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UBC Theses and Dissertations

An experimental study to evaluate the effect of planned teaching on self-medication practices of older… Goodman, Gertrude Warkentin 1972

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AN EXPERIMENTAL STUDY TO E V A L U A T E THE E F F E C T OF PLANNED TEACHING ON S E L F - M E D I C A T I O N P R A C T I C E S OF OLDER AMBULATORY CARDIAC P A T I E N T S by GERTRUDE WARKENTIN GOODMAN B . S . N . , U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1970 A THESIS SUBMITTED IN P A R T I A L F U L F I L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF -MASTER OF S C I E N C E IN NURSING i n t h e S c h o o l o f N u r s i n g We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA A p r i I , 1972 In presenting t h i s thesis i n p a r t i a l fulfilment of the requirements for an advanced, degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t freely available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the Head of my Department or by h i s representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia Vancouver 8, Canada i i ABSTRACT T h i s e x p e r i m e n t a l s t u d y was d e s i g n e d to e v a l u a t e the e f f e c t o f p l a n n e d t e a c h i n g on the s e l f - m e d i c a t i o n p r a c t i c e s o f a m b u l a t o r y c a r d i a c p a t i e n t s . The sample was composed o f f o r t y male and f e m a l e c a r d i a c p a t i e n t s who were ove r the age o f f o r t y - f i v e y e a r s , who l i v e d a t home and were of low s o c i o - e c o n o m i c s t a t u s . They a l l l i v e d i n a l a r g e urban c e n t r e and a t t e n d e d an o u t p a t i e n t c l i n i c f o r m e d i c a l a t t e n t i o n . A l l were t a k i n g d i g o x i n and t h i r t y - s i x , 1 8 f r om each g r o u p , were a l s o t a k i n g a d i u r e t i c . They were randomly a s s i g n e d to two g r o u p s , e x p e r i m e n t a l and c o n t r o l , when t h e y v i s i t e d the o u t p a t i e n t c l i n i c . The twen ty p a t i e n t s i n the c o n t r o l group were g i v e n the usua l r o u t i n e f a c t u a l i n f o r m a t i o n d u r i n g t h e i r c l i n i c v i s i t . The twenty p a t i e n t s i n the e x p e r i m e n t a l group r e c e i v e d a d d i t i o n a l p l a n n e d t e a c h i n g over a t h i r t y - m i n u t e p e r i o d by the r e s e a r c h e r . The da ta were g a t h e r e d by means o f a t w e n t y - i t e m q u e s t i o n n a i r e d e s i g n e d t o e l i c i t i n f o r m a t i o n r e g a r d i n g the s e l f - m e d i c a t i o n b e h a v i o r o f the s t u d y p o p u l a t i o n . The q u e s t i o n n a i r e was a d m i n i s t e r e d i n the homes o f the p a t i e n t s ten t o f o u r t e e n days f o l l o w i n g t h e i r v i s i t to the o u t p a t i e n t c l i n i c . Three h y p o t h e s e s were t e s t e d i n the s t u d y . A n a l y s i s o f the da ta i n r e l a t i o n to H y p o t h e s i s I i n d i c a t e d a i i i i v 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 i n the number o f s e l f - m e d i c a t i o n e r r o r s i n d i g o x i n and d i u r e t i c s made i n a t w e n t y - f o u r - h o u r p e r i o d by p a t i e n t s i n