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The effectiveness of planned teaching of mothers with children treated in emergency departments Power, Denise Mary 1972

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THE EFFECTIVENESS OF PLANNED TEACHING OF MOTHERS CHILDREN TREATED IN EMERGENCY DEPARTMENTS by DENISE MARY POWER B.Sc.N., Mount S a i n t Vincent U n i v e r s i t y , 1969 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n the School of Nursing We accept t h i s t h e s i s as conforming to the re q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA August, 1972 In present i ng. th 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- requirements fo r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia , I agree that 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 for reference and s tudy. I f u r t h e r agree t ha t permiss ion for e x t e n s i v e copying o f t h i s t h e s i s fo r s c h o l a r l y purposes may be granted by the Head o f my Department or by h i s r e p r e s e n t a t i v e s . I t i s understood that copying 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 ga in s h a l l not be a l lowed wi thout my w r i t t e n p e r m i s s i o n . Department o f Nursing The U n i v e r s i t y o f B r i t i s h Columbia Vancouver 8, Canada Date August, 1972 ABSTRACT THE EFFECTIVENESS OF PLANNED TEACHING OF MOTHERS WITH CHILDREN TREATED IN EMERGENCY DEPARTMENTS DENISE M. POWER This study concerned i t s e l f w i t h planned teaching i n the h o s p i t a l emergency department, t h a t area of the h o s p i t a l h e a l t h care system t h a t i s becoming i n c r e a s i n g l y popular f o r short-term ambulatory c a r e . However, the n u r s i n g care provided by t h i s department has been l a r g e l y unexplored by r e s e a r c h . The purpose of t h i s experimental study was to determine whether planned teaching i n v o l v i n g v e r b a l and w r i t t e n i n s t r u c -t i o n s g iven to a mother p r i o r to the d i s c h a r g e of her c h i l d from the emergency department f o l l o w i n g treatment f o r a traumatic limb f r a c t u r e r e q u i r i n g c a s t a p p l i c a t i o n , would enable her to cope more adequately w i t h the home care of her c h i l d than the mother not r e c e i v i n g t h i s planned t e a c h i n g . The N u l l hypothesis was t e s t e d : 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 coping a b i l i t i e s of the mothers of the experimental group as compared w i t h the mothers of the c o n t r o l group. i i i Using f i v e general h o s p i t a l emergency departments, twenty mothers were assigned to a l t e r n a t e experimental and c o n t r o l groups, w i t h the experimental s u b j e c t s r e c e i v i n g the planned teaching before d i s c h a r g e . Through home v i s i t i n t e r v i e w s w i t h a l l s u b j e c t s , the mothers' coping a b i l i t i e s were assessed by the number of s p e c i f i e d care o b j e c t i v e s they had achieved. The i n d i v i d u a l t o t a l s were ranked and analyzed u s i n g the Mann-Whitney U t e s t , the r e s u l t s of which l e d to the r e j e c t i o n of the N u l l hypothesis w i t h p = .001, thus i n d i c a t i n g a g r e a t e r a b i l i t y to cope by the mothers r e c e i v i n g the planned t e a c h i n g . The t o t a l achieve-ment scores of each o b j e c t i v e were analyzed using the F i s h e r Exact P r o b a b i l i t y Test, r e s u l t i n g i n f i v e of the twenty o b j e c t i v e s a c h i e v i n g s i g n i f i c a n c e a t the .05 l e v e l . As four of the c o n t r o l s u b j e c t s r e c e i v e d r o u t i n e w r i t t e n i n s t r u c t i o n s before discharge from one h o s p i t a l , the e v a l u a t i o n scores o f these were compared w i t h the remaining c o n t r o l s u b j e c t s using the Mann-Whitney U t e s t . No s i g n i f i c a n t d i f f e r e n c e was found suggesting the i n e f f e c t i v e n e s s of w r i t t e n i n s t r u c t i o n s without explanatory v e r b a l i n s t r u c t i o n s as w e l l . S e l e c t e d personal c h a r a c t e r i s t i c s o f the su b j e c t s and t h e i r c h i l d r e n provided a d e s c r i p t i o n of the study p o p u l a t i o n . The study's f i n d i n g s suggested t h a t there i s a l a c k of planned p a t i e n t teaching i n emergency departments although l i t e r a t u r e sources i n d i c a t e t h a t such teaching i s necessary i f p a t i e n t s and t h e i r f a m i l i e s are to assume f u l l r e s p o n s i b i l i t y i v f o r t h e i r own care. The study recommends t h a t nurse p r a c t i t i o n e r s be made aware of t h e i r teaching f u n c t i o n and be encouraged to achieve competence and confidence i n t h i s f u n c t i o n through i n s e r v i c e programs. 8 pages ACKNOWLEDGEMENT I am extremely g r a t e f u l to my committee members; Mrs. Ruth E l l i o t t , my committee chairman, and Dr. Margaret Campbell, f o r t h e i r c r i t i c i s m s , advice and encouragement throughout the study's progress. I owe a s p e c i a l debt of g r a t i t u d e to Dr. F r e d e r i c k G l i c k f o r h i s s t a t i s t i c a l e x p e r t i s e . And to my f a m i l y f o r twenty-four years of ' c a r e f u l h a n d l i n g ' , I w i l l always be t h a n k f u l . TABLE OF CONTENTS Pa g e L I S T OF TABLES C h a p t e r I INTRODUCTION TO THE STUDY 1 INTRODUCTION . . . . . . . . . . . . . . . . 1 THE PROBLEM 3 S t a t e m e n t o f t h e P r o b l e m 3 S p e c i f i c O b j e c t i v e s o f t h e S t u d y 4 S i g n i f i c a n c e o f t h e P r o b l e m 4 ASSUMPTION OF THE STUDY . . . . . . . . . . . 9 D E F I N I T I O N S OF TERMS USED 9 L I M I T A T I O N S OF THE STUDY 10 HYPOTHESIS TESTED I N THE STUDY 10 O v e r v i e w o f t h e R e m a i n d e r o f t h e S t u d y 10 I I REVIEW OF THE LITERATURE 11 THE CONCERNS OF HOSPITALIZED SCHOOL-AGED CHILDREN AND THEIR PARENTS 11 COMMUNICATION BETWEEN P A T I E N T S , THEIR F A M I L I E S AND THE PROFESSIONAL HEALTH TEAM 18 THE ROLE OF THE NURSE I N PATIENT TEACHING AS AN E F F E C T I V E MEANS OF COMMUNICATION . . . 23 SUMMARY 30 v i i C h a p t e r P a g e I I I THE RESEARCH DESIGN AND DEVELOPMENT OF THE STUDY 31 DESIGN 31 D e p e n d e n t V a r i a b l e 32 I n d e p e n d e n t V a r i a b l e 32 SELECTION OF THE STUDY GROUP . 32 The S e t t i n g 32 The S u b j e c t s 33 PROCEDURE 34 INSTRUMENTATION 35 T e a c h i n g G u i d e 35 L i s t o f " R e m i n d e r s " 36 The I n t e r v i e w S c h e d u l e 37 E v a l u a t i o n F o r m o f M o t h e r ' s C o p i n g A b i l i t i e s 37 C o n t r o l G r o u p I n f o r m a t i o n A s s e s s m e n t . . . 37 P e r s o n a l D a t a F o r m 38 P I L O T STUDY 38 S T A T I S T I C A L A N A L Y S I S 39 SUMMARY 39 I V A N A L Y S I S OF THE DATA 40 THE STUDY POPULATION 40 EVALUATION OF THE MOTHERS' COPING A B I L I T I E S 46 A N A L Y S I S OF EVALUATION FORM ITEMS 47 v i i i C h a p t e r P a g e U n d e r s t a n d i n g t h e R e a s o n f o r t h e C a s t 50 U n d e r s t a n d i n g C a s t C a r e 50 U n d e r s t a n d i n g o f C a r e f o r a C a s t e d L i m b 51 U n d e r s t a n d i n g o f S i g n s a n d Symptoms o f C o m p l i c a t i o n s 52 CONTROL GROUP INFORMATION ASSESSMENT . . . 54 I n f o r m a t i o n P a m p h l e t s 54 SUMMARY . 57 V SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS 61 SUMMARY . . . . . . . . . 61 CONCLUSIONS 62 IMPLICATIONS 63 RECOMMENDATIONS . . . . . . . 65 BIBLIOGRAPHY 67 APPENDIX A - INSTRUCTIONS GIVEN TO NURSING STAFF . . . . . . . . . . . . 74 APPENDIX B - INSTRUMENTS USED I N THE STUDY . . . . . 77 APPENDIX C - INFORMATION PAMPHLET ON CAST CARE AT HOME DISTRIBUTED BY ONE HOSPITAL 87 L I S T OF TABLES T a b l e P a g e I PERCENTAGE D I S T R I B U T I O N OF THE MOTHER BY AGE 41 I I PERCENTAGE D I S T R I B U T I O N OF THE MOTHERS BY HIGHEST EDUCATIONAL ATTAINMENT 42 I I I PERCENTAGE DIS T R I B U T I O N OF THE MOTHERS BY EMPLOYMENT OUTSIDE THE HOME 42 I V PERCENTAGE D I S T R I B U T I O N OF THE MOTHERS BY PREVIOUS EXPERIENCES WITH CASTS 43 V PERCENTAGE D I S T R I B U T I O N OF THE CHILDREN BY AGE 44 V I PERCENTAGE D I S T R I B U T I O N OF THE CHILDREN BY NUMBER OF PREVIOUS HOSPITALIZATIONS . . . . 45 V I I PERCENTAGE D I S T R I B U T I O N OF THE CHILDREN BY NUMBER OF PREVIOUS CASTS 45 V I I I RANKED SCORES OF THE COPING A B I L I T I E S OF EACH INDIVIDUAL MOTHER 47 I X MODEL OF 2 X 2 CONTINGENCY TABLE . . . . . . . 48 X GROUP SCORES OF IND I V I D U A L O B J E C T I V E S ACHIEVED 49 X I RANKED SCORES OF THE COPING A B I L I T I E S OF CONTROL SUBJECTS R E C E I V I N G PAMPHLET ( N i ) AND THOSE NOT RECE I V I N G PAMPHLET ( N 2 ) . . 54 X I I CONTROL SUBJECTS R E C E I V I N G INFORMATION REGARDING S P E C I F I C ASPECTS OF HOME CARE PRIOR TO DISCHARGE 58 CHAPTER I INTRODUCTION TO THE STUDY INTRODUCTION The t e a c h i n g o f p a t i e n t s a n d t h e i r f a m i l i e s i s a n i n t e g r a l p a r t o f t o t a l c o m p r e h e n s i v e p a t i e n t c a r e a n d t h e r e -f o r e a s i g n i f i c a n t c o m p o n e n t o f p r o f e s s i o n a l n u r s i n g p r a c t i c e . T h r o u g h h e r t e a c h i n g a c t i v i t i e s , t h e n u r s e p r a c t i t i o n e r d o e s n o t s e r v e a s a s u b s t i t u t e f o r t h e p h y s i c i a n , b u t r a t h e r e n h a n c e s h i s e f f e c t i v e n e s s i n m a k i n g f o r more t r u l y c o m p r e -h e n s i v e c a r e t h a n c o u l d b e r e a l i z e d b y t h e p h y s i c i a n w o r k i n g a l o n e . ^ A s t e a c h e r , t h e n u r s e p r a c t i t i o n e r i n t e r p r e t s t o p a t i e n t s a n d t h e i r f a m i l i e s f a c t s b a s i c t o t h e a c h i e v e m e n t , m a i n t e n a n c e , a n d p r o m o t i o n o f h e a l t h w i t h t h e e x p e c t a t i o n t h a t t h e s e f a c t s w i l l b e a p p l i e d i n t h e home s i t u a t i o n . C o n t i n u i t y o f c a r e c a n b e a c h i e v e d e f f e c t i v e l y o n l y t h r o u g h v a r i o u s a s p e c t s o f c o m m u n i c a t i o n , g o a l - s e t t i n g , t e a c h i n g , a n d c o o r d i n a t i o n o f h e a l t h s e r v i c e s . I n a d d i t i o n , p l a n n e d f o l l o w - u p c a r e w i l l p r o v i d e f o r " b e t t e r u t i l i z a t i o n o f t i m e a n d p e r s o n n e l , c o n s i s t e n t i n s t r u c t i o n s t o f a m i l y members, a n d M a r y Ann D u r o c h e r , " P a r e n t E d u c a t o r i n t h e O u t p a t i e n t D e p a r t m e n t , " A m e r i c a n J o u r n a l o f N u r s i n g , LXV ( J u n e , 1 9 6 5 ) , 1 0 1 . 2 m e a s u r e s f o r d e t e r m i n i n g t h e e f f e c t i v e n e s s o f h e a l t h t e a m 2 a c t i o n s . " When a c h i l d becomes i l l , t h e i n v o l v e m e n t o f h i s p a r e n t s i n t h e t r e a t m e n t a n d c a r e a c t i v i t i e s i s o f c r u c i a l i m p o r t a n c e . A d m i s s i o n t o h o s p i t a l f r e q u e n t l y becomes a c r i s i s s i t u a t i o n n o t o n l y f o r t h e c h i l d , b u t f o r t h e p a r e n t s a s w e l l , p r o d u c i n g a n x i e t y w h i c h may i n t e r f e r e w i t h t h e i r a b i l i t y t o g i v e a d e q u a t e s u p p o r t t o t h e c h i l d , w h i l e a t t h e same t i m e t r a n s m i t t i n g t h i s 3 a n x i e t y t o t h e c h i l d . F o r p a r e n t s who m u s t b r i n g t h e i r c h i l d t o a n e m e r g e n c y d e p a r t m e n t b e c a u s e o f a n a c c i d e n t , t h e u n -e x p e c t e d t r e a t m e n t s a n d p r o c e d u r e s c a n e a s i l y e n h a n c e t h e f e e l i n g s o f a n x i e t y a n d c o n f u s i o n w h i c h b o t h p a r e n t s a n d c h i l d may e x p e r i e n c e i n t r y i n g t o a d j u s t t o t h e s i t u a t i o n . Mean-w h i l e t h e y a r e o f t e n c o m p e l l e d t o w a i t f o r v a r y i n g l e n g t h s o f t i m e i n a n e m e r g e n c y s e r v i c e e n v i r o n m e n t w h i c h o f t e n a p p e a r s r u s h e d , i m p e r s o n a l , a n d u n c a r i n g t o many o f i t s c l i e n t e l e . I t i s n o t a b l e t h a t w i t h i n t h e s p a c e o f a f e w s h o r t h o u r s , a n a c c i d e n t c a n o c c u r , t r e a t m e n t g i v e n b y o n e o r a v a r i e t y o f u n f a m i l i a r p r o f e s s i o n a l s f o l l o w e d b y t h e d i s c h a r g e home. A t t h a t p o i n t , t h e c h i l d i s no l o n g e r a p a t i e n t o f t h e L y n n P. D e a k e r s , " C o n t i n u i t y o f F a m i l y - C e n t e r e d N u r s i n g C a r e B e t w e e n t h e H o s p i t a l a n d t h e Home," N u r s i n g C l i n i c s o f  N o r t h A m e r i c a , V I I ( M a r c h , 1 9 7 2 ) , 8 3 . 3 F l o r e n c e B r i g h t , "The P e d i a t r i c N u r s e a n d P a r e n t a l A n x i e t y , " N u r s i n g F o r u m , I V ( S p r i n g , 1 9 6 5 ) , 3 0 . 3 h o s p i t a l b u t o f h i s p a r e n t s who become t h e h e a l t h c a r e - t a k e r s , u n e x p e c t e d l y f a c e d w i t h t h e r e s p o n s i b i l i t y o f c a r i n g f o r a c h i l d who, h a d t h e d e c i s i o n b y t h e m e d i c a l s t a f f b e e n t o a d m i t t h e c h i l d t o h o s p i t a l , w o u l d s t i l l b e a h o s p i t a l p a t i e n t . I n s t e a d he g o e s home, t h u s f o r t u n a t e l y a v o i d i n g t h e p s y c h o -l o g i c a l t r a u m a a s s o c i a t e d w i t h p r o l o n g e d h o s p i t a l i z a t i o n . The n e e d t o p r e p a r e m o t h e r s a d e q u a t e l y f o r t h e c a r e t h e y a r e e x p e c t e d t o p r o v i d e a f t e r s u c h s h o r t - t e r m t r e a t m e n t i s t h e c o n c e r n o f t h i s s t u d y . THE PROBLEM S t a t e m e n t o f t h e P r o b l e m I t i s t h e e x p r e s s e d o p i n i o n o f a s o c i o l o g i s t , R o b e r t B e l l , t h a t t h e m o t h e r i s o f t e n t h e i n t e r m e d i a r y b e t w e e n t h e i m p e r s o n a l , r a t i o n a l d e c i s i o n s o f t h e m e d i c a l e x p e r t a n d t h e a p p l i c a t i o n o f t h o s e d e c i s i o n s w i t h i n t h e h i g h l y e m o t i o n a l 4 c o n t e x t o f i n t r a - f a m i l y r e l a t i o n s h i p s . The p u r p o s e o f t h i s s t u d y was t o d e t e r m i n e w h e t h e r o r n o t p l a n n e d t e a c h i n g i n -v o l v i n g v e r b a l a n d w r i t t e n i n s t r u c t i o n s , g i v e n t o a m o t h e r p r i o r t o t h e d i s c h a r g e o f h e r c h i l d f r o m a h o s p i t a l e m e r g e n c y d e p a r t m e n t f o l l o w i n g t r e a t m e n t f o r a t r a u m a t i c l i m b f r a c t u r e r e q u i r i n g c a s t a p p l i c a t i o n , e n a b l e s h e r t o c o p e more a d e q u a t e l y R o b e r t K. B e l l , "The I m p a c t o f I l l n e s s o n t h e F a m i l y , " A S o c i o l o g i c a l F r a m e w o r k f o r P a t i e n t C a r e , e d . J.R. F o l t a a n d E.S. Deck (New Y o r k : J o h n W x l e y a n d S o n s , I n c . , 1966), p . 179. 4 w i t h t h e home c a r e o f t h e c h i l d t h a n t h e m o t h e r n o t r e c e i v i n g t h i s p l a n n e d t e a c h i n g . S p e c i f i c O b j e c t i v e s o f t h e S t u d y The o b j e c t i v e s o f t h i s s t u d y w e r e t o : 1. p r o v i d e e a c h m o t h e r o f t h e e x p e r i m e n t a l g r o u p w i t h k n o w l e d g e c o n c e r n i n g t h e management o f h e r c h i l d ' s c a r e a t home. 2. e v a l u a t e t h e a b i l i t i e s o f t h e m o t h e r s o f t h e e x p e r i -m e n t a l g r o u p t o c o p e w i t h t h e home c a r e , b a s e d o n t h e i r c o m p r e h e n s i o n o f t h e s p e c i f i c i n s t r u c t i o n s g i v e n p r e v i o u s t o d i s c h a r g e . 3. e v a l u a t e t h e a b i l i t i e s o f t h e m o t h e r s o f t h e c o n t r o l g r o u p t o c o p e w i t h t h e home c a r e . S i g n i f i c a n c e o f t h e P r o b l e m The f o c u s o f t h i s s t u d y was o n t h e e d u c a t i o n o f t h e m o t h e r i n t h e c a r e a c t i v i t i e s r e q u i r e d b y h e r c h i l d a f t e r d i s c h a r g e f r o m a h o s p i t a l e m e r g e n c y d e p a r t m e n t . I n h e r b r i e f e x p e r i e n c e a s a s t a f f n u r s e i n b o t h p e d i a t r i c a n d e m e r g e n c y s e t t i n g s , t h e w r i t e r o b s e r v e d t h a t d i s c h a r g e i n s t r u c t i o n s w e r e g e n e r a l l y c o n s i d e r e d t o b e t h e r e s p o n s i b i l i t y o f t h e p h y s i c i a n , p o s s i b l y s u p p l e m e n t e d b y t h e n u r s e ' s r e s p o n s e s t o q u e s t i o n s w h i c h e i t h e r t h e p a t i e n t o r a c c o m p a n y i n g f a m i l y member w o u l d be p e r c e p t i v e e n o u g h o r d a r i n g e n o u g h t o a s k . No s p e c i f i c o p p o r t u n i t y was p r o v i d e d f o r d i s c u s s i o n w i t h t h e s e p e r s o n s a b o u t w h a t t r e a t m e n t h a d b e e n g i v e n , t h e e x p e c t e d 5 r e s u l t s o f t h a t t r e a t m e n t , o r how t o o b s e r v e f o r a n d manage p o s s i b l e c o m p l i c a t i o n s . S t u d i e s h a v e i n d i c a t e d t h a t a h o s p i t a l i z a t i o n p e r i o d o f s h o r t d u r a t i o n , o f a c h i l d a t a n y a g e , c a n p r o v e t o b e a v e r y 5 6 7 t r a u m a t i c e x p e r i e n c e . ' ' I n a d d i t i o n , i d e a s a b o u t i n j u r y o r i m m o b i l i z a t i o n c a n b e m i s i n t e r p r e t e d a n d / o r m i s c o n c e p t u a l -i z e d b y t h e c h i l d , r e s u l t i n g i n s t r e s s e s w i t h w h i c h he may 8 9 10 n o t b e a b l e t o c o p e a d e q u a t e l y . ' ' T h i s w i l l a f f e c t b o t h 5 H. Gofman e t a l . , "The C h i l d ' s E m o t i o n a l R e s p o n s e t o H o s p i t a l i z a t i o n , " AMA J o u r n a l o f D i s e a s e s o f C h i l d r e n , X C I I I ( 1 9 5 7 ) , 1 5 7 - 1 6 4 . g P.R. M a h a f f e y , J r . , "The E f f e c t s o f H o s p i t a l i z a t i o n o n C h i l d r e n A d m i t t e d f o r T o n s i l l e c t o m y a n d A d e n o i d e c t o m y , " N u r s i n g R e s e a r c h , X I V , 1 ( 1 9 6 5 ) , 1 2 - 1 9 . 7 W.S. L a n g f o r d , "The C h i l d i n t h e P e d i a t r i c H o s p i t a l : A d a p t a t i o n t o I l l n e s s a n d H o s p i t a l i z a t i o n , " A m e r i c a n J o u r n a l  o f O r t h o p s y c h i a t r y , X X X I ( 1 9 6 1 ) , 6 6 7 - 6 8 4 . g F.G. B l a k e , " I m m o b i l i z e d Y o u t h : A R a t i o n a l e f o r S u p p o i t i v e N u r s i n g I n t e r v e n t i o n , " A m e r i c a n J o u r n a l o f N u r s i n g , L X I X (November, 1 9 6 9 ) , 2 3 6 4 - 2 3 6 9 . g R.S. O'Grady, " R e s t r a i n t a n d t h e H o s p i t a l i z e d C h i l d , " C u r r e n t C o n c e p t s i n C l i n i c a l N u r s i n g , I I , e d . B.S. B e r g e r s o n e t a l . ( S a i n t L o u i s : The C V . M o s b y Co . , 1 9 6 9 ) , p p . 1 9 2 - 2 0 2 . J . Howe, " C h i l d r e n ' s I d e a s A b o u t I n j u r y , " ANA R e g i o n a l  C l i n i c a l C o n f e r e n c e s , 1 9 6 7 , P h i l a d e l p h i a / K a n s a s C i t y (New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 6 8 ) , p p . 1 8 9 - 1 9 5 ^ 6 h i s p h y s i c a l r e c o v e r y a s w e l l a s h i s e v e r y d a y b e h a v i o r , a n d h i s m o t h e r , who i s u n f a m i l i a r w i t h h a v i n g a t e m p o r a r i l y d i s -a b l e d c h i l d t o c a r e f o r , i s e x p e c t e d t o a d a p t a p p r o p r i a t e l y b u t w i t h o u t r e c e i v i n g a d e q u a t e i n s t r u c t i o n s a n d f o l l o w - u p . I n a c t u a l f a c t , t h i s a d a p t i n g may b e a n e a r i m p o s s i b i l i t y . L i t t l e a n d C a r n e v a l i s t a t e t h a t i f f a m i l y members a r e t o assume a n a c t i v e r o l e i n t h e p a t i e n t ' s c a r e , t h e y m u s t know how t h e y c a n p a r t i c i p a t e a p p r o p r i a t e l y T h e r e f o r e , a s t h e m o t h e r w i l l u s u a l l y assume t h e p r i m e c a r e t a k e r r o l e a t home, s h e s h o u l d b e a d e q u a t e l y p r e p a r e d f o r t h a t r o l e . I n t h e c a s e o f a c h i l d , t h e c o p i n g a b i l i t i e s o f t h e p a r e n t a r e a s i m p o r t a n t a s t h o s e o f t h e c h i l d . B o t h n e e d t o b e p r o v i d e d w i t h f a c t u a l i n f o r m a t i o n c o n c e r n i n g w h a t h a s o c c u r r e d a n d p r e d i c t i o n s o f w h a t w i l l o c c u r , r e a s s u r a n c e t o m a i n t a i n o p t i m i s m a n d r e c o m m e n d a t i o n s t o p r o v i d e a s e n s e o f 12 c o n t r o l , t h u s r e d u c i n g h e l p l e s s n e s s . I n a d d i t i o n , o p p o r -t u n i t i e s f o r p e r s o n a l e x p r e s s i o n o f f e a r s , u n c e r t a i n t i e s a n d a n x i e t i e s n e e d t o b e made a v a i l a b l e i n t h e p r e - d i s c h a r g e "*"^ "D.E. L i t t l e a n d D.L. C a r n e v a l i , N u r s i n g C a r e P l a n n i n g ( P h i l a d e l p h i a : J . B . L i p p i n c o t t Company, 1 9 6 9 ) , p . 1 9 0 . 