-p i t a l admission, and re i n f o r c e the i n s t r u c t i o n s at subsequent i n t e r v a l s both during the h o s p i t a l stay, and at home following discharge. The findings r e l a t e d to pa r t i c i p a n t ' s knowledge and s k i l l s has im-p l i c a t i o n s f o r nursing education and nursing administration. In most nursing schools, students are taught how to i n s t i l l eyedrops and ointment i n patients' eyes, and th i s same s k i l l i s applicable i n teaching family members. However, l i t t l e a t t e n t i o n i s paid to helping students learn strategies that are e f f e c t i v e f o r patient s e l f - a d m i n i s t r a t i o n , a teaching problem of a d i f f e r e n t order. Graduate nurses who work with patients who have eye problems might also benefit from education programmes that f o -cused on how to teach patients to perform eye care procedures for them-selves. Within the domain of nursing administration, alternate methods of nursing care d e l i v e r y might be considered. For instance, a nurse with expertise i n teaching eye care to patients and fa m i l i e s might be assigned 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 could extend t h e i r work into the community, making home v i s i t s to t h e i r patients to help them e s t a b l i s h a s a t i s f a c t o r y routine. The f i n d i n g that a large number of patients could not read the p r i n t on medication l a b e l s , or the regular type on the discharge i n s t r u c t i o n sheet, and the f i n d i n g that several patients were unsure about i n s t r u c -tions regarding medication routines f o r concomitant medical conditions, have implications f o r discharge planning. It would appear to be impor-tant to ensure that the patient could administer prescribed medications accurately. A s i g n i f i c a n t example would be a patient who was an i n s u l i n dependent d i a b e t i c , many of whom undergo cataract surgery. Nurses should a s c e r t a i n that these patients are able to measure and administer t h e i r i n s u l i n accurately, e i t h e r by observing the patient perform the procedure independently before h o s p i t a l discharge, or by arranging f o r a home care nurse to v i s i t i n the home. F i n a l l y , the i d e n t i f i e d need f o r assistance at home with heavy household maintenance, gardening and shopping a c t i v i t i e s has implications f o r discharge planning. Discussions with patients and family members can i d e n t i f y s p e c i f i c areas where help i s required, and community services can be arranged to supplement family support systems. Medical Practice The high degree of s a t i s f a c t i o n expressed by patients i n t h i s study with various components of t h e i r i n t e r a c t i o n with the physician, and the as s o c i a t i o n of t h i s s a t i s f a c t i o n with subsequent reduction of anxiety, implies that the time taken to discuss the surgery and l i s t e n to concerns i s w ell spent. 89 Although only a few subjects had problems manipulating small glass bo t t l e s with separate droppers, they represent 50 percent of the group fo r whom t h i s kind of dispenser was provided. I f p l a s t i c dropper b o t t l e s were viable options f o r the same generic drug, consideration might be given to ordering t h i s l a t t e r dispenser, e x p e c i a l l y f o r patients or fami-l y members who have diminished manual de x t e r i t y . An a d d i t i o n a l consider-a t i o n f o r presc r i b i n g practices i s suggested by the f i n d i n g that drops ordered at s i m i l a r i n t e r v a l s reduced concerns associated with remembering schedules and d i f f e r e n t i a t i n g medications. I t was noted that once patients had given the p r e s c r i p t i o n to the pharmacist, they no longer had a record of the physician's medication i n -stru c t i o n s f o r reference. Precautions to prevent p o t e n t i a l errors could be: 1) to give patients written i n s t r u c t i o n s of medications and times of administration f o r t h e i r own reference, and 2) encourage patients to bring medications with them to o f f i c e v i s i t s to assess currency and accu-racy of medications being used. I n i t i a l d i f f i c u l t i e s i n obtaining medications might be a l l e v i a t e d by providing s t a r t e r samples of medications. Patients could also be prov i d -ed with a l i s t of pharmacies that: 1) carry infrequently prescribed eye medications, and 2) are open on Sundays and Holidays. Pharmacist's Practice Several findings have implications f o r the dispensing practices of pharmacists. Study p a r t i c i p a n t s were noted to have problems reading l a -bels typed i n regular p r i n t , reading i n s t r u c t i o n s that were covered en-t i r e l y by glued-on typed l a b e l s , opening caps of eyedrops, and opening 90 c h i l d r e s i s t a n t containers. Consideration could be given to ways i n which these problems might be a l l e v i a t e d . For instance, f o r older pa-t i e n t s , pharmacists could remove the p l a s t i c c o l l a r s around the b o t t l e tops, could design some method f o r providing i n s t r u c t i o n s i n larger p r i n t , e s p e c i a l l y "shake w e l l " i n s t r u c t i o n s , and could review the neces-s i t y of dispensing eyedrops i n c h i l d r e s i s t a n t containers. Patient Self-Care Behaviour Implications f o r patient s e l f - c a r e behaviours are also generated by the f i n d i n g s . Since accurate understanding of expectations, and the a-b i l i t y to perform the necessary procedures i s e s s e n t i a l f o r managing home s e l f - c a r e , patients and family members should make sure they understand i n s t r u c t i o n s and f e e l confident i n performing procedures before they have to do them alone. Knowledge about cataracts, the surgery and the recovery process i s a fact o r i n a l l e v i a t i n g concerns. Therefore, patients and family members need to a v a i l themselves of opportunities to discuss the subject with nurses, h o s p i t a l resident doctors, and t h e i r ophthalmologist. In order to f a c i l i t a t e accomplishment of d a i l y routines following h o s p i t a l discharge, patients who are aware of expectations could stock staple food supplies, and plan f o r an t i c i p a t e d needed assistance well i n advance of surgery. F i n a l l y , since safety was an issue i n t h i s study, patients and fami-l y members should examine the home environment, and actions they custom-a r i l y perform, f o r p o t e n t i a l safety hazards. It may be safer f o r e l d e r l y patients to stay i n t h e i r own homes, and have others come to them to help. 91 Recommendations f o r Further Research Based on the findings of t h i s study, the following areas of research are suggested: 1. That t h i s study be r e p l i c a t e d with a large sample to increase c o n f i -dence i n the r e l i a b i l i t y of the findings and to increase the a b i l i t y to generalize the r e s u l t s . A larger sample would also permit wider s t a t i s t i c a l analysis of v a r i a b l e s , possibly f i n d i n g associations that would give d i r e c t i o n to nursing p r a c t i c e . 