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Effectiveness of teaching in the rehabilitation of patients with chronic bronchitis and emphysema Perry, JoAnn 1976

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THE EFFECTIVENESS OF TEACHING IN THE REHABILITATION OF PATIENTS WITH CHRONIC BRONCHITIS AND EMPHYSEMA by JoAnn Perry B.S.N., Adelphi U n i v e r s i t y , 1965 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n the School o f Nursing We accept t h i s t h e s i s as conforming to the required standard: THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1976 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree at the U n i v e r s i t y o f B r i t i s h Co lumb i a , I a g ree that I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d tha t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s tudy . Department o f The U n i v e r s i t y o f B r i t i s h Co lumbia 20 75 Wesbrook Place Vancouver, Canada V6T 1W5 ABSTRACT A STUDY ON THE EFFECTIVENESS OF TEACHING IN THE REHABILITATION OF PATIENTS WITH CHRONIC BRONCHITIS AND EMPHYSEMA This study concerned i t s e l f with planned teaching, based on p r i n c i p l e s o f adult education, as a component o f the r e h a b i l i t a t i o n of p a t i e n t s with chronic b r o n c h i t i s and emphysema. The need f o r teaching i n t h i s area has been recognized, but as yet not researched. The purpose of t h i s study was to determine whether the teaching i n t e r v e n t i o n , conducted i n groups and on a one-to-one b a s i s , would a f f e c t the patient's a b i l i t y to recognize and t r e a t h i s disease symptoms. The n u l l hypothesis was tested: there i s no s i g n i f i c a n t d i f f e r e n c e i n the patient's a b i l i t y to recognize and t r e a t disease symptoms a f t e r he has p a r t i c i p a t e d i n a teaching program as compared to h i s a b i l i t y to recognize and t r e a t disease symptoms before p a r t i c i p a t i n g i n such a program. Using two r e h a b i l i t a t i o n f a c i l i t i e s i n large metropolitan h o s p i t a l s , a l l p a t i e n t s accepted f o r the r e h a b i l i t a t i o n programs over a four-month period were asked to p a r t i c i p a t e i n the study. Ultimately, twenty p a t i e n t s made up the study group. Patients were i n s t r u c t e d i n diary-keeping s k i l l s and given one d i a r y per week for four weeks before they began the r e h a b i l i t a t i o n program. These d i a r i e s were reviewed on a weekly bas i s with the researcher. A f t e r the patients had p a r t i c i p a t e d i n the teaching program they were again given d i a r i e s (one per week f o r eight weeks) which were reviewed weekly with the researcher. i i i . The patients were asked to describe each day as being a good (comfortable) day or a bad (uncomfortable) day, to record the presence of any symptoms that they experienced, and to record any a c t i v i t i e s or treatments that they used to make themselves more comfortable. Twelve symptoms and eleven treatments were under consideration. The symptoms and treatments were divided i n t o before and a f t e r categories and analyzed using the t r a t i o f o r non-independent groups. The r e s u l t s o f the an a l y s i s lead to the r e j e c t i o n of the n u l l hypothesis with p=0.05, i n d i c a t i n g that p a t i e n t s with chronic b r o n c h i t i s and emphysema were bet t e r able to cope with t h e i r i l l n e s s e s a f t e r the teaching i n t e r v e n t i o n . The study recommends that health care f a c i l i t i e s e s t a b l i s h teaching programs f o r patients with these i l l n e s s e s , and that nurses assume greater involvement and r e s p o n s i b l i t y f o r teaching p a t i e n t s . The study concludes with recommendations f o r further i n v e s t i g a t i o n . i v . TABLE OF CONTENTS PAGE LIST OF TABLES v i i CHAPTER 1 Introduction to the Study 1 Introduction 1 Statement o f the Problem 2 Si g n i f i c a n c e of the Problem 2 The Disease, The D i s a b i l i t y and the Treatment 2 Prevalence 5 Compliance 7 Role of the Nurse 9 CHAPTER 2 T h e o r e t i c a l Basis f o r the Study 11 Need to Learn 11 A b i l i t y to Learn 14 Ma t e r i a l to be Learned - 16 A Review o f the L i t e r a t u r e Postulates on R e h a b i l i t a t i o n of the Pat i e n t 19 With Chronic B r o n c h i t i s and Emphysema CHAPTER 3 Design of the Study 23 Ori e n t a t i o n to the R e h a b i l i t a t i o n Programs 23 General Aim of the Study 26 S p e c i f i c Aims o f the Study 26 Hypothesis 27 Var i a b l e s 27 D e f i n i t i o n of Terms 28 Assumptions of the Study 29 Limit a t i o n s o f the Study 30 CHAPTER 4 Methodology 31 Overview o f the Methodology 31 Tools U t i l i z e d i n the Study 32 Diary 32 Objectives 35 Sample 37 CHAPTER 5 An a l y s i s o f the Data 38 The Study Population 38 Analysis o f the Data Accumulated on the T o t a l 40 Group Test o f the Hypothesis 46 Discussion 47 v. TABLE OF CONTENTS - Cont'd: PAGE CHAPTER 6 Summary, Implications for Practice, 49 Recommendations for Research Summary 49 Implications for Nursing Practice 50 Recommendations for Research 51 BIBLIOGRAPHY 53 APPENDIX A Patient Diary 57 APPENDIX B "Jog"List 59 APPENDIX C Patient Objectives 63 vi. LIST OF TABLES TABLE PAGE I Age, Sex, L i v i n g Arrangements and S e v e r i t y o f Disease 39 II Reported Symptoms Before and A f t e r Teaching 41 I I I Treatments Used to Relieve Symptoms and Maintain Health 43 IV Mean (X) Of Symptoms, Mean (X) Of Treatments, 45 Mean (X) Of Good Days, and Level of Objectives Achieved v i i CHAPTER I INTRODUCTION Throughout North America chronic b r o n c h i t i s and emphysema have increased, and continue to increase, as s i g n i f i c a n t causes of d i s a b i l i t y and death. Recognition o f the prevalence and s e v e r i t y o f t h i s problem has kindled an i n t e r e s t not only i n the diseases but also i n the p l i g h t o f persons a f f l i c t e d with the disease and i n the lung i t s e l f . Current l i t e r a t u r e i s replete with information on metabolic and biochemical mechanisms of the lung and the response o f the lung to a l l e r g e n s , i r r i t a n t s and a v a r i e t y of disease producing agents. Some of the enthusiasm d i r e c t e d towards the lung i n both i t s healthy and diseased states has fortunately found i t s way out o f the laboratory and i n t o the c l i n i c a l s i t u a t i o n . Thus, new approaches to the care o f persons with chronic b r o n c h i t i s and emphysema can a l s o be found i n the l i t e r a t u r e . One p a r t i c u l a r approach that i s r e c e i v i n g considerable a t t e n t i o n i s a combination o f p a t i e n t education and exercise r e t r a i n i n g , commonly r e f e r r e d to as r e h a b i l i t a t i o n . The focus of t h i s paper w i l l be on the educative component o f r e h a b i l i t a t i o n programs f o r patients with chronic b r o n c h i t i s and emphysema; f o r while there are many claims made that p a t i e n t education i s an e s s e n t i a l ingredient o f these programs,there i s no information to substantiate the claim. Further, while the exercise 2. r e t r a i n i n g helps the p a t i e n t a t t a i n a greater tolerance f o r p h y s i c a l a c t i v i t y , the educative component a s s i s t s the p a t i e n t to value and maintain h i s a c t i v i t y l e v e l and h i s optimal l e v e l o f health, by increasing the range o f behaviours that he can u t i l i z e to cope with and c o n t r o l h i s i l l n e s s . Statement of the Problem Redman states that p a t i e n t education should be defined as l e a r n i n g (a change of behaviour) which i s brought about as the r e s u l t of contact with a health care worker.* This study was concerned with whether or not patients learned (that i s , were able to execute a v a r i e t y o f symptom r e l i e v i n g and health maintaining behaviours) by p a r t i c i p a t i n g i n a r e h a b i l i t a t i o n program f o r p a t i e n t s with chronic b r o n c h i t i s and emphysema. Si g n i f i c a n c e o f the Problem The Disease, The D i s a b i l i t y and the Treatment Chronic b r o n c h i t i s i s characterized by the presence of a productive cough f o r three months o f the year, two years i n a row when 2 other p o s s i b l e causes f o r productive cough have been r u l e d out. Barbara K. Redman, "Guidelines for Q u a l i t y Care i n Patient Education," Canadian Nurse 71 (February 1975): 20. American Thoracic Society Committee on Diagnostic Standards f o r Nontuberculous Respiratory Disease: Chronic B r o n c h i t i s , Asthma and Pulmonary Emphysema, American Review o f Respiratory Disease 85 (May 1962): 762-768. 3. Pathologic changes that occur i n the airway may eventually d i s t o r t and scar the bronchial walls and i n t e r f e r e with the normal d i s t r i b u t i o n o f a i r throughout the lung. Emphysema i s defined i n anatomic terms and i s s a i d to e x i s t when there i s enlargement o f the airspace d i s t a l to the terminal bronchiole.* This area of the lung, the acinus, i s the s i t e o f gas exchange. Most often chronic b r o n c h i t i s and emphysema occur together, and t h i s has led to the use o f terms such as chronic airways obstruction, chronic obstructive pulmonary disease and chronic lung disease to i n d i c a t e the presence o f e i t h e r or both disorders. Regardless o f what they are c a l l e d , i t i s w e l l recognized that chronic b r o n c h i t i s and emphysema are d i s a b l i n g diseases. The pathogenesis o f the d i s a b i l i t y i s r e l a t e d to the presence o f re s p i r a t o r y i n s u f f i c i e n c y which occurs when the disease process has a f f e c t e d the a b i l i t y o f the lung to carry out i t s primary function o f gas exchange. M i l l e r describes the evolution o f the d i s a b i l i t y as: .... e i t h e r pulmonary, v e n t i l a t o r y or c i r c u l a t o r y i n s u f f i c i e n c y (which)may be responsible f o r e x e r t i o n a l dyspnea which, i n turn causes fear and i n a c t i v i t y . I n a c t i v i t y promotes diminished muscle tone, decreased muscle e f f i c i e n c y , easy f a t i g u a b i l i t y and progressive p h y s i c a l d i s a b i l i t y . A 1 J of these i n turn lead again to more i n a c t i v i t y and e x e r t i o n a l dyspnea. ""•American Thoracic Society Committee on Diagnostic Standards f o r Nontuberculous Respiratory Disease: Chronic B r o n c h i t i s , Asthma and Pulmonary Emphysema, American Review o f Respiratory Disease - 85 (May 1962): 762-768. 2 William F. M i l l e r , Harold F. Taylor and Alan K. Pierce, "Rehcibilitation of the Disabled Patient with Chronic B r o n c h i t i s and Emphysema," A.J.P.H. 53 (1963): 20. 4. The s e v e r i t y of the d i s a b i l i t y v a r i e s according to the se v e r i t y o f the disease. Thus, those i n the e a r l y stages o f i l l n e s s may f i n d i t to be l i t t l e more than an inconvenience, while to others i n more advanced stages the diagnosis portends a housebound, dependent existence where the adequacy of every breath i s questioned. The poverty o f experience which often t y p i f i e s the l i f e o f patients with chronic b r o n c h i t i s and emphysema l e d experts i n the f i e l d to seek out an e f f e c t i v e therapeutic i n t e r v e n t i o n . When authors such as 1 2 3 Barach , M i l l e r , and Pierce reported t h e i r findings on the e f f e c t s o f exercise r e t r a i n i n g , i n t e r e s t i n treatment was stimulated. These authors were among the very f i r s t to recognize that exercise r e t r a i n i n g l e d to an increase i n pa t i e n t s ' a b i l i t y to t o l e r a t e p h y s i c a l a c t i v i t y without experiencing that d i s a b l i n g dyspnea, which functioned l i k e an i n v i s i b l e tether. A number o f health care f a c i l i t i e s , from the physician's o f f i c e to the medical center, have developed comprehensive r e h a b i l i t a t i o n programs which, i n addi t i o n to the p h y s i c a l r e t r a i n i n g , place heavy emphasis on teaching the p a t i e n t about h i s i l l n e s s . Goals that are common to such x A l a n L. Barach, Hylan A. Bickerman and Gustov J . Beck, "Advances i n the Treatment of Non-Tuberculous Pulmonary Disease," B u l l e t i n New York  Academy o f Medicine 28 (June 1952): 353. 