12 I r v i n g J a m s , P s y c h o l o g i c a l S t r e s s : P s y c h o a n a l y t i c  a n d B e h a v i o r a l S t u d i e s o f S u r g i c a l P a t i e n t s (New Y o r k : J o h n W i l e y a n d S o n s , I n c . , 1 9 5 8 ) , p. 54. 7 p e r i o d t o e n s u r e t h a t b o t h m o t h e r a n d c h i l d w i l l b e a b l e t o c o p e t o g e t h e r i n t h e e v e r y d a y home s i t u a t i o n . W a l k e r s u g g e s t s t h a t t h e h o s p i t a l ' s a m b u l a t o r y s e r v i c e s , w h i c h i n c l u d e e m e r g e n c y s e r v i c e s , p r o v i d e a n e x c e l l e n t o p p o r -t u n i t y f o r p a t i e n t e d u c a t i o n a s t h e s u c c e s s o f t h e t r e a t m e n t p l a n i n s u c h a s i t u a t i o n r e s t s l a r g e l y w i t h t h e p a t i e n t ' s a n d h i s f a m i l y ' s u n d e r s t a n d i n g o f h i s i l l n e s s a n d i n s t r u c t i o n s . " 1 * Wang a n d B r a y t o n f e e l t h a t a s a m b u l a t o r y p a t i e n t s a n d t h e i r f a m i l i e s a r e a c t i v e p a r t i c i p a n t s i n t h e management o f t h e i r own h e a l t h , t h e y c a n e i t h e r n e g a t e t h e e f f o r t s o f a w e l l c o o r d i n a t e d p l a n a n d r e n d e r e f f e c t i v e c a r e i m p o s s i b l e , o r t h e y c a n b e e n c o u r a g e d t o assume t h e r o l e o f a t h i r d p a r t n e r -m a n a g e r i n b o t h p l a n n i n g a n d e x e c u t i n g t h e c a r e p r o g r a m , i f a p p r o p r i a t e t e a c h i n g a n d s u p p o r t a r e made a v a i l a b l e b y p r e p a r e d 14 a n d c o n c e r n e d p r o f e s s i o n a l s . The p o i n t i s e m p h a s i z e d b y F e l l s t h a t i n e m e r g e n c y s e r v i c e s , v e r y l i t t l e e x t r a t i m e i s r e q u i r e d t o e n s u r e t h a t t h e p a t i e n t a n d a c c o m p a n y i n g f a m i l y members James E.C. W a l k e r , " A x i s f o r C o m m u n i t y H e a l t h E d u c a t i o n : The H o s p i t a l ' s A m b u l a t o r y S e r v i c e , " H e a l t h E d u c a t i o n i n t h e  H o s p i t a l , P r o c e e d i n g s o f a n I n v i t a t i o n a l C o n f e r e n c e o f t h e A m e r i c a n H o s p i t a l A s s o c i a t i o n , C h i c a g o , May 4-6, 1964 ( C h i c a g o : A m e r i c a n H o s p i t a l A s s o c i a t i o n , 1 9 6 5 ) , p . 3 0 . 14 M.K. Wang a n d R.G. B r a y t o n , " H e a l t h M a i n t e n a n c e S e r v i c e f o r t h e H i g h - R i s k C h r o n i c a l l y 111 : A D e m o n s t r a t i o n o f C o l l a b o r a t i o n o f P h y s i c i a n a n d N u r s e , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , V ( J u n e , 1 9 7 0 ) , 1 9 9 - 2 1 0 . 8 know w h a t h a s b e e n p r e s c r i b e d , why, a n d how t h e c a r e may b e a d m i n i s t e r e d a t home.'*""* However l i m i t e d , t h i s t i m e m u s t b e w e l l s p e n t a n d s o m u s t i n c l u d e some f o r m o f o r g a n i z e d a c t i v i t y i f i t i s t o p r o d u c e e f f e c t i v e p a t i e n t e d u c a t i o n . A s a n y s o u n d e d u c a t i o n a l v e n t u r e , p a t i e n t e d u c a t i o n m u s t b e c a r e f u l l y p l a n n e d . T h e r e s h o u l d b e a n a n a l y s i s o f n e e d s a n d r e s o u r c e s . The o b j e c t i v e s s h o u l d b e c l e a r l y d e f i n e d a n d s p e c i f i c t o t h e p o i n t t h a t t h e y a r e r e a l i s -t i c a n d a c h i e v a b l e a n d c a n b e e v a l u a t e d . The c o n t e n t m u s t b e c a r e f u l l y d e t e r m i n e d a n d s e t i n t o a v a r i e t y o f l e a r n i n g e x p e r i e n c e s t h a t w i l l m e e t t h e n e e d s o f t h e p a t i e n t s i n v o l v e d . The m e t h o d s a n d m a t e r i a l s u s e d s h o u l d b e c a r e f u l l y s e l e c t e d a n d s k i l l f u l l y u s e d . F i n a l l y , a c a r e f u l e v a l u a t i o n s h o u l d b e made i n t e r m s o f t h e o b j e c -t i v e s i n o r d e r t o m e a s u r e t h e r e s u l t s , a n d i f n e c e s s a r y , t o make a d j u s t m e n t s . 16 T h u s t h e n e e d f o r p r o g r a m s o f p l a n n e d t e a c h i n g n e c e s s a r y f o r e f f e c t i v e p a t i e n t c a r e h a s b e e n i n d i c a t e d , b u t a s y e t , s c i e n t i f i c i n v e s t i g a t i o n a n d e v a l u a t i o n o f s u c h p r o g r a m s i n e m e r g e n c y d e p a r t m e n t s a r e l a c k i n g . T h i s i n v e s t i g a t i o n o f t h e e f f e c t i v e n e s s o f a t e a c h i n g p r o g r a m s h o u l d p r o v i d e a b a s i s f o r f u r t h e r s t u d i e s i n t h i s l a r g e l y u n e x p l o r e d , b u t i n c r e a s i n g l y p o p u l a r , c e n t e r f o r s h o r t - t e r m p a t i e n t c a r e . C.E. F e l l s , " N u r s i n g i n t h e A m b u l a t o r y S e r v i c e s , " N u r s i n g i n A m b u l a t o r y U n i t s , e d . E.D. S c h u l t z a n d E. R u d i c k (Dubuque, I o w a : Wm. C. B r o w n Company, P u b l i s h e r s , 1966), p . 56. ^ E . K a s e y a n d E. McMahon, " E d u c a t i o n a s a L i v i n g P r o c e s s , " H e a l t h E d u c a t i o n i n t h e H o s p i t a l , P r o c e e d i n g s o f a n I n v i t a t i o n a l C o n f e r e n c e o f t h e A m e r i c a n H o s p i t a l A s s o c i a t i o n , C h i c a g o , May 4-6, 1964 ( C h i c a g o : A m e r i c a n H o s p i t a l A s s o c i a t i o n , 1965), p . 13. 9 ASSUMPTION OF THE STUDY T h i s s t u d y was b a s e d o n t h e a s s u m p t i o n t h a t t h e c a r e w h i c h a m o t h e r i s e x p e c t e d t o g i v e t o h e r c h i l d a t home f o l l o w -i n g t r e a t m e n t i n a h o s p i t a l ' s e m e r g e n c y d e p a r t m e n t , i s com-p a r a b l e t o t h e n u r s i n g c a r e t h a t c h i l d w o u l d h a v e r e c e i v e d h a d h e b e e n a d m i t t e d t o a g e n e r a l h o s p i t a l w a r d . D E F I N I T I O N S OF TERMS USED To know. The r e m e m b e r i n g o f p r e v i o u s l y l e a r n e d i n -f o r m a t i o n . " ^ To u n d e r s t a n d . The i n d i v i d u a l knows w h a t i s b e i n g c o m m u n i c a t e d a nd c a n make u s e o f t h e m a t e r i a l o r i d e a b e i n g 18 c o m m u n i c a t e d . To c o p e . R e f e r s t o t h e a b i l i t y t o a p p l y p e r t i n e n t k n o w l e d g e a n d u n d e r s t a n d i n g i n m a n a g i n g a n u n f a m i l i a r s i t u a t i o n . C a s t . R e f e r s t o a f u l l l e n g t h o r b e l o w - t h e - k n e e , w a l k -i n g o r n o n - w a l k i n g , p l a s t e r o f P a r i s c a s t , o r a f u l l l e n g t h o r e l b o w l e n g t h a r m c a s t . P o s t - h o s p i t a l i z a t i o n / d i s c h a r g e p e r i o d . R e f e r s t o a f i v e t o t e n d a y p e r i o d a f t e r t r e a t m e n t i n a h o s p i t a l e m e r g e n c y d e p a r t m e n t . 17 B.S. B l o o m (ed.) e t a l . , Taxonomy o f E d u c a t i o n a l  O b j e c t i v e s : The C l a s s i f i c a t i o n o f E d u c a t i o n a l G o a l s - Handbook I : C o g n i t i v e D o m a i n (New Y o r k ; D a v i d McKay Company, I n c . , 1956) , p p . 62-67. 1 8 I b i d . , p . 89. I 10 LIMITATIONS OF THE STUDY The s t u d y i s s u b j e c t t o t h e f o l l o w i n g l i m i t a t i o n s : 1. No m e t h o d was u s e d t o c o n t r o l t h e r o u t i n e d i s c h a r g e p r o c e d u r e s g i v e n b y t h e s t a f f o f t h e v a r i o u s h o s p i t a l e m e r g e n c y d e p a r t m e n t s u t i l i z e d i n t h i s s t u d y . 2. The p o t e n t i a l a b i l i t i e s a n d a t t i t u d e s o f t h e m o t h e r i n h a n d l i n g s u c h a s i t u a t i o n w e r e n o t a s s e s s e d b e f o r e t h e s p e c i f i c i n f o r m a t i o n r e g a r d i n g home c a r e was g i v e n . HYPOTHESIS TESTED I N THE STUDY The N u l l h y p o t h e s i s was t e s t e d i n t h i s s t u d y : t h e r e 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 t h e c o p i n g a b i l i t i e s o f t h e m o t h e r s o f t h e e x p e r i m e n t a l g r o u p a s c o m p a r e d w i t h t h e m o t h e r s o f t h e c o n t r o l g r o u p . O v e r v i e w o f t h e R e m a i n d e r o f t h e S t u d y C h a p t e r I I i s a r e v i e w o f t h e l i t e r a t u r e , f o c u s i n g o n i l l n e s s a n d h o s p i t a l i z a t i o n o f c h i l d r e n a n d t h e r o l e o f t h e n u r s e i n p r e p a r i n g t h e p a t i e n t a n d h i s f a m i l y f o r home c a r e . C h a p t e r I I I - d e s c r i b e s t h e m e t h o d o l o g y u s e d i n t h i s s t u d y . C h a p t e r I V - i s a n a n a l y s i s o f t h e d a t a g a t h e r e d . C h a p t e r V - c o n t a i n s t h e summary o f t h e f i n d i n g s o f t h e s t u d y , t h e c o n c l u s i o n s a n d i m p l i c a t i o n s d r a w n , a n d r e c o m m e n d a t i o n s f o r f u r t h e r a r e a s f o r i n v e s t i g a t i o n . CHAPTER I I REVIEW OF THE LITERATURE I n r e v i e w i n g t h e l i t e r a t u r e , t h e r e was f o u n d t o b e a l a c k o f s t u d i e s d i r e c t l y c o n c e r n e d w i t h t h e t e a c h i n g o f p a r e n t s o r e v e n o f p a t i e n t s i n g e n e r a l , i n e m e r g e n c y d e p a r t m e n t s e t t i n g s . T h e r e f o r e , i n d i r e c t l y r e l a t e d a r e a s w e r e i n v e s t i g a t e d t o p r o v i d e t h e b a s e s o n w h i c h t h i s s t u d y was b u i l t . The l i t e r a t u r e r e v i e w i s d i s c u s s e d u n d e r t h e f o l l o w i n g h e a d i n g s : t h e c o n c e r n s o^f h o s p i t a l i z e d s c h o o l - a g e d c h i l d r e n a n d t h e i r p a r e n t s ; c o m m u n i c a t i o n b e t w e e n p a t i e n t s , t h e i r f a m i l i e s , a n d t h e p r o f e s s i o n a l h e a l t h team; a n d t h e r o l e o f t h e n u r s e i n p a t i e n t t e a c h i n g a s a means o f e f f e c t i v e c o m m u n i c a t i o n . THE CONCERNS OF HOSPITALIZED SCHOOL-AGED CHILDREN AND THEIR PARENTS P a r e n t s a r e t h e m o s t i m p o r t a n t p e o p l e t o a y o u n g c h i l d b e c a u s e t h e y p r o v i d e h i m w i t h p h y s i c a l a s w e l l a s e m o t i o n a l s u p p o r t a n d n u r t u r e . ^ " The g r o w i n g c h i l d c a n n o t a f f o r d t o 2 i n t e r r u p t t h e c y c l e o f h i s l i v i n g a n d g r o w t h , b u t when t h i s •""M.M. G r e e n , "The C o n c e r n s o f P a r e n t s o f a H o s p i t a l i z e d C h i l d , " ANA C o n v e n t i o n C l i n i c a l S e s s i o n s , V I I I ( 1 9 6 4 ) , 5. 2 Emma N. P l a n k , W o r k i n g W i t h C h i l d r e n i n H o s p i t a l s (2nd e d . ; C h i c a g o : P r e s s o f C a s e W e s t e r n R e s e r v e U n i v e r s i t y , 1 9 7 1 ) , p. 1. h a p p e n s a s i n t h e e v e n t o f i l l n e s s a n d h o s p i t a l i z a t i o n , a c h i l d ' s n e e d f o r h i s p a r e n t s i s n e c e s s a r i l y i n c r e a s e d a s he t r i e s t o c o p e w i t h t h e c h a n g e s t a k i n g p l a c e . To a c h i l d w hose i n n e r r e s o u r c e s a r e a l r e a d y s t r a i n e d b y h i s i l l n e s s a n d t h e s t r a n g e s u r r o u n d i n g s o f t h e h o s p i t a l , m i s c o n c e p t i o n s a b o u t t h e c a u s e o f h i s i l l n e s s a n d a b o u t t h e m o t i v e s o f t h o s e 3 a s s i g n e d t o h i s c a r e a r e a n a d d e d b u r d e n . E r i k s o n h a s s t a t e d t h a t c h i l d r e n o f e a r l y s c h o o l y e a r s h a v e more c a p a c i t y t o d e a l w i t h t h e s t r e s s o f i l l n e s s t h a n do y o u n g e r c h i l d r e n , b u t t h e y a r e s t i l l n o t a b l e t o f u l l y u n d e r s t a n d t h e i r i l l n e s s o r t r e a t m e n t r e g i m e n , o f t e n m a s k i n g t h e i r c o n c e r n w i t h a l o o f b e h a v i o r a n d c o n v e y i n g t h e i d e a t h a t t h e y know a l l a b o u t i t 4 b y r e p e a t i n g a d u l t e x p l a n a t i o n s t h a t t h e y do n o t u n d e r s t a n d . How a c h i l d p e r c e i v e s h i s i l l n e s s a n d how much f a c t u a l i n f o r -m a t i o n he h a s c o n c e r n i n g h i s i l l n e s s a n d i t s r e s u l t s w i l l d i r e c t l y a f f e c t h i s r e c o v e r y . L e d e r e r h a s t h e o r i z e d t h a t w h e n e v e r a n i n d i v i d u a l e n t e r s a n unknown o r p a r t i a l l y u n d e r s t o o d s i t u a t i o n , h e e x h i b i t s f a i r l y t y p i c a l r e s p o n s e s a n d t h a t a n x i e t y i s a r o u s e d C.G. G i p s , "The I n t e r p r e t a t i o n a n d M i s i n t e r p r e t a t i o n . . . b y H o s p i t a l i z e d S c h o o l - a g e C h i l d r e n . . . o f B e i n g S i c k ; I m p l i c a t i o n s f o r N u r s i n g , " ANA C o n v e n t i o n C l i n i c a l S e s s i o n s , I X ( 1 9 6 5 ) , 1 3 . 4 F l o r e n c e E r i k s o n , " N u r s i n g C a r e B a s e d o n N u r s i n g A s s e s s m e n t , " C u r r e n t C o n c e p t s i n C l i n i c a l N u r s i n g , I I , e d . B.S. B e r g e n s o n e t a l . ( S a i n t L o u i s ! The C.V. M o s b y C o . , 1 9 6 9 ) , 1 7 6 . 13 b e c a u s e o f f a n t a s i e d d a n g e r s a n d b e c a u s e o f u n f a m i l i a r i t y 5 w i t h w h a t one may e x p e c t . T h i s t h e o r y c a n b e e x t e n d e d t o c h i l d r e n a s w e l l a s t o a d u l t s . I n a s t u d y o f t h e s t r e s s o f h o s p i t a l i z a t i o n o n c h i l d r e n , L a n g f o r d f o u n d t h a t s c h o o l - a g e d c h i l d r e n seem b o t h e r e d when t h e d i s e a s e p r o c e s s c a r r i e s w i t h i t a t h r e a t o f a c t u a l i m p a i r -m e n t o f t h e i r c a p a c i t i e s t o c o m p e t e a c t i v e l y w i t h o t h e r c h i l d r e n , a n d t h a t l a t e p r e - a d o l e s c e n t y o u n g s t e r s t e n d t o e x p r e s s f e a r s o f p e r m a n e n t d i s a b i l i t y . ^ F r o m t h e i r s t u d i e s o f h o s p i t a l i z e d c h i l d r e n , P r u g h a n d h i s a s s o c i a t e s f o u n d t h a t s i x - t o - t e n y e a r o l d c h i l d r e n e x p r e s s e d f e a r f u l f a n t a s i e s o f m u t i l a t i o n , o f b r o k e n f i n g e r s a n d l o s i n g t e e t h , o f b e i n g p o i s o n e d , o f n o t g e t t i n g w e l l , and " o b s e s s i v e f e a r s o f d e a t h f r o m i l l n e s s 7 d u r i n g s l e e p . " I n a d d i t i o n , H u s c h k a a n d Ogden f o u n d t h a t o n e o f t h e p r i m a r y s o u r c e s o f a n x i e t y i n t h e y o u n g c h i l d i s t h e s e n s e o f h e l p l e s s n e s s he e x p e r i e n c e s when t h e r e i s g p h y s i c a l i n t e r f e r e n c e w i t h h i s a c t i v i t y . M o r e r e c e n t l y , S i b y l l e E s c a l o n a h a s r e a f f i r m e d t h i s i d e a , s t a t i n g t h a t f o r 5 H.D. L e d e r e r , "How t h e S i c k V i e w T h e i r W o r l d , " S o c i a l  I n t e r a c t i o n a n d P a t i e n t C a r e , e d . J . K . S k i p p e r a n d R.C. L e o n a r d ( P h i l a d e l p h i a : J . B . L i p p m c o t t Company, 1 9 6 5 ) , p . 1 5 4 . g W.S. L a n g f o r d , "The C h i l d i n t h e P e d i a t r i c H o s p i t a l : A d a p t a t i o n t o I l l n e s s a n d H o s p i t a l i z a t i o n , " A m e r i c a n J o u r n a l  o f O r t h o p s y c h i a t r y , X X X I ( 1 9 6 1 ) , 6 7 2 . 7 Dane G. P r u g h , e t a l . , "A S t u d y o f t h e E m o t i o n a l R e a c t i o n s o f C h i l d r e n a n d F a m i l i e s t o H o s p i t a l i z a t i o n a n d I l l n e s s , " A m e r i c a n J o u r n a l o f O r t h o p s y c h i a t r y , X X I I I ( J a n u a r y , 1 9 5 3 ) , 9 3 . g M. H u s c h k a a n d 0. Ogden, "The C o n d u c t o f a P e d i a t r i c P r o p h y l a x i s C l i n i c , " J o u r n a l o f P e d i a t r i c s , X I I ( 1 9 3 8 ) , 794-800, s c h o o l - a g e d c h i l d r e n , b o d i l y i n j u r y o r d e f e c t s t i l l c a r r i e s a v e r y p e r s o n a l m e a n i n g . T h i s i s u n d e r s t a n d a b l e a s b o d i l y c o m p e t e n c e a n d i n t e g r i t y a r e p r i m e s o u r c e s o f a s e n s e o f 9 s e l f a n d s e l f - e s t e e m a t t h i s s t a g e o f d e v e l o p m e n t . I n h e r d e s c r i p t i v e c a s e s t u d i e s o f a number o f h o s p i t a l i z e d c h i l d r e n , G r e e n s t a t e d t h a t a s p a r e n t s p r o v i d e p h y s i c a l a s w e l l a s e m o t i o n a l s u p p o r t a n d n u r t u r e , a c h i l d l e a r n s t o a d j u s t t o l i f e a n d r e a c t t o i t s s t r e s s e s a s a r e s u l t o f t h e b a s i c a n d c o n t i n u i n g i n t e r a c t i o n s w i t h h i s f a m i l y . H o w e v e r , t h e a n x i e t y p r o d u c e d when p a r e n t s c a n n o t m e e t t h e i r own n e e d s p r e v e n t s s u c c e s s f u l g i v i n g o f t h e m s e l v e s a n d t h i s i s communi-c a t e d t o t h e c h i l d , t h u s i n c r e a s i n g h i s i n a b i l i t y t o c o p e w i t h h i s d i f f i c u l t i e s . ^ B l o m ' s s t u d y o f t h e r e a c t i o n s o f h o s p i t a l i z e d c h i l d r e n t o i l l n e s s e v i d e n c e d t h a t r e a c t i o n s t o t h i s s i t u a t i o n a r e d e t e r m i n e d b y t h e n a t u r e a n d d e g r e e o f s t r e s s f r o m b o t h r e a l i s t i c a n d u n c o n s c i o u s s o u r c e s a n d t h e b a l a n c e o f t h e s e s o u r c e s w i t h i n t h e c h i l d , h i s p a r e n t s , a n d t h e h o s p i t a l e n v i r o n m e n t w h i c h w i l l e i t h e r f a c i l i t a t e o r i m p e d e a d a p t a t i o n . H i s s t u d y o f how two t o f o u r t e e n y e a r o l d s r e a c t e d t o b r i e f h o s p i t a l i z a t i o n a n d a m i n o r o p e r a t i o n , i n d i c a t e d t h a t a d e q u a t e a d j u s t m e n t was r e l a t e d t o t h e d o m i n a n c e o f r e a l i s t i c i n f o r -m a t i o n c o n c e r n i n g t h e i l l n e s s a n d t h e p r o p o s e d treatment."'"''" 9 S i b y l l e E s c a l o n a , "The P e r s o n a l i t y o f N o r m a l I n f a n t s a n d C h i l d r e n , " Needs o f C h i l d r e n i n t h e H o s p i t a l , S e l e c t e d P a p e r s f r o m t h e S i x t h A n n u a l C o n f e r e n c e , A m e r i c a n A s s o c i a t i o n f o r C h i l d C a r e i n H o s p i t a l s , May 19-22, 1971 ( C l e v e l a n d : A m e r i c a n A s s o c i a t i o n f o r C h i l d C a r e i n H o s p i t a l s , 1972), p . 19 G r e e n , o p . c i t . , p . 5. M a h a f f e y u n d e r t o o k a n e x p e r i m e n t a l s t u d y t o i n v e s t i g a t e t h e p o s s i b i l i t y o f i m p r o v i n g t h e h o s p i t a l c a r e f o r c h i l d r e n b y i n v o l v i n g t h e c h i l d ' s m o t h e r w i t h i n t h e r e c o g n i z e d l i m i t s o f h e r c a p a b i l i t i e s . The r e s u l t s showed a p o s i t i v e c o r r e l -a t i o n b e t w e e n t h e a c t i o n s o f t h e n u r s e w i t h t h e e x p e r i m e n t a l 12 g r o u p a n d b e t t e r a d j u s t m e n t a t home f o l l o w i n g d i s c h a r g e . Gofman e t a l . c o n c l u d e d i n t h e i r s t u d i e s t h a t t h e e m o t i o n a l t r a u m a o f h o s p i t a l e x p e r i e n c e may b e p r e v e n t e d b y a d e q u a t e p a r e n t - c h i l d r e l a t i o n s h i p s a n d p r o p e r p r e p a r a t i o n o f b o t h t h e p a r e n t s a n d t h e c h i l d f o r a d m i s s i o n , h o s p i t a l i z a t i o n a n d 13 d i s c h a r g e . T h e s e same r e s e a r c h e r s c o n d u c t e d a s t u d y i n w h i c h o n e h u n d r e d p a r e n t s w e r e i n t e r v i e w e d a t t h e t i m e o f t h e i r c h i l d ' s a d m i s s i o n t o h o s p i t a l a n d s i x t y - e i g h t p a r e n t s w e r e i n t e r v i e w e d o n d i s c h a r g e o f t h e i r c h i l d , f o r t h e p u r p o s e o f a s c e r t a i n i n g t h e i r r e a c t i o n s t o a d m i s s i o n , h o s p i t a l i z a t i o n a n d d i s c h a r g e , a s w e l l t h e i r own a n d t h e i r c h i l d ' s p r e p a r a t i o n , 14 t h e i r f e e l i n g s a n d u n d e r s t a n d i n g a b o u t h i s i l l n e s s . T h ey ^ G a s t o n E. B l o m , "The R e a c t i o n s o f H o s p i t a l i z e d C h i l d r e n t o I l l n e s s , " P e d i a t r i c s , X X I I ( S e p t e m b e r , 1958), 590-600. 12 P.R. M a h a f f e y , "The E f f e c t s o f H o s p i t a l i z a t i o n o n C h i l d r e n A d m i t t e d f o r T o n s i l l e c t o m y a n d A d e n o i d e c t o m y , " N u r s i n g R e s e a r c h , X I V ( W i n t e r , 1965), 12-19. 13 H. Gofman e t a l . , "The C h i l d ' s E m o t i o n a l R e s p o n s e t o H o s p i t a l i z a t i o n , " AMA J o u r n a l o f D i s e a s e s o f C h i l d r e n , X C I I I (1957), 157-164. 14 H. Gofman, e t a l . , " P a r e n t s * E m o t i o n a l R e s p o n s e t o C h i l d ' s H o s p i t a l i z a t i o n , " AMA J o u r n a l o f D i s e a s e s o f C h i l d r e n , X C I I I (1957), 629-637. 