2. That a s i m i l a r study be conducted with a s l i g h t l y d i f f e r e n t sample, f o r example, younger patients, or patients who have had i n t r a o c u l a r lens implants, to compare s i m i l a r i t i e s and differences with patients i n t h i s present study. 3. That a v a r i e t y of teaching strategies for patients and family mem-bers be developed and tested f o r e f f i c a c y . 4. That a study be undertaken to determine the optimum time and place f o r teaching patients and family members r e q u i s i t e home s e l f - c a r e knowledge and s k i l l s . 92 BIBLIOGRAPHY Aday, L., Anderson, R., & Fleming, G. Health care i n the United States. Beverly H i l l s : Sage Pub. Co., 1980. Arenberg, D. Concept problem so l v i n g i n young and old adults. Journal  of Gerontology, 1968, 23, 279-282. Baum, J.L. Ocular a n t i b i o t i c administration. Audio-Digest Ophthalmology, June 4, 1981, 19, (11). (Tape) Becker, M.H., Drachman, R.H., K i r s c h t , J.P. Predicting mother's compliance with p e d i a t r i c medical regimens. Journal 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 to receive p e n i c i l l i n by mouth. New England Journal of Medicine, 1963, 268, 1334-1338. Berkoben, R. The v i t a l l i n k . Home care for the patient a f t e r cataract surgery. Quality Review B u l l e t i n , 1978, 4_ (5), 11-12. Bigger, J.F. A comparison of patient compliance i n treated vs. untreated ocular hypertension. Transactions of the American Academy of  Ophthalmology and Otolaryngology, 1976, 81_, 277-285. Blackwell, B. Patient compliance. New England Journal of Medicine, 1973, 289, 249-252. Blishen, B.R., & McRoberts, H.A. A revised socioeconomic index for occupations i n Canada. Canadian Review of Sociology and Anthropology, 1976, 13 (1), 71-79. Bloch, S., Rosenthal, 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 Journal of Ophthalmology, 1977, 61, 531-534. Botwinick, J . Aging and behaviour (2nd ed.). New York: Springer Pub. Co., 1978. Boyd, J . , Covington, T., Stanaszek, W., & Cousins, R. Drug d e f a u l t i n g . Part I I : Analysis of noncompliance patterns. American Journal of  Hospital 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 Health. Annual Report. V i c t o r i a , B.C, 1980. 93 Brody, S.J. The graying of America. Hospitals, 1980, _54 (10), 63-66; 123. Caldwell, J., Cobb, S., Dowling, M.D., & de Jongh, D.D. The dropout problem i n antihypertensive therapy. Journal of Chronic Diseases, 1970, 22, 579-592. Campbell, M., Cruise, M., & Murakami, T.R. A model f o r nursing: University of B r i t i s h Columbia School of Nursing. Nursing Papers, 1976, 8 (2), 5-9. Canestrari, R. Paced and self-paced learning i n young and e l d e r l y adults. Journal of Gerontology, 1963, _18, 165-168. Caplan, R., Robinson, E., French, J . , Caldwell, J . , & Shinn, M. Adhering to medical regimens. Ann Arbor: I n s t i t u t e f o r S o c i a l Research, Un i v e r s i t y of Michigan, 1976. Clayton, T. Teaching and learning; a psychological perspective, Englewood C l i f f s : Prentice H a l l , 1965. Cohen, F., & Lazarus, R. Coping with the stresses of i l l n e s s . In G. Stone, F. Cohen, N. Adler, & Associates (Eds.), Health psychology; A handbook. San Francisco: Jossie-Bass, 1979. Combs, A., & Snygg, D. Individual behaviour, a perceptual approach to  behaviour (Rev. ed.). New York: Harper & Row, 1959. C o t l i e r , E. Senile cataract: evidence for a c c e l e r a t i o n by diabetes and deceleration by s a l i c y l a t e . Canadian Journal of Ophthalmology, 1981, 16 (3), 113-118. Crawford, C.I. Medicare's d e f i n i t i o n of s k i l l e d nursing care: impact on  home health services f o r cataract patients. Unpublished master's t h e s i s , Yale University, 1980. Davidson, S.I., & Akingbehin, T. Compliance i n ophthalmology. Transactions of the Ophthalmological Society of the United Kingdom, 1980, 100, 286-290. 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 (Eds.), Cancer:  The behavioural dimension. New York: Raven Press, 1976. Davis, M. Variations i n patients' compliance with doctors' advice: an empirical analysis of patterns of communication. American Journal of  Public Health, 1968, 58 (2), 274-288. (a) Davis, M. Physiologic, psychological and demographic factors i n patient compliance with doctors' orders. Medical Care, 1968, 6 (2), 115-120. (b) 94 Davis, M.S., & Eichhorn, R. Compliance with medical regimens: A panel study. Journal of Health and Human Behaviour, 1963, 4_, 240-249. Donabedian, A., & Rosenfeld, L. Follow up study of c h r o n i c a l l y i l l patients discharged from h o s p i t a l . Journal of Chronic Deseases, 1964, 17, 847-862. Duke-Elder, S i r Stewart (Ed.). System of ophthalmology: Diseases of the  lens and vitreous; glaucoma and hypotony (V o l . XI). London: Henry Kimpton, 1969. Fox, D. Fundamentals of nursing research (2nd ed.). New York: Appleton-Century-Crofts, 1970. Francis, V., Korsch, B., & Morris, M. Gaps i n doctor-patient communication. New England Journal of Medicine, 1969, 280, 535-540. Galin, M.A., Baras, I., Barasch, K., & Boniuk, V. Immediate ambulation and discharge a f t e r cataract e x t r a c t i o n . Transactions of the Amercian  Academy of Ophthalmology and Otolaryngology, 1974, 78, OP43. Gardener, P.A. A.B.C. of ophthalmology: cataracts. B r i t i s h Medical  Journal, 1979, I, 36-38. Gillum, F.R., & Barsky, A.J. Diagnosis and management of patient noncompliance. Journal of the American Medical Association, 1974, 228, 1563-1567. Green, L.W. Should health education abandon at t i t u d e change strategies? Perspectives from recent research. Health Education Monograph, 1970, 30, 25-48. Hammell, R.W., & Williams, P.O. Do patients receive prescribed medications? American Pharmaceutical Association Journal, 1964, 4-, 331-334. Havener, W., Saunders, W.H., Keith, C.F., & Prescott, A.W. Nursing care  i n eye, ear, nose and throat disorders (3rd ed.). St. Louis: Mosby, 1974. Haynes, R.B. A c r i t i c a l review of the "determinants" of patient compliance with therapeutic regimens. In D.C. Sackett & R.B. Haynes (Eds.), Compliance with therapeutic regimens. Baltimore: Johns Hopkins University Press, 1976. Haynes, R.B. Determinants of compliance: The disease and the mechanics of treatment. In R.B. Haynes, D.W. Taylor, & D.L. Sackett (Eds.), Compliance i n health care. Baltimore: Johns Hopkins University Press, 1979. 