2 M i l l e r e t a l : " R e h a b i l i t a t i o n , " 18-24 Alan K. P i e r c e , Harold P. Taylor, Richard K. Archer and William F. M i l l e r , "Response to Exercise Retraining i n Patients with Emphysema," Archives of Internal Medicine 113 (January 1964) : 78-86. programs are increasing patients* tolerance f o r p h y s i c a l a c t i v i t y and improving the q u a l i t y of l i f e . * The published information concerning the success o f r e h a b i l i t a t i o n programs leaves many questions unanswered. A l l reports i n d i c a t e that p a t i e n t s are able to t o l e r a t e greater l e v e l s o f a c t i v i t y than they were before attending the programs. However, there i s no d e f i n i t i v e answer; indeed there i s some controversy as to the p h y s i o l o g i c a l mechanism responsible f o r t h i s change. Further, those authors who maintain that p a t i e n t education i s an e s s e n t i a l component o f r e h a b i l i t a t i o n have not. established whether o r not, or how the educative process aids i n the attainment o f goals (improving the p a t i e n t ' s q u a l i t y o f l i f e and i n c r e a s i n g h i s tolerance f o r p h y s i c a l a c t i v i t y ) . Prevalence of the Diseases Anderson has r e f e r r e d to the obstructive airways disordeis 2 as the "mid-century epidemic," and s t a t i s t i c s from a v a r i e t y o f sources c e r t a i n l y support h i s statement. In a b u l l e t i n from the Sanitorium Board o f Manitoba i t was reported that deaths from b r o n c h i t i s and emphysema across Canada i n 1971 t o t a l l e d 3,136, which i s almost double the number 3 reported i n 1968. Further, the number of days i n h o s p i t a l i n 1968 t o t a l l e d 707,241; h o s p i t a l discharges numbered over 65,000. The figures for 1971 were 4 not a v a i l a b l e f o r comparison i n that report. * C o l i n R. Woolf, "A R e h a b i l i t a t i o n Program f o r Improving Exercise Tolerance o f Patients with Chronic Lung Disease," Canadian Med.Assoc.Jn. 106 (June 1972): 1289-1292; M i l l e r e t a l : " R e h a b i l i t a t i o n o f the Disabled Patient, 78-86; Fred A. Obley and F r a n k l i n M. P r e i s e r , "Comprehensive Outpatient Respiratory Care: A Program Conducted i n a Suburban Privat e P r a c t i c e , " Journal  o f the American G e r i a t r i c Society, 22 (November 1974): 522. 2 Donald 0. Anderson, "Chronic Non-Tuberculous Respiratory Disease" Preventive Medicine ed. D.W. Clark and B. MacMahen (Boston: L i t t l e , Brown and Co., 1967), 491. 3 News B u l l e t i n 13 (Manitoba: The Sanitorium Board o f Manitoba, 1972) 1 4 I b i d . 6. In B r i t i s h Columbia the research d i v i s i o n o f the P r o v i n c i a l Health Services and Hospital Insurance published a volume of s t a t i s t i c s on h o s p i t a l cases discharged i n 1971. For chronic b r o n c h i t i s and emphysema the t o t a l number of days i n h o s p i t a l was 32,626 f o r males and 17,280 f o r females.* The case d i s t r i b u t i o n according to age i n d i c a t e d that those between the age o f 60 and 74 were the most severely a f f e c t e d 2 (748 males and 273 females). The consideration o f age i s a s i g n i f i c a n t one because not only i s i t a recognized f a c t that the number o f e l d e r l y persons i s increasing, but a l s o within the given age d i s t r i b u t i o n there are a number of persons who are i n the pre-retirement age. (Exact figures about those i n the 60 to 65 age group were not a v a i l a b l e ) . Further, the numbers reported do not include patients i n Department o f Veterans A f f a i r s H o spitals, p a t i e n t s i n p r i v a t e h o s p i t a l s , patients who have chronic b r o n c h i t i s or emphysema as a secondary diagnosis, or patients who have the diagnosis o f chronic b r o n c h i t i s and emphysema but have not been h o s p i t a l i z e d for i t i n that y e a r . 3 Thus, the number o f persons a f f l i c t e d with these diseases i s l i k e l y to be considerably higher than i s i n d i c a t e d by counting h o s p i t a l admissions, and that number i s c e r t a i n l y high enough. S t a t i s t i c s of Hospital Cases Discharged During 1971 ( V i c t o r i a : Department of Health Services and Hospital Insurance, 1971) 40-41. 2 I b i d . 3 I b i d . 7. Compliance As stated earlier, one intent of the rehabilitation programs is to teach patients new ways and/or reinforce existing ways of coping with chronic bronchitis and emphysema. In order to achieve this end the behaviour change needs to be more than an added s k i l l ; i t must be an acceptance, or preference for, or commitment to a set of values regarding health. As Davis has pointed out, exposing patients to prescriptive and proscriptive behaviours which may be quite alien to his existing values, tastes and habits produces a state of dissonance.* As this i s not a state that can be maintained without considerable discomfort, the patient w i l l 2 make a decision to comply or not comply with the recommendations. Marston's review of the literature points out that compliance reports vary from four percent to one hundred percent in the extent of default, but adds that i t i s most lik e l y thirty to thirty-five percent of patients who 3 do not follow through on recommended health behaviours. Though the literature i s controversial on the significance of age, Marston found that demographic 4 variables were considered not significant m predicting compliance. However: ... an increasing number of recommendations have been found to be associated with increasing non-compliance. Further, i t has also been found that the^longer patients are under treatment the less l i k e l y they are to comply. """Milton S. Davis, "Predicting Non-Compliant Behavior," Journal of Health  and Social Behavior 8 (December 1967) : 265-266. 2 I b i d . 3 Mary Vesta Marston, "Compliance with Medical Regimens: A Review of the Literature," Nursing Research 19 (July-August 1970): 312. 4 I b i d . , 317. 5Ibid., 318. 8. As chronic bronchitis and emphysema are diseases without a known cure, remain with the patient for the rest of his l i f e and involve f a i r l y complex regimens for health maintenance, i t i s not unreasonable to suggest that persons with these illnesses w i l l encounter some d i f f i c u l t i e s regarding compliance. It i s a well-established fact that simply providing patients with factual information concerning their self care i s not a sufficient stimulus to evoke change in health beliefs and behaviours.* Neither i s 2 fear. Practitioners concerned with patient education and compliance point out that there i s a paucity of objective information on theories 3 of health behaviour and predicting compliance. Thus, patient education for persons with chronic bronchitis and emphysema is being advocated as an integral part of therapy for these disorders, which are increasing in prevalence, without substantive evidence that the educative effort w i l l in fact produce the desired effect - i.e. valuing a set of behaviours that assist the patient to maintain his optimal level of health. 1Barbara K. Redman, The Process of Patient Teaching in Nursing (Saint Louis: The C.V. Mosby Company, 1972) 23-24. 2 I b i d . Ibid., 29-32; and Marston, "Compliance with Medical Regimens" 320-321; and Davis, "Predicting Non-Compliant Behaviour" 271. Role o f the Nurse Germane to any consideration o f the goals o f r e h a b i l i t a t i o n for persons with chronic b r o n c h i t i s and emphysema i s the r o l e of the nurse As the teaching and research a c t i v i t i e s o f the nurse are already w e l l accepted and have been extensively documented,the author would p r e f e r to present extracts from the Model f o r Nursing o f the Un i v e r s i t y of B r i t i s h Columbia School of Nursing, which are relevant to the problem stated as wel l as to the approach to the problem. MODEL FOR NURSING  BELIEFS ABOUT NURSING AND ITS PRACTICE 2. Nursing makes a unique co n t r i b u t i o n to the goal o f optimal health of man. 4. Nursing's unique function i s to nurture man during c r i t i c a l periods o f h i s l i f e c y c l e so that he may develop and u t i l i z e a range of coping behaviours which permit him to s a t i s f y h i s basic human needs and thereby move to optimal health. 5. The nurturing of man during the c r i t i c a l periods o f h i s l i f e c y c l e makes a s i g n i f i c a n t d i f f e r e n c e i n the way he copes with these periods. ASSUMPTIONS ABOUT MAN 2. Man constantly s t r i v e s to s a t i s f y each basic human need by using a range o f coping behaviours. 4. Man's coping behaviours are organized i n t o r e p e t i t i v e , p r edictable patterns which become c h a r a c t e r i s t i c o f h i s ways o f meeting h i s basic needs. 5. Development of man's coping behaviours i s dependent upon h i s growth maturation, and l i f e experiences. Model Committee, "Model For Nursing," Vancouver: The U n i v e r s i t y of B r i t i s h Columbia School o f Nursing, 1974. (Mimeographed) 1. 10. 6. When man encounters the losses and/or demands of a c r i t i c a l period in his l i f e cycle, his repertoire of coping behavjours may not allow him to satisfy one or more of his basic needs. Chronic bronchitis and emphysema affect people in such a way as to require a greater range of coping behaviours than they may have developed. In her nurturing role, the nurse, with the patient, w i l l identify those coping behaviours which are inadequate in the areas of perception, recognition, planning and action. Further, she w i l l foster the development of cognitive and executive a b i l i t i e s that w i l l move the individual towards his optimal level of health. For example, the patient must know that upper respiratory tract infection i s a threat to his well-being. He therefore must know what precautions to take to minimize his chances of becoming infected and be physically and mentally able to act on this knowledge. He must also know how to recognize the presence of infection, and must be able to take the appropriate action when infection i s present (e.g., he may have antibiotics at home, or he may have to phone his physician for a prescription). The acquisition of coping behaviours that w i l l permit that patient to attain his optimal level of health i s the goal of the nurse-patient educative interaction. Model Committee, "Model For Nursing," 1. CHAPTER II THEORETICAL BASIS FOR THE STUDY I f one considers the information that i s a v a i l a b l e concerning r e h a b i l i t a t i o n o f the pa t i e n t with chronic obstructive lung disease^ i t i s immediately obvious that though a strong emphasis i s placed on the need f o r education of the p a t i e n t there i s a lack o f information concerning the educative process, or the influence o f education on the outcome of r e h a b i l i t a t i o n . Therefore t h i s chapter w i l l be divided i n t o four sections, and consider (1) the need o f patients to lea r n , (2) a b i l i t y of patients to lear n , (3) a review o f the l i t e r a t u r e to e s t a b l i s h the information to be learned, and (4) postulates on r e h a b i l i t a t i o n . The Need to Learn As stated above, nursing's unique function i s a s s i s t i n g the i n d i v i d u a l to develop h i s r e p e r t o i r e o f coping behaviours so that he may move to optimal health.* Model Committee, "Model f o r Nursing," 1. 12. The teaching/learning process i s an important route to this end. Barbara K. Redman suggests that there i s a priority system for educational needs: Acute educational needs exist when a lack of understanding i s causing psychological anguish and/or physical danger. Preventive educational needs exist when a condition of some threat i s l i k e l y to occur to an individual or group who has l i t t l e s k i l l for handling i t . The seriousness of the threat and the probability of i t s occuring both vary. Maintenance educational needs exist for those l i v i n g with medically derived alterations i n their l i v i n g patterns who w i l l need more or less frequent reteaching, and for whom a de f i c i t of understanding and s k i j l i s causing d i f f i c u l t y with normal developmental tasks. These categories implicitly recognize that i f educational needs are not met we cannot j u s t i f i a b l y assume that the patient w i l l be able to "satisfy 2 his basic human needs and thereby move to optimal health." Smyth suggests that patients need an ever increasing amount of "... information to process in order to make effective rational decisions concerning behaviour modification in l i f e s t y l e . " 3 She also notes that neither a l i s t of "do's and don'ts"given to a patient shortly before discharge from hospital, nor a brief film, nor a pamphlet i s li k e l y to provide sufficient 4 information or motivation to yield the desired behavioural outcome. Redman, "Guidelines for Quality of Care i n Patient Education," 20. 