16 f o u n d t h a t many p a r e n t s n o t o n l y w a n t e d i n f o r m a t i o n a n d t i m e t o p r e p a r e t h e i r c h i l d f o r h i s p i t a l i z a t i o n , b u t a l s o w a n t e d t h e p h y s i c i a n t o h e l p i n t h i s p r e p a r a t i o n . F o r t y - s e v e n o f t h e p a r e n t s e x p r e s s e d f e a r o f t h e unknown a s b e i n g t h e m o s t b e -w i l d e r i n g f a c t o r — n o t k n o w i n g w h a t was w r o n g o r w h a t t o e x p e c t . When a s k e d i f t h e y f e l t t h e y h a d r e c e i v e d t h e i n f o r m a t i o n n e c e s s a r y f o r f u r t h e r c a r e o f t h e c h i l d a t home, e i g h t e e n p a r e n t s f e l t t h e y h a d n o t r e c e i v e d i t , s t a t i n g t h a t t h e d o c t o r seemed t o o r u s h e d o r t h e y w e r e s o e x c i t e d t h e y f o r g o t t o a s k q u e s t i o n s , o r e l s e t h e y w e r e t o o u p s e t b y t h e d i a g n o s i s t o l i s t e n . S e v e r a l v o l u n t e e r e d t h a t t h e y w o u l d h a v e a p p r e c i a t e d w r i t t e n i n s t r u c t i o n s t o w h i c h t h e y c o u l d r e f e r a t home. I n a n a n a l y s i s o f i n t e r v i e w s w i t h p a r e n t s o f c h i l d r e n a t t e n d i n g a r h e u m a t i c f e v e r c l i n i c , t w o - t h i r d s o f t h e p a r e n t s s t a t e d t h a t no one h a d e v e r d i s c u s s e d t h e c h i l d ' s i l l n e s s w i t h them i n c l i n i c . The a n a l y s i s i n d i c a t e d t h a t t h e p a r e n t s ' u n d e r s t a n d i n g o f s e v e r a l c a r d i n a l a s p e c t s o f r h e u m a t i c f e v e r a n d i t s t r e a t m e n t was g e n e r a l l y c o n f u s e d , v a g u e , a n d d i s t o r t e d b y m i s c o n c e p t i o n s a n d u n r e a l i s t i c b e l i e f s . M o s t i m p o r t a n t , t h e e v i d e n c e showed t h a t a l m o s t n o n e o f t h e s e m o t h e r s h a d t a l k e d w i t h h e r c h i l d a b o u t h i s d i s e a s e a n d s o was c o m p l e t e l y u n a w a r e o f w h a t h e knew."''"*' J . H . K e n n e l l , e t a l . , "What P a r e n t s o f P h e u m a t i c F e v e r P a t i e n t s D o n ' t U n d e r s t a n d A b o u t t h e D i s e a s e a n d I t s P r o p h y l a c t i c Management," P e d i a t r i c s , X L I I I ( F e b r u a r y , 1 9 6 9 ) , 1 6 0 - 1 6 7 . 17 I t i s a p p a r e n t t h e n , t h a t i n i l l n e s s s i t u a t i o n s , s t r e s s i s a r o u s e d w i t h i n t h e c h i l d a n d h i s p a r e n t s b y c o n c e r n w i t h t h e u n k n o w n , t h e u n f a m i l i a r , a n d t h e l a c k o f i n f o r m a t i o n a b o u t t r e a t m e n t s , p r o c e d u r e s , a n d g e n e r a l c a r e . S k i p p e r a n d L e o n a r d , i n a s t u d y r e l a t i n g t h e s t r e s s o f t h e c h i l d w i t h t h a t o f t h e m o t h e r a s s e r t e d t h a t b y e s t a b l i s h i n g a r e l a t i o n -s h i p w i t h t h e m o t h e r o f a n i l l c h i l d a n d p r o v i d i n g h e r w i t h p e r t i n e n t i n f o r m a t i o n , a n a u t h o r i t a t i v e f i g u r e may r e d u c e h e r s t r e s s , t h u s a l l o w i n g h e r t o make a more r a t i o n a l a d a p t a t i o n t o t h e c h i l d ' s p r o b l e m s a n d t h e r e b y f a c i l i t a t i n g h e r a c t i v e r o l e i n h i s c a r e . They h y p o t h e s i z e t h a t t h i s p o s i t i v e b e h a v i o r o n t h e p a r t o f t h e m o t h e r w i l l h a v e a p r o f o u n d e f f e c t o n t h a t o f t h e c h i l d . S i m i l a r l y , P r a t t , i n a s t u d y o f a c h i l d w i t h a l o n g - t e r m i l l n e s s , s t r e s s e d t h e n e e d f o r a l i a i s o n p e r s o n t o c o m m u n i c a t e a n d r e i n t e r p r e t i n f o r m a t i o n among f a m i l y , 17 c h i l d a n d p r o f e s s i o n a l s t a f f . E i c h h o r n s e e s t h i s r o l e b e i n g f i l l e d b y t h e n u r s e s i n c e s h e i s t h e o n e p e r s o n who 18 r e m a i n s c o n s t a n t , t o whom p a t i e n t s a n d f a m i l y c a n r e l a t e . J.K. S k i p p e r a n d R.C. L e o n a r d , " C h i l d r e n , S t r e s s , a n d H o s p i t a l i z a t i o n : A F i e l d E x p e r i m e n t , " J o u r n a l o f H e a l t h a n d  S o c i a l B e h a v i o r , I X (December, 19 6 8 ) , 2 8 6 - 2 8 7 . 17 M.A. P r a t t , "A H o s p i t a l i z e d P r e s c h o o l C h i l d C o p e s W i t h a F a t a l I l l n e s s , " ANA C l i n i c a l S e s s i o n s , 1 9 6 8 , D a l l a s (New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 6 8 ) , p . 1 9 8 . 18 M.E. E i c h h o r n , " C h a l l e n g i n g R o l e o f C l i n i c N u r s e i n P a t i e n t L i a i s o n a n d S u p p o r t , " H o s p i t a l T o p i c s , X L V I I I ( F e b r u a r y , 1 9 7 0 ) , 9 7 - 1 0 0 . 18 COMMUNICATION BETWEEN PATIENTS, THEIR F A M I L I E S AND THE PROFESSIONAL HEALTH TEAM S c o t t Simmonds h a s w r i t t e n : " I f i n d i v i d u a l s a r e t o p a r t i c i p a t e e f f e c t i v e l y i n t h e i r own t r e a t m e n t a n d r e h a b i l i t a t i o n p r o g r a m s , i t i s o b v i o u s t h a t t h e y m u s t know a n d u n d e r s t a n d w h a t t o do a n d how t o do i t , a s w e l l a s b e s u f f i c i e n t l y 19 m o t i v a t e d t o t a k e a c t i o n . " W i t h t h e i n c r e a s i n g t r e n d o f r e l y i n g o n home c a r e a s a m a j o r p a r t o f t h e m e d i c a l t r e a t m e n t p l a n , e s p e c i a l l y f o r a m b u l a t o r y p a t i e n t s , t h e r e m u s t be a common a g r e e m e n t b e t w e e n t h e h e a l t h c a r e t e a m a n d t h e p a t i e n t o r f a m i l y member a s t o w h a t t h e l a t t e r n e e d s a n d w a n t s t o know t o p a r t i c i p a t e e f f e c t i v e l y i n t h i s p l a n , a s w e l l a s how a n d b y whom t h i s k n o w l e d g e i s t o b e p r o v i d e d . W i t h o u t t h i s a g r e e m e n t , c o n f u s i o n a n d i n e f f i c i e n c y w i l l p e r s i s t i n h a m p e r -i n g e f f e c t i v e c a r e . 20 I n s t u d i e s c o m p l e t e d b y P r a t t a n d h e r a s s o c i a t e s o n p r o b l e m s o f c o m m u n i c a t i o n b e t w e e n p a t i e n t s a n d p h y s i c i a n s i n a m e d i c a l o u t p a t i e n t c l i n i c , i t was f o u n d t h a t p a t i e n t s g a v e l i t t l e e v i d e n c e o f c o n s c i o u s , a g g r e s s i v e demand f o r i n f o r m a t i o n 19 S c o t t K. S i m o n d s , " H e a l t h E d u c a t i o n a n d M e d i c a l C a r e : F o c u s o n t h e P a t i e n t , " H e a l t h E d u c a t i o n M o n o g r a p h s , 16 ( 1 9 6 3 ) , p. 3 4 . 20 L o i s P r a t t , A r t h u r S e l i g m a n , a n d G e o r g e R e a d e r , " P h y s i c i a n s ' V i e w s o n t h e L e v e l o f M e d i c a l I n f o r m a t i o n Among P a t i e n t s , " P a t i e n t s , P h y s i c i a n s a n d I l l n e s s , e d . E. G a r t l y J a c o ( G l e n c o e , I l l i n o i s : The F r e e P r e s s , 1 9 5 8 ) , p p . 2 2 2 - 2 2 9 . 19 a b o u t t h e i r c o n d i t i o n f r o m t h e p h y s i c i a n , a l t h o u g h t h e r e a p p e a r e d t o b e a n u n f o r m u l a t e d l a t e n t d e s i r e f o r more i n f o r -m a t i o n among t h e m a j o r i t y . P h y s i c i a n s who s e r i o u s l y u n d e r -e s t i m a t e d t h e p a t i e n t ' s k n o w l e d g e w e r e l e s s l i k e l y t o d i s c u s s t h e i l l n e s s a t a n y l e n g t h w i t h t h e p a t i e n t t h a n w e r e t h o s e p h y s i c i a n s who d i d n o t s e r i o u s l y u n d e r e s t i m a t e t h e p a t i e n t ' s k n o w l e d g e . P a t i e n t s who w e r e g i v e n more t h o r o u g h e x p l a n a t i o n s w e r e f o u n d t o p a r t i c i p a t e somewhat more e f f e c t i v e l y w i t h t h e p h y s i c i a n a n d w e r e more l i k e l y t o a c c e p t c o m p l e t e l y t h e d o c t o r ' s f o r m u l a t i o n t h a n w e r e p a t i e n t s who r e c e i v e d v e r y l i t t l e e x p l a n a t i o n . I t seems t h a t p a t i e n t s do n o t a l w a y s r e c e i v e t h e i n f o r m a t i o n t h e y n e e d o r w a n t d e s p i t e i t s r e c o g n i z e d i m p o r -t a n c e . Dodge c o n d u c t e d a n e x p l o r a t o r y s t u d y t o d e t e r m i n e w h a t i n f o r m a t i o n p a t i e n t s r e a l l y w a n t a n d t h e way i n w h i c h d o c t o r s ' a n d n u r s e s ' a t t i t u d e s t o w a r d g i v i n g t h i s i n f o r m a t i o n d i f f e r e d 21 f r o m t h o s e o f t h e i r p a t i e n t s . D a t a w e r e c o l l e c t e d t h r o u g h i n t e r v i e w s a t two v o l u n t a r y t e a c h i n g h o s p i t a l s , a n d w e r e s t a t i s t i c a l l y a n a l y z e d t o d e t e r m i n e t h e n a t u r e a n d e x t e n t o f t h e d i f f e r e n c e s among t h e t h r e e g r o u p s i n t e r v i e w e d — p a t i e n t s , n u r s e s a n d d o c t o r s — o n t h e i r a t t i t u d e s t o w a r d t h e i m p o r t a n c e o f k e e p i n g p a t i e n t s i n f o r m e d . A t t i t u d e s w e r e i n f e r r e d f r o m J o a n S. Dodge, "How Much S h o u l d t h e P a t i e n t Be T o l d -A n d B y Whom?" H o s p i t a l s X X X V I I (December 16, 1963), 66-76, 125. 20 r e s p o n s e s t o a s e t o f q u e s t i o n s d e s i g n e d t o m e a s u r e how i m p o r t a n t t h e r e s p o n d e n t s f e l t i t was t h a t n u r s e s a n d d o c t o r s p e r f o r m c e r t a i n a c t s a s s o c i a t e d w i t h g i v i n g g o o d p a t i e n t c a r e . P h y s i c i a n s , n u r s e s a n d p a t i e n t s d i f f e r e d i n t h e i r a t t i t u d e s c o n c e r n i n g w h a t p a t i e n t s s h o u l d b e t o l d , w i t h t h e t e n d e n c y f o r d o c t o r s ' c o m m u n i c a t i o n f u n c t i o n s b e i n g s e e n b y a l l g r o u p s a s more i m p o r t a n t t h a n t h o s e o f t h e n u r s e s . The d a t a a l s o s t r o n g l y i n d i c a t e d t h a t p a t i e n t s d o n o t a l w a y s r e c e i v e t h e i n f o r m a t i o n t h e y w a n t , f o r u n l e s s t h e d o c t o r s e e s t h i s i n f o r m a t i o n a s b e i n g i m p o r t a n t , i t i s r e l a t i v e l y u n l i k e l y i t w i l l b e c o m m u n i c a t e d b y h i m o r t h a t h e w o u l d e n c o u r a g e o r p e r m i t t h e n u r s e o f p r o v i d e i t . W h i l e Dodge's s t u d y c o n c e n t r a t e d o n p a t i e n t ' s n e e d s f o r i n f o r m a t i o n r e g a r d i n g h i s c a r e i n h o s p i t a l . A l t i n v e s t i -g a t e d t h e p r e p a r e d n e s s o f p a t i e n t s o n d i s c h a r g e , s e e k i n g t o 22 f i n d o u t w h a t t h e p a t i e n t w a n t e d t o know. The n u r s e p a r t i c i p a n t i n t h i s same s t u d y , D o r o t h y L i n e h a n , s t a t e d t h e s t u d y ' s p r e m i s e a s b e i n g t h a t , o n d i s c h a r g e f r o m h o s p i t a l , p a t i e n t s a n d t h e i r f a m i l i e s h a v e q u e s t i o n s t h a t o f t e n go u n -a n s w e r e d , t h a t many c o u l d b e a n s w e r e d , a n d t h a t i f t h e y w e r e a n s w e r e d , t h e p a t i e n t ' s r e c o v e r y w o u l d b e h a s t e n e d , h i s m i n d e a s e d , a n d h i s o p i n i o n o f t h e h o s p i t a l a n d h e a l t h p r o f e s s i o n a l s R i c h a r d E . A l t , " P a t i e n t E d u c a t i o n P r o g r a m A n s w e r s Many U n a n s w e r e d Q u e s t i o n s , " H o s p i t a l s XL (November 16, 1966), 77-78, 166. ~ 21 23 e n h a n c e d . O v e r a n e i g h t m o n t h p e r i o d , f o u r h u n d r e d a n d f i f t y p a t i e n t s i n one t e a c h i n g h o s p i t a l w e r e i n t e r v i e w e d a t t h e t i m e o f d i s c h a r g e . A n i n t e r v i e w s c h e d u l e was d e v e l o p e d i n w h i c h t w e n t y q u e s t i o n s r e l a t e d t o t h e p a t i e n t ' s s o c i a l , e t h n i c a n d e d u c a t i o n a l b a c k g r o u n d , f i v e w e r e c o n c e r n e d w i t h q u e s t i o n s t h e p a t i e n t m i g h t h a v e h a d o n a d m i s s i o n , a n d n i n e t e e n w i t h t h e p a t i e n t ' s q u e s t i o n s a n d t h o u g h t s o n d i s c h a r g e . A n i n d i c a t i o n o f some o f t h e f i n d i n g s i n c l u d e d t h e f o l l o w i n g : - 51.2 p e r c e n t h a d o n e o r more q u e s t i o n s o n a d m i s s i o n - 49 p e r c e n t h a d one o r more q u e s t i o n s o n d i s c h a r g e t h a t w e r e u n a n s w e r e d - 65 p e r c e n t s a i d t h e y w e r e g i v e n no s p e c i f i c i n s t r u c -t i o n s a b o u t t h e i r c a r e a f t e r d i s c h a r g e - 64 p e r c e n t s a i d t h e y w e r e g i v e n no t i m e f o r i n s t r u c -t i o n - 35 p e r c e n t s a i d t h e y h a d a q u e s t i o n t h e y w i s h e d t h e y h a d a s k e d t h e i r d o c t o r . To o b t a i n a n s w e r s t o u n a s k e d q u e s t i o n s , 61 p e r c e n t s a i d t h e y w o u l d p h o n e t h e d o c t o r a f t e r t h e y g o t home; 16 p e r c e n t w o u l d make a n a p p o i n t m e n t w i t h t h e d o c t o r t o a s k t h e q u e s t i o n ; a n d 3 p e r c e n t s a i d t h e y w o u l d w a i t u n t i l t h e i r n e x t s c h e d u l e d a p p o i n t m e n t . Of p a r t i c u l a r n o t e was t h a t 33 p e r c e n t made D o r o t h y T. L i n e h a n , "What Does t h e P a t i e n t Want To Know," A m e r i c a n J o u r n a l o f N u r s i n g , L X V I (May, 1 9 6 6 ) , 1 0 6 6 -1 0 7 0 . s u g g e s t i o n s a s t o how t o i m p r o v e t h e m e t h o d i n w h i c h p a t i e n t s c a n g e t t h e i r q u e s t i o n a n s w e r e d . As a r e s u l t o f t h i s s t u d y , a new p r o g r a m t o p l a n f o r d i s c h a r g e was d e v e l o p e d w i t h r e p r e s e n t a t i v e s o f a l l f a c e t s o f t h e h e a l t h t e a m p a r t i c i p a t i n g . I n a d d i t i o n , p a t i e n t t e a c h i n g was i n c o r p o r a t e d i n t o i n s e r v i c e a n d w a r d t e a c h i n g p r o g r a m s . I n c o n c l u s i o n , A l t s u g g e s t s t h e c r e a t i o n o f a " d i s c h a r g e o f f i c e " w h e r e t h e p a t i e n t c o u l d r e c e i v e i n s t r u c t i o n s i n v o l v -i n g home c a r e a s w e l l a s h a v e a n y q u e s t i o n s a n s w e r e d . S i m o n d s s t r e s s e s t h e p o i n t t h a t " u n d e r s t a n d i n g a n d a c c e p t a n c e o f m e d i c a l a d v i c e i s c r u c i a l t o t h e s u c c e s s o f a 24 p a t i e n t ' s t r e a t m e n t , " a n d Wooden c o n t e n d s , " P a t i e n t e d u c a t i o n 25 a n d p a t x e n t c a r e a r e i n s e p a r a b l e . " I t seems t h e n , t h a t i f t h e p a t i e n t i s n o t p r o v i d e d w i t h i n f o r m a t i o n he n e e d s a n d w a n t s t o c a r e i n d e p e n d e n t l y f o r h i m s e l f , he c a n n o t be c o n -s i d e r e d t o h a v e b e e n a d e q u a t e l y t r e a t e d e v e n t h o u g h he i s " w e l l e n o u g h " t o b e d i s c h a r g e d f r o m h o s p i t a l . A s A l t h a s s t a t e d : S i m o n d s , l o c . c i t . 25 H oward E. Wooden, "The I n s e p a r a b i l i t y o f E d u c a t i o n a n d P a t i e n t C a r e , " H e a l t h E d u c a t i o n i n t h e H o s p i t a l , P r o c e e d -i n g s f r o m a n I n v i t a t i o n a l C o n f e r e n c e o f t h e A m e r i c a n H o s p i t a l A s s o c i a t i o n , C h i c a g o , May 4-6, 1964 ( C h i c a g o : A m e r i c a n H o s p i t a l A s s o c i a t i o n , 1 9 6 5 ) , p . 4 1 . I f p h y s i c i a n s a n d n u r s e s i n h o s p i t a l s h a v e a d u t y t o e x e r c i s e f u l l y t h e r e s t o r a t i v e f u n c t i o n o f t h e h e a l t h team a n d t o r e t u r n t h e p a t i e n t t o s o c i e t y , t o h i s f a m i l y , t o h i s j o b w i t h a minimum o f u n -c e r t a i n t y and f e a r , t h e i r r e s p o n s i b i l i t i e s do n o t e n d a t t h e h o s p i t a l d o o r . We a r e l e t t i n g t h e p a t i e n t d a n g l e i n u n c e r t a i n t y b e c a u s e o f a l a c k i n p a t i e n t e d u c a t i o n . 26 The l i t e r a t u r e r e v i e w e d t h u s f a r seems t o e x p o s e t h e l a c k o f common u n d e r s t a n d i n g among d o c t o r s , n u r s e s , a n d p a t i e n t s a n d f a m i l y members a s t o w h a t i n f o r m a t i o n i s n e c e s s a r y b e f o r e a n i n d i v i d u a l c a n p a r t i c i p a t e i n t h e r e s t o r a t i v e p h a s e o f h i s i l l n e s s . Once t h e d i s c r e p a n c i e s a r e made a p p a r e n t , p l a n n i n g c a n b e i n i t i a t e d f o r t e a c h i n g -l e a r n i n g s i t u a t i o n s t h a t w i l l e n a b l e t h e p a t i e n t a n d h i s f a m i l y t o manage c a r e a t home w i t h o u t h a v i n g t o c o p e w i t h u n n e c e s s a r y , r e a l o r i m a g i n a r y s t r e s s e s t h a t i g n o r a n c e c a n c r e a t e . I n t h i s way, c o n t i n u i t y o f c a r e w o u l d b e a r e a l i t y . THE ROLE OF THE NURSE I N PATIENT TEACHING AS AN E F F E C T I V E MEANS OF COMMUNICATION The t e a c h i n g o f p a t i e n t s i s r e c o g n i z e d a s a n i n t e g r a l 27 28 29 30 p a r t o f p r o f e s s i o n a l n u r s i n g p r a c t i c e . ' ' ' H o w e v e r , 2 6 A l t , o p . c i t . , p p . 7 6 - 7 7 . 27 F r a n c e s S t o r l i e , "A P h i l o s o p h y o f P a t i e n t T e a c h i n g , " N u r s i n g O u t l o o k , X I X ( J u n e , 1 9 7 1 ) , 3 8 7 - 3 8 9 . 28 J e a n n e C. H a l l b u r g , " T e a c h i n g P a t i e n t s S e l f - C a r e , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , V ( J u n e , 1 9 7 0 ) , 2 2 3 . 29 L o i s A. M o n t e i r o , " N o t e s o n P a t i e n t T e a c h i n g - A N e g l e c t e d A r e a , " N u r s i n g F o r u m , I I I ( W i n t e r , 1 9 6 4 ) , 2 6 2 . 24 studies i n patient teaching i n nursing are s t i l l r e l a t i v e l y scarce. Pohl describes the teaching function of the nursing p r a c t i t i o n e r as c o n s i s t i n g of: A system of actions, intended to induce learning, which provides a c t i v i t i e s , materials, and guidance i n informal and formal s i t u a t i o n s ; i t includes both the a c t i v i t i e s of communication and the a c t i v i t i e s of structured teaching; i t i s directed toward a s s i s t -ing the learner to achieve his p o t e n t i a l : the patient for s e l f - d i r e c t i o n , the co-workers f o r the improvement of patient care. 31 This d e f i n i t i o n was a conclusion drawn from a study i n which the purpose was to describe, c l a r i f y , and define the l i m i t s for the nurse p r a c t i t i o n e r ' s teaching r o l e , and i t s implications 3 2 for nursing education. Her questionnaire was completed by f i f t e e n hundred nurses employed i n various settings through-out the United States. The findings indicated a general lack of c l a r i t y i n the concept of teaching with ideas ranging from l i m i t e d formal classroom i n s t r u c t i o n to any a c t i v i t y by which an i n d i v i d u a l learns. Pohl f e e l s that t h i s indicates a marked lack of preparation i n patient teaching, that a l -though many p r a c t i t i o n e r s recognize the importance of t h i s r o l e , they don't have a c l e a r concept of what i t e n t a i l s . Margaret L. Pohl, "Teaching A c t i v i t i e s of the Nursing P r a c t i t i o n e r , " Nursing Research, XIV (Winter, 1965), 11. 3 2 I b i d . , pp. 4-11. 3 1 I b i d . 25 She s t a t e s t h a t a l a r g e p a r t o f t h e n u r s e ' s t e a c h i n g c a n b e d o n e a t t h e b e d s i d e w h i l e g i v i n g n u r s i n g c a r e , a n d t h a t t h i s t i m e w i l l b e m o s t e f f e c t i v e l y s p e n t when s h e h a s p l a n n e d h e r t e a c h i n g o b j e c t i v e s i n a d v a n c e o f g i v i n g c a r e . P a l m s t a t e s t h a t : A l t h o u g h i n f o r m a l t e a c h i n g a t t h e p a t i e n t ' s b e d s i d e d u r i n g d a i l y n u r s i n g c a r e i s c o n s i d e r e d m o s t e f f e c t i v e a n d i m p o r t a n t , n u r s e s t e n d t o v i e w t e a c h -i n g n a r r o w l y a s f o r m a l i n s t r u c t i o n . T h i s u n s t r u c t u r e d a n d i n c i d e n t a l t e a c h i n g i s d e p e n d e n t u p o n t h e n u r s e ' s r e c o g n i t i o n o f t h e t e a c h i n g o p p o r t u n i t y a n d t h e p r i o r i t y w h i c h s h e g i v e s t o t h e t e a c h i n g f u n c t i o n i n t h a t p a r t i c u l a r s i t u a t i o n . 33 W i t h t h i s p r e m i s e , P a l m c o n d u c t e d a d e s c r i p t i v e s u r v e y t o d e t e r m i n e w h e r e n u r s e s p l a c e t h e i r p a t i e n t t e a c h i n g 34 p r i o r i t y . Of 151 m e d i c a l - s u r g i c a l n u r s e s w o r k i n g i n n o n -e m e r g e n c y s i t u a t i o n s , 59 p e r c e n t a s s i g n e d t o p p r i o r i t y t o p a t i e n t e d u c a t i o n o v e r p h y s i c a l c a r e , s u p p o r t i v e e m o t i o n a l c a r e , a n d l i a i s o n a c t i v i t i e s o f t h e n u r s e p r a c t i t i o n e r . How-e v e r , t h e s t u d y i n d i c a t e d t h a t t h e s e n u r s e s t e n d e d t o e x p l a i n i m m e d i a t e c a r e t o p a t i e n t s a n d n e g l e c t e d h e a l t h t e a c h i n g w h i c h p r e p a r e s t h e p a t i e n t f o r d i s c h a r g e a n d s e l f - c a r e a t home. L e s s t h a n 25 p e r c e n t o f t h e s u b j e c t s g a v e t h i s a r e a t o p p r i o r i t y a l t h o u g h , a s P a l m c o n c l u d e s , " S u c h t e a c h i n g i s m o s t 35 i m p o r t a n t f o r t h e p a t i e n t ' s h e a l t h m a i n t e n a n c e . " M a r y L. P a l m , " R e c o g n i z i n g O p p o r t u n i t i e s f o r I n f o r m e d P a t i e n t T e a c h i n g , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , V I (December, 1 9 7 1 ) , 6 7 1 . 