the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p . The e x p e r i m e n t a l group made s i g n i f i c a n t l y f ewer e r r o r s . A l t h o u g h p a t i e n t s i n the e x p e r i m e n t a l group made fewer e r r o r s o f the f o u r t y p e s o f e r r o r s s t u d i e d w i t h r e g a r d t o H y p o t h e s i s I I , t h e r e was not 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 i n e r r o r s r e l a t e d t o t i m e , dosage and n o n - p r e s c r i b e d m e d i c a t i o n s made i n a t w e n t y - f o u r - h o u r p e r i o d by p a t i e n t s i n the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p . There was , however , 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 i n the f o u r t h t ype o f e r r o r - - t h a t o f o m i s s i o n . The t e s t i n g o f H y p o t h e s i s I I I 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 i n the l e v e l o f knowledge o f the two g roups o f p a t i e n t s . The e x p e r i m e n t a l group had a h i g h e r l e v e l o f knowledge o f t h e i r m e d i c a t i o n s . The s t u d y c o n c l u d e s w i t h c o n s i d e r a t i o n o f i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e and r e s e a r c h . 86 pages ACKNOWLEDGEMENTS My thanks a r e e x p r e s s e d to D r . D. S . Munroe , M r s . D. Babcock and the s t a f f and p a t i e n t s o f the Vancouver Gene ra l H o s p i t a l O u t p a t i e n t Depar tment f o r c o o p e r a t i o n and a s s i s t a n c e ; to D r . F . P . G l i c k o f the U n i v e r s i t y o f B r i t i s h C o l u m b i a f o r c o n s u l t a t i v e t ime on sample s e l e c t i o n and s t a t i s t i c a l a n a l y s i s ; to my c o m m i t t e e , P r o f e s s o r s He len E l f e r t and K i r s t e n Weber f o r s u g g e s t i o n s and c r i t i c i s m s ; to the o u t s i d e i n t e r v i e w e r s , M r s . W i n n i f r e d M i l l e r and M r s . Ruth L a p o i n t e f o r w o r k i n g w i l l i n g l y and c o m p e t e n t l y ; and to my p a r e n t s f o r t h e i r encouragement and i n s p i r a t i o n . v T A B L E OF CONTENTS Pa ge ACKNOWLEDGEMENTS v L I S T OF TABLES i x L I S T OF F IGURES x i C h a p t e r 1 . INTRODUCTION 1 INTRODUCTION TO THE PROBLEM 1 STATEMENT OF THE PROBLEM 2 S I G N I F I C A N C E OF THE PROBLEM 2 THE NEED FOR RESEARCH 6 2 . RESUME' OF PRESENT KNOWLEDGE 8 INCIDENCE OF S E L F - M E D I C A T I O N ERRORS . . . . 8 THE TEACHING FUNCTION OF A NURSE 12 THE ROLE OF THE NURSE IN THE OUTPATIENT C L I N I C 14 SUMMARY 17 3. THE DESIGN OF THE STUDY 19 GENERAL AIM OF THE STUDY 19 S P E C I F I C O B J E C T I V E S OF THE STUDY 19 THE HYPOTHESES 20 V A R I A B L E S INCLUDED IN THE STUDY 20 D E F I N I T I O N OF TERMS 21 L IM ITAT IONS OF THE STUDY 23 ASSUMPTIONS 24 v i v i i C h a p t e r Page 4. METHODOLOGY 2 5 THE SAMPLE 2 5 THE BIOGRAPHICAL DATA 2 5 THE PLANNED TEACHING 26 THE QUESTIONNAIRE 2 7 P u r p o s e o f t h e Q u e s t i o n n a i r e 2 7 C o n s t r u c t i o n o f t h e Q u e s t i o n n a i r e . . . . 2 7 P r e - t e s t o f t h e Q u e s t i o n n a i r e 28 A d m i n i s t r a t i o n o f t h e Q u e s t i o n n a i r e . . . 2 9 R e l i a b i l i t y , V a l i d i t y and P r a c t i c a b i l i t y o f t h e Q u e s t i o n n a i r e 30 METHOD OF DATA A N A L Y S I S 33 5. A N A L Y S I S OF THE DATA 35 THE STUDY POPULATION 35 SUMMARY OF THE DATA 37 A N A L Y S I S IN RELATION TO HYPOTHESIS I . . . . 