2 Model Committee, "Model For Nursing," 1. 3 Kathleen Smyth, "Symposium on Teaching Patients - Foreword," Nursing Clinics of North America 6 (December 1971): 571. 4 I b i d . 13. When patients face a change in their l i f e style, with which they must learn to cope, knowledge of the disease and goals of treatment are essential factors in adequate adaptation states Haferkorn. 1 In addition she wisely observes that a lack of knowledge can be deleterious to the patient who i s "... unable to protect his health and may unknowingly 2 do himself harm." An editorial in the American Journal of Public Health observed that some health care workers may feel that teaching patients about their illness i s a moral or ethical responsibility while others expect better 3 cooperation from the patients who have received instruction. It i s further noted that ... some recognize the need for an educational process through participation and involvement in order to bring about the proper decisions which the patient must face many times each day, e.g. to eat an apple or a candy bar, to walk instead of ride... The patient who i s re-admitted or whose recovery at home i s lengthened because of a failure to take medication correctly, to adhere to a prescribed regimen, or to follow a prepared exercise program must^be considered as an educational failure and inadequately treated. Redman notes that health care workers expect the patient to seek help at the appropriate time and to comply with care regimens, but they do not "Virginia Haferkorn, "Assessing Individual Learning Needs for Patient Teaching," (Nursing Clinics of North America) 6 March 1971 : 199. 2 I b i d . 3 "Public Health: Then and Now - The Need for Patient Education," Editorial American Journal of Public Health 61 (July 1971): 1278. 4 I b i d 1278-1279. 14. help the patient acquire the s k i l l s necessary for him to do so. 1 She has also called attention to the fact that in the near future patient 2 education may be a therapy for which we are legally responsible. The Ability to Learn Implicit in the belief that nurses can assist the patient develop or expand his coping behaviours i s the assumption that adults can learn. Adult learning, however, differs in many significant ways from child learning and the a b i l i t y of the adult to learn can be enhanced or impeded by the method of teaching. Malcolm S. Knowles has identified four assumptions that affect adult learning: one i s that the self-concept of the adult has moved from one of dependency to one of self-direction. 3 The second assumption i s that 4 the adult's l i f e experience i s a resource for learning. Third i s the assumption that the adult's readiness to learn becomes increasingly oriented to his social role; and, la s t l y , the adult's orientation to learning i s one of problem-centeredness.^ Principles of learning which il l u s t r a t e the significance of these assumptions were developed independently by Redman when writing on learning process. She stresses the use of explicit objectives which help the learner ''Barbara K. Redman, "Client Education Therapy in Treatment and Prevention of Cardiovascular Diseases," Cardio Vascular Nursing 10 (January-February 1974): 2. 2 Redman, "Guidelines for Quality of Care in Patient Education," 19. 3 Malcolm S. Knowles, "Andragogy: An Emerging Technology For Adult Learning," The Modern Practice of Adult Education 37 4 Ibid. 5 I b i d . 15. become self-directed. The health educator further fosters self-direction in the learner by role modeling, providing reinforcement for execution of the desired behaviour, and correcting errors promptly. Meaningful material i s learned faster and remembered longer, notes Redman, as are concepts and s k i l l s which can be described or presented in relationship to things and ideas the learner already knows.* Knowles has li s t e d and described principles of teaching somewhat more e x p l i c i t l y . For example: The teacher helps the students identify the l i f e problems ^ they experience because of gaps in their personal equipment. The teacher helps the students exploit their own experiences as resources for learning through the use of such techniques as discussion, role-playing, case method, etc. Thus, given the situation where the patient feels the need to learn, the environment i s conducive to learning and the patient participates actively i n the learning process which i s related to, and makes use of the l i f e experience of the learner, a greater range of coping behaviours w i l l be developed. These behaviours permit the patient to meet his basic human needs and move to optimal health. Barbara K. Redman, The Process of Patient Teaching In Nursing (Saint Louis: The C.V. Mosby Company, 1972), 72. 2 Knowles, "Andragogy," 52. 3Ibid., 53. 16. The Material to be Learned: A Review of the Literature Thomas Petty and his co-workers in Denver have been writing p r o l i f i c a l l y since 1968 in an effort to inform medical, nursing and para-medical workers of the benefits and methods of rehabilitating persons with chronic bronchitis and emphysema. One of the earliest and frequently cited works identifies the following learning needs: knowledge of the nature of the disease, the effects of the disease, and the goals of disease management.* Petty advocates the use of group and individualized instruction for teaching bronchial hygiene, breathing retraining and physical reconditioning. 2 A more recent statement by Dr Petty reiterates the above learning needs and also notes that i f the patient i s to make the requisite contribution to his own health care (i.e. regulation of drugs and diet, and modification of l i f e style) he must be cognizant of the disease process and goals of therapy. He states, "The cost of this modality of care i s only time? the benefits are 4 an enlightened patient; side effects are nonexistent." ''"Thomas L. Petty et a l , "A Comprehensive Care Program for Chronic Airways Obstruction," Annals of Internal Medicine 70 (June 1969): 1111. 2 Ibid. "^ Thomas L. Petty, "Does Treatment for Severe Emphysema and Chronic Bronchitis Really Help? (A Response)" Chest 65 (February 1974): 124. 4 . Ibid. 17. Neff and Petty have suggested that in addition to educating the patient, the family and friends of the patient should also receive information on chronic airways obstruction; i n fact, these people should be incorporated into the health team as soon as rehabilitation i s considered. 1 The specific modalities of care prescribed in this a r t i c l e were bronchial hygiene, abdominal diaphragmatic breathing, physical conditioning and general considerations such as the use of antibiotics for infection, and the avoidance 2 of respiratory i r r i t a n t s . Miller, after contributing to publications on the benefit of 3 exercise retraining, became involved in the more comprehensive approach to the care of the patient with chronic bronchitis and emphysema. He has observed that i t i s imperative for health care workers who are educating the patient to emphasize in their teaching that there i s often a reversible component to chronic bronchitis, and that the patient's case i s not "hopeless." Like Petty, Miller i s of the belief that patients must know the nature and cause of their symptoms i f they are to be expected to intelligently cooperate with the recommendations. The approach advocated by Dr Miller i s that three forms; of airway care be taught to the patient: (1) a prophylactic approach of avoiding respiratory i r r i t a n t s and maintaining a patent airway, (2) a ""Thomas A. Neff and Thomas L. Petty, "Outpatient Care for Patients with Chronic Airways Obstruction - Emphysema and Bronchitis," Chest 60 (August 1971) A Supplement: 11S-12S. "'ibid. "'Pierce, et a l "Response to Exercise Retraining," 78-86. William F. Miller, "Useful Methods of Therapy," Chest 60 (August 1971) A Supplement: 2S. 18. pharmacologic approach which emphasizes the correct use of drugs, especially the bronchodilator drugs and antibiotics for treating respiratory infection, and, (3) the physical approach, which refers to breathing retraining and physical reconditioning.* Colin Woolf in Toronto also published on the effects of exercise 2 retraining before developing a comprehensive rehabilitation program. The general purpose of the program and the content of the educative component are the same as that described by Petty and M i l l e r . 3 Woolf states that i t i s important that a l l members of the health team be involved in educating the patient, and that the teaching process be related to the individual needs of the patient. He also notes: The success of the program depends on demonstrating steady progress in the physical conditioning aspect and much depends on the enthusiasm of the team who takes an interest in the patient and constantly encourages him. It i s probable that some of the success i s due to constant in-hospital care and to psychological factors where the patient learns that he i s capable of a considerably better exercise tolerance than he believed possible. The possibility of a relationship between success and progress i s supported by Silver and Eaton who found in their evaluation of response to therapy that patients who continued to follow up on recommended therapies were the patients who had the greater percentage of good or excellent results. ""Ibid. 3S - 4S. 2 Colin R. Woolf and Suero, J.T., "Alterations in Lung Mechanics and Gas Exchange Following Training in Chronic Obstructive Lung Disease," Diseases  of the Chest 55 (January, 1969) 3Woolf, "A Rehabilitation Program," 1290-1291. 4 Woolf, "A Rehabilitation Program," 1292. Harold M. Silver and Olga M. Eaton, "Subjective Response to Therapy in Chronic Obstructive Lung Disease." Medical Annals of the Dist r i c t of Columbia 43 (March 1974): 121. 19. -There are others who have wr i t t e n on r e h a b i l i t a t i o n o f pa t i e n t s with chronic b r o n c h i t i s and emphysema, but the authors c i t e d above are the recognized experts i n the f i e l d . Further, the other a r t i c l e s on r e h a b i l i t a t i o n r e i t e r a t e the p r i n c i p l e s presented. In summary, the information described as e s s e n t i a l f o r the pati e n t s i s : (1) knowledge of the normal lung, (2) knowledge of the disease process and r e s u l t a n t symptomatology, (3) a b i l i t y to t r e a t the symptoms, (4) a b i l i t y to recognize and avoid environmental f a c t o r s which adversely a f f e c t t h e i r state of health, and, (5) the a b i l i t y and the de s i r e to reach and maintain t h e i r optimal l e v e l o f p h y s i c a l ) a c t i v i t y . Postulates on R e h a b i l i t a t i o n o f the Pat i e n t  With Chronic B r o n c h i t i s and Emphysema As noted previously, the major proponents of r e h a b i l i t a t i o n s t r e s s the need f o r enthusiasm on the pa r t of the health care team. Kimbel and co-workers a l s o note that the success o f t h e i r r e h a b i l i t a t i o n program depends more on the motivation o f the p a t i e n t and the enthusiasm of the therapy team than i t does on the surroundings. 1 T h i s i s i n contrast to Woolf*s claim that a t t e n t i o n received as an i n - h o s p i t a l p a t i e n t p o s i t i v e l y a f f e c t e d the p a t i e n t s ' response. Neither author o f f e r s support f o r t h e i r claim. P h i l i p Kimbel e t a l , "An In-hospital Program f o r R e h a b i l i t a t i o n o f Patients with Chronic Obstructive Lung Disease," Chest 60 (August 1971) A Supplement: 6S. 20. Farther study would be necessary to resolve this conflict. Richard Hatzen states: "That support, a positive attitude and a cheerful outlook must be maintained i s quite evident. This i s perhaps possible only for physicians with a particularly optimistic personality." 