95 Hermann, F. The outpatient p r e s c r i p t i o n l a b e l as a source of medication e r r o r s . American Journal of Hospital Pharmacy, 1973, 30, 155-159. Hilbourne, J.F.H. S o c i a l and other aspects of adjustment to s i n g l e eye cataract extraction i n e l d e r l y patients. Transactions of the  Ophthalmological Society of the United 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. Taylor, & D.L. Sackett (Eds.), Compliance i n health care. Baltimore: Johns Hopkins University Press, 1979. Ingram, R.M., Banerjee, D., Traynar, J . J . , & Thompson, R.K. Day-case cataract surgery. Transactions of the Ophthalmological Society of  the United Kingdom, 1980, 100, 205-209. J a f f e , N.S. Intraocular lenses, 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 . Transactions of the American Academy of Ophthalmology and  Otolaryngology, 1976, 81, OP 93-96 J a f f e , N.S. Current concepts i n ophthalmology; cataract surgery. New England Journal of Medicine, 1978, 299, 235-238. Janis, I.L. Psychological s t r e s s , psychological and behavioural studies  of s u r g i c a l patients. New York: John Wiley & Sons Inc., 1958. Johnson, J.D. One-day stay 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 for patients b r i e f l y h o s p i t a l i z e d f or cataract surgery. Quality Review B u l l e t i n , 1978, _4 (5), 16-19. Kahn, R., & Cannell, C. The dynamics of interviewing; theory, techniques  and cases. New York: Wiley, 1957. Kidger, J . Home v i s i t i n g scheme for ophthalmic patients. Nursing Times, August 4, 1977, 1212-1214. King, I.M. Conceptual frame of reference f o r nursing. Nursing Research, 1968, 17_ (1), 27-31. K i n l e i n , M. A s e l f - c a r e concept. American Journal of Nursing, 1977, 77_ (4), 598-601. 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 sciences; v e r s i o n 8, CROSSTABS. Vancouver: The University of B r i t i s h Columbia Computing Centre, 1980. Korsch, B., & Negrete, V. Doctor-patient communication. S c i e n t i f i c  American, 1972, 277 (2), 66-76. Kwitko, M.L. A r t i f i c i a l lens implant. Journal of the Association of  Operating Room Nurses, 1978, 28, 47-53. 96 Lewin, K. Selected t h e o r e t i c a l papers. In D. Cartwright (Ed.), F i e l d  theory i n s o c i a l science. New York: Harper, 1951. Ley, P. The psychology of compliance. In D. Oborne, M. Gruneberg, & J . Eisen (Eds.), Research i n Psychology and Medicine, ( V o l . 2). New York: Academic Press, 1980. Low, C.R. Outpatient cataract surgery. Journal of the Association of Operating Room Nurses, 1978, 2_8 (1), 35-40. Luckman, J . , & Sorensen, K. Medical-surgical nursing: A psychophysio- l o g i c a l approach (2nd e l d . ) . Philadelphia: W.B. Saunders, 1980. Marram. G. Patients' evaluation of nursing performance. Nursing Research, 1973, 22 (2), 153-157. Marston, M. Compliance with medical regimens: A review of the l i t e r a t u r e . Nursing Research, 1970, 19_ (4), 312-322. Mausolf, F. The eye and systemic disease. St. Louis: C V . Mosby, 1975. Mazzullo, J . , L'asagna, L., & Griner, P. Variations 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 . Journal of the American Medical  Association, 1974, 227, 929-931. McAlister, A.L., Farquhar, J.W., Thoresen, C.E., & Maccoby, N. Behavioural science applied to cardiovascular health: Progress and research needs i n the modification of r i s k - t a k i n g habits i n adult populations. Health Education Monographs, 1976, 4^  45-74. McClelland, R.H. P r o v i n c i a l home care program. B r i t i s h Columbia Medical  Journal, 1976, 18 (10), 328-329. Mclntire, M., Angle, C , Sathees, K., & Lee, P. Safety packaging - what does the pu b l i c think? American Journal of Public Health, 1977, 67, 169-171. Nadler, D.J., & Schwartz, B. Cataract surgery i n the United States, 1968-1976. A d e s c r i p t i v e epidemiologic study. Ophthalmology, January, 1980, 87_ (1), 10-18. Neely, E., & Patrick, M. Problems of aged persons taking medications at home. Nursing Research, 1968, 1_7 (1), 52-55. Neuman, B. The Betty Neuman health care systems model: A t o t a l person approach to patient problems. In J . Rie h l , & C. Roy (Eds.), Conceptual models for nursing p r a c t i c e . New York: Appleton-Century-Crofts, 1974. 97 N o r r i s , C. Sel f - c a r e . American Journal of Nursing, 1979, _9 (3), 486-489. Nurses Guide to Drugs. Nursing 80 Books. Horsham, Pennsylvania: Intermed Communications Inc., 1980. Parkin, D.M., Brown, G.W., & Monk, E.M. Deviation from prescribed drug treatment a f t e r discharge 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 research: P r i n c i p l e s and methods. New York: J.B. Li p p i n c o t t , 1978. Potash, M.A., & Jones, B. Aging and decision c r i t e r i a f o r the detection of tones i n noise. Journal of Gerontology, 1977, 32, 436-440. Powell, A.H., E i s d o r f e r , C , Bogdonoff, M., & Durham, N.C. Physiologic response patterns observed i n a learning task. Archives of General  Psychiatry, 1964, 10, 192-195. Pra t t , L., Seligmann, A., & Reader, G. Physicians' views on the l e v e l of medical information among patients. American Journal of Public  Health, 1957, 47, 1277-1283. Publica t i o n Manual of the American Psychological Association, (2nd ed.) Baltimore: Garamond/Pridemark Press, Inc., 1981 Rabbitt, P. An age decrement i n the a b i l i t y to ignore i r r e l e v a n t information. Journal of Gerontology, 1965, 20, 233-238. Redman, B.K. The process of patient teaching i n nursing (2nd ed.). St. Louis: Mosby, 1972. Riffenburgh, R.S. Doctor-patient r e l a t i o n s h i p i n glaucoma therapy. Archives of Ophthalmology, 1966, _5, 204-206. Rosenstock, I.M. The health b e l i e f model and preventive health behaviour. Health Education Monographs, 1974, 2. (4), 354-386. Roy, C. The Roy adaptation model. In J . Riehl, & C. Roy (Eds.), Conceptual models f or nursing p r a c t i c e . New York: Appleton-Century-Crofts , 1974. Saxon, S., & Etten, M. Physical change and aging: A guide f o r the  helping professions. New York: T i r e s i a s Press", 1978. Schwartz, D., Wang. M., Z e i t z , L., Goss, M. Medication errors 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 ients. American Journal of Public  Health, 1962, 52, 2018-2019. 