3 4 I b i d . , p p . 6 6 9 - 6 7 8 . 3 5 I b i d . , p . 6 7 6 . 26 A n e x p e r i m e n t a l s t u d y c a r r i e d o u t b y S t a r f i e l d a n d S h a r p i n v e s t i g a t e d t h e e f f e c t o f n u r s i n g i n t e r v e n t i o n o n a f a m i l y ' s c o m p l i a n c e w i t h a l o n g - t e r m c o m p l e x r e g i m e n p r e -s c r i b e d f o r a m b u l a t o r y i n d i g e n t c h i l d r e n b e t w e e n t h e a g e s o f 3 6 s i x t o t h i r t e e n w i t h c h r o n i c e n u r e s i s . The r e s u l t s o f t h i s s t u d y c l e a r l y i n d i c a t e d a s i g n i f i c a n t d i f f e r e n c e (p < .01) i n t h e k n o w l e d g e a n d r e s p o n s e s b e t w e e n t h e e x p e r i m e n t a l g r o u p w h i c h r e c e i v e d t h e a d d i t i o n a l n u r s i n g c a r e a n d t h e c o n t r o l g r o u p w h i c h r e c e i v e d no e x t r a c a r e . T h o s e f a m i l i e s i n t h e e x p e r i m e n t a l g r o u p f o l l o w e d i n s t r u c t i o n s b e t t e r t h e r e b y e n a b l i n g them t o c a r r y o u t t r e a t m e n t s w i t h m ore r e l i a b i l i t y . H a l l b u r g d e s c r i b e s two a p p r o a c h e s t o t e a c h i n g p a t i e n t s 37 s e l f - c a r e . One o f t h e s e i s p l a n n i n g f o r t h e p a t i e n t i n w h i c h t h e g o a l i s t o g i v e t h e p a t i e n t i n f o r m a t i o n w h i c h t h e n u r s e p o s s e s s e s . I t i s d e s c r i b e d a s l a r g e l y a one-way a p p r o a c h w i t h l i t t l e n u r s e - p a t i e n t i n t e r a c t i o n a n d t h e r e f o r e a l l o w s f o r l i t t l e i n c l u s i o n o f e x t r a n e o u s v a r i a b l e s s u c h a s t h e p a t i e n t ' s s o c i a l o r e d u c a t i o n a l b a c k g r o u n d . E v a l u a t i o n i s l i m i t e d t o t h e g o a l a n d t h e r e f o r e p r o v i d e s l i t t l e r e a l l y v a l i d i n f o r m a t i o n w i t h t h i s a p p r o a c h . H a l l b u r g s t a t e s , " I t 3 6 B. S t a r f i e l d a n d E. S h a r p , " A m b u l a t o r y P e d i a t r i c C a r e ; The R o l e o f t h e N u r s e , " N u r s i n g R e s e a r c h , X V I I I (May-J u n e , 1 9 6 9 ) , 277. 37 J e a n n e C. H a l l b u r g , " T e a c h i n g P a t i e n t s S e l f - C a r e , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , V ( J u n e , 1 9 7 0 ) , 2 2 3 - 2 3 1 . 27 s h o u l d b e n o t e d t h a t t h e r e i s c o n s i d e r a b l e e x p e r i m e n t a l e v i d e n c e t o s u g g e s t t h a t t h e r e i s no d i r e c t r e l a t i o n s h i p b e t w e e n t h e a c q u i s i t i o n o f new k n o w l e d g e a n d a c h a n g e i n s u b s e q u e n t 3 8 b e h a v i o r . " She n e g l e c t s h o w e v e r , t o s u b s t a n t i a t e t h i s s t a t e m e n t . H a l l b u r g ' s s e c o n d a p p r o a c h i s p l a n n i n g w i t h t h e p a t i e n t , b a s e d o n t h e a s s u m p t i o n t h a t t h e p a t i e n t a n d t h e n u r s e a r e b o t h a c t i v e p a r t i c i p a n t s i n t h e t e a c h i n g - l e a r n i n g p r o c e s s , t h u s a l l o w i n g f o r c o n s i d e r a t i o n o f i n d i v i d u a l a n d s i t u a t i o n a l v a r i a b l e s i n p l a n n i n g a n d c a r r y i n g o u t t h e a c t i v i t y . "The g o a l o f t h i s a p p r o a c h i s r e l a t e d more t o t h e p a t i e n t ' s s u b s e q u e n t b e h a v i o r r e g a r d i n g s e l f - c a r e t h a n t o t h e a c q u i s i t i o n 39 o f s p e c i f i c k n o w l e d g e a n d s k i l l . " T h i s a p p r o a c h r e q u i r e s m ore t i m e i n v o l v e m e n t , w i t h t h e t e a c h i n g - l e a r n i n g a c t i v i t i e s b e i n g e x t e n d e d a n d r e i n f o r c e d o v e r a p e r i o d o f t i m e , e . g . i n a number o f o u t - p a t i e n t c l i n i c v i s i t s . A n e x p e r i m e n t a l s t u d y w i t h 103 e l d e r l y c l i n i c p a t i e n t s t o t e s t t h i s a p p r o a c h , c a l l e d a ' d e c i s i o n - m a k i n g ' a p p r o a c h , f a i l e d t o show s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s b u t s h o u l d , a s t h e a u t h o r s u g g e s t s , b e i n v e s t i g a t e d f u r t h e r . A c o m p a r a t i v e i n v e s t i g a t i o n b y L i n d e m a n a n d V a n A e r n a m o n t h e e f f e c t s o f s t r u c t u r e d a n d u n s t r u c t u r e d p r e - o p e r a t i v e t e a c h i n g o f d e e p b r e a t h i n g , c o u g h i n g , a n d b e d e x e r c i s e s w i t h I b i d . , p . 227. 3 9 I b i d . , p . 228. 28 s u r g i c a l p a t i e n t s , c o n c l u d e d t h a t t h e s t r u c t u r e d t e a c h i n g i m p r o v e d t h e s u b j e c t s ' a b i l i t y t o d e e p b r e a t h e a n d c o u g h p o s t o p e r a t i v e l y a n d t h e mean l e n g t h o f h o s p i t a l s t a y was s i g n i f i c a n t l y r e d u c e d , a l t h o u g h t h e r e was no s u b s t a n t i a l e f f e c t o n t h e t h i r d v a r i a b l e i n v e s t i g a t e d — p o s t o p e r a t i v e n e e d f o r , . 40 a n a l g e s i a . P a c k a r d a n d V a n E s s i n a n e x p e r i m e n t a l s t u d y c o m p a r i n g i n f o r m a l a n d r o l e - d e l i n e a t e d p a t i e n t o n i m p r o v i n g f o o d s e l e c t i o n b e h a v i o r o f p o s t - p a r t u m p a t i e n t s , f o u n d a s i g n i f i c a n t d i f f e r e n c e i n p r e - a n d p o s t - t e a c h i n g s c o r e s , i n d i c a t i n g t h e e f f e c t i v e n e s s o f b o t h a p p r o a c h e s a s c o m p a r e d w i t h a c o n t r o l g r o u p . The r o l e -d e l i n e a t e d a p p r o a c h showed a s i g n i f i c a n t i m p a c t ( a s o p p o s e d t o t h e i n f o r m a l g r o u p ) o n t h e t h i r d d a y o n l y . U n f o r t u n a t e l y , 41 t h e r e was no f o l l o w - u p a f t e r d i s c h a r g e o n t h e f o u r t h d a y . S i m i l a r l y , C r o s s a n d P a r s o n s f o u n d s i g n i f i c a n t c h a n g e i n t h e f o o d s e l e c t i o n b e h a v i o r o f o r t h o p e d i c p a t i e n t s who w e r e 42 t a u g h t b y t h e n u r s e i n a n i n f o r m a l s t r u c t u r e d s i t u a t i o n . 40 C A . L m d e m a n a n d B. V a n A e r n a n , " N u r s i n g I n t e r v e n t i o n W i t h t h e P r e s u r g i c a l P a t i e n t - The E f f e c t s o f S t r u c t u r e d a n d U n s t r u c t u r e d P r e o p e r a t i v e T e a c h i n g , " N u r s i n g R e s e a r c h , XX ( J u l y - A u g u s t , 1971), 319-332. 41 R o s e B. P a c k a r d a n d H a r r i e t t V a n E s s , "A C o m p a r i s o n o f I n f o r m a l a n d R o l e - D e l i n e a t e d P a t i e n t T e a c h i n g S i t u a t i o n s , " N u r s i n g R e s e a r c h , V I I I ( S e p t e m b e r - O c t o b e r , 1969), 443-446. 42 J . E . C r o s s a n d C R . P a r s o n s , " N u r s e - T e a c h i n g a n d G o a l - D i r e c t e d N u r s e - T e a c h i n g To M o t i v a t e C h a n g e i n F o o d S e l e c t i o n B e h a v i o r o f H o s p i t a l i z e d P a t i e n t s , " N u r s i n g R e s e a r c h , XX ( S e p t e m b e r - O c t o b e r , 1971), 454-457. 29 P a t i e n t t e a c h i n g t h e n c a n b e v e r y i n f o r m a l t e a c h i n g d o n e i n c i d e n t a l l y a t t h e p a t i e n t ' s b e d s i d e o r f o r m a l a n d h i g h l y 43 s t r u c t u r e d . I n e i t h e r c a s e , i t i s " c o m m u n i c a t i o n e s p e c i a l l y 44 . • s t r u c t u r e d t o p r o d u c e l e a r n i n g . " I t i s a p r o c e s s r e q u i r i n g m o t i v a t i o n o n t h e p a r t o f t h e l e a r n e r , a s s e s s m e n t o f h i s l e a r n i n g n e e d s b y t h e n u r s e , t h e e s t a b l i s h m e n t o f o b t a i n a b l e o b j e c t i v e s , i m p l e m e n t a t i o n o f t e a c h i n g , f o l l o w e d b y e v a l u a t i o n 45 o f l e a r n i n g a n d t e a c h i n g . The s t r u c t u r e a n d f o r m a l i t y seem t o d e p e n d o n t h e t i m e l i m i t a t i o n s o f t h e n u r s e p r a c t i t i o n e r a n d a l s o h e r p r e p a r a t i o n a n d c a p a b i l i t i e s f o r t e a c h i n g a s p e c i f i c g r o u p o f p a t i e n t s . A g r e a t d e a l d e p e n d s o n t h e p a t i e n t a s w e l l , f o r e x a m p l e , w h e t h e r h e i s a n i n p a t i e n t o r o u t p a t i e n t , t h e v i s i t i n g t i m e s o f f a m i l y members i n c l u d e d i n t h e t e a c h i n g a c t i v i t i e s — e s p e c i a l l y i m p o r t a n t i n t h e t e a c h i n g o f p a r e n t s o f h o s p i t a l i z e d c h i l d r e n . I n a n y c a s e , i t c a n n o t b e h a p h a z a r d b u t m u s t b e p l a n n e d . 43 L o i s A. M o n t e i r o , " N o t e s o n P a t i e n t T e a c h i n g - A N e g l e c t e d A r e a , " N u r s i n g F o r u m , I I I ( W i n t e r , 1964), 26. 44 B a r b a r a K. Redman, The P r o c e s s o f P a t i e n t T e a c h i n g i n N u r s i n g ( S a i n t L o u i s : The C V . M osby Company, 1968), p . 4. 45 B a r b a r a K. Redman, " P a t i e n t E d u c a t i o n a s a F u n c t i o n o f N u r s i n g P r a c t i c e , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , V I (December, 1971), 578. 30 SUMMARY T h i s c h a p t e r p r e s e n t e d a r e v i e w o f t h e l i t e r a t u r e . A s t h e r e h a v e b e e n no s y s t e m a t i c i n v e s t i g a t i o n s o f t h e t e a c h i n g o f p a r e n t s o f c h i l d r e n t r e a t e d i n e m e r g e n c y d e p a r t m e n t s e t t i n g s , t h e l i t e r a t u r e r e v i e w f o c u s e d o n r e l a t e d a r e a s . The h o s p i t a l -i z a t i o n o f c h i l d r e n was s e e n t o b e a s t r e s s f u l a n d s t r e s s -p r o d u c i n g s i t u a t i o n f o r b o t h t h e p a r e n t s a n d t h e i r c h i l d . T h i s s t r e s s seems t o b e e n h a n c e d b y l a c k o f p r e p a r a t i o n f o r home c a r e w h i c h e x i s t s b e c a u s e o f p a r e n t s ' f e a r o f s e e k i n g i n f o r m a t i o n o r i g n o r a n c e i n k n o w i n g w h a t o r whom t o a s k . I n a d d i t i o n , t h e r e seems t o b e c o n f u s i o n among d o c t o r s , n u r s e s , p a r e n t s a n d p a t i e n t s i n g e n e r a l a s t o w h a t i n f o r m a t i o n i s n e e d e d b e f o r e d i s c h a r g e a n d who s h o u l d p r o v i d e i t . The n u r s e p r a c t i t i o n e r i n h e r r o l e a s p a t i e n t t e a c h e r i s i n c r e a s i n g l y b e i n g r e c o g n i z e d a s t h e h e a l t h t eam member who c a n m o s t e f f e c t i v e l y a n d c o n s i s t e n t l y p r e p a r e p a t i e n t s a n d t h e i r f a m i l i e s f o r t h e i r h o s p i t a l e x p e r i e n c e s a n d f o r c a r e a f t e r d i s c h a r g e . The v a r i o u s a p p r o a c h e s t o p a t i e n t t e a c h i n g , a s r e p o r t e d w i t h i n t h e l i t e r a t u r e s o u r c e s , a l l r e c o g n i z e t h e n e e d f o r t h e n u r s e t o s e l e c t t h e a p p r o a c h w h i c h b e s t f i t s t h e i n d i v i d u a l p a t i e n t s i t u a t i o n . CHAPTER I I I THE RESEARCH DESIGN AND DEVELOPMENT OF THE STUDY DESIGN L e v i n e h a s s t a t e d t h a t t h e e x p e r i m e n t a l a p p r o a c h i s ". . . g e n e r a l l y c o n s i d e r e d s u p e r i o r t o o t h e r f o r m s o f r e s e a r c h when t h e o b j e c t i v e o f t h e r e s e a r c h e r i s t o f i n d b a s i c r e l a t i o n -s h i p s ( c a u s a l p a t t e r n s ) among v a r i a b l e s b e i n g s t u d i e d . " ^ I n a d d i t i o n , H e l m s t a d t e r h a s a s s e r t e d t h a t , a s a r i g o r o u s a p p r o a c h t o t h e s t u d y o f c a u s e - e f f e c t r e l a t i o n s h i p s , t h e e x p e r i m e n t a l m e t h o d h a s " p r o v i d e d r e s u l t s w h i c h a r e l a s t i n g o v e r t i m e , w h i c h h a v e l e d t o f r u i t f u l new s t u d i e s , a n d w h i c h 2 h a v e s u g g e s t e d m ore p r a c t i c a l a p p l i c a t i o n s . " A s t h i s s t u d y was a i m e d a t e v a l u a t i n g t h e e f f e c t i v e n e s s o f o n e n u r s i n g i n t e r v e n t i o n u t i l i z i n g a p l a n n e d t e a c h i n g a p p r o a c h a s c o m p a r e d w i t h r o u t i n e h o s p i t a l p r o c e d u r e s , t h e e x p e r i m e n t a l m e t h o d o f r e s e a r c h seemed t h e m o s t a p p r o p r i a t e t o u s e . E u g e n e L e v i n e , " E x p e r i m e n t a l D e s i g n i n N u r s i n g R e s e a r c h , " N u r s i n g R e s e a r c h , I X ( F a l l , 1 9 6 0 ) , 2 0 3 . G.C. H e l m s t a d t e r , R e s e a r c h C o n c e p t s i n Human B e h a v i o r (New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 7 0 ) , p . 1 1 8 . 32 D e p e n d e n t V a r i a b l e The d e p e n d e n t v a r i a b l e m e a s u r e d i n t h e s t u d y was t h e a b i l i t i e s o f e a c h m o t h e r t o c o p e w i t h t h e home c a r e o f h e r c h i l d a f t e r h e h a d r e c e i v e d t r e a t m e n t i n t h e E m e r g e n c y d e p a r t m e n t f o r a t r a u m a t i c l i m b f r a c t u r e r e q u i r i n g c a s t a p p l i c a t i o n . T h i s was e v a l u a t e d t h r o u g h a n i n t e r v i e w s c h e d u l e a d m i n i s t e r e d i n t h e home d u r i n g t h e p o s t - d i s c h a r g e p e r i o d . I n d e p e n d e n t V a r i a b l e The i n d e p e n d e n t v a r i a b l e o f t h e s t u d y was a p l a n n e d n u r s i n g i n t e r v e n t i o n . B e f o r e t h e c h i l d ' s d i s c h a r g e f r o m h o s p i t a l , t h e r e s e a r c h e r g a v e t h e m o t h e r s i n t h e e x p e r i m e n t a l g r o u p s p e c i f i c i n s t r u c t i o n s r e g a r d i n g t h e c a r e o f t h e i r c h i l d a t home. B e s i d e s b e i n g s u p p l i e d w i t h v e r b a l i n f o r m a t i o n , t h e s e m o t h e r s w e r e p r o v i d e d w i t h a w r i t t e n s u m m a r i z e d l i s t o f t h e s e i n s t r u c t i o n s . A n y q u e s t i o n s t h e m o t h e r s h a d w e r e a n s w e r e d a n d f u r t h e r c l a r i f i c a t i o n s w e r e made a s n e c e s s a r y . M e a n w h i l e , t h e m o t h e r s i n t h e c o n t r o l g r o u p w e r e d i s c h a r g e d i n t h e r o u t i n e m anner o f t h a t h o s p i t a l . S ELECTION OF THE STUDY GROUP The S e t t i n g The s u b j e c t s w e r e c h o s e n f r o m t h e p o p u l a t i o n o f t h e E m e r g e n c y d e p a r t m e n t s o f f i v e g e n e r a l h o s p i t a l s l o c a t e d t h r o u g h o u t t h e G r e a t e r V a n c o u v e r a r e a . None o f t h e s e E m e r g e n c y d e p a r t m e n t s h a d a p l a n n e d t e a c h i n g a p p r o a c h f o r p r e p a r i n g m o t h e r s f o r t h e home c a r e o f t h e i r c h i l d w i t h a 33 new f r a c t u r e and c a s t . The i n s t r u c t i o n s t h a t were g i v e n v a r i e d w i t h t h e i n d i v i d u a l d o c t o r o r n u r s e i n a t t e n d a n c e and t h e q u e s t i o n s asked by t h e p a r e n t b e f o r e d i s c h a r g e . However, one o f t h e Emergency departments p r o v i d e s a l l o f i t s p a t i e n t s who r e c e i v e a c a s t w i t h a pamphlet on how t o c a r e f o r t h e c a s t a t home. The e i g h t s u b j e c t s o b t a i n e d from t h i s p a r t i c u l a r h o s p i t a l a l l r e c e i v e d t h i s pamphlet, a copy o f w h i c h i s i n c l u d e d i n A p p e n d i x C. The d a t a were c o l l e c t e d i n t h e p e r i o d between mid-F e b r u a r y and the end o f May, 1972. The S u b j e c t s The s u b j e c t s c o n s i s t e d o f twenty mothers who q u a l i f i e d f o r i n c l u s i o n i n t h e s t u d y because t h e i r c h i l d met t h e f o l l o w i n g c r i t e r i a : - was between t h e ages o f s i x and t w e l v e y e a r s ; - had j u s t r e c e i v e d a t r a u m a t i c f r a c t u r e o f a l i m b r e q u i r i n g t h e a p p l i c a t i o n o f a c a s t ; - had no major i n j u r i e s o t h e r t h a n t h i s l i m b f r a c t u r e ; - was n o t a d m i t t e d t o any ward o t h e r t h a n Emergency; - was l i v i n g w i t h h i s mother. I n a d d i t i o n , the mother had t o be p r e s e n t w i t h h e r c h i l d i n t h e Emergency department f o r a t l e a s t p a r t o f t h e t i m e and o f c o u r s e , be w i l l i n g t o p a r t i c i p a t e i n t h e s t u d y . No r e f u s a l s t o p a r t i c i p a t e were e n c o u n t e r e d . 34 S u b j e c t s f i t t i n g t h e s e c r i t e r i a w e r e a s s i g n e d t o a l t e r n a t e g r o u p s a c c o r d i n g t o t h e o r d e r i n w h i c h t h e c h i l d was a d m i t t e d t o t h e E m e r g e n c y d e p a r t m e n t i n e a c h h o s p i t a l , i . e . t h e f i r s t q u a l i f y i n g s u b j e c t was a s s i g n e d t o t h e e x p e r i -m e n t a l g r o u p , t h e n e x t t o t h e c o n t r o l g r o u p , e t c . I f t h e r e s e a r c h e r was u n a b l e t o b e c o n t a c t e d when a n e x p e r i m e n t a l s u b j e c t was a v a i l a b l e , t h a t s u b j e c t was n o t u s e d , b u t t h e n e x t s u b j e c t was s t i l l a s s i g n e d t o t h e c o n t r o l g r o u p . A c o p y o f t h e i n s t r u c t i o n s h e e t w h i c h was p o s t e d i n e a c h E m e r g e n c y d e p a r t m e n t i s i n c l u d e d i n A p p e n d i x A. Of n e c e s s i t y , t h e r e s e a r c h e r h a d t o r e l y o n t h e n u r s i n g s t a f f t o c o n t a c t h e r when a n e x p e r i m e n t a l s u b j e c t was a v a i l a b l e a n d t o remember t o r e c o r d t h e names a n d h o s p i t a l n umbers o f c o n t r o l s u b j e c t s . B u t i n a d d i t i o n , t h e r e s e a r c h e r c a l l e d t h e s e d e p a r t m e n t s a t v a r i o u s t i m e s t o c h e c k f o r t h e names o f c o n t r o l s u b j e c t s a n d t o r e m i n d t h e s t a f f o f t h e s t u d y . PROCEDURE The e x p e r i m e n t a l s u b j e c t s w e r e g i v e n s p e c i f i c i n s t r u c -t i o n s b y t h e r e s e a r c h e r r e g a r d i n g t h e home c a r e o f t h e i r c h i l d b e f o r e d i s c h a r g e f r o m t h e E m e r g e n c y d e p a r t m e n t . The t e a c h i n g was d o n e i n one s e s s i o n when b o t h t h e m o t h e r a n d t h e r e s e a r c h e r w e r e a v a i l a b l e . U s u a l l y i t o c c u r r e d w h i l e w a i t i n g f o r t h e d o c t o r t o p u t t h e c a s t o n a f t e r d i a g n o s i s o r w h i l e t h e c h i l d was h a v i n g h i s c a s t a p p l i e d . O n l y o c c a s i o n a l l y was i t d o n e a f t e r c a s t a p p l i c a t i o n a s i n m o s t c a s e s t h e s t a f f was a n x i o u s 35 t o d i s c h a r g e t h e c h i l d t o make room f o r o t h e r p a t i e n t s a n d / o r t h e p a r e n t s w e r e a n x i o u s t o l e a v e . . The c o n t r o l s u b j e c t s d i d n o t r e c e i v e t h e s e i n s t r u c t i o n s b u t o n l y t h o s e g i v e n r o u t i n e l y i n e a c h E m e r g e n c y d e p a r t m e n t . A home v i s i t was made t o e a c h s u b j e c t i n t h e p o s t -d i s c h a r g e p e r i o d t o e v a l u a t e how w e l l t h e m o t h e r was a b l e t o c o p e w i t h t h e home c a r e . INSTRUMENTATION The i n s t r u m e n t s d e v e l o p e d f o r t h e s t u d y i n c l u d e d a T e a c h i n g G u i d e a n d a L i s t o f " R e m i n d e r s " w h i c h w e r e u s e d w i t h t h e e x p e r i m e n t a l s u b j e c t s ; a n I n t e r v i e w S c h e d u l e , E v a l u a t i o n F o r m o f M o t h e r s ' C o p i n g A b i l i t i e s a n d P e r s o n a l D a t a F o r m , u s e d w i t h a l l s u b j e c t s d u r i n g t h e home v i s i t ; a n d a C o n t r o l G r o u p I n f o r m a t i o n A s s e s s m e n t F o r m , u s e d w i t h t h e c o n t r o l s u b j e c t s d u r i n g t h e home v i s i t . T h e s e f o r m s a r e c o n t a i n e d i n A p p e n d i x B. T e a c h i n g G u i d e T h i s i n s t r u m e n t was d e v e l o p e d a s a g u i d e f o r t h e r e -s e a r c h e r t o u s e i n t e a c h i n g m o t h e r s a s s i g n e d t o t h e e x p e r i m e n t a l g r o u p . The g e n e r a l o b j e c t i v e was t o p r e p a r e t h e m o t h e r f o r c a r i n g f o r h e r c h i l d a t home w i t h a n e w l y c a s t e d l i m b b y p r o v i d i n g h e r w i t h i n f o r m a t i o n t o u s e i n c o p i n g w i t h t h e s i t u a t i o n . A s t h e s t u d y a s s u m e d t h a t t h e c a r e w h i c h a m o t h e r i s e x p e c t e d t o g i v e t o h e r c h i l d a t home a f t e r t r e a t m e n t i n a h o s p i t a l ' s e m e r g e n c y d e p a r t m e n t i s c o m p a r a b l e t o t h e n u r s i n g c a r e t h a t c h i l d w o u l d h a v e r e c e i v e d h a d he b e e n a d m i t t e d t o a g e n e r a l h o s p i t a l w a r d , t h e i n f o r m a t i o n i n c l u d e d i n t h e t e a c h i n g g u i d e was s i m i l a r t o t h a t p r o v i d e d i n s t a n d a r d n u r s -i n g t e x t b o o k s . 