1 He also notes that the need for optimism i s c r i t i c a l because of the personality of the patient. He refers to a study which describes the personality of patients with chronic bronchitis and emphysema as being 2 depressed and more neurotic than the average person. Haas and Cardon speculate that rehabilitation of patients with chronic lung disease lags behind other forms of rehabilitation because (II the results are not as impressive or spectacular as the rehabilitation of a paralyzed patient, (2) the patient has the prognosis of a shorter l i f e span, and, (3) because of the slow deterioration of the patient and his declining socio-economic standing, his self-supporting productivity for the future i s questionable and the financial investment i s not considered to be fuJLly j u s t i f i e d . 3 Another factor that may have an influence on the patient's participation and a b i l i t y to learn in the rehabilitation setting focusses on 1 Richard Matzen, "Vocational Rehabilitation - The culmination of Physical Reconditioning," Chest 60 (August 1971) A Supplement: 23S. 2 Dominic DeCencio et a l , "Personality Characteristics of Patients with Chronic Obstructive Pulmonary Emphysema," Archives of Physical Medicine 49 (August 1968): 471-475. 3 Albert Haas and Hugh Cardon, "Rehabilitation i n Chronic Obstructive Pulmonary Disease," Medical Clinics of North America 53 (May 1969) 393-394. 21. the way in which the patient sees himself. Ruth Barstow introduces the p o s s i b i l i t y that the patient experiences role ambiguity."'' This i s based on the theory that when a patient i s acutely i l l he i s allowed to assume the dependent patient role until he gets better; however, the patient with chronic obstructive lung disease never gets better and consequently cannot 2 relinquish the sick role. The ambiguity comes about because the incapacity is p a r t i a l , rather than total, and may vary from day to day. The patient and those close to him often find this confusing and frustrating, as expectations become very d i f f i c u l t to establish on a reliable basis. Certain losses experienced by the patient because of his illness may tie compounded because of his age. As stated previously in this paper,, the vast majority of persons a f f l i c t e d with these diseases are elderly. Some specific losses are the loss of the work role, the loss of strength, loss of 3 contact with family and/or friends and the possible loss of independence. Jennings states that increasing activity strengthens self-confidence i n the 4 elderly, as i t does for the patient with chronic bronchitis and emphysema. Ruth E. Barstow, "Coping with Emphysema" Nursing Clinics of North America 9 (March 1974) : 139. 2 I b i d . 3Ibid. 4 Muriel Jennings, Marlene J. Nordstrom and Norene Shumake, "Physiologic Functioning in the Elderly," Nursing Clinics of North America 7 (June 1972): 246. 22. Culbert and Kos suggest that independence i s the most important goal for the elderly person regardless of his state of health, and that this independence i s an expression of self-respect and pride.* Barstow believes that i f the patient has some measure of control and i s action oriented he i s far more 2 li k e l y to cope with his i l l n e s s . She believes that i t i s imperative that the patient be able to actively do something about his condition and not just passively wait for whatever comes. Although there are no hard data available to support these postulates, i t i s possible that attitude towards the patient, attitude and personality of the patient and cultural influences on the patient may affect the extent to which he i s able to learn to cope with his i l l n e s s . *Pamela A. Culbert and Barbara A. Kos, "Aging: Considerations for Health Teaching," Nursing Clinics of North America, 6 (December 1971): 607. 2 Barstow, "Coping with Emphysema," 140. CHAPTER I I I DESIGN OF THE STUDY This chapter w i l l present the design o f the study. A b r i e f o r i e n t a t i o n to the r e h a b i l i t a t i o n programs has been included to f a c i l i t a t e discussion of s p e c i f i c aspects of the study. Ori e n t a t i o n to the R e h a b i l i t a t i o n Programs Two r e h a b i l i t a t i o n f a c i l i t i e s i n the C i t y o f Vancouver were u t i l i z e d i n t h i s study. The philosophy of and approach to r e h a b i l i t a t i o n are s i m i l a r at both f a c i l i t i e s , and the method of education u t i l i z e d i s the same, hence there i s no need to describe them separately. Patients are r e f e r r e d to a program by t h e i r family p h y s i c i a n . A chest physician, r e s p i r a t o r y nurse and physiotherapist cooperate i n the c o l l e c t i o n o f data to determine the s u i t a b i l i t y of the p a t i e n t . This group meets on a regular b a s i s to review the r e h a b i l i t a t i v e approach and assess the p a t i e n t s ' progress. In a d d i t i o n there i s free flowing communication and consultation between the team and the p a t i e n t i n order t o incorporate new data and current problems i n t o the plan of care. 24. One g o a l t h a t i s common t o a l l r e h a b i l i t a t i o n p r o g r a m s i s i n c r e a s i n g t h e p a t i e n t Vs t o l e r a n c e f o r p h y s i c a l a c t i v i t y . To meet t h i s g o a l , t h e p a t i e n t a t t e n d s t h e r e h a b i l i t a t i o n f a c i l i t y o n a r e g u l a r b a s i s a n d p a r t i c i p a t e s i n a p r o g r a m o f i n c r e a s i n g e x e r c i s e t h a t i s t a i l o r e d t o h i s s p e c i f i c needs and a b i l i t i e s . The a c t i v i t i e s t h a t a r e u t i l i z e d t o i n c r e a s e t h e p a t i e n t ' s e x e r c i s e c a p a c i t y a r e w a l k i n g on a t r e a d m i l l and c y c l i n g o n a s t a t i o n a r y b i c y c l e . The work l o a d f o r e a c h a c t i v i t y i s s e t b y t h e p h y s i o t h e r a p i s t i n a c c o r d a n c e w i t h t h e a s s e s s e d a b i l i t y o f t h e p a t i e n t . When t h e work c a n be p e r f o r m e d f o r a g i v e n p e r i o d o f t i m e w i t h o u t d y s p n o e a , t h e work l o a d i s i n c r e a s e d . T h i s p r o c e s s i s r e p e a t e d u n t i l a p l a t e a u i s r e a c h e d and t h e p a t i e n t h a s c e a s e d t o i m p r o v e . S p e c i f i c g o a l s f o r i n c r e a s e d a c t i v i t y a r e s e t b y t h e p a t i e n t i n c o n j u n c t i o n w i t h t h e n u r s e and p h y s i o t h e r a p i s t . T h e s e g o a l s may be s t a t e d i n t e r m s o f a s p e c i f i c d i s t a n c e w a l k e d t h a t t h e p a t i e n t s e e s as d e s i r a b l e , ("I'd l i k e t o be a b l e t o w a l k t o my d a u g h t e r ' s " ) o r i n t e r m s o f a n a c t i v i t y , ("I'd l o v e t o be a b l e t o dance a g a i n . " ) Thus t h e w a l k i n g and c y c l i n g a c t i v i t i e s a r e n o t an e n d i n t h e m s e l v e s , b u t r a t h e r t h e means b y w h i c h a p a t i e n t c a n a t t a i n a g o a l t h a t h a s meaning t o h i m . Sometimes p a t i e n t s have d i f f i c u l t y o r a r e r e l u c t a n t t o s e t a g o a l and s i m p l y s a y t h a t t h e y w o u l d " l i k e t o g e t a r o u n d a l i t t l e b e t t e r , " o r " l i k e t o f e e l more c o m f o r t a b l e . " I n t h e s e i n s t a n c e s , a s p e c i a l e f f o r t i s made t o k e e p t h e p a t i e n t i n f o r m e d a n d aware o f h i s p r o g r e s s i n t e r m s o f work l o a d a n d e n d u r a n c e i n t h e hope he w i l l a t t e m p t t o c a r r y o v e r h i s i n c r e a s e d t o l e r a n c e t o h i s d a i l y l i f e , and e x p e r i e n c e i n a way t h a t h a s s i g n i f i c a n c e t o h i m a n i n c r e a s e d f e e l i n g o f w e l l - b e i n g . 25. Though p h y s i c a l reconditioning i n i t s e l f may be a major b e n e f i t to the p a t i e n t , i t i s only a p a r t of what i s required f o r the maintenance o f optimal health. Thus, through teaching, the r e h a b i l i t a t i o n programs a s s i s t the p a t i e n t i n gaining knowledge and s k i l l s which w i l l allow him some co n t r o l over the way that h i s disease a f f e c t s h i s d a i l y l i v i n g . In addition to s e t t i n g t h e i r own a c t i v i t y goals,patients are encouraged to e s t a b l i s h t h e i r own p r i o r i t y l i s t f o r s e l e c t i n g the problems that pose the most d i f f i c u l t y f o r them. The nurse and physiotherapist provide the p a t i e n t with whatever information i s a v a i l a b l e on various approaches to the problem. The p a t i e n t may s e l e c t on h i s own or with the assistance o f the nurse, the approach o r approaches that best s u i t him. Patients are encouraged to t r y a v a r i e t y of therapies to determine which one, or which combination, works best f o r them. For example, a p a t i e n t who experiences d i f f i c u l t y c l e a r i n g secretions from h i s chest may f i n d drinking hot f l u i d s followed by m o b i l i t y exercises and expulsive coughing a s a t i s f a c t o r y routine, while another p a t i e n t may f i n d that to solve t h i s problem he must inhale a broncho-dilating drug, inhale moist a i r , increase h i s f l u i d intake to four l i t e r s a day, and do p o s t u r a l drainage two times a day. In a d d i t i o n , there are c e r t a i n s k i l l s that are considered e s s e n t i a l , such as the a b i l i t y to recognize the signs of i n f e c t i o n . Patients are asked to demonstrate t h e i r a b i l i t y to accomplish t h i s task. Behavioural objectives are used to evaluate p a t i e n t l e a r n i n g . These obj e c t i v e s include aspects of the c o g n i t i v e , a f f e c t i v e and psycho-motor domains and are arranged h i e r a r c h i c a l l y . These are discussed i n d e t a i l on page 35. 26. Patients are considered to have completed t h e i r program when they have ceased to increase t h e i r exercise tolerance and reached at l e a s t l e v e l s i x o f the o b j e c t i v e s . I f the p a t i e n t cannot demonstrate that he has acquired the s k i l l s r e q u i s i t e for maintenance of h i s health, the family p h y s i c i a n i s n o t i f i e d and an a l t e r n a t i v e method of care discussed, such as weekly v i s i t s to a s p e c i f i c a l l y i d e n t i f i e d health care f a c i l i t y . General Aim o f the Study The a c q u i s i t i o n of coping behaviours that permit the p a t i e n t to move towards h i s optimal l e v e l of health i s the goal o f r e h a b i l i t a t i o n o f persons with chronic b r o n c h i t i s and emphysema. In order to meet t h i s goal,the nurse a s s i s t s the p a t i e n t i n the learning process so that he may master and value the r e q u i s i t e knowledge and s k i l l s . The general aim of t h i s study i s to evaluate the e f f e c t i v e n e s s of the teaching process by examining the various health behaviours reported i n interviews and recorded i n a d i a r y by the p a t i e n t before and a f t e r he p a r t i c i p a t e s i n a r e h a b i l i t a t i o n program. Thus the i n d i v i d u a l ' s w i l l i n g n e s s and a b i l i t y to attend to the symptomatic d i s t r e s s e s of h i s i l l n e s s w i l l be compared before and a f t e r the teaching i n t e r v e n t i o n . S p e c i f i c Aims o f the Study In order to evaluate the e f f e c t i v e n e s s of p a t i e n t teaching the following questions w i l l be asked. 1. A f t e r p a r t i c i p a t i n g i n a r e h a b i l i t a t i o n program which stresses the need f o r patients to l e a r n about t h e i r i l l n e s s , 27. a) i s there a change i n the number o f days that the p a t i e n t perceives as being "good" (comfortable) days? b) do the reported number of symptoms increase, decrease or remain the same? c) are the reported symptoms treated by the patient? d) are the treatments selected the appropriate care measures fo r the reported symptom? e) i s there a change i n the numbers and/or types of treatments u t i l i z e d by the patient? f) do the treatments u t i l i z e d help to r e l i e v e the symptoms? 