98 Schwartz, D., Henley, B., & Z e i t z , L. The e l d e r l y ambulatory pati e n t :  Nursing and psychological needs. New York: MacMillan, 1964. Shafer, K., Sawyer, J . , McCluskey, A., Beck, E., & Phipps, W. Medical- s u r g i c a l nursing (6th ed.). St. Louis: Mosby, 1975. Shanahan, M., & Pelham, V. Nursing evaluation of the care of patients with cataracts. Quality Review B u l l e t i n , 1978, h_ (5), 8-10. Shock, D. Operative management of cataracts: Introduction. In H.E.J. Kolder (Ed.), Cataracts: Proceedings of the Paul Boeder i n t e r n a t i o n a l symposium. International 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! nursing. Boston: L i t t l e Brown & Company, 1980. Spaeth, G.L. V i s u a l loss i n a glaucoma c l i n i c . S o c i o l o g i c a l considera-t i o n s . Investigative Ophthalmology, 1970, 9, 73-82. S t a r f i e l d , B. Health services research: A working model. The New  England Journal of Medicine, 1973, 289 (3), 132-136. S t a t i s t i c s Canada. Surgical procedures and treatments (p. 34). Ottawa: Mi n i s t r y of Industry, Trade & Commerce, 1969. S t a t i s t i c s Canada. Surgical procedures and treatments (p. 52). Ottawa: Minis t r y of Supply and Services, 1977. Stedman's Medical Dictionary (22nd ed., p. 214). Baltimore: Williams & Williams, 1972. Stimson, G. Obeying doctors orders: A view from the other sid e . S o c i a l  Science and Medicine, 1974, j}, 97-104. Strachan, I.M., & Bowell, R.E. 1972. Reduced in-p a t i e n t stay following cataract e x t r a c t i o n . Transactions of the Ophthalmological Society of  the United Kingdom, 1972, 92_, 629-636. Svarstad, B. Physician-patient communication and patient conformity with medical advice. In D. Mechanic (Ed.), The growth of bureaucratic  medicine. New York: Wiley, 1976. Tagliacozzo, D.M., & Ima, K. Knowledge of i l l n e s s as a predictor of patient behaviour. Journal of Chronic Diseases, 1970, 22_, 765-775. Tolman, E.C. Behavioural and psychological man (p. 144-178; 241-264). Berkeley: University of C a l i f o r n i a Press, 1958. Troutman, R.C. Techniques i n surgery: Suturing techniques for cornea  and cataract. Ethicon, 1971. 99 Vincent, P. Factors i n f l u e n c i n g patient noncompliance: A t h e o r e t i c a l approach. Nursing Research, 1971, 20, 509-516. Vincent, P. Patient's viewpoint of glaucoma therapy. Sight Saving Review, Winter 1973, 42 (4), 213-221. Vukcevich, W.M. Outpatient cataract surgery and lens implantation. Journal of the American Intraocular Implant Society, 1979, _5 (4), 324-325. Weinstock, F.J. What your aging patient may want to know about cataracts. G e r i a t r i c s , 1978, 33 (12), 57-60; 64. White, M.B. Importance of selected nursing a c t i v i t i e s . Nursing  Research, 1972, 21 (1), 4-14. Williamson, D.E. Outpatient cataract-implant surgery compared with outpatient cataract standard surgery. Annals of Ophthalmology, 1978, 7, 957-965. Worthen, D.M. Patient compliance and the "usefulness product" of Timolol. Survey of Ophthalmology, 1979, 23, 403-405. APPENDIX A INFORMATION LETTER 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 DESCRIP-TION 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 Univ e r s i t y of B r i t i s h Columbia School of Nursing 2075 Wesbrook Mall Vancouver, B.C. V6T 1W5 Dear Doctor : Thank you f o r agreeing to a s s i s t me i n contacting subjects f o r my research study on po s t s u r g i c a l cataract patients during t h e i r f i r s t few weeks at home following h o s p i t a l discharge. I am requesting written permission that i t i s acceptable f o r your patient to receive one extra drop of prescribed eye medication on the day I make a home v i s i t i f I am unable to coincide my v i s i t with a regular medication administration time. I would appreciate i t i f you would sign the permission noted below. Thank You, Shelagh Smith I agree that the p o s t s u r g i c a l cataract patients under my care who are v i s i t e d by Shelagh Smith f o r a research study may receive f o r reasons of the study, one extra a p p l i c a t i o n of a prescribed eye medication on the day of her v i s i t . In my opinion t h i s extra medication would i n no way be detrimental to the patient. Signature: APPENDIX D INTERVIEW GUIDE INTERVIEW GUIDE POST-SURGICAL PATIENTS PROFILE SHEET 1. Patient Number 2. Doctor Number _*3. Patient Age i n Years _ 4. Sex [M] [F] 1 2 5. Ethnic Background *6. Type of Anaesthetic 1. General 2. Local *Length of Hospital Stay i n Days 7. Before Surgery 8. A f t e r Surgery 9. T o t a l *10. Other medical problems L i s t : *11. *12. Medications prescribed on discharge from h o s p i t a l . L i s t : Frequency & Route of Name Dosage Admin. Vi s i o n : Best corrected v i s u a l acuity unoperated eye +14. 15. 16. 17. +18. +13. Manual Dexterity ( f i n e motor co-ordination) 1. No impairment 2. Some impairment 3. Impaired Manual Dexterity of Family Member ( i f applicable) Level of Physical Functioning: 1. Independent with no regular household or gardening help. 2. Independent, but employs regular household or gardening help to f a c i l i t a t e d a i l y l i v i n g . 3. Requires assistance with routine household or gardening a c t i v i t i e s one-half day per week or less frequently. 4. Requires assistance with routine household or gardening a c t i v i t i e s more than one-half day per week. Cl i e n t Pre-op Level C l i e n t Post-op Level Spouse/Family Member ( i f applicable) Hearing 1. No apparent impairment 2. Mild impairment (needs occasional r e p e t i t i o n s , increased volume). 3. Moderate impairment r e p e t i t i o n s ) . 19. Smoking Status 1. Non-smoker 2. Smoker 20. Education Level i n Years 21. Occupation +22. Housing: 23. 1. House 2. Apartment 3. Room 4. F a c i l i t y (without nursing care) 5. Other (specify) Household Composition Pre-surgery L i v e s : 1. Alone 2. With able spouse 3. With dependent spouse 4. With other family member (specify) 5. With f r i e n d 6. Other +Physical Environment [Y] [N] [Y] [N] [Y] [N] [Y] [N] 28. Adequate l i g h t i n g [Y] [N] 24. Outside s t a i r s 25. Handrails 26. Inside s t a i r s 27. Handrails 29. Furniture Arrangement 1. Clear passageways 2. Complicated arrangement 30. Scatter Rugs [Y] +Neighbourhood 31. T r a f f i c 1. Light 2. Moderate 3. Heavy 32. Curbs 1. None 2. Few 3. Many 33. Rough T e r r a i n 1. None 2. A l i t t l e 3. A l o t 34. Proximity of usual shopping f a c i l i t i e s . * Data from h o s p i t a l chart + Observations I l l FIRST HOME VISIT INTERVIEW GUIDE General Introductory Remarks Explain focus of the study again, and r e i t e r a t e option of subject to have tape stopped or portions erased. To begin, t e l l me how you have gotten along since you came home from h o s p i t a l yesterday. (Ask about anything unexpected that happened, anything for which subject or family were unprepared, any v i s i t s from a home care nurse, any phone c a l l s requesting information or assistance r e l a t e d to eye care) 35. I would now l i k e to ask a few questions about your eye. Since you got home from h o s p i t a l , have you had any pain or discomfort i n your eye? 1. Yes - Elaborate. E l i c i t d e s c r i p t i o n , duration, s e v e r i t y , frequency, comfort measures (Items 36-43). 