3 ' 4 ' ^ ' ^ L i s t o f " R e m i n d e r s " A s f e e l i n g s o f s t r e s s a n d u r g e n c y c a n b e e a s i l y a r o u s e d b y t h e u n e x p e c t e d i l l n e s s a n d t h e e m e r g e n c y d e p a r t m e n t e n v i r o n -m e n t , t h e amount o f i n f o r m a t i o n t h e m o t h e r w o u l d r e t a i n a f t e r t h e s i n g l e t e a c h i n g s e s s i o n i s v a r i a b l e . T h e r e f o r e , a summar-i z e d l i s t o f t h e i n f o r m a t i o n g i v e n , e n t i t l e d " R e m i n d e r s t o H e l p Y o u C a r e f o r Y o u r C h i l d a n d H i s C a s t a t Home" was p r o v i d e d t o e a c h o f t h e m o t h e r s i n t h e e x p e r i m e n t a l g r o u p t o s e r v e a s a r e f e r e n c e a n d a s a r e i n f o r c e m e n t o f t h e i n f o r m a t i o n g i v e n . 3 D o r o t h y H oehne, "The C h i l d w i t h S c o l i o s i s : N u r s i n g I n t e r v e n t i o n , " N u r s i n g C a r e o f t h e C h i l d w i t h L o n g T e r m I l l n e s s , e d . S h i r l e y S t e e l e (New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 7 1 ) , p p . 3 3 4 - 3 3 9 . 4 C a r r o l l B. L a r s o n a n d M a r j o r i e G o u l d , C a l d e r w o o d 1 s  O r t h o p e d i c N u r s i n g ( 5 t h e d . ; S a i n t L o u i s : The C V . M o s b y Company, 1961) , p p . 7 3 - 9 2 . 5 . . P a t r i c i a E a t o n a n d F l o r e n c e H e l l e r , " T h e r a p e u t i c N u r s i n g o f O r t h o p e d i c P a t i e n t s , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , I I ( S e p t e m b e r , 1 9 6 7 ) , 4 2 9 - 4 3 5 . ^ H e l e n C. L a t h a m a n d R o b e r t V. H e c k e l , P e d i a t r i c N u r s i n g (2nd e d . ; S a i n t L o u i s : The C V . M osby Company, 1 9 7 2 ) , p p . 2 8 1 - 2 8 2 . 37 The I n t e r v i e w S c h e d u l e The I n t e r v i e w S c h e d u l e was d e v e l o p e d f o r u s e d u r i n g t h e home v i s i t made t o a l l s u b j e c t s w i t h i n f i v e t o t e n d a y s a f t e r d i s c h a r g e . A s i t was a n t i c i p a t e d t h a t t h e d e s i r e d i n f o r m a t i o n c o u l d b e o b t a i n e d t h r o u g h i n f o r m a l c o n v e r s a t i o n w i t h t h e m o t h e r , t h e q u e s t i o n s w e r e o p e n - e n d e d . M o r e s p e c i f i c q u e s t i o n s w e r e i n c l u d e d a s a f o l l o w - u p when t h e m o t h e r ' s r e s p o n s e s w e r e t o o v a g u e t o b e c o n c l u s i v e . E v a l u a t i o n F o r m o f M o t h e r ' s C o p i n g A b i l i t i e s B a s e d o n t h e i n f o r m a t i o n o b t a i n e d w i t h t h e I n t e r v i e w S c h e d u l e , t h i s f o r m r e c o r d e d w h e t h e r o r n o t t h e f o l l o w i n g s p e c i f i c b e h a v i o r a l o b j e c t i v e s w e r e met: - m o t h e r u n d e r s t a n d s t h e r e a s o n f o r t h e c a s t - m o t h e r u n d e r s t a n d s how t o c a r e f o r t h e c a s t - m o t h e r u n d e r s t a n d s how t o c a r e f o r t h e c a s t e d l i m b - m o t h e r u n d e r s t a n d s t h e s i g n s a n d symptoms o f c o m p l i c a t i o n s b y l o o k i n g f o r s i g n s a n d symptoms a n d d e a l i n g w i t h them a p p r o p r i a t e l y i f a n y a r e p r e s e n t . S p e c i f i c b e h a v i o r s w h i c h w e r e i n c l u d e d i n t h e t e a c h i n g g u i d e w e r e l i s t e d u n d e r t h e s e o b j e c t i v e s a s a means o f m e a s u r i n g w h e t h e r o r n o t t h e o b j e c t i v e was m e t . C o n t r o l G r o u p I n f o r m a t i o n A s s e s s m e n t The f o r m , f a s h i o n e d o n t h e e v a l u a t i o n f o r m , was u s e d w i t h t h e m o t h e r s i n t h e c o n t r o l g r o u p t o d e t e r m i n e w h a t i n f o r -m a t i o n t h e y h a d r e c e i v e d , f r o m whom t h e y h a d r e c e i v e d i t , a n d 38 w h e t h e r o r n o t t h e y w e r e s a t i s f i e d . The m o t h e r s w e r e a s k e d g e n e r a l l y a b o u t t h i s i n f o r m a t i o n w i t h t h e r e s e a r c h e r s e e k i n g c l a r i f i c a t i o n a s n e c e s s a r y . T h e s e d a t a w e r e n o t c o l l e c t e d f o r s t a t i s t i c a l a n a l y s i s b u t f o r i n t e r e s t a n d d i s c u s s i o n o n l y . P e r s o n a l D a t a F o r m T h i s f o r m was c o m p l e t e d d u r i n g t h e home i n t e r v i e w s f o r e a c h o f t h e s u b j e c t s i n t h e s t u d y . T h i s i n f o r m a t i o n was u s e d t o d e s c r i b e t h e p o p u l a t i o n s t u d i e d a n d t o p r o v i d e t h e b o u n -d a r i e s f o r p o s s i b l e g e n e r a l i z a t i o n s t o o t h e r p o p u l a t i o n s . I n c l u d e d w e r e t h e a g e , s e x , a n d r a c e o f t h e c h i l d a s w e l l a s t h e number o f s i b l i n g s , p r e v i o u s h o s p i t a l i z a t i o n s a n d number o f p r e v i o u s c a s t s t h e c h i l d h a d h a d . I n f o r m a t i o n p e r t i n e n t t o t h e m o t h e r i n c l u d e d h e r a g e , m a r i t a l s t a t u s , l e v e l o f e d u c a t i o n , a n d e m p l o y m e n t s t a t u s o u t s i d e t h e home, a s w e l l a s a n i n d i c a t i o n o f h e r p r e v i o u s e x p e r i e n c e s w i t h c a s t s a n d h e r g e n e r a l h e a l t h a n d m o b i l i t y . P I L O T STUDY The i n s t r u m e n t s w e r e r e v i e w e d b y a p e d i a t r i c n u r s i n g s p e c i a l i s t a n d a n u r s e e d u c a t o r , f o l l o w i n g w h i c h a p i l o t was c o n d u c t e d o n a s a m p l e o f t h r e e f o r t h e p u r p o s e s o f r e v i s i o n a n d c l a r i f i c a t i o n . A f t e r m a k i n g a f e w m i n o r a l t e r a t i o n s , t h e i n s t r u m e n t s w e r e c o n s i d e r e d r e a d y f o r u s e . 39 S T A T I S T I C A L A N A L Y S I S A f t e r t o t a l l i n g t h e number o f " y e s " a n s w e r s o n t h e c o n -s i s t e n t l y a p p l i c a b l e i t e m s o n e a c h s u b j e c t ' s e v a l u a t i o n f o r m , t h e M a n n - W h i t n e y U T e s t t e s t e d t h e N u l l h y p o t h e s i s o f t h e s t u d y . T h i s p a r t i c u l a r t e s t h a s b e e n d e s c r i b e d a s "one o f t h e m o s t p o w e r f u l o f t h e n o n p a r a m e t r i c t e s t s , a n d i s a m o s t u s e f u l a l t e r n a t i v e t o t h e p a r a m e t r i c t t e s t when t h e r e s e a r c h e r 7 w i s h e s t o a v o i d t h e t t e s t ' s a s s u m p t i o n s . " I n a d d i t i o n , e a c h o f t h e i t e m s o n t h e e v a l u a t i o n f o r m was a n a l y z e d u s i n g t h e F i s h e r E x a c t P r o b a b i l i t y T e s t d e s c r i b e d b y S i e g e l a s "an e x t r e m e l y u s e f u l n o n p a r a m e t r i c t e c h n i q u e f o r a n a l y z i n g d i s c r e t e d a t a ( e i t h e r n o m i n a l o r o r d i n a l ) when t h e two i n d e p e n d e n t s a m p l e s a r e s m a l l i n s i z e . I t i s u s e d when t h e s c o r e s f r o m two i n d e p e n d e n t r a n d o m s a m p l e s a l l f a l l i n t o g o n e o r t h e o t h e r o f two m u t u a l l y e x c l u s i v e c l a s s e s . " The minimum s i g n i f i c a n c e l e v e l was s e t a t a £ .05. SUMMARY T h i s c h a p t e r h a s d e s c r i b e d t h e d e s i g n u s e d i n t h e s t u d y , t h e m e t h o d o f p o p u l a t i o n s e l e c t i o n , a n d t h e i n s t r u m e n t s d e v e l o p e d f o r t h e s t u d y . The m e t h o d o f s t a t i s t i c a l a n a l y s e s was a l s o d e s c r i b e d . 7 . S i d n e y S i e g e l , N o n p a r a m e t r I c S t a t i s t i c s f o r t h e  B e h a v i o r a l S c i e n c e s (New Y o r k : M c G r a w - H i l l B o o k Company, I n c . , 1 9 5 6 ) , p . 1 1 6 . 8 I b i d . , p. 9 8 . CHAPTER I V AN A L Y S I S OF THE DATA T h i s c h a p t e r i s p r e s e n t e d i n f o u r s e c t i o n s : (1) t h e s e l e c t e d p e r s o n a l c h a r a c t e r i s t i c s o f t h e s u b j e c t s ; (2) t h e t e s t o f t h e s t u d y ' s h y p o t h e s i s ; (3) a n a l y s i s o f t h e d a t a o b t a i n e d f o r e a c h o b j e c t i v e ; (4) a d e s c r i p t i v e summary o f t h e i n f o r m a t i o n r e c e i v e d b y t h e c o n t r o l g r o u p b e f o r e d i s c h a r g e . THE STUDY POPULATION The s t u d y p o p u l a t i o n c o n s i s t e d o f t w e n t y m o t h e r s whose c h i l d r e n h a d r e c e i v e d t r e a t m e n t i n one o f f i v e s e l e c t e d h o s p i t a l e m e r g e n c y d e p a r t m e n t s f o r a t r a u m a t i c l i m b f r a c t u r e r e q u i r i n g c a s t a p p l i c a t i o n . A g e . The m a j o r i t y o f s u b j e c t s , n i n e (45 p e r c e n t ) w e r e b e t w e e n 30-34 y e a r s o f a g e . Two s u b j e c t s (10 p e r c e n t ) w e r e b e t w e e n 25-29 y e a r s o f a g e , s i x (30 p e r c e n t ) w e r e b e t w e e n 35-39 y e a r s o f a g e , a n d t h e r e m a i n i n g t h r e e m o t h e r s (15 * p e r c e n t ) w e r e f o r t y y e a r s o f age o r o v e r ( T a b l e I ) . 41 TABLE I PERCENTAGE DIST R I B U T I O N OF THE MOTHERS BY AGE Ag e N % 25-29 y e a r s 2 10 30-34 9 45 35-39 6 30 40 o r o v e r 3 15 T o t a l 20 100 M a r i t a l s t a t u s . The m a j o r i t y o f t h e m o t h e r s , e i g h t e e n (9.0 p e r c e n t ) , w e r e m a r r i e d . One was s e p a r a t e d a n d t h e o t h e r was d i v o r c e d . E d u c a t i o n . The h i g h e s t e d u c a t i o n a l a t t a i n m e n t o f t h e m o t h e r s i s shown i n T a b l e I I . The l a r g e s t number, s e v e n (35 p e r c e n t ) h a d a t t e n d e d h i g h s c h o o l w h i l e f o u r (20 p e r c e n t ) h a d c o m p l e t e d h i g h s c h o o l . C o m p l e t i o n o f g r a d e s c h o o l was t h e maximum l e v e l o f f o r m a l s c h o o l i n g f o r o n e m o t h e r (5 p e r -c e n t ) . F o u r m o t h e r s (20 p e r c e n t ) h a d c o m p l e t e d v o c a t i o n a l t r a i n i n g a f t e r h i g h s c h o o l . One i n t h i s c a t e g o r y h a d c o m p l e t e d a b u s i n e s s c o u r s e , two h a d r e c e i v e d d i p l o m a s i n l a b o r a t o r y t e c h n o l o g y , a n d t h e o t h e r was a g r a d u a t e o f a t h r e e y e a r d i p l o m a p r o g r a m i n n u r s i n g . The f o u r r e m a i n i n g s u b j e c t s w e r e u n i v e r s i t y b a c c a l a u r e a t e g r a d u a t e s i n e i t h e r e d u c a t i o n , E n g l i s h , m i c r o b i o l o g y , o r a n t h r o p o l o g y . 42 TABLE I I PERCENTAGE DIS T R I B U T I O N OF THE MOTHERS BY HIGHEST EDUCATIONAL ATTAINMENT H i g h e s t E d u c a t i o n a l A t t a i n m e n t N % C o m p l e t e d g r a d e s c h o o l 1 5 A t t e n d e d h i g h s c h o o l 7 35 C o m p l e t e d h i g h s c h o o l 4 20 V o c a t i o n a l t r a i n i n g p o s t h i g h s c h o o l 4 20 C o m p l e t e d u n i v e r s i t y 4 20 T o t a l 20 100 E m p l o y m e n t . The m a j o r i t y o f t h e s u b j e c t s (65 p e r c e n t ) w e r e n o t e m p l o y e d o u t s i d e t h e home. Two (10 p e r c e n t ) h e l d p a r t - t i m e j o b s a n d t h e r e m a i n i n g f i v e s u b j e c t s (25 p e r c e n t ) w e r e e m p l o y e d f u l l - t i m e ( T a b l e I I I ) . TABLE I I I PERCENTAGE D I S T R I B U T I O N OF THE MOTHERS BY EMPLOYMENT OUTSIDE THE HOME E m p l o y m e n t O u t s i d e t h e Home N % None 13 65 P a r t - t i m e 2 10 F u l l - t i m e 5 25 T o t a l 20 100 P r e v i o u s e x p e r i e n c e w i t h c a s t s . T h i s c h a r a c t e r i s t i c i n c l u d e d p r e v i o u s e x p e r i e n c e s t h e m o t h e r h a d h a d i n c a r i n g f o r h e r s e l f a n d / o r o t h e r s w i t h a c a s t . T w e l v e s u b j e c t s (60 p e r c e n t ) h a d n e v e r h a d s u c h a n e x p e r i e n c e . T h r e e (15 p e r c e n t ) h a d c a r e d f o r someone w i t h a c a s t o n c e b e f o r e a n d t h e same number h a d d o n e t h i s t w i c e . Two m o t h e r s (10 p e r c e n t ) h a d h a d t h i s e x p e r i e n c e m ore t h a n t w i c e , i n c l u d i n g t h e o n e s u b j e c t who was a n u r s e . ( T a b l e I V ) . TABLE I V PERCENTAGE D I S T R I B U T I O N OF THE MOTHERS BY PREVIOUS EXPERIENCES WITH CASTS P r e v i o u s e x p e r i e n c e s w i t h c a s t s N % None 12 60 Once 3 15 T w i c e 3 15 M o r e t h a n t w i c e 2 10 T o t a l 20 100 G e n e r a l h e a l t h a n d m o b i l i t y . A l l o f t h e m o t h e r s a p p e a r e d g e n e r a l l y h e a l t h y w i t h no i m p a i r m e n t t o t h e i r m o b i l i t y . H o w e v e r o n e o f t h e m o t h e r s was a l m o s t t o t a l l y d e a f b u t t h i s was n o t c o n s i d e r e d t o b e a n i m p a i r m e n t t o h e r h e a l t h o r m o b i l i t y . The c h i l d r e n . The c h i l d r e n i n v o l v e d w i t h t h e s t u d y r a n g e d i n age f r o m s i x t o t w e l v e y e a r s a s shown i n T a b l e V, w i t h t h e l a r g e s t number, s e v e n (35 p e r c e n t ) b e i n g e l e v e n y e a r s o f a g e . The mean a g e was 9.4 y e a r s . TABLE V PERCENTAGE D I S T R I B U T I O N OF THE CHILDREN BY AGE A g e N % 6 y e a r s 1 5 7 4 20 8 1 5 9 3 15 10 3 15 11 7 35 12 1 5 T o t a l 20 100 Mean = 9.4 y e a r s T h e r e was a n e q u a l number o f m a l e a n d f e m a l e c h i l d r e n a n d a l l w e r e C a u c a s i a n . T h e r e was o n e s i b l i n g i n t h e f a m i l i e s o f e i g h t o f t h e c h i l d r e n (40 p e r c e n t ) , w h i l e n i n e (45 p e r c e n t ) h a d two o r t h r e e b r o t h e r s a n d s i s t e r s . The r e m a i n i n g t h r e e (15 p e r c e n t ) h a d f o u r t o f i v e s i b l i n g s . T en o f t h e c h i l d r e n (50 p e r c e n t ) h a d n e v e r b e e n h o s p i t a l -i z e d o v e r n i g h t , w h i l e s i x (30 p e r c e n t ) h a d h a d s u c h a n e x p e r i e n c e o n c e , a n d t h e r e m a i n i n g f o u r (20 p e r c e n t ) , t w i c e b e f o r e ( T a b l e V I ) . 45 TABLE V I PERCENTAGE DI S T R I B U T I O N OF THE CHILDREN BY NUMBER OF PREVIOUS HOSPITALIZATIONS Number o f P r e v i o u s H o s p i t a l i z a t i o n s N % None 10 50 1 6 30 2 4 20 T o t a l 20 100 The m a j o r i t y o f c h i l d r e n (70 p e r c e n t ) h a d n e v e r h a d a c a s t b e f o r e , f o u r (20 p e r c e n t ) h a d h a d a c a s t o n c e b e f o r e , a n d two c h i l d r e n (10 p e r c e n t ) , t w i c e b e f o r e ( T a b l e V I I ) . TABLE V I I PERCENTAGE D I S T R I B U T I O N OF THE CHILDREN BY NUMBER OF PREVIOUS CASTS Number o f P r e v i o u s C a s t s N % j None 1 14 70 2 4 20 2 10 T o t a l 20 100 EVALUATION OF THE MOTHERS' COPING ABILITIES Hypothesis: t h e r e 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 c o p i n g a b i l i t i e s o f the mothers of the e x p e r i m e n t a l group as compared w i t h the mothers o f the c o n t r o l group. The measure of the mothers' c o p i n g a b i l i t i e s was dependent on the number o f o b j e c t i v e s f o r c a r i n g f o r a c h i l d w i t h a c a s t e d limb t h a t each mother met. The mother's s c o r e was determined by t o t a l l i n g the number o f "yes" answers to the c o n s i s t e n t l y a p p l i c a b l e items on the " E v a l u a t i o n of Mother's Coping A b i l i t i e s " form. Items were excluded from the t a l l y i f they were marked n o n - a p p l i c a b l e f o r any of the s u b j e c t s as they had to a p p l y to a l l s u b j e c t s i n o r d e r to be i n c l u d e d i n the s t a t i s t i c a l a n a l y s i s . Those items excluded were numbered on the E v a l u a t i o n form as 2d, 3e, 4f, 4h, and 4k. In a d d i t i o n , o n l y o n e p o s i t i v e answer o f 4a and 4b, and one o f 4c and 4d were counted as o n l y one was c o n s i d e r e d necessary f o r meeting the o b j e c t i v e s . The h i g h e s t p o s s i b l e s c o r e was f i f t e e n , i n d i c a t i n g a h i g h a b i l i t y to cope. The t o t a l s c o r e s a r e t a b u l a t e d i n T a b l e V I I I . 47 TABLE VIII RANKED SCORES OF THE COPING ABILITIES OF EACH INDIVIDUAL MOTHER Group Ranked Scores Within Group Experimental 12 12 13 13 13 13 14 14 14 15 Control 8 8 8 9 10 10 10 10 11 11 When the Mann -Whi tney U t e s t was applied to the t o t a l scores, the U value was found to be s i g n i f i c a n t at a = .001. Thus, the Nu l l hypothesis was rejected with confidence, i n d i c a t i n g that the mother's a b i l i t i e s to cope with the home care of her c h i l d following treatment i n a h o s p i t a l emergency department, because of a traumatic limb fracture r e q u i r i n g cast a p p l i c a t i o n , was strongly affected by the teaching she received before taking her c h i l d home. ANALYSIS OF EVALUATION FORM ITEMS i Although the Null hypothesis was rejected a f t e r analyz-ing the o v e r a l l coping a b i l i t i e s of the subjects, an i n d i v i d u a l analysis of the scores of each objective was made to determine whether the two groups d i f f e r e d s i g n i f i c a n t l y i n the proportion with which they were c l a s s i f i e d as meeting or not meeting each o b j e c t i v e . The scores for each objective were tabulated as shown i n Table X. They were then represented as frequencies i n a 48 2 x 2 c o n t i n g e n c y t a b l e , a m o d e l o f w h i c h i s p r e s e n t e d i n T a b l e I X . TABLE I X MODEL OF 2 X 2 CONTINGENCY TABLE S a t i s f a c t o r y A c h i e v e m e n t G r o u p T o t a l E x p e r i m e n t a l C o n t r o l Y e s A B A + B No C D C + D T o t a l A + C B + D N The F i s c h e r E x a c t P r o b a b i l i t y T e s t was u s e d t o d e t e r m i n e t h e s i g n i f i c a n c e l e v e l s a c c o r d i n g t o t h e m e t h o d d e s c r i b e d b y S i e g e l . " * " S i d n e y S i e g e l , N o n p a r a m e t r i c S t a t i s t i c s f o r t h e B e - h a v i o r a l S c i e n c e s (New Y o r k : M c G r a w - H i l l B o o k Company, I n c . , 1 9 5 6 ) , p p . 