2. Is there a r e l a t i o n s h i p between the behaviours reported and recorded by the pa t i e n t and the health team's evaluation of the pa t i e n t at the end of the teaching program? The evaluation i s based on behavioural o b j e c t i v e s . Hypothesis There i s no s i g n i f i c a n t d i f f e r e n c e i n the patient's a b i l i t y to recognize and t r e a t disease symptoms a f t e r he has p a r t i c i p a t e d i n a teaching program as compared to h i s a b i l i t y to recognize and t r e a t disease symptoms before p a r t i c i p a t i n g i n such a program. Variables The independent v a r i a b l e i s the teaching program. I t i s the purposeful introduction of t h i s v a r i a b l e that separates the c o n t r o l and experimental data on each p a t i e n t . The dependent va r i a b l e i s the pat i e n t ' s a b i l i t y to recognize and t r e a t disease symptoms. This information w i l l be gathered from p a t i e n t interviews and d i a r i e s which are reviewed on a weekly b a s i s . 28. D e f i n i t i o n of Terms Teaching program: t h i s c o nsists o f forty-minute sessions conducted on three consecutive days i n which information concerning the nature of chronic b r o n c h i t i s and emphysema and s e l f - c a r e measures which help to c o n t r o l the symptoms of the disease are discussed with the p a t i e n t . In a d d i t i o n , there i s one-to-one teaching to r e i n f o r c e the material presented i n the structured c l a s s e s . P a r t i c u l a r emphasis i s placed on each patient's s p e c i f i c complaints. Patients' a b i l i t y to recognize and t r e a t disease symptoms: t h i s term i s used to describe s p e c i f i c symptoms as w e l l as a c t u a l behaviours undertaken by the p a t i e n t to t r e a t the reported symptoms. The s p e c i f i c symptoms that the patients were asked to report and record are: d i f f i c u l t y i n r a i s i n g phlegm tightness i n chest shortness o f breath that i s s l i g h t l y , moderately or markedly greater than usual headache swollen ankles fatigue d i f f i c u l t y i n sleeping due to chest condition an increase i n sputum change i n the colour of sputum head c o l d increase i n cough wheezing 29. The treatments that the patient i s asked to report and record are: breathing exercises relaxation and mobility exercises general exercise (walking or cycling) postural drainage purposeful positioning to relieve shortness of breath increased f l u i d intake intake of hot fluids use of broncho-dilators which have been prescribed on a p.r.n. basis use of other medications (aspirin, diuretics, cold tablets) rest contacting a physician, nurse or physiotherapist for assistance, advice, or to report a symptom The patients are also asked to evaluate each day as being a "good" or "bad" day based on the.presence or absence of symptoms of their chest conditions. When patients report or record the use of any therapy to relieve a symptom, they are asked to evaluate i t s efficiency. Assumptions of the Study 1. One assumption i s that patients have been honest in their reporting and record-keeping. 2. The second assumption i s that by including a l l patients who are participating i n the rehabilitation program the data w i l l not be skewed or unreliable. 30. Limitations o f the Study A l l p a t i e n t s who attend the r e h a b i l i t a t i o n f a c i l i t y have e i t h e r requested assistance or have been r e f e r r e d by t h e i r family p h y s i c i a n s - I t i s the b e l i e f o f t h i s author that to withhold treatment and/or information from these patients would be decidedly u n e t h i c a l . Therefore there i s no c o n t r o l group of patients who kept records and reported on a weekly b a s i s , but d i d not p a r t i c i p a t e i n the teaching program. CHAPTER 4 METHODOLOGY  Overview of the Methodology This experimental study was conducted from December 1974 through October 1975 i n B r i t i s h Columbia. The study c o n s i s t s of four phases: 1) A f t e r each p a t i e n t had been assessed by the r e h a b i l i t a t i o n team and determined su i t a b l e f o r the program, the researcher interviewed the pa t i e n t . The purpose o f the study was explained to the pa t i e n t and h i s w i l l i n g n e s s to p a r t i c i p a t e ascertained. I f the pa t i e n t agreed to p a r t i c i p a t e he was given a d i a r y . In the d i a r y he was asked to record on a d a i l y b a s i s , i n the space provided, the symptoms that he experienced and how he coped with these symptoms. The researcher and the pat i e n t reviewed the di a r y each week, i n person or by phone, fo r a t o t a l of four weeks. 2) The p a t i e n t p a r t i c i p a t e d i n the r e h a b i l i t a t i o n program. In t h i s time period he exercised on a regular b a s i s , attended structured teaching sessions and received one-to-one i n s t r u c t i o n from a l l members o f the r e h a b i l i t a t i o n team, in c l u d i n g the researcher, concerning h i s p a r t i c u l a r d i f f i c u l t i e s . 32. 3) When the pa t i e n t had completed the teaching program, that i s when he had attained h i s highest l e v e l o f achievement on the behavioural o b j e c t i v e s , he resumed diary-keeping f o r a pe r i o d of eight weeks. During the eight weeks he had weekly contact with the researcher to review the diary-4) When a l l the data had been c o l l e c t e d , the d i a r i e s from phase I were compared with the d i a r i e s c o l l e c t e d i n phase I I I . The questions enumerated on pages 26-27 (above) were addressed to the data. Tools U t i l i z e d i n the Study The p a t i e n t d i a r y : the di a r y was developed by the author and was approved by the Thesis Committee and two r e s p i r a t o r y physicians. The terminology u t i l i z e d i n the diary was selected from a review of p a t i e n t interviews and records i n order to determine the most frequently reported symptoms and to i d e n t i f y the words that patients used to describe t h e i r symptoms. S e l e c t i o n of the most commonly reported symptoms was al s o i n agreement with those symptoms 1 2 reported by M i l l e r and Petty . As stated previously, the diary was used i n conjunction with a weekly interview with the researcher. (See Appendix A). M i l l e r , "Useful Methods of Therapy," 2S. Thomas L. Petty and Louise M. Nett, For Those Who Live and Breathe ( S p r i n g f i e l d : Charles C. Thomas, 1967). 33. The r e l i a b i l i t y of the diary-interview technique has been suggested by a variety of authors concerned with public health and epidemiology, who report that i t i s the most effective method available for e l i c i t i n g information concerning day-to-day health behaviour. 1 Roghmann and Haggerty specifically state: Recall of frequent or minor events, and the details thereof, i s usually insufficient to gather this information (a more accurate description g f the events under investigation) in a retrospective interview. As many of the subjects are elderly and are l i k e l y to have some 3 d i f f i c u l t y with short term memory, and many of the frequently occurring symptoms have been with the patient for a number of years, the researcher concluded that a diary coupled with a weekly interview would be the most appropriate tool for gathering data. The decision to combine the closed and open-ended design was based on the need to avoid long l i s t s of symptoms and treatments. This would not only make the diary cluttered and cumbersome, but also would eliminate the po s s i b i l i t y of evaluating the patient's a b i l i t y to recognize unaided any other than the most obvious symptoms. In the weekly interview with the patient, he was questioned from a prepared l i s t of symptoms and treatment modalities to ensure that the information recorded was as complete as possible (see Appendix B). ^George I. Allen et a l . , "Interviewing Versus Diary Keeping in E l i c i t i n g Information in a Morbidity Survey," American Journal of Public  Health 44 (July 1954): 919-927; Klauss J. Roghmann and Robert J. Haggerty, "The Diary as a Research Instrument in the Study of Health and Illness Behaviour," Medical Care 10 (March-April 1972): 143-163; Joel J. Alpert, John Kosa and Robert Haggerty, "A Month of Illness and Health Care Among Low-Income Families," Public Health Reports 82 (August 1967): 705-713 2 Roghmann and Haggerty, "The Diary as a Research Instrument In the Study of Health and Illness Behaviour," 144. ^Culbert and Kos, "Aging: Considerations for Health Teaching," 612. 3 4 . In an effort to ascertain the s u i t a b i l i t y of wording and spacing and the relevancy of the diary,a pre-test of the tool was conducted. Five patients participating i n the rehabilitation program kept the diaries for a period of three weeks. A l l five patients were fai t h f u l in their diary-keeping and met with the researcher on a weekly basis to review the contents of the diary. Over this three week period, while patients were exercising and receiving instruction concerning their i l l n e s s , the number of self-care behaviours that were reported increased. y The five patients stated that there was adequate space for writing and that the directions were not ambiguous. These patients were not included in the study sample. One f i n a l consideration about the diary i s that i t was u t i l i z e d in the teaching process and the care-planning for the individual patient. The health care team working with the patient found that the diary had relevance to their work, while the patients in the pre-test group stated that i t had practical significance i n their day-to-day l i f e because i t asked the question, "Did you do anything to make yourself feel better?" Levine states that relevance i s related to validity.* From the feedback received from the patients i n the pre-test group and the rehabilitation team who u t i l i z e d the diary the researcher concluded that the instrument was clear and relevant for gathering Eugene Levine, "Experimental Design in Nursing Research," Nursing Research 9 (Fall 1960): 208. 35. data, without serving as a source of information. The Objectives: Though a l l the patients received information concerning the nature of their i l l n e s s and hope to cope with the symptoms of their i l l n e s s , the researcher could not assume that learning had occurred. 1 In this study, behavioural objectives were used to help measure and guide the patients' learning. (See Appendix C). The behavioural objectives describe the specific behaviours which indicate how the patient 2 demonstrates that he has learned. This, states Gronlund, shifts the focus "... from the teacher to the student and from the learning process to the learning outcomes."3 The objectives u t i l i z e d i n this study involve the cognitive, affective and psychomotor domains and are arranged hierarchically. The cognitive domain includes those objectives which i l l u s t r a t e the r e c a l l and/or u t i l i z a t i o n of knowledge and "... the development of intellectual s k i l l s 4 and a b i l i t i e s . " The affective domain considers objectives which "... describe changes in interest, attitudes and values and the development of 1Barbara K. Redman, "Patient Education as a Function of Nursing Practice," Nursing Clinics of North America 6 (December 1971): 578. 2 Norman E. Gronlund, Stating Behavioural Objectives for Classroom  Instruction (New York: The Macmillan Company 1970) 1. 3 I b i d . 4 Committee of College and University Examiners, Taxonomy of Educational  Objectives Handbook I Cognitive Domain ed. by Benjamin S. Bloom with Max EngleharJ et a l , (New York: David McKay Company, Inc. 1956) 7. 36. 1 appreciations and adequate adjustment." The t h i r d domain, psychomotor, 2 includes objectives measuring manipulations or motor s k i l l s . The p a t i e n t who has p a r t i c i p a t e d i n r e h a b i l i t a t i o n programs i n d i c a t e s h i s l e v e l o f learning by the score he receives i n a t t a i n i n g the o b j e c t i v e s . The i d e a l score i n d i c a t e s that not only does the p a t i e n t know about the disease and i t s r e s u l t a n t symptomatology and treatments, but a l s o that he i s capable o f c a r r y i n g out the behaviours and that he values the behaviours. Scoring, or r a t i n g of the p a t i e n t s ' behaviours, was done by the researcher and the physiotherapist working a t the r e h a b i l i t a t i o n f a c i l i t y . A copy o f the objectives was i n s e r t e d i n the p a t i e n t ' s record. Those behaviours that could be recorded ( s t a t i n g , d e f i n i n g , d i s t i n g u i s h i n g ) were written i n on the objective sheet and i n i t i a l e d and dated by the recorder. Those behaviours that were observed (demonstrating, reporting) were simply i n i t i a l e d and dated. Besides serving as a measuring t o o l f o r learning, the o b j e c t i v e s serve as a r e l i a b i l i t y check on the d i a r y . That i s , there should be a r e l a t i o n s h i p between the p a t i e n t ' s score and h i s reported a b i l i t y to recognize and t r e a t disease symptoms. Committee of College and U n i v e r s i t y Examiners, Taxonomy of  Educational Objectives Handbook I Cognitive Domain ed. by Benjamin S. Bloom with Max Englehart et a l , (New York: David McKay Company, Inc. 1956) 7. 