2. No - Go to 44. _36. In which of the following words would you describe the way your eye feels? 1. Itchy 2. Scratchy cue 3. Smarting 4. Aching 5. Throbbing 6. Sharp pain _37. Would you describe the discomfort as: 1.' Mild cue 2. Moderate 3. Severe 38. How frequently has the f e e l i n g of discomfort occurred? 1. Once or twice (very occasionally) cue 2. Three to f i v e times (occasionally) 3. More than f i v e times 39. Does the discomfort l a s t : cue 40. 41. cue 42. 1. A few minutes 2. Several hours 3. A l l day Did you take any medication for the pain, discomfort? 1. Yes (what?) 2. No Did t h i s medicine r e l i e v e your discomfort? 1. Completely 2. Some 3. Not at a l l Did you use any other measure to make your eye more comfortable? 1. Yes (specify) 2. No 112 43. Have you noticed anything i n p a r t i c u l a r that you think causes your eye to be uncomfortable? Free response: Probe f o r 1. Photophobia 2. Cigarette smoke Now, I would l i k e to ask about some general problems that people sometimes have. Since you got home from h o s p i t a l , have you had any: 44. ""45. "46. ~47. "48. "49. ~50. 51. 52. 53. 54. 55. cue Nausea Vomiting Coughing Sneezing Headache Sore throat Other discomforts (specify) If a f f i r m a t i v e f or sore throat, e l i c i t s e v e r i t y . 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 (53). E l i c i t comfort measures employed for above. E l i c i t success of any comfort measures: Relieved 1. Completely 2. Moderately w e l l 3. Not at a l l 56. 57. 58. 59. 60. How well did you sleep l a s t night? Free response, then v a l i d a t e with cues: 1. Slept w e l l 2. Awake a l o t of time the How does t h i s compare with your usual sleeping pattern? 1. Same 2. D i f f e r e n t If 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 for the dif f e r e n c e . Did you take a sleeping p i l l , or use a home remedy to help you sleep? 1. Sleeping p i l l 2. Home remedy 3. Nothing Is i t usual for you to take something to help you sleep? 1. 2. Yes No Now I would l i k e to ask a few questions about your medications and treatments. 61. When you l e f t h o s p i t a l you were given a p r e s c r i p t i o n for eye medicines. How did you obtain these medications? 1. Delivered by pharmacy 2. Picked up by r e l a t i v e or f r i e n d 3. Picked up by s e l f 4. Other (specify) 113 Interviewer: Check medications against discharge orders. 62. Was there any d i f f i c u l t y i n obtaining the medicines? 1. Yes (specify) 2. No 63. How long a f t e r you returned home from h o s p i t a l did you receive your f i r s t a p p l i c a t i o n of eye medication? 1. Scheduled time 2. Discrepancy -elaborate _64. Were there any other supplies r e l a t e d to the care of your eye that you needed to purchase? 1. Cotton b a l l s 2. Tape 3. Other (specify) 65. Were there any problems i n obtaining the supplies? 1. Yes (specify) 2. No _66. Are there any other medications that you take regularly? 1. Yes ( l i s t ) 2. No 67. Who puts the drops i n your eyei 1. 2. 3. 4. 5. 6. Self Spouse Relative Friend, neighbour Home care nurse Other (specify) Interviewer: Direct the next s i x questions to person i n s t i l l i n g drops. 68. 69. cue 70. 71. 72. How d i d you manage with the f i r s t few applications? Did you experience any d i f f i c u l t i e s ? (Ask about opening b o t t l e s ) . 1. Yes - elaborate 2. No How do you f e e l about putting i n the eyedrops? Free response. Then cue: 1. Confident 2. A l i t t l e nervous 3. Very nervous Have you ever i n s t i l l e d eyedrops before? 1. Yes (describe circumstances) 2. No Would a demonstration have been h e l p f u l to you? 1. 2. Yes No Would an opportunity to practice have been helpful? 1. Yes 2. No Do you have any s p e c i a l methods to d i f f e r e n t i a t e the medications? 73. Can read the labels 74. Colour of top 75. Size or shape of container 76. Place of storage "77. Other (specify) 114 I would l i k e to t a l k about some of the ways i n which you care f o r your eye now that you are home from h o s p i t a l . T e l l me what you do to keep your eye clean? 78. Cleanse eye with s t e r i l e cotton b a l l s and water as necessary to remove crusts and mucus 79. Wash hands before treatment 80. Other - describe T e l l me some of the actions you avoid because you understand they may be harmful to your eye. Free response, then ask: Did anyone mention? Free Probe 81. "82. "83. "84. "85. "86. 87. 88. 89. 1. Bending 2. L i f t i n g 3. S t r a i n i n g 4. Rubbing eye 5. Squeezing eye 6. Sudden movements 7. Other (s p e c i f y ) 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. Yes - elaborate 2. No How do you pick up something that has f a l l e n to the f l o o r ? Are there any s p e c i a l precautions that you take to protect your eye from injury? Free response then probe f o r : Free Probe 90. 91. 92. 93. 1. Wear glasses during the day 2. Wear eye sh i e l d at night ( e l i c i t success of f i r s t a p p l i cation) 3. Hold glasses by ear t i p s when putting on 4. Other ( e n v i r -onmental hazards, s t a i r s , use of cane or other support) Who were the people that provided you with information about what would be expected of you and what you could expect to do once you were home from hospital? Free response, then probe: Free Probe 94. "95. "96. "97. 1. Nurses 2. Doctors 3. Interns 4. Other (other people who had had cataract surgery, other patients) When did you receive information about expectations f o r home care? Free response, then probe: Free Probe 98. 1. Before admission to ho s p i t a l 115 100. 101. 102. 99. 2. Several times during h o s p i t a l stay 3. Day of discharge 4. Other (s p e c i f y ) When you l e f t h o s p i t a l , did you receive a printed sheet that gave i n s t r u c t i o n s f o r home eye care? 1. Yes-Ask items 102-106 2. No-Go to item 107 103. Did anyone discuss the in s t r u c t i o n s with you? 1. Yes 2. No 104. Did you f i n d t h i s sheet helpful? 1. Yes 2. No 105. Were there any items you did not understand? 1. Yes 2. No 106. Could you read the print? 1. Yes 2. No 107. Could a family member read the print? 1. Yes 2. No 108. 109. 