9 6 - 1 0 0 . TABLE X 49 GROUP SCORES OF I N D I V I D U A L O B J E C T I V E S ACHIEVED S a t i s f a c t o r y A c h i e v e m e n t o f O b j e c t i v e s E x p e r i m e n t a l C o n t r o l O b j e c t i v e s y e s no n/a y e s no n/a U n d e r s t a n d s r e a s o n f o r c a s t 10 10 a H a n d l e s w e t c a s t w i t h p a l m s o f h a n d s 7 3 - 1 9 -K e e p s c a s t a s d r y a s p o s s i b l e 10 - - 8 2 -K e e p s c a s t a s i n t a c t a s p o s s i b l e 10 - - 10 - -C a r e s a p p r o p r i a t e l y f o r damaged c a s t 1 1 8 - - 10 K e e p s c a s t e d g e s s m o o t h 10 - - 9 1 -S e e k s t o k e e p l i m b p r o p e r l y s u p p o r t e d 10 - - 9 1 -A l l o w s c h i l d amount o f a c t i v i t y p e r m i t t e d b y t h e d o c t o r 10 - - 10 - -b C l e a n s a n d m a i n t a i n s t h e e x p o s e d p a r t s o f t h e l i m b u n d e r c a s t e d g e s 8 2 - 1 9 -o D i s c o u r a g e s c h i l d f r o m p l a c i n g o b j e c t s i n s i d e t h e c a s t 10 - - 5 5 -E n c o u r a g e s c h i l d t o u s e c r u t c h e s p r o p e r l y 2 - 8 2 1 7 Has c o m p a r e d t h e s i z e s o f b o t h l i m b s t o d e t e r m i n e t h e p r e s e n c e o f edema 10 - - 10 - -Has l o o k e d f o r p a l l o r a n d / o r c y a n o s i s o f s k i n s u r r o u n d i n g o r d i s t a l t o c a s t 10 - - 10 - -Has f e l t t e m p e r a t u r e o f s k i n s u r r o u n d -i n g a n d / o r d i s t a l t o c a s t e d a r e a 3 7 - 3 7 -Has c a r e d f o r c i r c u l a t o r y p r o b l e m s a p p r o p r i a t e l y 4 - 6 4 1 5 d Has q u e s t i o n e d c h i l d r e : numbness a n d / o r t i n g l i n g o f a f f e c t e d l i m b 8 2 - 3 7 -Has c a r e d f o r n e r v e t r a n s m i s s i o n p r o b l e m s a p p r o p r i a t e l y 2 - 8 1 1 8 Has s m e l l e d t h e c a s t f o r f o u l o d o r s 8 2 - 5 5 -b Has q u e s t i o n e d c h i l d r e : b u r n i n g , p a i n a n d / o r m o i s t u r e u n d e r c a s t 9 1 - 1 9 -Has c a r e d a p p r o p r i a t e l y f o r s i g n s o f p r e s s u r e s o r e s u n d e r c a s t — — 10 — 1 10 a S i g n i f i c a n t a t p = .01 b S i g n i f i c a n t a t p = .005 o S i g n i f i c a n t a t p = .025 d S i g n i f i c a n t a t p = .05 50 U n d e r s t a n d i n g t h e R e a s o n f o r t h e C a s t A l l t h e m o t h e r s e x p r e s s e d a b a s i c u n d e r s t a n d i n g o f t h e r e a s o n why t h e c a s t was n e c e s s a r y , i . e . t o k e e p t h e e n d s o f t h e b r o k e n b o n e a p p r o x i m a t e d f o r r e - g r o w t h . A t t h e t i m e o f t h e home v i s i t , s e v e r a l c o n t r o l s u b j e c t s q u e s t i o n e d t h e l e n g t h o f t h e c a s t , e . g . t h e n e e d f o r a l o n g - l e g c a s t f o r a f r a c t u r e d t i b i a . A s t h e p o s t - d i s c h a r g e v i s i t was u s u a l l y made b e f o r e t h e f i r s t r e t u r n v i s i t t o t h e d o c t o r , some c o n t r o l s u b j e c t s w o n d e r e d a b o u t t h e l e n g t h o f t i m e t h e c a s t h a d t o b e o n . E x p l a n a t i o n s r e g a r d i n g t h e s e a s p e c t s h a d b e e n g i v e n t o t h e e x p e r i m e n t a l s u b j e c t s b e f o r e d i s c h a r g e a n d s o t h e i r q u e r i e s w e r e m a i n l y t o s e e k c l a r i f i c a t i o n o f t h e i r d o u b t s . U n d e r s t a n d i n g C a s t C a r e T h e r e w e r e f i v e s p e c i f i c o b j e c t i v e s l i s t e d u n d e r " M o t h e r u n d e r s t a n d s how t o c a r e f o r t h e c a s t . " A l l s u b j e c t s s o u g h t t o p r e v e n t t h e c a s t f r o m g e t t i n g b r o k e n a n d n i n e t y p e r c e n t t o o k m e a s u r e s t o p r e v e n t t h e c a s t f r o m g e t t i n g w e t , i n c l u d i n g t h e t e n e x p e r i m e n t a l s u b j e c t s . S u c h m e a s u r e s i n c l u d e d c o v e r i n g t h e c a s t w i t h a p l a s t i c b a g b e f o r e t a k i n g a b a t h o r a s h o w e r a n d g i v i n g t h e c h i l d a p l a s t i c b a g t o h a v e i n s c h o o l i n t h e e v e n t o f u n e x p e c t e d r a i n . A l l m o t h e r s e x c e p t one c o n t r o l h a d k e p t a c h e c k o n t h e c a s t e d g e s a n d r e p a i r e d t h e m a s n e c e s s a r y . The e x p e r i m e n t a l s u b j e c t s u s e d t h e a d v i c e g i v e n b y t h e r e s e a r c h e r w h i l e some c o n t r o l s u b j e c t s t e n d e d t o u s e s u c h m a t e r i a l s a s f a c i a l t i s s u e s , a n d 51 o t h e r s , r e p o r t i n g t h a t t h e e d g e s w e r e j u s t b e g i n n i n g t o r o u g h e n , w e r e u n s u r e o f w h a t t o u s e f o r r e p a i r . T h e r e w e r e no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s i n t h e s e p a r a t e a n a l y s e s o f t h e t h r e e o b j e c t i v e s . S e v e n e x p e r i m e n t a l a n d n i n e c o n t r o l s u b j e c t s d i d n o t , a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e a t t h e .01 l e v e l . A damaged c a s t was e n c o u n t e r e d b y o n l y two s u b j e c t s , b o t h e x p e r i m e n t a l . One h a n d l e d t h e s i t u a t i o n a p p r o p r i a t e l y b y c a l l i n g h e r d o c t o r i m m e d i a t e l y . The o t h e r d e c i d e d t o w a i t u n t i l t h e s c h e d u l e d d o c t o r 1 s a p p o i n t m e n t when s h e s h o u l d h a v e n o t i f i e d h i m i m m e d i a t e l y a s t h e c a s t h a d s o f t e n e d , p o s s i b l y a f f e c t i n g b o n e a l i g n m e n t . U n d e r s t a n d i n g o f C a r e f o r a C a s t e d L i m b N i n e t y - f i v e p e r c e n t o f t h e s u b j e c t s s o u g h t t o k e e p t h e l i m b p r o p e r l y s u p p o r t e d , e . g . t h e c h i l d k e p t t h e l i m b e l e v a t e d o n a p i l l o w a t n i g h t a n d when s i t t i n g w a t c h i n g t e l e v i s i o n o r r e a d i n g . T h i s c a t e g o r y a l s o i n c l u d e d p r o p e r u s e o f a s l i n g . The o n e c o n t r o l s u b j e c t who n e g l e c t e d t h i s a s p e c t o f c a r e d i d n o t r e a l i z e t h a t a s l i n g was n e c e s s a r y a s s h e s a i d s h e h a d n o t b e e n t o l d a b o u t i t n o r d i d h e r c h i l d r e c e i v e o n e b e f o r e d i s c h a r g e . F i v e o f t h e c h i l d r e n h a d f r a c t u r e d l o w e r l i m b s a n d s o r e q u i r e d c r u t c h e s . F o u r o f t h e s e w e r e u s i n g c r u t c h e s p r o p e r l y a n d o n e ( o f t h e c o n t r o l g r o u p ) was n o t . T h i s c h i l d was u s i n g t h e a r m p i t s a s t h e m a i n p o i n t o f s u p p o r t . 52 A l l s u b j e c t s p e r m i t t e d t h e i r c h i l d r e n t h e amount o f a c t i v i t y recommended b y t h e d o c t o r . T h e r e w e r e no s t a t i s t i c -a l l y s i g n i f i c a n t d i f f e r e n c e s i n t h e a c h i e v e m e n t o f t h e t h r e e o b j e c t i v e s s o f a r d i s c u s s e d i n t h i s s e c t i o n . E i g h t e x p e r i m e n t a l s u b j e c t s a n d one c o n t r o l c a r e d f o r t h e e x p o s e d a r e a s u n d e r t h e c a s t e d g e s . T h i s i n c l u d e d w a s h -i n g a n d r u b b i n g t h e a r e a a t r e g u l a r i n t e r v a l s . The r e m a i n i n g s u b j e c t s n e g l e c t e d t h i s a s p e c t o f c a r e , r e s u l t i n g i n a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e a t t h e .005 l e v e l . A l l t e n o f t h e e x p e r i m e n t a l a n d f i v e o f t h e c o n t r o l g r o u p d i s c o u r a g e d t h e c h i l d f r o m p l a c i n g o b j e c t s i n s i d e t h e c a s t ; f i v e c o n t r o l m o t h e r s d i d n o t , a f r e q u e n t comment b e i n g "I h o p e he h a s n ' t , " b u t t h e y h a d n o t i n s t r u c t e d t h e c h i l d n o t t o . A n a l y s i s showed a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e a t t h e .025 l e v e l . U n d e r s t a n d i n g o f S i g n s a n d Symptoms o f C o m p l i c a t i o n s T h i s c a t e g o r y was i n t e n d e d t o d e t e r m i n e i f t h e m o t h e r k e p t a k n o w l e d g e a b l e c h e c k f o r t h e s i g n s a n d symptoms o f p o s s i b l e c o m p l i c a t i o n s a nd c o n s e q u e n t l y d e a l t a p p r o p r i a t e l y w i t h t h e c o m p l i c a t i o n s i f p r e s e n t . S u c h a c t i o n s o n h e r p a r t w e r e e x p e c t e d t o a l l e v i a t e u n n e c e s s a r y c a l l s t o t h e d o c t o r a s w e l l a s p r o v i d e more i m m e d i a t e r e l i e f f o r t h e c h i l d . I n l o o k i n g f o r s i g n s a n d symptoms o f c i r c u l a t i o n i m -p a i r m e n t a n d s w e l l i n g , a l l t h e m o t h e r s r e p o r t e d c o m p a r i n g l i m b s i z e s a n d n o t i n g l i m b d i s c o l o r a t i o n a s t h e m e t h o d s u s e d . 53 O n l y o n e e x p e r i m e n t a l s u b j e c t r e p o r t e d t h a t s h e d e p r e s s e d t h e s u r r o u n d i n g s k i n a r e a s t o d e t e r m i n e edema a n d n o n e v o l u n t e e r e d t h a t t h e y u s e d t h e " b l a n c h i n g " t e c h n i q u e . H o w e v e r , a s t h e f i r s t two m e t h o d s a r e p e r h a p s t h e m o s t commonly known a n d e a s i l y r e m e m b e r e d , t h e i r u s e was c o n s i d e r e d s u f f i c i e n t i n c h e c k i n g f o r s w e l l i n g a n d c i r c u l a t i o n i m p a i r m e n t . O n l y t h r e e o f t h e e x p e r i m e n t a l a n d t h r e e o f t h e c o n t r o l s u b j e c t s u s e d s k i n t e m p e r a t u r e t o c h e c k f o r c i r c u l a t i o n i m p a i r m e n t , y i e l d i n g no s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s . C i r c u l a t o r y p r o b l e m s t h a t w e r e r e c o g n i z e d w e r e a p p a r e n t l y c a u s e d b y s w e l l i n g . F o u r i n e a c h g r o u p d e a l t w i t h t h e p r o b l e m a p p r o p r i a t e l y a n d o n e c o n t r o l d i d n o t , w h i l e t h e r e m a i n i n g e l e v e n e n c o u n t e r e d no o b v i o u s p r o b l e m s i n t h i s r e g a r d . E i g h t e x p e r i m e n t a l a n d t h r e e c o n t r o l m o t h e r s c h e c k e d f o r n e r v e t r a n s m i s s i o n p r o b l e m s b y l o o k i n g f o r numbness o r " t i n g l i n g " s e n s a t i o n s i n t h e a f f e c t e d l i m b . S t a t i s t i c a l a n a l y s i s o f t h e two g r o u p s - i n d i c a t e d a s i g n i f i c a n t d i f f e r e n c e a t t h e .05 l e v e l . F o u r s u b j e c t s d e t e c t e d n e r v e t r a n s m i s s i o n p r o b l e m s . Two e x p e r i m e n t a l a nd o n e c o n t r o l m o t h e r s o l v e d t h e p r o b l e m i n a s i m i l a r m a n n e r — b y e l e v a t i n g t h e l i m b t o r e d u c e s w e l l i n g . The r e m a i n i n g m o t h e r , a c o n t r o l s u b j e c t , h a n d l e d t h e p r o b l e m i n -a d e q u a t e l y b y n o t c h e c k i n g f o r s w e l l i n g a n d n o t c a l l i n g t h e d o c t o r u n t i l a d a y l a t e r . I n t h e a n a l y s i s , no s i g n i f i c a n c e was d e t e r m i n e d b e t w e e n t h o s e who d i d and d i d n o t c h e c k t h e c a s t f o r f o u l o d o r s a l t h o u g h 54 t h e r e was a s i g n i f i c a n t d i f f e r e n c e a t t h e .005 l e v e l i n t h e number who c h e c k e d f o r o t h e r s i g n s o f p r e s s u r e s o r e s — b u r n i n g , p e r s i s t e n t p a i n a n d / o r m o i s t u r e u n d e r t h e c a s t . S i g n s o f p r e s s u r e s o r e s w e r e p r e s e n t i n o n l y o ne c h i l d , o f t h e c o n t r o l g r o u p , a n d i t was d e t e r m i n e d t h a t t h e m o t h e r d e a l t i n a p p r o p r i a t e l y w i t h t h a t p r o b l e m . CONTROL GROUP INFORMATION ASSESSMENT I n f o r m a t i o n P a m p h l e t s As m e n t i o n e d p r e v i o u s l y , o n e o f t h e e m e r g e n c y d e p a r t -m e n t s g a v e i n f o r m a t i o n p a m p h l e t s o n c a s t c a r e t o e a c h p a t i e n t who r e c e i v e d a c a s t ( A p p e n d i x C ) . To d e t e r m i n e i f t h i s p a m p h l e t made a n y s i g n i f i c a n t d i f f e r e n c e b e t w e e n t h e c o n t r o l s u b j e c t s who r e c e i v e d i t a n d t h e c o n t r o l s u b j e c t s f r o m t h e o t h e r f o u r h o s p i t a l s , t h e M a n n - W h i t n e y U t e s t was a p p l i e d t o t h e e v a l u a t i o n s c o r e s ( T a b l e X I ) . TABLE X I RANKED SCORES OF THE COPING A B I L I T I E S OF CONTROL SUBJECTS R E C E I V I N G PAMPHLET (N,) AND THOSE NOT R E C E I V I N G PAMPHLET ( N 0 ) G r o u p R a n k e d S c o r e s W i t h i n G r o u p N 1 10 10 10 11 N 2 8 8 8 9 10 11 55 The r e s u l t s g a v e a n o b s e r v e d U v a l u e o f 7 w i t h p = .176, t h u s i n d i c a t i n g t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e i n t h e c o p i n g a b i l i t i e s o f t h o s e c o n t r o l s u b j e c t s who r e c e i v e d t h e w r i t t e n i n s t r u c t i o n s a n d t h o s e who d i d n o t r e c e i v e t h e i n s t r u c t i o n s . C o n t r o l g r o u p w i t h p a m p h l e t s . I n t h i s g r o u p , o n e m o t h e r r e p o r t e d t h e p a m p h l e t a s b e i n g h e r o n l y s o u r c e o f i n f o r m a t i o n a l t h o u g h s h e was a d v i s e d b y t h e d o c t o r r e g a r d i n g a n a l g e s i c s . T h i s m o t h e r h a d a s s i s t e d t h e d o c t o r b y h o l d i n g t h e l i m b w h i l e t h e c a s t was b e i n g a p p l i e d a n d y e t s h e r e p o r t e d t h a t s h e h a d r e f r a i n e d f r o m a s k i n g a n y q u e s t i o n s a s t h e d o c t o r ' s m anner seemed v e r y r u s h e d a n d q u i t e b r u s q u e a s he " o r d e r e d " h e r a b o u t w h i c h way t o h o l d t h e l i m b w h i l e t h e c a s t was b e i n g a p p l i e d , e t c . A n o t h e r m o t h e r g a v e t h e p a m p h l e t a s a m a j o r s o u r c e o f i n f o r m a t i o n a n d t h e q u e s t i o n s s h e s a i d s h e h a d a s k e d t h e d o c t o r . The r e m a i n i n g two s u b j e c t s named t h e d o c t o r a s t h e s o u r c e o f i n f o r m a t i o n r e g a r d i n g t h e r e a s o n f o r t h e c a s t a n d how much e x e r c i s e t h e c h i l d was a l l o w e d w h i c h i n b o t h c a s e s i n v o l v e d t h e amount o f w e i g h t b e a r i n g i n c r u t c h w a l k i n g . The n u r s e was m e n t i o n e d a s a s o u r c e o f i n f o r m a t i o n b y o n l y o n e s u b j e c t a n d t h a t was i n r e g a r d t o c r u t c h w a l k i n g o n l y . The r e m a i n i n g i n f o r m a t i o n t h e y r e p o r t e d a s h a v i n g b e e n o b t a i n e d f r o m t h e p a m p h l e t w h i c h was g i v e n t o them b y t h e n u r s e p r i o r t o d i s c h a r g e 56 These four s u b j e c t s seemed to have r e c e i v e d l i m i t e d or no i n f o r m a t i o n on how to handle a wet c a s t , how to keep the c a s t edges smooth, how to maintain the areas under the c a s t edges, the need to discourage the c h i l d from p l a c i n g o b j e c t s i n s i d e the c a s t , and how to check f o r c i r c u l a t i o n impairment by f e e l i n g the s k i n temperature near the c a s t edges. C o n t r o l group without pamphlets. For two s u b j e c t s i n t h i s group, the doctor was r e p o r t e d as the o n l y source of i n f o r m a t i o n before discharge and t h a t was f o r c l a r i f i c a t i o n of the reason f o r the c a s t o n l y . N e i t h e r mother reported having r e c e i v e d any f u r t h e r i n f o r m a t i o n from the emergency department s t a f f . On a r r i v i n g home, one c a l l e d her s i s t e r who i s a nurse and was advised by her on how to care f o r the c h i l d . This mother f e l t very s t r o n g l y t h a t the h o s p i t a l should provide a l l such p a t i e n t s w i t h a l i s t of w r i t t e n i n s t r u c t i o n s on how to care f o r a c a s t . The other mother reporte d c a l l i n g the doctor the f o l l o w i n g day w i t h her c a l l being answered the day f o l l o w -in g t h a t , and was t o l d then what to do f o r the c h i l d ' s apparently s w o l l e n , o c c a s i o n a l l y cyanosed and p a i n f u l l i m b . N e i t h e r of these c h i l d r e n had r e c e i v e d s l i n g s f o r t h e i r arm c a s t s p r i o r to d i s c h a r g e . One s u b j e c t r e p o r t e d r e c e i v i n g i n f o r m a t i o n from the doctor regarding the reason f o r the c a s t and the need to keep i t d r y. This mother s t a t e d t h a t she would have appreciated r e c e i v i n g more i n f o r m a t i o n before d i s c h a r g e , but any problems she d i d have she r e f e r r e d to her husband who had had a S a i n t John's Ambulance course. 57 W i t h t h e r e m a i n i n g t h r e e s u b j e c t s , t h e d o c t o r s p r o v i d e d e a c h w i t h i n f o r m a t i o n r e g a r d i n g t h e n e e d f o r t h e c a s t , how t o s u p p o r t t h e c a s t e d l i m b a n d i n f o r m a t i o n r e g a r d i n g s i g n s o f c i r c u l a t i o n i m p a i r m e n t — s w e l l i n g , c y a n o s i s , and a l t e r a t i o n i n t h e s k i n t e m p e r a t u r e s u r r o u n d i n g t h e c a s t . The m o t h e r s r e p o r t e d h a v i n g r e c e i v e d no o t h e r i n f o r m a t i o n f r o m t h e E m e r g e n c y d e p a r t m e n t s t a f f . One c h i l d r e q u i r e d c r u t c h e s w h i c h h a d t o b e o b t a i n e d b y t h e p a r e n t s a t a n o u t s i d e d r u g s t o r e . I n s t r u c t i o n s i n t h e u s e o f t h e c r u t c h e s was p r o v i d e d b y t h e d r u g g i s t a n d n o t b y a n y o f t h e E m e r g e n c y d e p a r t m e n t s t a f f , a c c o r d i n g t o t h e m o t h e r . T a b l e X I I l i s t s t h e i t e m s o f t h e C o n t r o l G r o u p I n f o r -m a t i o n A s s e s s m e n t a n d t h e n u m bers w i t h i n t h e two c o n t r o l g r o u p s who r e c e i v e d i n f o r m a t i o n p r i o r t o d i s c h a r g e . SUMMARY D a t a r e g a r d i n g t h e s e l e c t e d p e r s o n a l c h a r a c t e r i s t i c s o f t h e s t u d y p o p u l a t i o n w e r e d e s c r i b e d . D a t a c o l l e c t e d t o t e s t t h e s t u d y ' s h y p o t h e s i s w e r e s t a t i s t i c a l l y a n a l y z e d a n d t h e N u l l h y p o t h e s i s was c o n s e q u e n t l y r e j e c t e d i n d i c a t i n g a g r e a t e r a b i l i t y t o c o p e b y t h e m o t h e r s o f t h e e x p e r i m e n t a l g r o u p . A n i n d i v i d u a l a n a l y s i s i n r e l a t i o n t o e a c h e v a l u a t i n g o b j e c t i v e was made t o d e t e r m i n e o n w h i c h o b j e c t i v e s t h e g r o u p s d i f f e r e d s i g n i f i c a n t l y . The s u b j e c t s w e r e f o u n d t o d i f f e r s i g n i f i c a n t l y o n f i v e o u t o f t w e n t y o b j e c t i v e s . 58 TABLE X I I CONTROL SUBJECTS R E C E I V I N G INFORMATION REGARDING S P E C I F I C ASPECTS OF HOME CARE PRIOR TO DISCHARGE Number R e c e i v i n g I n f o r m a t i o n S u b j e c t s w i t h S u b j e c t s P a m p h l e t s W i t h o u t N = 4 P a m p h l e t s I n f o r m a t i o n On Home C a r e N = 6 C l a r i f i c a t i o n o f r e a s o n f o r c a s t 4 6 How t o h a n d l e a w e t c a s t 1 -How t o k e e p c a s t d r y 2 1 How t o p r e v e n t b r e a k a g e 3 -How t o c a r e f o r a damaged c a s t 3 -How t o k e e p c a s t e d g e s s m o o t h - -How t o e x e r c i s e c a s t e d l i m b 3 1 How t o s u p p o r t c a s t e d l i m b 4 2 How t o u s e a u x i l i a r y d e v i c e s 3 1 How t o c l e a n a n d m a i n t a i n e x p o s e d p a r t s o f l i m b u n d e r c a s t — -Need t o d i s c o u r a g e c h i l d f r o m p l a c i n g o b j e c t s i n s i d e c a s t — — I n f o r m a t i o n o n s i g n s a n d symptoms o f c o m p l i c a t i o n s : - edema i n a f f e c t e d l i m b 4 3 - p a l l o r a n d / o r c y a n o s i s o f l i m b 4 2 - c o l d n e s s i n s k i n t e m p e r a t u r e 1 2 a r o u n d c a s t - numbness a n d / o r t i n g l i n g o f A i l i m b H - f o u l o d o r s f r o m u n d e r c a s t 4 -- s u b j e c t i v e p r e s e n c e o f b u r n i n g , p a i n a n d / o r m o i s t u r e u n d e r c a s t 3 -59 I n f o r m a t i o n w h i c h t h e c o n t r o l s u b j e c t s r e p o r t e d t h e y h a d r e c e i v e d p r i o r t o d i s c h a r g e f r o m t h e E m e r g e n c y d e p a r t m e n t s was d e s c r i b e d . I n a d d i t i o n , t h e a n a l y s i s o f t h e e v a l u a t i o n s c o r e s o f t h o s e c o n t r o l s u b j e c t s who d i d a n d t h o s e who d i d n o t r e c e i v e i n f o r m a t i o n p a m p h l e t s p r i o r t o d i s c h a r g e , i n d i c a t e d no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e b e t w e e n t h e two g r o u p s . CHAPTER V SUMMARY/ CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS SUMMARY The p u r p o s e o f t h i s e x p e r i m e n t a l s t u d y was t o d e t e r m i n e w h e t h e r o r n o t p l a n n e d t e a c h i n g i n v o l v i n g v e r b a l a n d w r i t t e n i n s t r u c t i o n s g i v e n t o a m o t h e r p r i o r t o t h e d i s c h a r g e o f h e r c h i l d f r o m a h o s p i t a l e m e r g e n c y d e p a r t m e n t f o l l o w i n g t r e a t m e n t f o r a t r a u m a t i c l i m b f r a c t u r e r e q u i r i n g c a s t a p p l i c a t i o n , e n a b l e s h e r t o c o p e more a d e q u a t e l y w i t h t h e home c a r e o f h e r c h i l d t h a n t h e m o t h e r n o t r e c e i v i n g t h i s p l a n n e d t e a c h i n g . The s t u d y a s s u m e d t h a t t h e home c a r e a m o t h e r i s e x -p e c t e d t o g i v e i n s u c h a s i t u a t i o n , i s c o m p a r a b l e t o t h e n u r s i n g c a r e t h a t c h i l d w o u l d h a v e r e c e i v e d h a d he b e e n a d m i t t e d t o a g e n e r a l h o s p i t a l w a r d . The N u l l h y p o t h e s i s t e s t e d i n t h i s s t u d y w as: t h e r e 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 t h e c o p i n g a b i l i t i e s o f t h e m o t h e r s o f t h e e x p e r i m e n t a l a s c o m p a r e d w i t h t h e m o t h e r s o f t h e c o n t r o l g r o u p . A s t a t i s -t i c a l l y s i g n i f i c a n t l e v e l o f .05 was c h o s e n f o r a c c e p t a n c e o r r e j e c t i o n o f t h i s h y p o t h e s i s . A s t h e r e i s a l a c k o f s t u d i e s d i r e c t l y c o n c e r n e d w i t h t e a c h i n g p a r e n t s o f c h i l d r e n t r e a t e d i n e m e r g e n c y d e p a r t m e n t s e t t i n g s , t h e l i t e r a t u r e r e v i e w f o c u s e d o n t h e f o l l o w i n g r e l a t e d a r e a s : t h e c o n c e r n s o f h o s p i t a l i z e d s c h o o l - a g e d c h i l d r e n a n d t h e i r p a r e n t s , c o m m u n i c a t i o n b e t w e e n p a t i e n t s , t h e i r f a m i l i e s , a n d t h e p r o f e s s i o n a l h e a l t h t e a m , a n d t h e r o l e o f t h e n u r s e i n p a t i e n t t e a c h i n g a s a means o f e f f e c t i v e communi-c a t i o n . The l i t e r a t u r e s o u r c e s i n d i c a t e d a d e f i n i t e n e e d f o r p a t i e n t t e a c h i n g b u t t h a t i t s u t i l i z a t i o n i n c l i n i c a l s e t t i n g s i s o f t e n c o n f u s e d , s c a r c e , o r c o m p l e t e l y a b s e n t . The n u r s e p r a c t i t i o n e r was r e v e a l e d t o b e t h e m o s t c o n s i s -t e n t l y a v a i l a b l e h e a l t h t e am member t o p r e p a r e p a t i e n t s a n d t h e i r f a m i l i e s e f f e c t i v e l y f o r home c a r e a f t e r d i s c h a r g e , w i t h t h e t e a c h i n g m e t h o d s e l e c t e d b e i n g t h e m o s t a p p r o p r i a t e i n r e l a t i o n t o t h e i n d i v i d u a l s i t u a t i o n . The s t u d y p o p u l a t i o n c o n s i s t e d o f t w e n t y m o t h e r s w h o s e c h i l d r e n w e r e t r e a t e d f o r a t r a u m a t i c l i m b f r a c t u r e r e q u i r i n g c a s t a p p l i c a t i o n , i n o n e o f f i v e h o s p i t a l e m e