2 I b i d . 37. The Sample A l l patients who were assessed as suitable for the rehabilitation program were approached by the researcher for inclusion in the study. The c r i t e r i a for admitting patients to the study were: (1) acceptance by the rehabilitation team for the program, (2) willingness to participate, (3) a b i l i t y to read and write, or the a v a i l a b i l i t y of a family member or friend who would keep the diary for them. A l l patients were informed that participation in the study was voluntary, that i t would not affect their treatment in any way should they decide not to participate, and that i f they agreed to participate they were free to withdraw from the study at any time. A total of thirty-one patients i n i t i a l l y agreed to participate in the study. Of these thirty-one subjects, eleven withdrew. Of these, five decided not to continue on the rehabilitation program for unstated reasons, two went on holidays (but later returned for rehabilitation); two stated fears that exercise would affect other medical conditions, one withdrew because of illness i n the family, and one did not want to participate in rehabilitation u n t i l he had stopped smoking. Thus the study group was composed of twenty subjects. Data obtained from the diaries of the twenty subjects are presented and discussed i n the following chapter. CHAPTER 5 ANALYSIS OF THE DATA This chapter i s presented in four sections: 1) characteristics of the study population, 2) analysis of the data, 3) test of the hypothesis, and 4) the discussion. The Study Population Twenty patients with diagnosed chronic bronchitis and emphysema who participated in a rehabilitation program made up the study group. Details of the backgrounds of the patients are presented in Table 1. Age: The patient's age was recorded as the number of years lived as of his last birthday. The age range was from 51 to 70 years; the mean age was 60.5 years; the mode was 64 years. Sex: Seventeen of the subjects were male, and three were female. Living Arrangements: Seventeen of the subjects lived with spouses or significant others. Of the three subjects who lived alone, two stated that they saw close friends frequently, while one described himself as a "loner." Severity of the Disease: Classification of the disease as mild, moderate, moderately-severe, or severe obstructive airways disease i s based on the physician's interpretation of pulmonary function tests. These tests were performed as part of the patient's assessment for the rehabilitation program and became part of his record. One patient had mild disease, two had moderate 39. disease, three had moderately-severe disease and the remaining fourteen were diagnosed as having severe obstructive airways disease. TABLE 1 AGE, SEX, LIVING ARRANGEMENTS, AND SEVERITY OF DISEASE Patient Living ^ Severity of Number Age Sex Arrangement Disease 1 64 M S Severe 2 66 M S Severe 3 62 M S Mild 4 65 M S Severe 5 63 M S Severe 6 70 M S Severe 7 62 M S Moderate 8 59 M S Severe 9 58 F S Severe 10 63 M s Mod-Severe 11 51 F A Severe 12 61 M s Mod-Severe 13 64 M S Severe 14 58 M A Mod-Severe 15 63 M S Severe 16 67 M S Severe 17 66 F S Severe 18 50 M S Moderate 19 61 M S Severe 20 63 M A Severe S - Spouse or significant other A = Alone 40. Analysis of the Data Accumulated on the Total Group The specific aims of the study were to answer the question: After participating in a rehabilitation program which stressed the need for patients to learn about their i l l n e s s : a) was there a change in the number of days that the patients perceived as being "good" (comfortable) days? b) did the reported number of symptoms increase, decrease or remain the same? c) were the reported symptoms treated by the patients? d) were the treatments selected the appropriate care measures for the reported symptoms? e) was there a change in the numbers and types of treatments ut i l i z e d by the patients? In order to answer these questions, the symptoms and treatments reported in the patients' diaries were transcribed into numerical values to f a c i l i t a t e data handling. A positive response to the presence of a symptom or utilization of a treatment was recorded as one (1=YES). A negative response was recorded as zero (0=N0). Each symptom and treatment reported by the patients during the before phase (28 days) was compared with the symptoms and treatments reported by the patients during the after phase (56 days). The data was adjusted to allow for the difference in time periods by normalizing the means and then compared by the t ratio. The 0.05 or better level of significance was accepted. Data concerning the number of good days and the symptoms experienced before and after participating in the rehabilitation program are presented in Table 2. In each case, N=20, and there are 19 degrees of freedom. 41. TABLE 2 REPORTED SYMPTOMS BEFORE AND AFTER TEACHING Symptom Mean Before (X) After Standard Deviation Before After t Value 2 T a i l Probability D i f f i c u l t y raising phlegm 0.2732 0.0955 0.284 0.115 3.71 0.001 Chest tight 0.3839 0.2000 0.298 0.265 5.10 0.000 Increased shortness of breath 0.6363 0.4687 0.184 0.143 2.42 0.025 Headache 0.0321 0.0250 0.109 0.077 0.87 0.397 Swollen ankles 0.0446 0.0116 0.140 0.037 1.36 0.189 Fatigue 0.2250 0.1018 0.254 0.154 3.02 0.007 Diff i c u l t y sleeping 0.1286 0.0098 0.240 0.021 2.23 0.038 Increased sputum 0.0607 0.0437 0.119 0.069 0.94 0.360 Sputum discolored 0.0571 0.0187 0.108 0.035 1.54 0.141 Cold 0.0964 0.0491 0.150 0.070 1.51 0.148 Increased cough 0.0857 0.0429 0.137 0.075 1.25 0.227 Increased wheezing 0.0571 0.0071 0.117 0.019 2.15 0.044 Good days 0.5054 0.7509 0.231 0.251 10.68 0.000 Total 3-358 1-8248 0.950 0.576 4.69 0.000 42. The total sum of symptoms reported in Table 2 indicates a significant decrease in the number of symptoms that the patients reported after the teaching intervention. However, looking at the Table symptom-by-symptom reveals that not only are some symptoms more significant in their magnitude of change, but also that some symptoms are clearly more problematic in terms of their frequency of occurrence. The low mean value reported for the symptoms of headache and swollen ankles (0.0321 and 0.0321) indicate that these symptoms occurred so infrequently as to suggest that they did not pose problems to the patients. The symptoms of discolored sputum, increased sputum, and cold occur slightly more frequently, but again the mean values are below 0.1000. This i s not surprising for these are d i f f i c u l t i e s that occur intermittently, rather than on a daily basis. They were included in the study on the rationale that when these symptoms do occur i t i s important that the patient recognize them. These symptoms may portend respiratory infection which, l e f t untreated, can result in catastrophic i l l n e s s . To have captured this data, the study would have to be carried on for a longer period of time and/or included a measurement tool that indicated the a b i l i t y of the patient to recognize symptoms i f they did occur. The symptoms of d i f f i c u l t y raising phlegm, tightness in chest, increased shortness of breath, and increased wheezing occurred most frequently and changed most significantly. These symptoms are ones which may well occur on a daily basis for patients with chronic bronchitis and emphysema. Data concerning the therapies u t i l i z e d by the study group are presented in Table 3. As stated previously, the values reported are based on transcribing positive and negative responses into the numerical values of (1) and (0) respectively. Again, N=20, and there are 19 degrees of freedom. 43. TABLE 3 TREATMENTS USED RELIEVE SYMPTOMS AND MAINTAIN HEALTH Treatment Mean (X) Before After Standard Deviation Before After t Value 2 T a i l Probability Breathing exercises Relaxation exercises General exercises Postural drainage Purposeful positioning Increased f l u i d intake Intake of hot fluids Bronchodilators p.r.n. Antibiotics p.r.n. Contacted M.D. Rest 0.0607 0.9241 0.225 0.194 13.40 0.000 0.0018 0.8893 0.008 0.246 16.16 0.000 0.0875 0.8027 0.204 0.193 12.66 0.000 0.0000 0.0955 0.000 0.179 99.00 0.000 0.0018 0.4125 0.008 0.364 5.04 0.000 0.0196 0.3080 0.088 0.354 3.56 0.002 0.0036 0.1786 0.016 0.256 3.15 0.005 0.2125 0.2920 0.305 0.263 1.15 0.266 0.0482 0.0464 0.106 0.072 0.06 0.953 0.0536 0.0125 0.148 0.016 1.34 0.196 0.2214 0.0929 0.231 0.135 2.33 0.031 Total 0.7107 4.0545 0.627 1.526 10.77 0.000 The sum of positive responses to use of treatment modalities indicates a significant increase in the number and types of therapies by patients after the teaching intervention. Of the eleven treatments considered, a l l but four passed the 0.05 level of significance. The 44. treatments that did not improve significantly were: use of p.r.n. bronchodilators, use of p.r.n. antibiotics, and contacting the physician or other health care worker for advice or assistance.. Resting as a treatment changed significantly, but in the opposite direction. That i s , most therapies increased in frequency after the teaching intervention, whereas resting decreased. Use of bronchodilators and antibiotics are also interesting. Bronchodilators may provide rapid r e l i e f for wheezing, tight-ness in chest and shortness of breath. This intervention and rest appeared to be the major means of coping before the patient attended the rehabilitation program. The use of antibiotics on a p.r.n. basis i s an essential step for the early treatment of infection. Patients need to know the signs of infection, recognize them when they occur and i n i t i a t e treatment promptly. It may be suggested, though certainly not concluded, that information regarding infection and i t s treatment i s stressed by physicians, nurses and physio-therapists who have contact with the patients outside the rehabilitation f a c i l i t i e s . Consideration of the patients' prior level of knowledge was a serious omission from the study. The therapies of breathing exercises, relaxation exercises and general exercises (such as walking and cycling) are considered to be health maintaining behaviours for a l l patients with chronic bronchitis and emphysema. The means reported on these behaviours, coupled with the fact that they passed the 0.05 level of significance, i s reflective not only of the patients' a b i l i t y to learn the exercises, but also of a willingness to carry them out regularly. (Mean of 0.9241, 0.8893 and 0.8893 respectively). The therapies of postural drainage, purposeful positioning to relieve shortness of breath, increased f l u i d intake and drinking hot fluids also increased markedly, and the T values passed the 0.05 level of significance. 45. These treatments alone, and c e r t a i n l y when coupled with health maintaining behaviours, are appropriate care measures for the frequently occurring symptoms of d i f f i c u l t y r a i s i n g phlegm, tightness i n chest, increased shortness of breath and wheezing. The p.r.n. use of bronchodilating drugs appears to already have been p a r t of the pat i e n t s ' s e l f care regimens. A second question that was included i n the o r i g i n a l aims of the study was to query the presence of a r e l a t i o n s h i p between the p a t i e n t s ' reported a b i l i t y to cope with t h e i r i l l n e s s e s and t h e i r l e v e l s of lear n i n g as measured by the ob j e c t i v e s . Table 4 displays the t o t a l s of symptoms reported before and a f t e r , treatments u t i l i z e d before and a f t e r , and l e v e l s of achievement on the obje c t i v e s . TABLE 4 MEAN (X) OF SYMPTOMS, MEAN (X) OF TREATMENTS, MEAN (X) OF GOOD DAYS, AND LEVEL OF OBJECTIVES ACHIEVED Patient Number (X)Good Before Days A f t e r (X) Symptoms Before A f t e r (X)Treatment Before A f t e r Level Objective! 1 0. .89 0. 96 1. .04 0. 29 0. 0 2. .62 35 2 0. .68 0. 88 1. .71 0. 52 0. 43 2. .86 29 3 0. .39 0. 75 3. .54 1. 30 0. 36 4. .62 30 4 0. .71 0. 96 1. .50 0. 75 0. 18 3. ,59 22 5 0. .61 0. 95 1. .29 0. 02 0. 43 3. ,16 30 6 0. .36 0. 66 1. .68 0. 70 0. 61 1. .41 25 7 0. .00 0. 