110. Was a family member able to be present to receive i n s t r u c t i o n s about home eye care? 1. Yes 2. No Was i t h e l p f u l to have a family member present f o r instructions? 1. Yes 2. No Would i t have been h e l p f u l for a family member to be present f o r in s t r u c t i o n s ? 1. Yes 2. No E l i c i t opinion family member ( i f present). 1. Helpful 2. Not h e l p f u l 3. Would have been h e l p f u l 4. Not necessary When patients leave h o s p i t a l , they are usually instr u c t e d to phone t h e i r doctor i f they have undue discomfort or notice a change i n the condition of t h e i r eye. What s p e c i f i c signs would you think required a c a l l to your eye doctor? Free response. Then ask: Do you think you would c a l l your eye doctor i f you noticed: Free Probe 111. 112. 113. 114. 1. 2. 3. Severe pain i n the eye Increased redness Discharge from eye 116 115. 116. 4. Severe headache 5. Onset of nausea or vomiting 6. Change i n v i s i o n 7. Other (speci f y ) Is there anyone else you would c a l l i f you needed some help or information regarding your eye or i t s treatments? 117. 118. 119. ~120. "121. "122. ~123. 124. - Family doctor - Public health nurse - Hospital nurse - Neighbour - Other Have you c a l l e d your eye doctor or any of these other people since you got home from hospital? 1. Yes - e l i c i t (who and reason) 2. No My next question i s re l a t e d to support people that are a v a i l a b l e to you. Who do you have that you can c a l l on i f you need to have an errand done or want someone to t a l k to? 125. - Family members 126. - Neighbours, good friends "127. - Other 128. Has an appointment been made for you to see your eye doctor f o r a check up? 1. Yes 2. No - What are your plans about making an appointment? 129. Is there any problem associated with transportation? 1. Yes - elaborate 2. No 130. Do you have any questions that you would l i k e to ask ...anything you have been wondering? EYE STATUS OBSERVATIONS 131. Lids 134. 1. Normal 2. Swollen 3. Ecchymosis 132. Conjunctiva 1. No i n j e c t i o n 2. S l i g h t i n j e c t i o n 3. Moderate i n j e c t i o n 4. Marked i n j e c t i o n 133. I n c i s i o n 1. Normal 2. Abnormal (describe) Cornea 1. Clear, lustrous 2. Steamy, hazy 135. Anterior chamber 1. Normal, formed 2. Shallow, f l a t 136. Pupil 1. Round 2. Irregular 3. Keyhole 4. Other 117 137. Pupil 1. Dilated 2. Constricted 3. Other 138. Discharge 1. Absent 2. Watery 3. Mucus 4. Purulent 5. Other 139. Crusting 1. Absent 2. Present 140. Subject's report of crusting i n a.m. 1. Absent 2. Present OBSERVATION OF INSTILLATION OF EYEDROPS Code: 1 = Yes 2 = No 141. Washed hands before procedure 142. Assumed a safe p o s i t i o n 143. Reclined head to f a c i l i t a t e eyedrop administration 144. Agitated medicine b o t t l e i f necessary 145. I n s t i l l e d correct medication 146. I n s t i l l e d correct amount 147. Drop went into eye on f i r s t attempt (describe attempts i f more than one) 148. Maintained cl e a n l i n e s s of b o t t l e of eyedrops 149. Touched l i d s or lashes 150. Touched globe 151. Washed hands upon completion of procedure Comments: APPLICATION OF EYE SHIELD 152. Applies s h i e l d securely 153. Applies s h i e l d confidently 154. 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 Comments: 118 SECOND HOME VISIT INTERVIEW GUIDE General Introductory Remarks Reiterate tape recording p o l i c i e s . 155. How have you been getting along since I l a s t v i s i t e d you? 156. Has there been anything about your eye or i t s treatments that has worried you, or that you have wondered about? 157. Have you noticed any differe n c e i n your a b i l i t y to manage d a i l y routine a c t i v i t i e s ? Today I have some questions that are s i m i l a r to those I asked on my l a s t v i s i t , and some new ones that are re l a t e d to the changes, i f any, you have made i n your d a i l y routine since you had the surgery. 158. 159. 160. Since I was here l a s t , how many v i s i t s have you made to your eye doctor's o f f i c e ? Did you encounter any d i f f i c u l t i e s r e l a t e d to keeping your appointment? 1. Yes - elaborate 2. No Have there been any changes made i n your treatments, or any new in s t r u c t i o n s r e l a t e d to a c t i v i t y ? 1. Yes - elaborate 2. No 161. Compared with my l a s t v i s i t , do you f e e l your eye i s : 1. More comfortable 2. About the same 3. Less comfortable If less comfortable, e l i c i t frequency, severity, duration and des c r i p t i o n of discomfort. 162. Frequency 1. Occasionally 2. Frequently 163. Duration 1. Few minutes 2. Several hours 3. A l l day 164. Severity 1. Mild 2. Moderate 3. Severe 165. Description 1. Itchy 2. Sandy, scratchy 3. Smarting 4. Aching 5. Throbbing 6. Sharp pain E l i c i t comfort measures, success of comfort measures. 119 Since my l a s t v i s i t have you had any: Code frequency 1 = Not at a l l 2 = Occasionally 3 = Most of the time 166. "167. ~168. "169. "170. "171. "172. 173. 174. Nausea Vomiting Coughing Sneezing Headache Sore throat Other discomforts (speci f y ) I f a f f i r m a t i v e , e l i c i t s e v e r i t y , duration frequency, comfort measures and success of comfort measures. Since my l a s t v i s i t , i n addition to the scheduled v i s i t ( s ) to your eye doctor, have you consulted anyone or phoned anyone because you had a question or a concern about your eye or i t s treatment? 1. 2. Yes No I f a f f i r m a t i v e , describe concern, e l i c i t who was c a l l e d . How have you been managing with the eye drops? Free response, then ask: Compared with my l a s t v i s i t , do you f e e l : 1. More confident 2. About the same 3. Less confident 175. Do you have any s p e c i a l methods that you use to help you remember when each of the medications i s due? 1. Yes - elaborate 2. No Probe for ass o c i a t i o n with meal times, other medication times. 176. How w e l l have you been able to have the drops put i n the prescribed number of times each day? Would you say: 1. Always received medications according to i n s t r u c t i o n s cue 2. Sometimes missed a does 3. Often missed a dose 177. How have you managed with the metal eye shield? Free response, then ask: Does i t stay on a l l night? 1. Yes 2. No _178. How w e l l have you managed to avoid bending, l i f t i n g or straining? _179. Did 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 d a i l y 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 Daily L i v i n g I am interest e d In knowing what changes, i f any, you have made i n your routine household and personal care a c t i v i t i e s since 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. Yes 2. No 181. Do you have regular or per i o d i c household or gardening help? 1. Yes 2. No 182. Have you made any changes i n the frequency or type of assistance you receive? 