r g e n c y d e p a r t -m e n t s . The s u b j e c t s w e r e a s s i g n e d t o a l t e r n a t e e x p e r i m e n t a l a n d c o n t r o l g r o u p s . The e x p e r i m e n t a l s u b j e c t s w e r e g i v e n s p e c i f i c v e r b a l i n s t r u c t i o n s r e g a r d i n g t h e home c a r e o f t h e i r c h i l d r e n b e f o r e d i s c h a r g e , p l u s a l i s t o f w r i t t e n r e m i n d e r s . The c o n t r o l s u b j e c t s w e r e d i s c h a r g e d i n t h e r o u t i n e m a n n e r o f t h e E m e r g e n c y d e p a r t m e n t . A home v i s i t was made t o e a c h s u b j e c t f i v e t o t e n d a y s a f t e r d i s c h a r g e . T h r o u g h t h e a d m i n i s t r a t i o n o f a n o p e n - e n d e d i n t e r v i e w s c h e d u l e , t h e m o t h e r s ' a b i l i t i e s t o c o p e w e r e r e c o r d e d o n a n e v a l u a t i o n f o r m . A l s o , t h e i n f o r m a t i o n r e c e i v e d b y t h e c o n t r o l s u b j e c t s p r i o r t o d i s c h a r g e was a s s e s s e d . I n 62 a d d i t i o n , s e l e c t e d p e r s o n a l c h a r a c t e r i s t i c s o f t h e s u b j e c t s w e r e r e c o r d e d t o d e s c r i b e t h e p o p u l a t i o n . The M a n n - W h i t n e y U T e s t was u s e d t o t e s t t h e N u l l h y p o t h e s i s , r e s u l t i n g i n a r e j e c t i o n o f t h i s h y p o t h e s i s . E a c h i n d i v i d u a l e v a l u a t i n g o b j e c t i v e was a n a l y z e d u s i n g t h e F i s h e r E x a c t P r o b a b i l i t y t e s t w i t h t h e r e s u l t t h a t t h e two g r o u p s d i f f e r e d s i g n i f i c a n t l y i n f i v e o f t h e t w e n t y o b j e c t i v e s i n t h e p r o p o r t i o n w i t h w h i c h t h e y w e r e c l a s s i f i e d a s m e e t i n g o r n o t m e e t i n g e a c h o b j e c t i v e . A s f o u r o f t h e c o n t r o l s u b j e c t s r e c e i v e d i n f o r m a t i o n p a n p h l e t s o n c a s t c a r e a t home w h i c h w e r e d i s t r i b u t e d r o u t i n e l y i n o n e o f t h e h o s p i t a l s , t h e t o t a l s c o r e s o f t h e s e w e r e a n a l y z e d w i t h t h o s e n o t r e c e i v i n g t h e p a m p h l e t s . U s i n g t h e Mann-W h i t n e y U t e s t , no s i g n i f i c a n t d i f f e r e n c e was f o u n d . A l s o , t h e i n f o r m a t i o n o n c a s t c a r e a t home w h i c h t h e c o n t r o l s u b j e c t s r e p o r t e d t h e y h a d r e c e i v e d p r i o r t o d i s c h a r g e , was d i s c u s s e d . CONCLUSIONS F r o m t h e r e s u l t s o f t h i s s t u d y , t h e f o l l o w i n g c o n c l u s i o n i s d r a w n : A m o t h e r r e c e i v i n g p l a n n e d t e a c h i n g a c t i v i t i e s i s a b l e t o c o p e b e t t e r w i t h t h e home c a r e o f h e r c h i l d a n d h i s c a s t f o l l o w i n g t r e a t m e n t i n a n E m e r g e n c y d e p a r t m e n t , t h a n t h e m o t h e r n o t r e c e i v i n g t h i s p l a n n e d t e a c h i n g , p a r t i c u l a r l y i n t h e f o l l o w i n g a s p e c t s o f c a r e : - h a n d l i n g t h e w e t c a s t ; - c l e a n i n g a n d m a i n t a i n i n g t h e v i s i b l e p a r t s o f t h e l i m b u n d e r t h e c a s t ; - d i s c o u r a g i n g t h e c h i l d f r o m p l a c i n g o b j e c t s i n s i d e t h e c a s t ; - q u e s t i o n i n g t h e c h i l d t o d e t e c t s i g n s o f n e r v e t r a n s -m i s s i o n p r o b l e m s , i . e . numbness a n d / o r " t i n g l i n g " o f t h e a f f e c t e d l i m b ; - q u e s t i o n i n g t h e c h i l d t o d e t e c t s i g n s o f c i r c u l a t i o n i m p a i r m e n t , i . e . b u r n i n g , p a i n , a n d / o r m o i s t u r e u n d e r t h e c a s t . I MPLICATIONS The E m e r g e n c y d e p a r t m e n t i s b e c o m i n g i n c r e a s i n g l y c o n -c e r n e d w i t h p r o v i d i n g c a r e f o r p a t i e n t s t h r o u g h s i n g l e , s h o r t -t e r m e n c o u n t e r s . T h i s s e r v i c e i s n e c e s s a r y i n o r d e r t o r e l i e v e t h e o v e r - b u r d e n i n g o f a l r e a d y c r a m p e d i n - p a t i e n t a n d o u t - p a t i e n t f a c i l i t i e s . The l i m i t e d t i m e a v a i l a b l e f o r p r o v i d i n g c a r e m u s t b e u t i l i z e d i n a way t h a t w i l l p r o m o t e k n o w l e d g e a b l e p a t i e n t a n d f a m i l y p a r t i c i p a t i o n a n d c o o p e r a t i o n i n t h e c a r e a c t i v i t i e s a f t e r e m e r g e n c y t r e a t m e n t h a s b e e n a d m i n i s t e r e d , i . e . i n t h e home c a r e . P l a n n e d t e a c h i n g a c t i v i t i e s a r e t h e m o s t a p p r o p r i a t e m e t h o d f o r p r e p a r i n g t h e p a t i e n t a n d h i s f a m i l y f o r home c a r e . The r e s u l t s o f t h i s s t u d y s u g g e s t t h a t , a l t h o u g h t h e p h y s i c i a n i s c o n s i d e r e d t o b e t h e s o u r c e o f p a t i e n t t e a c h i n g i n t h e e m e r g e n c y s e t t i n g ( p e r h a p s b e c a u s e he i s o f t e n t h e l a s t p e r s o n t o s e e t h e p a t i e n t a n d h i s f a m i l y b e f o r e d i s c h a r g e ) , he d o e s n o t a p p e a r t o be a d e q u a t e l y f u l f i l l i n g t h i s r o l e o t h e r t h a n t o p r o v i d e a few i s o l a t e d f a c t s . I n t h i s s t u d y t h e s e f a c t s i n c l u d e d t h e r e a s o n f o r t h e c a s t a n d how much e x e r c i s e t h e c h i l d was a l l o w e d . R a t h e r t h a n s e e k more i n f o r m a t i o n f r o m t h e e m e r g e n c y d e p a r t m e n t s t a f f , some m o t h e r s s o u g h t a d v i c e r e g a r d i n g home c a r e f r o m o t h e r t h a n t h e p r o f e s s i o n a l h e a l t h t e a m . T h i s s u g g e s t s t h a t p a t i e n t s a n d t h e i r f a m i l i e s w a n t i n f o r m a t i o n t h a t w i l l e n a b l e them t o p r o v i d e k n o w l e d g e a b l e , c o m p e t e n t c a r e b u t a r e r e l u c t a n t t o " b o t h e r " t h e s t a f f w i t h t h e i r q u e s t i o n s u n l e s s e n c o u r a g e d t o do s o . A s t h e f i n d i n g s o f t h i s s t u d y s u g g e s t , p l a n n e d t e a c h i n g a c t i v i t i e s a r e n o t i c e a b l y a b s e n t i n t h e E m e r g e n c y d e p a r t m e n t a l t h o u g h t h e n e e d i s o b v i o u s . The s t u d y a l s o s u g g e s t s t h a t p l a n n e d t e a c h -i n g i n v o l v i n g o n l y w r i t t e n i n s t r u c t i o n s i s n o t n e c e s s a r i l y a n e f f e c t i v e m e t h o d o f t e a c h i n g u n l e s s t h e y a r e c o m p l e m e n t e d w i t h v e r b a l i n s t r u c t i o n s . P a t i e n t t e a c h i n g i s a r e c o g n i z e d f u n c t i o n o f t h e n u r s e p r a c t i t i o n e r . The r e s u l t s o f t h i s s t u d y show t h a t t h e n u r s e was m e n t i o n e d o n l y o n c e b y t h e c o n t r o l s u b j e c t s a s b e i n g a s o u r c e o f i n f o r m a t i o n b e f o r e d i s c h a r g e o t h e r t h a n a s t h e d i s t r i b u t o r o f t h e i n f o r m a t i o n p a m p h l e t t o t h e f o u r s u b j e c t s c o n c e r n e d . A s t h e a b i l i t i e s o f t h e m o t h e r s t o c o p e w i t h t h e home c a r e a f t e r r e c e i v i n g p l a n n e d v e r b a l a n d w r i t t e n i n s t r u c t i o n s h a v e b e e n shown t o b e b e t t e r t h a n t h o s e n o t r e c e i v i n g t h e s e p l a n n e d i n s t r u c t i o n s , n u r s e p r a c t i t i o n e r s i n t h e s e E m e r g e n c y d e p a r t m e n t s do n o t a p p e a r t o b e e x e r c i s i n g t h e i r t e a c h i n g f u n c t i o n . T h e r e f o r e , t h e r e s u l t s o f t h i s s t u d y s u g g e s t t h a t , i f p a t i e n t s a r e t o r e c e i v e c a r e t h a t i s c o m p a r a b l e t o t h e c a r e t h e y w o u l d r e c e i v e i n h o s p i t a l , t h e r e i s a d e f i n i t e n e e d f o r t h e n u r s e p r a c t i t i o n e r t o b e g i n e x e r c i s i n g h e r r o l e a s p a t i e n t t e a c h e r , s e r v i n g a s a l i a i s o n among p a t i e n t , h i s f a m i l y a n d t h e p r o f e s s i o n a l h e a l t h t e a m . RECOMMENDATIONS F r o m t h e r e s u l t s o f t h i s s t u d y , t h e f o l l o w i n g recommen-d a t i o n s a r e made: F o r N u r s i n g E d u c a t i o n : 1. T h a t t h e r o l e o f t h e n u r s e p r a c t i t i o n e r a s p a t i e n t t e a c h e r i n s h o r t - t e r m e m e r g e n c y s e t t i n g s a s w e l l a s i n l o n g - t e r m s e t t i n g s b e e m p h a s i z e d i n n u r s i n g s c h o o l c u r r i c u l a . 2. T h a t i n c r e a s i n g e m p h a s i s b e p l a c e d o n i n t e r p r o f e s s i o n a l c o m m u n i c a t i o n i n t h e e d u c a t i o n o f n u r s e s t o p r e p a r e them f o r e f f e c t i v e i n t e r p r o f e s s i o n a l p r a c t i c e . F o r N u r s i n g P r a c t i c e : 1. T h a t i n - s e r v i c e e d u c a t i o n p r o g r a m s b e c a r r i e d o u t f o r n u r s e p r a c t i t i o n e r s i n t h e e m e r g e n c y d e p a r t m e n t t o a s s i s t t h e m i n d e v e l o p i n g t h e i r p a t i e n t t e a c h i n g f u n c t i o n . 2. T h a t a w e l l p r e p a r e d r o l e m o d e l ( e . g . n u r s e c l i n i c i a n ) b e i n t r o d u c e d i n t o t h e e m e r g e n c y d e p a r t m e n t t o s e r v e a s a c a t a l y s t i n t h e d e v e l o p m e n t o f p a t i e n t t e a c h -i n g p r o g r a m s . T h a t a n u r s e p r a c t i t i o n e r i n t h e e m e r g e n c y d e p a r t -m e n t c a r r y o u t t h e r o l e o f " d i s c h a r g e n u r s e / " t o be c o n s u l t e d b e f o r e p a t i e n t s a r e d i s c h a r g e d t o e n s u r e t h a t t h e p a t i e n t a n d h i s f a m i l y a r e a d e q u a t e l y p r e -p a r e d f o r s e l f - c a r e . T h i s n u r s e c o u l d a l s o s e r v e a s a r e f e r r a l p o i n t t o o t h e r a g e n c i e s . F o r N u r s i n g R e s e a r c h : T h a t s t u d i e s b e c o n d u c t e d i n e m e r g e n c y d e p a r t m e n t s w i t h v a r i o u s t y p e s o f p a t i e n t s t o d e t e r m i n e w h a t p a t i e n t t e a c h i n g d o e s t a k e p l a c e / who c a r r i e s o u t t h i s p a t i e n t t e a c h i n g , o f w h a t d o e s i t c o n s i s t , how e f f e c t i v e i t i s , e t c . T h a t s t u d i e s o f t h e c h a n n e l s o f c o m m u n i c a t i o n among h e a l t h p r o f e s s i o n a l s i n t h e e m e r g e n c y d e p a r t m e n t b e made t o a s s e s s t h e i r e f f e c t i v e n e s s i n r e g a r d t o p a t i e n t t e a c h i n g a n d t o p r o v i d e i n d i c a t i o n s o f means f o r i m p r o v e m e n t . BIBLIOGRAPHY A. BOOKS B l o o m , B.S. ( e d . ) , e t a l . Taxonomy o f E d u c a t i o n a l O b j e c t i v e s : The C l a s s i f i c a t i o n o f E d u c a t i o n a l G o a l s - Handbook I : C o g n i t i v e D o m a i n . New Y o r k : D a v i d McKay Company, I n c . , 1 9 5 6 . C a m p b e l l , W i l l i a m G. F o r m a n d L i f e i n T h e s i s W r i t i n g . 3 r d e d . B o s t o n : H o u g h t o n M i f f l i n Company, 1 9 6 9 . D i x o n , W i l f r i d J . , a n d F r a n k J . M a s s e y , J r . I n t r o d u c t i o n t o  S t a t i s t i c a l A n a l y s i s . 3 r d e d . New Y o r k : M c G r a w - H i l l B o o k Company, 1 9 6 9 . E r i k s o n , F l o r e n c e . " N u r s i n g C a r e B a s e d o n N u r s i n g A s s e s s m e n t , " C u r r e n t C o n c e p t s i n C l i n i c a l N u r s i n g . I I . E d . B.S. B e r g e n s o n e t a l . S a i n t L o u i s : The C V . Mosby Company, 1 9 6 9 . F o l t a , J . R., a n d E . J . Deck ( e d s . ) . A S o c i o l o g i c a l F r a m e - w o r k f o r P a t i e n t C a r e . New York"! J o h n W i l e y a n d S o n s , I n c . , 1 9 6 6 . F o x , D a v i d J . F u n d a m e n t a l s o f R e s e a r c h i n N u r s i n g . 2nd e d . New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 7 0 . H e l m s t a d t e r , G . C R e s e a r c h C o n c e p t s i n Human B e h a v i o r . New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 7 0 . Howe, J e a n n e . " C h i l d r e n ' s I d e a s A b o u t I n j u r y , " ANA R e g i o n a l  C l i n i c a l C o n f e r e n c e s , 1 9 6 7 , P h i l a d e l p h i a / K a n s a s C i t y . New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 6 8 . J a c o , E. G a r t l y ( e d . ) . P a t i e n t s , P h y s i c i a n s a n d I l l n e s s . G l e n c o e , I l l i n o i s : The F r e e P r e s s , 1 9 5 8 . J a n i s , I r v i n g . P s y c h o l o g i c a l S t r e s s : P s y c h o a n a l y t i c a n d B e h a v i o r a l S t u d i e s o f S u r g i c a l P a t i e n t s . New Y o r k : J o h n W i l e y a n d S o n s , I n c . , 1 9 5 8 . J o h n s o n , E l i z a b e t h S. " U t i l i z a t i o n o f B e h a v i o r S c i e n c e C o n -c e p t s f o r a F a m i l y i n C r i s i s , " ANA R e g i o n a l C l i n i c a l  C o n f e r e n c e s , 1 9 6 9 , M i n n e a p o l i s / A t l a n t a . New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 7 0 . 68 L a r s o n , C a r r o l l B., a n d M a r j o r i e G o u l d . C a l d e r w o o d ' s O r t h o - p e d i c N u r s i n g . 5 t h e d . S a i n t L o u i s : The C.V. Mosby Company, 1 9 6 1 . L a t h a m , H e l e n C , a n d R o b e r t V. H e c k e l . P e d i a t r i c N u r s i n g . 2nd e d . S a i n t L o u i s : The C.V. M o s l e y Company, 1 9 7 2 . L i t t l e , D.E., a n d D.L. C a r n e v a l i . N u r s i n g C a r e P l a n n i n g . P h i l a d e l p h i a : J . B . L i p p i n c o t t Company, 1 9 6 9 . 0 ' G r a d y , R o b e r t a S. " R e s t r a i n t a n d t h e H o s p i t a l i z e d C h i l d , " C u r r e n t C o n c e p t s i n C l i n i c a l N u r s i n g . I I . E d . B.S. B e r g e n s o n e t a l . S a i n t L o u i s ! The C.V. Mosby Company, 1 9 6 9 . P l a n k , Emma N. W o r k i n g w i t h C h i l d r e n i n H o s p i t a l s . 2nd e d . C h i c a g o : P r e s s o f C a s e W e s t e r n R e s e r v e U n i v e r s i t y , 1 9 7 1 . Redman, B a r b a r a K. The P r o c e s s o f P a t i e n t T e a c h i n g i n N u r s i n g . S a i n t L o u i s : The C.V. Mosby Company, 1 9 6 8 . S c h u l t z , E.D., a n d E. R u d i c k ( e d s . ) N u r s i n g i n A m b u l a t o r y U n i t s . Dubuque: W i l l i a m C. B r o w n Company, P u b l i s h e r s , l9~g6T S i e g e l , S i d n e y . N o n p a r a m e t r i c S t a t i s t i c s f o r t h e B e h a v i o r a l  S c i e n c e s . New Y o r k : M c G r a w - H i l l Book Company, I n c . , 1 9 5 6 . S k i p p e r , J . K . , a n d R.C. L e o n a r d ( e d s . ) . S o c i a l I n t e r a c t i o n  a n d P a t i e n t C a r e . P h i l a d e l p h i a : J . B . L i p p e n c o t t Company, 1 9 6 5 . S t e e l e , S h i r l e y ( e d . ) . N u r s i n g C a r e o f t h e C h i l d w i t h L o n g - Term I l l n e s s . New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1 9 7 1 . B. PERIODICALS A l t , Richard. "Patient Education Program Answers Many Un-answered Questions," Hospitals, XL (November 16, 1966) , 76-78, 166 . Blake, Florence G. "Immobilized Youth: A R a t i o n a l l for Suppor-t i v e Nursing Intervention," American Journal of Nursing, LXIX (November, 1969), 2364-2369. 69 B l o m , G a s t o n E. "The R e a c t i o n s o f H o s p i t a l i z e d C h i l d r e n t o I l l n e s s , " P e d i a t r i c s , X X I I ( S e p t e m b e r , 1 9 5 8 ) , 5 9 0 -6 0 0 . B r i g h t , F l o r e n c e . "The P e d i a t r i c N u r s e a n d P a r e n t a l A n x i e t y . " N u r s i n g F o r u m , I V ( S p r i n g , 1 9 6 5 ) , 3 0 - 4 7 . C l i s s o l d , G.K., a n d C A . M e t z . " E v a l u a t i o n - A T a n g i b l e P r o c e s s , " N u r s i n g O u t l o o k , X I V ( M a r c h , 1 9 6 6 ) , 4 1 - 4 5 . C r o s s , J . E . , and C R . P a r s o n s . " N u r s e - T e a c h i n g a n d G o a l -D i r e c t e d N u r s e - T e a c h i n g t o M o t i v a t e C hange i n F o o d S e l e c t i o n B e h a v i o r o f H o s p i t a l i z e d P a t i e n t s , " N u r s i n g  R e s e a r c h , XX ( S e p t e m b e r - O c t o b e r , 1 9 7 1 ) , 4 5 4 - 4 5 7 . D a v i d , J a n i s H. " L i a i s o n N u r s e , " A m e r i c a n J o u r n a l o f N u r s i n g , L X I X ( O c t o b e r , 1 9 6 9 ) , 2 1 4 2 - 2 1 4 5 . D e a k e r s , L y n n P. " C o n t i n u i t y o f F a m i l y - C e n t e r e d N u r s i n g C a r e B e t w e e n t h e H o s p i t a l a n d t h e Home," N u r s i n g C l i n i c s  o f N o r t h A m e r i c a , V I I ( M a r c h , 1 9 7 2 ) , 8 3 - 9 3 Dodge, J o a n S. "How Much S h o u l d t h e P a t i e n t Be T o l d - A n d By Whom," H o s p i t a l s , X X X V I I (December 1 6 , 1 9 6 3 ) , 6 6 - 7 6 , 1 2 5 . . " N u r s e s ' S e n s e o f A d e q u a c y a n d A t t i t u d e s T o w a r d K e e p i n g P a t i e n t s I n f o r m e d , " J o u r n a l o f H e a l t h a n d  Human B e h a v i o r , I I ( F a l l , 1 9 6 1 ) , 2 1 3 - 2 1 6 . . " F a c t o r s R e l a t e d t o P a t i e n t s ' P e r c e p t i o n s o f T h e i r C o g n i t i v e N e e d s , " N u r s i n g R e s e a r c h , X V I I I (November-D e c e m b e r , 1 9 6 9 ) , 5 0 2 - 5 1 3 . D u r o c h e r , M a r y A n n . " P a r e n t E d u c a t o r i n t h e O u t p a t i e n t D e p a r t m e n t , " A m e r i c a n J o u r n a l o f N u r s i n g , LXV ( J u n e , 1 9 6 5 ) , 9 9 - 1 0 1 . E a t o n , P a t r i c i a , a n d F l o r e n c e H e l l e r . " T h e r a p e u t i c N u r s i n g C a r e o f O r t h o p e d i c P a t i e n t s , " N u r s i n g C l i n i c s o f N o r t h  A m e r i c a , I I ( S e p t e m b e r , 1967) , 4 2 9 - 4 3 5 . E i c h h o r n , M.E. " C h a l l e n g i n g R o l e o f C l i n i c N u r s e i n P a t i e n t L i a i s o n a n d S u p p o r t , " H o s p i t a l T o p i c s , X L V I I I ( F e b r u a r y , 1970) , 9 7 - 1 0 0 . E l l i n g , R a y , e t a l . " P a r e n t P a r t i c i p a t i o n i n a P e d i a t r i c P r o g r a m . " J o u r n a l o f H e a l t h a n d Human B e h a v i o r , I ( F a l l , 1960) , 183^T9I": 70 G i p s , C.G. "The I n t e r p r e t a t i o n a n d M i s i n t e r p r e t a t i o n . . . b y H o s p i t a l i z e d S c h o o l - a g e C h i l d r e n . . . o f B e i n g S i c k ; I m p l i c a t i o n s f o r N u r s i n g , " ANA C o n v e n t i o n  C l i n i c a l S e s s i o n s , I X (1965), 13-20. Gofman, H e l e n , e t a l . " P a r e n t s ' E m o t i o n a l R e s p o n s e t o C h i l d ' s H o s p i t a l i z a t i o n , " AMA J o u r n a l o f D i s e a s e s o f C h i l d r e n , X C I I I (1957), 629-6T7". ~" . "The C h i l d ' s E m o t i o n a l R e s p o n s e t o H o s p i t a l i z a t i o n , " AMA J o u r n a l o f D i s e a s e s o f C h i l d r e n , X C I I I (1957), 157-164. G r e e n , M.M. "The C o n c e r n s o f P a r e n t s o f a H o s p i t a l i z e d C h i l d , " ANA C o n v e n t i o n C l i n i c a l S e s s i o n s , V I I I (1964), 5-11. H a l l b u r g , J e a n n e C. " T e a c h i n g P a t i e n t s S e l f - C a r e , " N u r s i n g  C l i n i c s o f N o r t h A m e r i c a , V ( J u n e , 1970), 223-231. H e s s , G e r t r u d e , " H e a l t h C a r e N eeds I n h e r e n t i n E m e r g e n c y S e r v i c e s - C a n T h e y Be M e t ? " N u r s i n g C l i n i c s o f N o r t h  A m e r i c a , V ( J u n e , 1970), 243-249. H u s c h k a , M., a n d O Ogden, "The C o n d u c t o f a P e d i a t r i c P r o p h y -l a c i c C l i n i c , " J o u r n a l o f P e d i a t r i c s , X I I (1938), 794-800. K e n n e l l , J . H . , e t a l . "What P a r e n t s o f R h e u m a t i c F e v e r P a t i e n t s D o n ' t U n d e r s t a n d A b o u t t h e D i s e a s e a n d I t s P r o p h y l a c t i c Management," P e d i a t r i c s , X L I I I ( F e b r u a r y , 1969), 160-167. K i l p a t r i c k , H e l e n M. "The F r i g h t e n e d P a t i e n t i n t h e E m e r g e n c y Room," A m e r i c a n J o u r n a l o f N u r s i n g , L X V I (May, 1966), 1031-1032": K o r s c h , B a r b a r a M., a n d V i d a F r a n c i s N e g r e t e . " D o c t o r - P a t i e n t C o m m u n i c a t i o n , " S c i e n t i f i c A m e r i c a n , C C X X V I I ( A u g u s t , 1972), 66-74. L a n g f o r d , W.S. " P h y s i c a l I l l n e s s a n d C o n v a l e s c e n c e : T h e i r M e a n i n g t o t h e C h i l d , " J o u r n a l o f P e d i a t r i c s , X X X I I I ( J u l y - D e c e m b e r , 1948), 245-250. . "The C h i l d i n t h e P e d i a t r i c H o s p i t a l : A d a p t a t i o n zo I l l n e s s a n d H o s p i t a l i z a t i o n , " A m e r i c a n J o u r n a l o f  O r t h o p s y c h i a t r y , X X X I (1961), 667-684. 