00 2. .31 1. 20 0. 00 0. .64 12 8 0. .61 0. 91 2. .21 0. 91 0. 07 3. .71 19 9 0. .46 0. 86 4. .64 1. 13 1. 61 4. .32 26 10 0. .71 0. 88 1. .54 1. 25 0. 29 4. .82 18 11 0. .54 0. 80 2. .11 0. 95 0. 71 6. ,82 21 12 0. .57 0. 75 4. .29 2. 07 0. 71 6. .52 32 13 0. .71 0. 84 1. .93 1. 37 1. 25 4. .91 20 14 0. .64 0. 93 0. .96 0. 31 0. 43 3. .30 26 15 0. .39 0. 75 4. .54 2. 84 0. 71 6. .52 32 16 0. .50 0. 82 2, .21 1. 79 0. 96 3. .64 17 17 0. .29 0. 41 3. .25 1. 75 0. 79 3. .80 22 18 0. .0 0. 30 2. .89 2. 00 1. 00 4, .86 22 19 0. .68 0. 91 2, .11 1. 67 0. 71 1. .41 34 20 0. .36 0. 63 2. .29 1. 89 1. 00 5. .71 18 T o t a l 0. .505 0. 75 2.402 1. 204 0. 71 4. .05 46. Table 4 i s simply a summation of data on the individual patients along with their objective scores (score i s reported as the highest level reached, thirty-five being the highest possible score). The researcher originally intended to establish a correlation, but this would not yield any meaningful data as the objectives were not a before and after test, but rather an established goal for achievement. Further, correlation between the number of symptoms that a patient experienced and the objective level i s meaningless, as some symptomatology i s beyond the patient's control in terms of i t s occurrence. Correlation with treatments can establish whether or not the patient who indicated that he learned the most carried out the higher number of treatments; but again, the data would be meaningless because i t i s not simply a question of treatments for the individual patient but also of the appropriateness of the treatments for the particular problems or d i f f i c u l t i e s . Therefore the Table may be interesting as an overview of the extent of the changes that occurred for each patient relative to his achievement, but such data does not lend i t s e l f to meaningful analysis. TEST OF THE HYPOTHESIS Hypothesis: There i s no significant difference i n the patient's a b i l i t y to recognize and treat disease symptoms after he has participated in a teaching program as compared to his a b i l i t i e s to recognize and treat disease symptoms before participating in such a program. Evaluation of the patient's a b i l i t i e s to cope i s based on the recorded information as presented. The t values for the total symptom responses and the total treatment responses passed the 0.05 level of significance. Of the twelve symptoms considered, six t values passed the 0.05 level of significance; and of the eleven possible treatments, eight t values passed the 0.05 level of significance. Thus, the null hypothesis can be rejected. Patients who have been 47. taught about t h e i r i l l n e s s e s do expand t h e i r r e p e r t o i r e of coping behaviours. DISCUSSION Despite the high l e v e l of s i g n i f i c a n c e attained by the v a r i a b l e s , one must be cautious of o v e r - i n t e r p r e t i n g the r e s u l t s because of shortcomings inherent i n the study design. Kerlinger has i d e n t i f i e d three major shortcomings of the before/after approach as: s e n s i t i z a t i o n (or r e a c t i v e measures), h i s t o r y and maturation. 1 S e n s i t i z a t i o n suggests that since the subject has been exposed to the data reported i n the before phase of the study h i s memory would a f f e c t h i s response i n the a f t e r phase. Though t h i s i s more of a problem i n a t e s t i n g s i t u a t i o n as opposed to d i a r y -keeping, i t s t i l l must be considered. History and maturation allow for the f a c t that between the pre and post measurements any number of things may have occurred that could have af f e c t e d the subjects' responses besides the purposeful introduction of the independent v a r i a b l e . Maturation of the subject ( i . e . changes due to growth and development) does not o f f e r i t s e l f as a r e a l l y s i g n i f i c a n t f a c t o r i n t h i s study. History, however, could c e r t a i n l y a f f e c t the data c o l l e c t i o n . Fred N. Kerlinger, Foundations of Behavioral Research, (New York: Holt, Rinehart and Winston, Inc., 1965): 295-297. 48. Considering the lengthy period of data collection, an incalculable number of extraneous variables may have been in operation. As Kerlinger suggests, the weakness of the design i s not so much that extraneous factors can affect the data but rather, since they are not controlled we never know i f they have been operation or not.* The f i n a l , and to this researcher, the most serious outside factor 2 to be considered i s the Hawthorne effect. That i s , knowing that the study was being conducted and that subjects were receiving extra attention from the rehabilitation team, including the researcher, the patients may well have responded to the extra attention. Considering the setting and the purpose of the rehabilitation program, i t was certainly not d i f f i c u l t to conclude that the researcher was looking for improvement. One factor that cannot be documented but i s worth mentioning i s that patients placed considerable emphasis on how far they had walked on the treadmill or how long they had cycled. Thus, though they were li k e l y aware that the study was looking for improvement in each patient, i t i s not l i k e l y that they were as aware of the specific behaviours that were being examined in the study. Ibid. 2 I b i d . CHAPTER 6 SUMMARY, IMPLICATIONS FOR PRACTICE AND  RECOMMENDATIONS FOR RESEARCH Summary This experimental study was designed to evaluate the e f f e c t o f teaching as pa r t of the r e h a b i l i t a t i o n of pat i e n t s with chronic b r o n c h i t i s and emphysema. The sample was comprised of twenty subjects, seventeen o f whom were male and three female, between the ages of f i f t y - o n e and seventy. This group was obtained by i n c l u d i n g a l l p a t i e n t s over a five-month period who were accepted i n t o r e h a b i l i t a t i o n programs and agreed to p a r t i c i p a t e i n the study. The teaching o f patients has been i d e n t i f i e d as an e s s e n t i a l component i n the r e h a b i l i t a t i o n o f persons with chronic obstructive lung disease, but a review of the l i t e r a t u r e i n d i c a t e d that there i s no information to support t h i s statement. Therefore, the l i t e r a t u r e review for t h i s study focused on the approach to adult teaching, p a t i e n t compliance and that information which the experts in the f i e l d have i d e n t i f i e d as e s s e n t i a l knowledge f o r the p a t i e n t s . T h i s study considered a teaching approach i n which p a t i e n t involvement i s considered to be e s s e n t i a l . E f f o r t s were made to have pat i e n t s become a c t i v e p a r t i c i p a n t s i n e s t a b l i s h i n g p r i o r i t i e s f o r learning, ( r e l a t i v e to t h e i r p a r t i c u l a r problems) to s e l e c t approaches t o care that best f i t t h e i r l i f e s t y l e and set t h e i r own goals f o r exercise 50 tolerance. Data were gathered by interview and d i a r y before and a f t e r the p a t i e n t s became involved i n the teaching program. The.focus o f the data c o l l e c t i o n was on the patient's a b i l i t y to recognize symptoms o f h i s disease and h i s a b i l i t y to t r e a t the symptoms of h i s disease appropriately. The summary s t a t i s t i c s i n d i c a t e a decrease i n the number of symptoms experienced and an increase i n the numbers and types of treatments used a f t e r the pa t i e n t had p a r t i c i p a t e d i n the lear n i n g program. The t r a t i o i n d i c a t e d that these changes were beyond the 0.05 l e v e l o f s i g n i f i c a n c e . On t h i s b a s i s the n u l l hypothesis was r e j e c t e d . Despite r e j e c t i o n of the n u l l hypothesis, one must consider that there are basic weaknesses i n the design of the study, most notably the lack of a c o n t r o l group and the number of extraneous v a r i a b l e s that might have influenced the p a t i e n t s ' diary-keeping. Implications f o r Nursing P r a c t i c e As stated e a r l i e r , the incidence of chronic b r o n c h i t i s and emphysema i s increasing i n North America. Health maintenance f o r pa t i e n t s a f f l i c t e d with these diseases may be complex and demand cognit i v e and executive a b i l i t i e s that are beyond the pat i e n t s usual a b i l i t y f o r coping. Unaided or provided with only cursory information concerning h i s i l l n e s s , i t i s unwise f o r the nurse to assume that he w i l l modify h i s l i f e -s t y l e to adhere to these routines. This study i n d i c a t e s that f o s t e r i n g the pat i e n t ' s a b i l i t y to make decisions and take actions concerning h i s health maintenance i s a s i g n i f i c a n t undertaking. I t s s i g n i f i c a n c e l i e s i n the f a c t that the pat i e n t s reported a decrease i n the number of symptoms that they experienced, and an increase i n the numbers and types o f treatments used to r e l i e v e the symptoms when they d i d occur. 51. The study does not suggest that p a t i e n t s do not receive any i n s t r u c t i o n concerning health. Indeed, the p o i n t was made that i t was c l e a r to the researcher that some teaching had occurred before the p a t i e n t s embarked on the r e h a b i l i t a t i o n program. The study does provide guidelines f o r the process of teaching these patients as w e l l as the content f o r teaching. Though conducted i n an out-patient s e t t i n g , the p r i n c i p l e s are a p p l i c a b l e to any s e t t i n g . The e s s e n t i a l ingredient i s the c o l l a b o r a t i v e r e l a t i o n s h i p between the nurse and the p a t i e n t . The teaching intervention of the nurse reduces negative forces that impede the a t t a i n i n g and maintaining o f optimal h e a l t h , strengthens the p o s i t i v e forces and f o s t e r s the development and expansion of new behaviours f o r the p a t i e n t . To t h i s end i t i s recommended that: 1) Teaching programs f o r p a t i e n t s with chronic b r o n c h i t i s and emphysema be developed i n a l l health care f a c i l i t i e s that deal with the e l d e r l y p a t i e n t , regardless of the presence or absence of machinery f o r exercise. 2) The teaching aspect of nursing care be developed as one of i t s independent functions. This requires the p r o f e s s i o n a l nurse recognize teaching as p a r t of her r o l e , a c t i v e l y implement teaching, and assume autonomy and r e s p o n s i b i l i t y f o r her actions. 3) That i n - s e r v i c e programs be conducted i n h e a l t h care f a c i l i t i e s to develop the nurse's cognitive and executive a b i l i t i e s as a teacher of health maintenance f o r the p a t i e n t s . Recommendations f o r Research The following recommendations are made f o r f u r t h e r i n v e s t i g a t i o n : 1) R e p l i c a t i o n of the study i n another r e h a b i l i t a t i o n f a c i l i t y i n order to support or dispute the findings as presented. 52. 2) Replication of the study in another health care f a c i l i t y to investigate the influence of setting. 3) Studies focusing on the teaching of patients with chronic bronchitis and emphysema which u t i l i z e different approaches to teaching. 53. BIBLIOGRAPHY BOOKS Anderson, Donald O. "Chronic Non-Tuberculous Respiratory Disease." In Preventive Medicine, eds. D.W. Clark and B. MacMahen. Boston: L i t t l e , Brown & Co., 1967. British Columbia, Department of Health Services and Hospital Insurance. Statistics of Hospital Cases Discharged During 1971. Victoria, British Columbia: 1973. Committee of College and University Examiners. Taxonomy of Educational  Objectives. Handbook I: Cognative Domain. New York: David McKay Company Inc., 1956. Glass, Gene V. and Stanley, Julian V. S t a t i s t i c a l Methods in Education and Psychology. Englewood C l i f f s , New Jersey: Prentice-Hall, Inc., 1970. Gronlund, Norman E. Stating Behavioural Objectives for Classroom Instruction. New York: The MacMillan Company, 1970. Kerlinger, Fred N. Foundations of Behavioral Research. New York: Holt, Rinehart and Winston, Inc., 1965. Knowles, Malcolm S. The Modern Practice of Adult Education. New York: Association Press, 1970. . Krathwohl, David R.; Bloom, Benjamin S.; and Masin, Bertram B. Taxonomy of  Educational Objectives. Handbook II: Affective Domain. New York: David McKay Company Inc., 1956. Redman, Barbara K. The Process of Patient Teaching. Saint Louis: The C.V. Mosby Company, 1972. Treece, Eleanor Walters and Treece, James William Jr. Elements of Research  in Nursing. St. Louis: The C.V. Mosby Company, 1973. PERIODICALS Allen, George I.; Breslow, Lester; Weissman, Arthur and Nisselson, Harold. "Interviewing Versus Diary-Keeping i n E l i c i t i n g Information in a Morbidity Survey." American Journal of Public Health 44 (July 1954): 919-927. Alpert, Joel J.; Kosa, John, and Haggerty, Robert. "A Month of Illness and Health Care Among Low-Income Families." Public Health Reports 82 (August 1967): 707-713. 