1. Yes - elaborate 2. No Have you made any changes i n your general routine i n regard to: Code: 1. Yes - elaborate 2. No 183. Shopping 184. Food preparation 185. Housecleaning 186. Laundry 187. Transportation 188. Use of the telephone (ask about any s p e c i a l aids to f a c i l i t a t e telephone use i e . magnifying lens, large p r i n t attachment, operator assistance) Other home maintenance or household management tasks In r e l a t i o n to personal care a c t i v i t i e s , have you made any changes related to: 190. Bathing 191. Dressing 192. Hair shampoo 193. Other 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 to do? Were they more d i f f i c u l t to do than they were before your surgery? 195. Have you developed any sp e c i a l methods f or managing things at home that might be u s e f u l f o r someone e l s e to know about, and that you would share? 196. Can you think of any other kind of help other than what you had that would have been u s e f u l to you? N u t r i t i o n 197. Has there been any change i n your eating pattern since the operation? 1. Yes 2. No If 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 subject from eating normal d i e t . 189 121 Elimination My re 198. Have you had any d i f f i c u l t y with constipation since you came home from hospital? 1. 2. Yes No 199. "200. 201. "202. If a f f i r m a t i v e , e l i c i t any acti o n taken: Laxative Dietary measure Other No action Exercise and rel a x a t i o n 203. 204. 205. 206. 207. T e l l me how you have spent your time during a t y p i c a l day since your surgery? How does t h i s way of spending time compare with a t y p i c a l day before your surgery? 1. Same 2. Dif f e r e n t - elaborate: e l i c i t energy l e v e l , v i s i o n , a c t i v i t y r e s t r i c t i o n s as possible f a c t o r s . Are there a c t i v i t i e s you would l i k e to do that you are unable to do just now? Do you a n t i c i p a t e that you w i l l be able to do these things l a t e r on? When you returned home from h o s p i t a l , how confident did you f e e l about managing your personal care, and household a c t i v i t i e s ? l a s t group of questions are ela t e d to your understanding of the cataract surgery, and your f e e l i n g s about the whole experience. 208. What i s your understanding of what a cataract i s ? 209. What i s your understanding of the operation that was done? If not f r e e l y offered, ask: Did you expect that you would not be able to see out of the operated eye for several weeks? E l i c i t expectations regarding type of o p t i c a l c o rrection and v i s u a l improvement. E l i c i t f e e l i n g s about waiting for o p t i c a l c o r r e c t i o n . _210. Was the amount of knowledge you had regarding the s u r g i c a l procedure, the waiting time a f t e r surgery for the eye to heal, and the choices you might have for v i s u a l c o r r e c t i o n : 1. S u f f i c i e n t to s a t i s f y you 2. Not s u f f i c i e n t -elaborate 211. Is there any information that you would l i k e to have had that was not provided? _212. How does t h i s eye s u r g i c a l experience compare with previous h o s p i t a l admissions, or surgery you have had? 1. Confident 2. Insecure - elaborate 122 213. 214. 215. cue 216. Some people say that any surgery creates anxiety, but that eye surgery i s p a r t i c u l a r l y s t r e s s f u l . What i s your opinion regarding t h i s statement? Can you think of any factors that influenced your f e e l i n g s . Have you a r e l a t i v e or f r i e n d who has had cataract surgery? Was t h e i r experience: 1. H e l p f u l 2. Not h e l p f u l You were i n h o s p i t a l days a f t e r your surgery. What i s your opinion regarding the length of your h o s p i t a l stay? 1. Not long enough 2. About r i g h t 3. Too long Can you think of anything more that could have been done to better prepare you fo r the f i r s t few weeks at home following h o s p i t a l discharge? Complete p r o f i l e sheet items that have not been f i l l e d i n , i e . education l e v e l , ethnic background, occupation, smoking status. Terminate v i s i t with examination of operated eye, and observation of eyedrop i n s t i l l a t i o n . cue 217. EYE STATUS OBSERVATIONS 218. Lids 1. Normal 2. Swollen 3. Ecchymosis 219. Conjunctiva 224. 1. No i n j e c t i o n 2. S l i g h t i n j e c t i o n 3. Moderate i n j e c t i o n 4. Marked i n j e c t i o n 220. I n c i s i o n 1. Normal 2. Abnormal (describe) 221. Cornea 1. Clear, lustrous 2. Steamy, hazy 222. Anterior chamber 1. Normal, formed 2. Shallow, f l a t 223. Pupil 1. Round 2. Irregular 3. Keyhole 4. Other 1. D i l a t e d 2. Constricted 3. Other 225. Discharge 1. Absent 2. Watery 3. Mucus 4. Purulent 5. Other 226. Crusting 1. Absent 2. Present 227. Subject's report of crusting i n a.m. 1. Absent 2. Present OBSERVATION OF INSTILLATION OF EYEDROPS  Code: 1 = Yes 2 = No _228. Washed hands before procedure _229. Assumed a safe p o s i t i o n _230. Reclined head to f a c i l i t a t e eyedrop administration _231. Agitated medicine b o t t l e i f necessary _232. I n s t i l l e d correct medication 233. I n s t i l l e d correct amount _234. Drop went i n t o eye on f i r s t attempt (describe attempts i f more than one) _235. Maintained c l e a n l i n e s s of b o t t l e of eyedrops _236. Touched l i d s or lashes _237. Touched globe 238. Washed hands upon completion of procedure Comments: APPENDIX E DISCHARGE INSTRUCTION HAND-OUT 125 INSTRUCTIONS FOR EYE PATIENTS ON DISCHARGE FROM HOSPITAL 1. Make an appointment to see your doctor i n time. The phone number i s and the address i s 2. Before carrying out any treatment to your eye, wash hands thoroughly and again upon completion. 3. Have your pre s c r i p t i o n s f i l l e d at your drugstore 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 pharmacist should t h i s be necessary. Ca r e f u l l y follow the d i r e c t i o n s on the b o t t l e . 4. Bathe your eyes with warm tap water as necessary, using s t e r i l e cotton b a l l s which may be purchased at the drugstore. 5. If your eye i s uncomfortable you may take one or two a s p i r i n s or your f a v o r i t e headache remedy. 6. Your eye may remain red for a month or so as part of the normal healing process. Moderate mucous discharge i s to be expected and your l i d s may be swollen. If you have undue discomfort or notice a change of the condition of your eye please c a l l your doctor's o f f i c e at once. 7. Wear dark glasses during the day e s p e c i a l l y when out of doors or i n any g l a r e . At bedtime apply the eye s h i e l d over your operated eye using scotch tape to hold i t i n place. 