71 L e v i n e , E u g e n e . " E x p e r i m e n t a l D e s i g n i n N u r s i n g R e s e a r c h , " N u r s i n g R e s e a r c h , I X ( F a l l , 1 9 6 0 ) , 2 0 3 - 2 1 2 . L i n e h a n , D o r o t h y T. "What Does t h e P a t i e n t Want t o Know," A m e r i c a n J o u r n a l o f N u r s i n g , L X V I (May, 1966) , 1 0 6 6 -mnr. L i n d e m a n , C.A., a n d B. V a n A e r n a n . " N u r s i n g I n t e r v e n t i o n w i t h t h e P r e s u r g i c a l P a t i e n t - The E f f e c t s o f S t r u c t u r e d a n d U n s t r u c t u r e d P r e o p e r a t i v e T e a c h i n g , " N u r s i n g R e s e a r c h , XX ( J u l y - A u g u s t , 1 9 7 1 ) , 3 1 9 - 3 3 2 . M a h a f f e y , P.R. "The E f f e c t s o f H o s p i t a l i z a t i o n o n C h i l d r e n A d m i t t e d f o r T o n s i l l e c t o m y a n d A d e n o i d e c t o m y , " N u r s i n g R e s e a r c h , X I V , 1 ( 1 9 6 5 ) , 1 2 - 1 9 . M o n t e i r o , L o i s A. " N o t e s o n P a t i e n t T e a c h i n g - A N e g l e c t e d A r e a , " N u r s i n g F o r u m , I I I ( W i n t e r , 1 9 6 4 ) , 2 6 - 3 3 . 0 ' B o y l e , C a t h e r i n e . "A New E r a i n E m e r g e n c y S e r v i c e s , " A m e r i c a n J o u r n a l o f N u r s i n g , L X X I I ( A u g u s t , 1 9 7 2 ) , 1 3 9 2 - 1 3 9 7 . P a c k a r d , R o s e B., a n d H a r r i e t t V a n E s s . "A C o m p a r i s o n o f I n f o r m a l a n d R o l e - D e l i n e a t e d P a t i e n t T e a c h i n g S i t u a t i o n s , " N u r s i n g R e s e a r c h , V I I I ( S e p t e m b e r - O c t o b e r , 1969) , 4 4 3 - 4 4 6 . P a l m , M a r y L. " R e c o g n i z i n g O p p o r t u n i t i e s f o r I n f o r m a l P a t i e n t T e a c h i n g , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , V I (December, 1971) , 669-678 . P e l l e g r i n o , E.D. "The N u r s e M u s t Know, The N u r s e M u s t S p e a k , " A m e r i c a n J o u r n a l o f N u r s i n g , L X ( M a r c h , 1 9 6 0 ) , 3 6 0 -3 6 3 . P o h l , M a r g a r e t L . " T e a c h i n g A c t i v i t i e s o f t h e N u r s i n g P r a c t i t i o n e r , " N u r s i n g R e s e a r c h , X I V ( W i n t e r , 1 9 6 5 ) , 4 - 1 1 . P r a t t , M.A. "A H o s p i t a l i z e d P r e s c h o o l C h i l d C o p e s w i t h a F a t a l I l l n e s s , " ANA R e g i o n a l C l i n i c a l S e s s i o n s , X I I ( 1 9 6 8 ) , 1 9 0 - 1 9 8 . P r u g h , Dane G., e t a l . "A S t u d y o f t h e E m o t i o n a l R e a c t i o n s o f C h i l d r e n a n d F a m i l i e s t o H o s p i t a l i z a t i o n a n d I l l n e s s , " A m e r i c a n J o u r n a l o f O r t h o p s y c h i a t r y , X X I I I ( J a n u a r y , 1953) , IO^IW: 72 Redman, B a r b a r a K. " P a t i e n t E d u c a t i o n a s a F u n c t i o n o f N u r s -i n g P r a c t i c e , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , V I (December, 1971) , 513-5M~. S h e a h a n , M a r i o n W. " T h r o u g h C o m m u n i t y A c t i o n : A H e a l t h C o m m i s s i o n R e p o r t s , " A m e r i c a n J o u r n a l o f N u r s i n g , L X V I ( J u n e , 1 9 6 6 ) , 1 2 9 8 - 1 3 0 2 . S h r a n d , H. " B e h a v i o r C h a n g e s i n S i c k C h i l d r e n N u r s e d a t Home," P e d i a t r i c s , X X X V I ( O c t o b e r , 1 9 6 5 ) , 6 0 4 - 6 0 7 . S i m o n d s , S c o t t K. " H e a l t h E d u c a t i o n a n d M e d i c a l C a r e : F o c u s o n t h e P a t i e n t , " H e a l t h E d u c a t i o n M o n o g r a p h s , 16 ( 1 9 6 3 ) , 3 2 - 4 0 . S k i p p e r , J . K . , a n d R.C. L e o n a r d . " C h i l d r e n , S t r e s s , a n d H o s p i t a l i z a t i o n : A F i e l d E x p e r i m e n t , " J o u r n a l o f H e a l t h a n d S o c i a l B e h a v i o r , I X (De c e m b e r , 1 9 6 8 ) , 2 7 5 - 2 8 7 . S t a r f i e l d , B., and E. S h a r p . " A m b u l a t o r y P e d i a t r i c C a r e : The R o l e o f t h e N u r s e , " N u r s i n g R e s e a r c h , X V I I I (May-J u n e , 1969) , 2 7 7 . S t e i g e r , W i l l i a m A., "A D e f i n i t i o n o f C o m p r e h e n s i v e M e d i c i n e , " J o u r n a l o f H e a l t h a n d Human B e h a v i o r , I (Summer, I 9 6 0 ) , 8 3 - 8 6 . S t o r l i e , F r a n c i s . "A P h i l o s o p h y o f P a t i e n t T e a c h i n g , " N u r s i n g O u t l o o k , X I X ( J u n e , 1 9 7 1 ) , 3 8 7 - 3 8 9 . V e r n o n , D a v i d T.A., e t a l . "Changes i n C h i l d r e n ' s B e h a v i o r A f t e r H o s p i t a l i z a t i o n , " A m e r i c a n J o u r n a l o f D i s e a s e s  o f C h i l d r e n , C X I ( J u n e , 1 9 6 6 ) , 5 8 1 - 5 9 3 . Wang, M.K., a n d R.G. B r a y t o n . " H e a l t h M a i n t e n a n c e S e r v i c e f o r t h e H i g h - R i s k C h r o n i c a l l y 1 1 1 : A D e m o n s t r a t i o n o f C o l l a b o r a t i o n o f P h y s i c i a n a n d N u r s e , " N u r s i n g C l i n i c s  o f N o r t h A m e r i c a , V ( J u n e , 1 9 7 0 ) , 1 9 9 - 2 1 0 . Y o u n g , M a r j o r i e A.C. " R e v i e w o f R e s e a r c h a n d S t u d i e s R e l a t e d t o H e a l t h E d u c a t i o n P r a c t i c e ( 1 9 6 1 - 1 9 6 6 ) : P a t i e n t E d u c a t i o n , " H e a l t h E d u c a t i o n M o n o g r a p h s , 26 (1968) , 1-64. 73 C. CONFERENCE REPORTS A m e r i c a n A s s o c i a t i o n f o r C h i l d C a r e i n H o s p i t a l s . Needs o f  C h i l d r e n i n t h e H o s p i t a l . S e l e c t e d P a p e r s f r o m t h e S i x t h A n n u a l C o n f e r e n c e , A m e r i c a n A s s o c i a t i o n f o r C h i l d C a r e i n H o s p i t a l s , May 1 9 - 2 2 , 1 9 7 1 . C l e v e l a n d : A m e r i c a n A s s o c i a t i o n f o r C h i l d C a r e i n H o s p i t a l s , 1 9 7 2 . A m e r i c a n H o s p i t a l A s s o c i a t i o n . H e a l t h E d u c a t i o n i n t h e H o s p i t a l . P r o c e e d i n g s o f a n I n v i t a t i o n a l C o n f e r e n c e , C h i c a g o , May 4-6, 1 9 6 4 . C h i c a g o : A m e r i c a n H o s p i t a l A s s o c i a t i o n , 1 9 6 5 . i A P P E N D I X A I N S T R U C T I O N S G I V E N TO N U R S I N G S T A F F 1. EXPERIMENTAL CHILD'S NAME: HOSPITAL NUMBER: RESEARCHER N O T I F I E D : 2. CONTROL CHILD'S NAME: HOSPITAL NUMBER: 3. EXPERIMENTAL CHILD'S NAME: HOSPITAL NUMBER: RESEARCHER N O T I F I E D : 4. CONTROL CHILD'S NAME: HOSPITAL NUMBER: 5. EXPERIMENTAL CHILD'S NAME: HOSPITAL NUMBER: RESEARCHER N O T I F I E D : 6. CONTROL CHILD'S NAME: HOSPITAL NUMBER: 7. EXPERIMENTAL CHILD'S NAME: HOSPITAL NUMBER: RESEARCHER N O T I F I E D : 8. CONTROL CHILD'S NAME: HOSPITAL NUMBER: 9 . EXPERIMENTAL CHILD'S NAME: HOSPITAL NUMBER: RESEARCHER N O T I F I E D : A P P E N D I X B I N S T R U M E N T S U S E D I N T H E S T U D Y 78 TEACHING GUIDE P u r p o s e : To p r e p a r e t h e m o t h e r f o r c a r i n g a t home f o r h e r c h i l d who h a s a n e w l y c a s t e d l i m b , b y p r o v i d i n g h e r w i t h t h e f o l l o w i n g i n f o r m a t i o n : 1. C l a r i f i c a t i o n o f t h e r e a s o n f o r t h e c a s t . 2. I n f o r m a t i o n o n how t o c a r e f o r t h e c a s t i t s e l f , s t r e s s i n g - how t o h a n d l e a w e t c a s t w i t h t h e p a l m s o f t h e h a n d s - how t o k e e p i t d r y - how t o p r e v e n t b r e a k a g e - w h a t t o do s h o u l d t h e c a s t become w e t o r b r o k e n - how t o k e e p t h e e d g e s o f t h e o f t h e c a s t s m o o t h . 3. I n f o r m a t i o n o n c a r i n g f o r t h e c a s t e d l i m b , s t r e s s i n g - how t o e x e r c i s e t h e c a s t e d l i m b - how t o s u p p o r t t h e c a s t e d l i m b - how t o u s e a u x i l i a r y d e v i c e s ( s l i n g s , c r u t c h e s ) - how t o c l e a n a n d m a i n t a i n t h e e x p o s e d p a r t s o f t h e l i m b u n d e r t h e c a s t e d g e s - t h e n e e d t o d i s c o u r a g e t h e c h i l d f r o m p l a c i n g o b j e c t s i n s i d e t h e c a s t . 4. I n f o r m a t i o n o n t h e s i g n s a n d symptoms o f c o m p l i c a t i o n s , s t r e s s i n g w h a t t o l o o k f o r , how t o t e s t f o r i t , a n d w h a t t o do a b o u t i t . T h e s e s i g n s a n d symptoms w i l l i n c l u d e : - t h e p r e s e n c e o f edema i n e x p o s e d a r e a s s u r r o u n d i n g a n d / o r d i s t a l t o t h e c a s t - p a l l o r a n d / o r c y a n o s i s o f t h e s k i n a n d n a i l s s u r r o u n d -i n g a n d / o r d i s t a l t o t h e c a s t - c o l d n e s s i n t h e t e m p e r a t u r e o f t h e s k i n s u r r o u n d i n g a n d / o r d i s t a l t o t h e c a s t e d a r e a - numbness a n d / o r t i n g l i n g o f t h e c a s t e d a r e a i t s e l f o r t h e e x p o s e d a r e a d i s t a l t o i t - t h e p r e s e n c e o f f o u l o d o r s f r o m u n d e r t h e c a s t - t h e s u b j e c t i v e p r e s e n c e o f b u r n i n g , p a i n , a n d / o r m o i s t u r e u n d e r t h e c a s t . 79 REMINDERS TO HELP YOU CARE FOR YOUR CHILD AND HIS CAST AT HOME 1. Handle the wet c a s t w i t h the palms o f the hands, making sure not to use the f i n g e r t i p s . 2. Support the wet c a s t on p i l l o w s when a t r e s t . 3. Keep the l e g o r arm e l e v a t e d to pre v e n t s w e l l i n g which i s u s u a l l y the cause of p a i n and impaired b l o o d supply. 4. Check f o r s w e l l i n g by d e p r e s s i n g the s k i n around the c a s t , or by comparing the exposed p a r t s o f the a f f e c t e d limb w i t h those of the u n a f f e c t e d l i m b — f o r example, comparing the f o o t of the broken l e g w i t h t h a t o f the "good" l e g . I f s w e l l i n g i s p r e s e n t , the limb should be e l e v a t e d . 5. Check f o r impaired b l o o d supply by (a) l o o k i n g a t the c o l o r o f the surrounding s k i n a r e a — i t should be a normal s k i n c o l o r and not a v e r y p a l e or b l u i s h c o l o r ; o r (b) by p r e s s i n g a n a i l i n a f i n g e r o r toe of the limb w i t h the c a s t - - i f i t r e t u r n s t o a normal p i n k c o l o r q u i c k l y , the bl o o d supply i s a l r i g h t , b u t i f i t r e t u r n s s l o w l y , the b l o o d supply i s im p a i r e d . In the case o f impairment, check a g a i n f o r s w e l l i n g . 6. Ask your c h i l d i f the arm o r l e g f e e l s t i n g l y . I f the answer i s yes, check f o r s w e l l i n g and check the support (e.g. s l i n g ) . 7. Smell the c a s t f o r f o u l o d o r s . I f these a re present,, c a l l your d o c t o r immediately. 8. A l l o w your c h i l d to use the arm o r l e g as much as the d o c t o r p e r m i t t e d . 9. Keep the c a s t d r y . I f i t becomes s o f t , wet o r broken,, n o t i f y your d o c t o r . 10. Keep the c a s t edges smooth w i t h s t o c k i n e t t e and/or adhesive tape. 11. C l e a n under the edges o f the c a s t , d r y thoroughly, and rub d a i l y . 12. Discourage your c h i l d from p u t t i n g a r t i c l e s i n s i d e the c a s t . 13. I f your c h i l d complains o f f r e q u e n t p a i n under the c a s t , c a l l your d o c t o r . TF VOTT ARF. UNSURE OF ANV STGN WHTCH PERSISTENT AND WHICH MIGHT CAUSE YOU TO WORRY, DO NOT HESITATE TO CALL YOUR DOCTOR. INTERVIEW SCHEDULE 80 1. Do y o u u n d e r s t a n d why X h a s t o w e a r a c a s t ? 2. How d i d y o u h a n d l e t h e w e t c a s t ? 3. Have y o u h a d a n y d i f f i c u l t y i n c a r i n g f o r t h e c a s t ? (a) Has t h e c a s t become w e t ? - I f y e s : How d i d t h i s h a p p e n ? What d i d y o u do f o r i t ? - I f no: How h a v e y o u k e p t i t d r y ? (b) Has i t become b r o k e n ? - I f y e s : How d i d t h i s h a p p e n ? What d i d y o u do f o r i t ? - I f n o : How h a v e y o u k e p t i t i n t a c t ? (c) Have y o u b e e n a b l e t o k e e p t h e e d g e s s m o o t h ? How h a v e y o u d o n e t h i s ? 4„ (a) What d o e s X do w i t h h i s l e g when h e ' s r e s t i n g -w a t c h i n g t e l e v i s i o n , f o r e x a m p l e ? (b) I s X s t i l l w e a r i n g a s l i n g ? I f y e s : Does h e k e e p h i s h a n d i n s i d e ? I f n o : Why n o t ? 5. Has X h a d a n y d i f f i c u l t y u s i n g c r u t c h e s ? (a) Where d o e s he c o m p l a i n o f s o r e n e s s - h i s h a n d s , h i s a r m p i t s ? 6. How m u s t h a s X b e e n u s i n g h i s a r m / l e g ? (a) I s t h i s a s much a s t h e d o c t o r p e r m i t t e d ? (b) I f n o t , why n o t ? 7. Have y o u g i v e n any s p e c i a l c a r e t o t h e s k i n u n d e r t h e e d g e s o f t h e c a s t ? (a) What h a v e y o u d o n e ? 8. Has X p u t a n y t h i n g down i n s i d e t h e c a s t t h a t y o u a r e a w a r e o f ? (a) I f y e s : How d i d he do i t ? 4 Why d i d he do i t ? (b) I f n o : How d i d y o u p r e v e n t t h i s f r o m h a p p e n i n g ? 9. Have y o u c h e c k e d f o r s i g n s o f c o m p l i c a t i o n s ? (a) What w e r e y o u l o o k i n g f o r ? (b) How d i d y o u c h e c k f o r i t ? (c) What d i d y o u do a b o u t i t ? 10. Have y o u h a d any s p e c i a l p r o b l e m s i n t a k i n g c a r e o f X an d h i s c a s t ? 81 EVALUATION FORM OF MOTHER'S COPING A B I L I T I E S BEHAVIORAL O B J E C T I V E S S a t i s f a c t o r y A c h i e v e -m e n t o f O b j e c t i v e s YES NO N/A 1. M o t h e r u n d e r s t a n d s t h e r e a s o n f o r t h e c a s t . 2. M o t h e r u n d e r s t a n d s how t o c a r e f o r t h e c a s t . (a) By h a n d l i n g t h e w e t c a s t w i t h t h e p a l m s o f t h e h a n d s . (b) By k e e p i n g i t a s d r y a s p o s s i b l e (c) By k e e p i n g i t a s i n t a c t a s p o s s i b l e (d) B y c a r i n g a p p r o p r i a t e l y f o r t h e damaged c a s t (e) By k e e p i n g t h e c a s t e d g e s s m o o t h 3. M o t h e r u n d e r s t a n d s how t o c a r e f o r t h e c a s t e d l i m b . (a) Has s o u g h t t o k e e p t h e l i m b p r o p e r l y s u p p o r t e d (b) Has a l l o w e d t h e c h i l d t h e amount o f a c t i v i t y p e r m i t t e d b y t h e d o c t o r (c) Has c l e a n e d a n d m a i n t a i n e d t h e e x p o s e d p a r t s o f t h e l i m b u n d e r c a s t e d g e s (d) Has d i s c o u r a g e d c h i l d f r o m p l a c -i n g o b j e c t s i n s i d e t h e c a s t (e) Has e n c o u r a g e d c h i l d t o u s e c r u t c h e s p r o p e r l y 4. M o t h e r u n d e r s t a n d s t h e s i g n s a n d symptoms o f c o m p l i c a t i o n s — l o o k s f o r s i g n s a n d symptoms a n d d e a l s w i t h them a p p r o p r i a t e l y i f p r e s e n t . (a) Has d e p r e s s e d t h e s k i n s u r r o u n d -i n g t h e c a s t t o d e t e r m i n e t h e p r e s e n c e o f edema o r (b) Has c o m p a r e d t h e s i z e s o f b o t h l i m b s t o d e t e r m i n e t h e p r e s e n c e o f edema (c) Has l o o k e d f o r p a l l o r a n d / o r c y a n o s i s o f s k i n s u r r o u n d i n g o r d i s t a l t o t h e c a s t o r 82 YES NO N/A (d) Has c a r r i e d out "blanch-in g technique (e) Has f e l t the temperature of the s k i n surrounding and/or d i s t a l to the casted area (f) Has cared f o r c i r c u l a t o r y problems a p p r o p r i a t e l y (g) Has questioned the c h i l d res numbness and/or " t i n g l i n g " of any p a r t of the a f f e c t e d limb (h) Has cared f o r nerve t r a n s m i s s i o n problems a p p r o p r i a t e l y (i ) Has smelled the c a s t f o r f o u l odors (j) Has questioned the c h i l d r e : burning, p a i n , and/or moisture under the c a s t (k) Has cared a p p r o p r i a t e l y f o r s i g n s of pressure sores under the c a s t 83 CONTROL GROUP INFORMATION ASSESSMENT INFORMATION S o u r c e o f I n f o r m a t i o n S a t i s f i e d Y e s No No I n f o r -m a t i o n C l a r i f i c a t i o n o f t h e r e a s o n f o r t h e c a s t . I n f o r m a t i o n o n how t o c a r e f o r t h e c a s t i t s e l f (a) how t o h a n d l e a w e t c a s t (b) how t o k e e p i t d r y (c) how t o p r e v e n t b r e a k a g e (d) w h a t t o do i f t h e c a s t b ecomes w e t o r b r o k e n (e) how t o k e e p t h e e d g e s o f t h e c a s t s m o o t h I n f o r m a t i o n o n c a r i n g f o r t h e c a s t e d l i m b (a) how t o e x e r c i s e t h e c a s t e d l i m b (b) how t o s u p p o r t t h e c a s t e d l i m b (c) how t o u s e a u x i l i a r y d e v i c e s (d) how t o c l e a n a n d m a i n t a i n t h e e x p o s e d p a r t s o f l i m b u n d e r c a s t (e) n e e d t o d i s c o u r a g e c h i l d f r o m p l a c i n g o b j e c t s i n s i d e c a s t I n f o r m a t i o n o n s i g n s a n d symptoms o f c o m p l i c a t i o n s — w h a t t o l o o k f o r , how t o t e s t f o r i t , w h a t t o do a b o u t i t . (a) p r e s e n c e o f edema i n a f f e c t e d l i m b (b) p a l l o r a n d / o r c y a n o s i s o f s k i n a n d n a i l s o f a f f e c t e d l i m b (c) c o l d n e s s i n t e m p e r a t u r e o f t h e s k i n s u r r o u n d i n g c a s t 84 Source of Information S a t i s f i e d Yes No No I n f o r -mation (d) numbness and/or t i n g l i n g of the casted and surround-i n g area (e) s u b j e c t i v e presence of burning, p a i n , and/or moisture under c a s t PERSONAL DATA FORM C h i l d ' s a g e l a s t b i r t h d a y (a) 6 y e a r s (b) 7 y e a r s (c) 8 y e a r s (d) 9 y e a r s (e) 10 y e a r s ( f ) 11 y e a r s (g) 12 y e a r s C h i l d ' s s e x (a) m a l e (b) f e m a l e C h i l d ' s r a c e (a) w h i t e (b) o r i e n t a l (c) o t h e r Number o f s i b l i n g s (a) none .(b) 1 (c) 2-3 (d) 4-5 (e) o v e r 5 Number o f p r e v i o u s h o s p i t a l i z a t i o n s o f c h i l d (a) n o n e IZZZ <b> 1 ZZZI <c> 2 (d) more t h a n 2 Number o f p r e v i o u s c a s t s (a) n o n e ZZZI (b) 1 ( c ) 2 (d) more t h a n 2 Age o f m o t h e r (a) l e s s t h a n t w e n t y (b) 20-24 (c) 25-29 (d) 30-34 (e) 35-39 ( f ) 40 o r O v e r 86 8. M a r i t a l s t a t u s o f m o t h e r (a) s i n g l e (b) m a r r i e d (c) w i d o w e d (d) d i v o r c e d (e) s e p a r a t e d 9. H i g h e s t e d u c a t i o n o f m o t h e r (a) a t t e n d e d g r a d e s c h o o l (b) c o m p l e t e d g r a d e s c h o o l (c) a t t e n d e d h i g h s c h o o l (d) c o m p l e t e d h i g h s c h o o l (e) v o c a t i o n a l t r a i n i n g i n h i g h s c h o o l ( f ) v o c a t i o n a l t r a i n i n g p o s t h i g h s c h o o l (g) a t t e n d e d u n i v e r s i t y (h) c o m p l e t e d u n i v e r s i t y 10. M o t h e r ' s p r e v i o u s e x p e r i e n c e s w i t h c a s t s (a) none (b) o n c e (c) t w i c e (d) more t h a n t w i c e 11. A p p a r e n t g e n e r a l h e a l t h a n d m o b i l i t y o f m o t h e r - (a) g o o d (b) f a i r ( c ) p o o r 12. E m p l o y m e n t o f m o t h e r o u t s i d e t h e home (a) none (b) p a r t - t i m e e m p l o y m e n t (c) f u l l - t i m e e m p l o y m e n t APPENDIX C INFORMATION PAMPHLET ON CAST CARE AT HOME DISTRIBUTED BY ONE HOSPITAL This pamphlet i s designed to help you to care for your cast at home. WHAT IS A CAST?' A cast is a rig i d dressing composed of gauze bondages impregnated with plaster of paris. The gauze is applied wot so that the hardened cast w i l l conform to the shape of the injured part. During or shortly after cast application you may have noticed that your cast f e l t quite warm. This is due to a chemical reaction which occurs in the wet plaster. It w i l l subside in 10 to 20 minutes, depending on the thickness of your cast. PURPOSE OP A CAST A cast is applied to an injured part to support and protect i t during healing. Handle with care un t i l i t has dried completely. This w i l l take an hour or more, depending on i t s size and thickness. 48 hours - weightbearing MANAGING A CAST ON A LIMB Any cast is quite heavy and cumbersome. Because of this, they require extra support. An arm must be suirported by a sling when standing or s i t t i n g , or by a pillow when sitting. A leg must be elevated on a stool when you s i t down. This elevation is to help avoid or decrease sAvelling of the limb due to 'pooling' of f l u i d in the tissues„ ACTIVITY VITH A CAST Your allowed activities w i l l depend greatly on the location of your cast. Regardless of the location of your cast, avoid strenous or danger-ous a c t i v i t i e s , c„g. skiing, football, as participating in such activities might crack your cast. I f your cast i s on a limb you should be able to wiggle the fingers or toes of the involved hand or f o o t o Do this several times a day. This w i l l help to maintain the circulation and provides some-exercise for the involved muscles and tendons. The length of time your cast stays on depends on the severity of your injury. Your doctor w i l l indicate the approximate time you w i l l need a cast. POINTS TO REMEMBER 1„ Keep your cast dry. If you shower or bath, keep the cast dry. Do not go swimming. A plastic cover w i l l protect i t i f i t is raining or i f the street is wet. 2 0 Keep your cast as clean as possible A small amount of powdered household cleanser on a damp — Not wet — cloth may be used to clean your cast, 3. Protect your cast. Avoid knocks and bangs that could crack your cast. This could cause a change in the alignment of the involved structures. 4. Protect your toes and fingers from the cold by a cover. A man's sock is a good cover for the toes. CALL YOUR DOCTOR IF: - your fingers or toes become numb or discoloured or your cast feels very tight or slides. - any cracks or breaks in your cast should occur - your cast has a foul smell, or i f there is a discharge on your cast from the tissues under your cast. If you have any problem with your cast, cither your doctor or the staff of the Hospital Emergency Department w i l l be pleased to help you. 

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