54 . Barach, Alan; Bickerman, Hylan A., and Beck, Gustov. "Advances i n the Treatment of Non-Tuberculous Pulmonary Disease." B u l l e t i n of  N.Y. Academy o f Medicine 28 (June 1952): 351-384. Barstow, Ruth E. "Coping with Emphysema." Nursing C l i n i c s o f North  America 9 (March 1974): 137-154. Committee on Diagnostic Standards for Nontuberculous Respiratory Disease: Chronic B r o n c h i t i s , Asthma and Pulmonary Emphysema. American Review  o f Respiratory Disease 85 (May 1962): 762-768. Culbert, Pamela A. and Kos, Barbara A. "Aging: Considerations f o r Health Teaching." Nursing C l i n i c s of North America 6 (December 1971): 605-614. Davis, Milton S. "Predicting Non-Compliant Behavior." Journal of Health  and S o c i a l Behavior 8 (December 1967): 265-271. De Cencio, Dominic V.; Leshner, Martin,and Leshner, Bonnie. "Personality C h a r a c t e r i s t i c s o f Patients with Chronic Obstructive Pulmonary Emphysema." Archives of Physical Medicine 49 (August 1968): 47/475. E d i t o r i a l . "Public Health: Then and Now - The Need f o r Patient Education." American Journal o f Public Health 61 (July 1971): 1277-1279. Haas, A l b e r t and Cardon, Hugh. "Rehabiliation i n Chronic Obstructive Pulmonary Disease." Medical C l i n i c s o f North America 53 (May 1969); 593-606. Haferkorn, V i r g i n i a , "Assessing I n d i v i d u a l Learning Needs as a Basis f o r Patient Teaching." Nursing C l i n i c s of North America 6 (March 1971): 199-209. Jennings, Muriel; Nordstrom, Marlene J . ; and Shumake, Norene. "Physiologic Functioning i n the E l d e r l y . " Nursing C l i n i c s of North America 7 (June 1972): 237-252. Kimbel, P h i l i p ; Kaplan, A.S.; Alkalay, I., and Lester, D. "An In-Hospital Program for R e h a b i l i t a t i o n of Patients with Chronic Obstructive Pulmonary Disease." Chest 70 (August 1971) A Supplement: 6S - 10S. Levine, Eugene. "Experimental Design i n Nursing Research." Nursing Research 9 ( F a l l 1960): 203-212. Marston, Mary-Vesta. "Compliance with Medical Regimens: A Review of the L i t e r a t u r e . " Nursing Research 19 (July-August 1970): 312-323. Matzen, Richard. "Vocational R e h a b i l i a t i o n - The Culmination o f P h y s i c a l Reconditioning." Chest 60 (August 1971) A Supplement: 21S - 24S. M i l l e r , William F.; Taylor, Harold F.; and Pierce,' Alan K. " R e h a b i l i t a t i o n of the Disabled Patient with Chronic Br o n c h i t i s and Emphysema." A.J.P.H. Part II 53 (March 1963): 18-24. M i l l e r , William F. "Useful Methods of Therapy." Chest 60 (August 1971) A Supplement: 2S - 5S. 55. News Bulletin Winnipeg, Manitoba: Sanitorium Board of Manitoba, 1972. Obley, Fred A., and Preiser, Franklin M. "Comprehensive Outpatient Respiratory Care: A Program Conducted in a Suburban Private Practice." Journal of the American Geriatrics Society 22 (November 1974) : 521-524. Petty, Thomas L.; Nett, L.M.; Finigan, M.M.; Brink, G.A., and Corsillo, P.R. "A Comprehensive Care Program for Chronic Airway Obstruction." Annals  of Internal Medicine 70 (June 1969): 1109-1120. Petty, Thomas L. "Does Treatment for Severe Emphysema and Chronic Bronchitis Really Help? (A Response)." Chest 65 (February 1974): 124-127. Pierce, Alan K»; Taylor, H.F.; Archer, R.K.; and Miller, W.F. "Response to Exercise Retraining i n Patients with Emphysema." Archives of Internal  Medicine 113 (January 1964): 78-86. Redman, Barbara K. "Client Education Therapy in Treatment and Prevention of Cardiovascular Disease." Cardio-Vascular Nursing 10 (January-February 1974): 1-6. Redman, Barbara K. "Guidelines for Quality Care i n Patient Education." Canadian Nurse 71 (February 1975): 19-21. Redman, Barbara K. "Patient Education as a Function of Nursing Practice." Nursing Clinics of North America 6 (December 1971). Silver, Harold M., and Eaton, Olga M. "Subjective Response to Therapy in Chronic Obstructive Lung Disease." Medical Annals of the Di s t r i c t of  Columbia 43 (March 1974): 120-123. Roghmann, Klauss J., and Haggerty, Robert J. "The Diary as a Research Instrument in the Study of Health and Illness Behavior." Medical Care 10 (March-April 1972): 143-163. Smyth, Kathleen. "Symposium on Teaching Patients - Foreword." Nursing Clinics  of North America 6 (December 1971): 571-573. Woolf, Colin R., and Soero, J.T. "Alterations in Lung Mechanics and Gas Exchange Following Training in Chronic Obstructive Lung Disease." Diseases of the Chest 55 (January 1969): 37-44. Woolf, Colin R. "A Rehabilitation Program for Improving Exercise Tolerance of Patients with Chronic Lung Disease." Canadian Medical Association  Journal 106 (June 1972): 1289-1292. UNPUBLISHED Model Committee, "Model for Nursing." University of British Columbia School of Nursing, Vancouver, 1974. (Mimeographed). APPENDIX A Sample Page of Patient Diary 57. For each day of the week (/) if it was a good day or a bad day. If it v/as bad day check ( /) the box, or boxes that help describe the trouble. If none of the boxes describe the trouble you had, f i l l in the space marked "OTHER" Include things like getting a cold, headaches, fatigue or swollen ankles. We would also like to know if you did anything to make yourself feel better and whether or not it helped. | M O N D A Y G O O D D A Y Q BAD D A Y • COULD NOT RAISE PHLEGM • CHEST TIGHTQ j MORE SHORT OF BREATH THAN USUAL: A LITTLEQ MODERATE D V E R Y Q OTHER DID YOU DO ANYTHING TO MAKE YOURSELF FEEL BETTER? IF SO WHAT? DID IT HELP? T U E IS D A Y G O O D D A Y • B A D D A Y Q COULD NOT RAISE PHLEGMQ CHEST TIGHTQ MORE SHORT OF BREATH THAN USUAL: AL ITTLEQ MODERATE D VERY • OTHER : : DI D YOU DO ANYTHING TO MAKE YOURSELF FEEL BETTER? IF SO WHAT? DID IT HELP? |W E ID I N E S D A Y G O O D D A Y O BAD D A Y • COULD NOT RAISE PHLEGM • CHEST TIGHTQ MORE SHORT OF BREATH THAN USUAL: A LITTLEQ MODERATED VERYQ OTHER . • DI D YOU DO ANYTHING TO MAKE YOURSELF FEEL BETTER? IF SO WHAT? DID IT HELP? APPENDIX B THE "JOG" LIST 5 9 The purpose o f the jog l i s t i s to ensure that the pa t i e n t i s reminded of the various symptoms and treatments that are to be recorded i n the d i a r y . The jog l i s t was u t i l i z e d i n the weekly interview with the pa t i e n t to review the content of the dia r y . I t includes a l l the symptoms and a l l the treatments that are included i n the data base. Symptoms Good (comfortable) day D i f f i c u l t y r a i s i n g phlegm Tightness i n chest Shortness of breath that i s greater than usual Headache Swollen ankles Fatigue D i f f i c u l t y i n sleeping due to chest condition Increased amount of sputum Discoloured sputum Cold (head or chest) Increased cough Wheezing 60 Treatments Breathing exercises Relaxation exercises General exercises (walking or c y c l i n g Postural drainage Purposeful p o s i t i o n i n g to r e l i e v e shortness o f breath Increased f l u i d intake Intake o f hot f l u i d s Use o f bronchodilators prescribed on a p.r.n. b a s i s A n t i b i o t i c s prescribed on a p.r.n. basis Contact M.D. or other health care worker Rest Sample of the use of the Jog L i s t : Researcher: I see that you have had d i f f i c u l t y c l e a r i n g the phlegm from your chest i n the morning four times t h i s week. Patient: Yes. I often have trouble l i k e that i n the morning. Researcher: I s there anything that you do to make t h i s easier? I can see that you haven't written down anything i n that space, but the reason I am asking i s that often people are used to dealing with d i f f i c u l t i e s l i k e that, and tend to think they aren't important. For example, do you drink water or tea to loosen-up the phlegm? Or use any medication? 61 Patient: Well, I keep my spray (Ventolin) at the night t a b l e , and sometimes I take a s q u i r t o f i t . Researcher: Did you use the spray t h i s week? Pati e n t : Yes, I d i d . Do you want me to write that down? Researcher: Yes, I am i n t e r e s t e d i n a l l o f the things that you do that help you handle your chest condition. Patient: When I think about i t , there are a couple of things that I know I do on bad days - l i k e leaning over (patient leans forward, bending a t the w a i s t ) . I t sometimes helps c l e a r things out. Researcher: Yes, I am i n t e r e s t e d i n that too. Patient: Well, i t ' s no trouble to write i t down - i t j u s t doesn't seem very important. This section o f an interview occurred e a r l y i n the study while p a t i e n t s were developing t h e i r diary-keeping s k i l l s . These interviews were often lengthy but f r u i t f u l , as within two weeks the majority o f p a t i e n t s were recording comprehensively. APPENDIX C Patient Objectives 63. Patient Objectives NAME: 1.0 Is aware that he has a chronic i l l n e s s . 1.1 States the name of his chest condition or describes the symptoms of his condition. 1.2 States (as many as possible) the effects that his il l n e s s has had on his l i f e . 1.3 States the length of time he has had the i l l n e s s . 2.0 Is i n a state of readiness for learning. 2.1 Is free from acute physical distress. 2.2 Approaches nurse, physiotherapist, physician or other patients without apprehension. 2.3 Makes himself comfortable (takes off coat, s i t s down, assumes comfortable position). 3.0 Is willing to receive information. 3.1 Defines his goals in terms of a c t i v i t i e s . 3.2 Attends classes. 3.3 Attends rehabilitation f a c i l i t y as scheduled, and on time. 3.4 Listens attentively, looks at teacher, diagrams, demonstration. 3.5 Asks questions. 3.6 Responds when questioned. 4.0 Recognizes breathing patterns. 4.1 Touches part of his chest that moves the most when he i s breathing in his usual pattern. 4.2 Estimates his rate of breathing. 4.3 Describes the relative ease (or dif f i c u l t y ) of his breathing. 4.4 On another person, points to the part of the chest that moves the most when that person i s breathing diaphragmatically. 4.5 Estimates the rate of the other person, i n comparison to his own. 4.6 Describes the relative ease (or dif f i c u l t y ) of the other person's breathing in comparison to his own. 64. 5.0 Knows basic facts related to his i l l n e s s . 5.1 Identifies three sources of d i f f i c u l t y for him. 5.2 States three signs of infection. 5.3 States two signs of "trouble" not necessarily associated with infection. 6.0 Distinguishes between normality (usual) and abnormality in himself. 6.1 Describes normal (usual) and abnormal sputum. 6.2 Describes normal (usual) and abnormal activity level. 6.3 Describes normal (usual) breathing pattern (ease of respiration, rate of respiration, and part of his chest that i s moving the most). 7.0 Understands principles of self care that w i l l promote the attainment and maintenance of his optimal level of health. 7.1 Outlines daily exercise routine. 7.2 Describes ways of maintaining a patent airway. 7.3 Describes what he w i l l do when he recognizes d i f f i c u l t y . 8.0 Demonstrates s k i l l s necessary for the promotion and maintenance of his optimal level of health. 8.1 Gives a return demonstration of diaphragmatic breathing while s i t t i n g , standing and walking. 8.2 Performs exercises for mobility and relaxation a) without the presence of obvious muscular tension b) with optimal range of motion c) in a comfortable position d) without becoming short of breath 8.3 Walks on the treadmill at a fixed rate and incline for a specified period of time. 8.4 Coughs with control. 9.0 Recognizes the value of u t i l i z i n g and adhering to the principles of self care. 9.1 Is observed to be breathing diaphragmatically without reminders. 9.2 Is free from chest infection or takes immediate measures to control infection. 9.3 Describes a c t i v i t i e s that he can now participate i n , (which had been unavailable to him previously, because of his chest condition). 9.4 Reflects a positive feeling about himself (physical appearance, posture, gait). 

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