8. Be very c a r e f u l to avoid 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 dress yourself, be up and about the house, walk outside, watch t e l e v i s i o n and prepare l i g h t meals. You must not read, do housework, gardening or return to work u n t i l directed by your doctor. 9. You may brush your teeth, take a tub bath, or shower. Men may shave. You may have your h a i r washed and s e t . Avoid shaking your head during these a c t i v i t i e s 10. Do not resume sports or strenuous a c t i v i t i e s u n t i l directed by your doctor. Special Instructions: APPENDIX F RESULTS OF EYE STATUS OBSERVATIONS 127 TABLE 12 RESULTS OF EYE STATUS OBSERVATIONS Feature Frequency V i s i t V i s i t V i s i t V i s i t 1 2 1 2 Lids : Anterior Chamber: Normal 12 18 Normal, formed 20 20 Swollen 5 2 Shallow, f l a t 0 0 Ecchymosis 3 0 Discharge: Conjuctiva: Absent 11 15 No i n j e c t i o n 3 5 Watery 3 3 S l i g h t i n j e c t i o n 6 8 Mucus 6 2 Moderate i n j e c t i o n 8 5 Purulent 0 0 Marked i n j e c t i o n 3* 2* Crusting: Cornea: Present 2 2 Clear, lustrous 18 20 Absent 18 18 Steamy, hazy 2 0 Subject's report of P u p i l : crusting i n a.m. 6 7 Round, d i l a t e d * * 13 13 In c i s i o n : Round, small*** 3 3 Normal 20 20 Ovoid, d i l a t e d * * 1 1 Abnormal 0 0 Irregular, mod. d i l a t e d * * 1 1 Keyhole, d i l a t e d * * 2 2 * Subjects had subconjunctival inje ;ction of a n t i b i o t i c (Garamycin) Feature Frequency during surgery ** Atropine drops ordered *** Phospholine Iodide or Timolol drops ordered APPENDIX G RESULTS OF ANALYSIS FOR ASSOCIATION AMONG SELECTED VARIABLES USING FISHER EXACT TEST METHOD OF DICHOTOMIZING CONTINUOUS VARIABLES FOR FISHER EXACT TEST Age: 1 = 71 years or l e s s ; 2 = more than 71 years Length of Stay: 1 = 4 days or l e s s ; 2 = more than 4 days V i s u a l Acuity, Unoperated Eye: 1 = 20/100 or better; 2 = 20/200 or less L i v i n g Arrangements: 1 = with able r e l a t i v e ; 2 = alone Education Level: 1 = 12 years school or l e s s ; 2 = more than 12 years Socio-economic Status: 1 = Rank less than 250; 2 = Rank 250 or greater (Blishen & McRoberts, 1976) Manual Dexterity: 1 = no impairment; 2 = impaired Understanding of Cataract Surgery: 1 = knew lens became opaque, surgery was in t r a o c u l a r 2 = thought cataract was external growth 130 TABLE 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 Tests 1- 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 A G E S E X E D U C A T I 0 N A L L E V E L S S 0 T C A 1 T 0 S E C 0 N 0 M I C M P D A E R N R 0 U S P A O S L N D I E N X S T T E I R L I L T I Y N G 0 F U C N A D T E A R R S A T C A T N D S I U N R G G E 0 R F Y P W R I E T V H I 0 E U Y S E E S X U P R E G R E 1 R E Y N C E P w R I E T V H I 0 E U Y S E D E R X 0 P P E S R I E N C E 0 P T R H 0 E B R L E M M E S D I C A L V I S u A L A C U I T Y Change i n l i v i n g arrangements .08 .09 Length of s t a y ^ 1.0 .58 Phone c a l l s t o o p h t h a l m o l o g i s t .05 .61 U n d e r s t a n d i n g of c a t a r a c t s u r g e r y .30 1.0 .27 .61 Knowledge of w a i t i n g p e r i o d 1.0 .28 .53 1.0 D i f f i c u l t y g e t t i n g drop i n t o eye .64 .54 1.0 Manual d e x t e r i t y .17 D i f f i c u l t y s q u e e z i n g b o t t l e 1.0 D i f f i c u l t y w i t h b o t t l e opening . .28 C o n t a m i n a t i o n of eyedrop b o t t l e .62 .64 Concern about t o u c h i n g eye w i t h dropper 1.0 D i f f i c u l t y r e a d i n g l a b e l s 1.0 F e e l i n g s of c o n f i d e n c e 1.0 1.0 1.0 1 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 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 used t o perform t h i s t e s t . S e l e c t e d s i g n i f i c a n c e : cC 2 = .05. 2 The method used t o d i c h o t o m i z e c o n t i n u o u s v a r i a b l e s i s p r o v i d e d on the f a c i n g page. APPENDIX H P A T I E N T SUGGESTIONS THAT F A C I L I T A T E COMPLIANCE WITH RECOMMENDATIONS 132 PATIENT SUGGESTIONS THAT FACILITATE COMPLIANCE WITH RECOMMENDATIONS Dressing: 1. Bend knees or use salad tongs to pick up objects from the f l o o r . 2. Select c l o t h i n g that buttons down the front and does not need to be pulled on over the head. 3. Hang up clothes immediately so they w i l l not end up on the f l o o r . 4. L i f t feet to put on shoes and stockings. 5. Use long shoe horn to a s s i s t with putting on shoes. 6. Use shoes without l a c e s . 7. Store shoes on chai r s , chests, or cl o s e t shoe bags so they w i l l be high enough to prevent the need to bend. Bathing: 8. Turn one's back to the shower spray. 9. Wear metal eye s h i e l d when taking a shower. 10. Use sponge baths f o r the f i r s t while as a precaution against f a l l i n g i n the tub. Meal Preparation: 11. Keep kitchen u t e n s i l s and frequently used pots and pans at counter l e v e l . 12. Ask family members to put objects back i n t h e i r usual places so they may be located e a s i l y and thereby permit patient to be more independent. Garden: 13. S i t on a piece of carpet or mat to " p u l l a few weeds." 133 Dark Glasses; 14. Cut off side of p l a s t i c c l i p - o n glasses to provide r e l i e f from photophobia f o r the operated eye, but enough l i g h t f o r the other. Eye Shield: 15. Bend edges of metal eye s h i e l d to f i t i n d i v i d u a l f a c i a l configuration. 16. Place a piece of tape on the s h i e l d f i r s t and then apply i t to the face. 17. Have patient hold the s h i e l d i n place while a family member applies the tape. Eyedrops - Family Member Administration: 18. Have patient hold down the lower l i d while family member i n s t i l l s the drop. Eyedrops - Self-Administration: 19. Place knuckle of thumb on bridge of nose and hold eye dropper between thumb and f o r e f i n g e r , to estimate correct p o s i t i o n , of dropper. 20. Place thumb knuckle on middle of eyebrow to estimate correct p o s i t i o n of dropper. 21. Use non-dominant f o r e f i n g e r to p u l l down lower l i d , and use extended middle finger of t h i s hand to judge distance the dropper i s from the eye. 22. L i e on bed with a small 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 angle 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}]}"
                            data-media="{[{embed.selectedMedia}]}"
                            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:
https://iiif.library.ubc.ca/presentation/dsp.831.1-0095286/manifest

Comment

Related Items