47 A N A L Y S I S IN RELATION TO HYPOTHESIS II . . . 50 ANALYSIS IN RELATION TO HYPOTHESIS II I . . . 5 2 SUMMARY OF RESULTS OF DATA A N A L Y S I S . . . . 53 6. SUMMARY, IMPLICATIONS FOR NURSING P R A C T I C E , AND RECOMMENDATIONS FOR FURTHER STUDY . . . 55 SUMMARY 55 IMPLICATIONS FOR NURSING P R A C T I C E 5 6 RECOMMENDATIONS FOR FURTHER STUDY 58 BIBLIOGRAPHY 62 APPENDICES 67 A . I n t r o d u c t i o n t o t h e P a t i e n t 68 v i i i Pa ge B . B i o g r a p h i c a l D a t a F o r m 70 C . S e m i - S t r u c t u r e d I n t e r v i e w G u i d e F o l l o w e d i n P a t i e n t T e a c h i n g 72 D. A T e a c h i n g D i s c u s s i o n w i t h a P a t i e n t 75 E . The Q u e s t i o n n a i r e 80 F . L i s t o f A l l M e d i c a t i o n s P r e s c r i b e d f o r t h e S t u d y P o p u l a t i o n 84 G . S t a t i s t i c a l T r e a t m e n t o f t h e Da ta 86 LIST OF TABLES T a b l e Page 1. S e x , A g e , L i v i n g Ar rangement and T o t a l Number o f M e d i c a t i o n s o f P a t i e n t s i n the E x p e r i m e n t a l Group 38 2 . S e x , A g e , L i v i n g Ar rangement and T o t a l Number o f M e d i c a t i o n s o f P a t i e n t s i n the C o n t r o l Group 39 3 . Number and P e r c e n t a g e o f Types o f S e l f -M e d i c a t i o n E r r o r s i n M e d i c a t i o n s Other Than D i g o x i n and D i u r e t i c s Made by Both Groups 42 4 . Number o f P a t i e n t s i n Both Groups who Made S e l f - M e d i c a t i o n E r r o r s i n the T o t a l M e d i c a t i o n Reg imen , w i t h Regard t o Age Group , and Mean Number o f E r r o r s per P a t i e n t i n Each Age Group 44 5 . Number and P e r c e n t a g e o f P a t i e n t s i n Both Groups Who Made S e I f - M e d i c a t i o n E r r o r s i n D i g o x i n and D i u r e t i c s as E v i d e n c e d by the Three I n t e r v i e w e r s 48 6 . Number o f S e l f - M e d i c a t i o n E r r o r s o f D i g o x i n and D i u r e t i c s Made Pe r P a t i e n t by Both Groups 49 7 . Number o f S e l f - M e d i c a t i o n E r r o r s o f T a k i n g N o n - P r e s c r i p t i o n M e d i c a t i o n Made by Both Groups 5 0 8 . Number o f E r r o r s o f O m i s s i o n i n S e l f -M e d i c a t i o n o f D i g o x i n and D i u r e t i c s Made by Both Groups 51 9 . Number o f E r r o r s o f Improper Time i n S e l f -M e d i c a t i o n o f D i g o x i n and D i u r e t i c s Made by Both Groups 51 1 0 . Number o f E r r o r s o f I n c o r r e c t Dosage i n S e l f - M e d i c a t i o n o f D i g o x i n and D i u r e t i c s Made by Both Groups 52 i x X T a b l e Page 11. L e v e l o f Knowledge o f S e l f - M e d i c a t i o n o f D i g o x i n and D i u r e t i c s of Both Groups . . . . 53 LIST OF FIGURES F i g u r e Page 1. P e r c e n t a g e D i s t r i b u t i o n o f S e l f - M e d i c a t i o n E r r o r s i n D i g o x i n and D i u r e t i c s , and O the r M e d i c a t i o n s , and Ave rage L e v e l o f Knowledge o f D i g o x i n and D i u r e t i c s , and O the r M e d i c a t i o n s , o f Both E x p e r i m e n t a l and C o n t r o l Groups 41 2. P e r c e n t a g e D i s t r i b u t i o n o f S e l f - M e d i c a t i o n E r r o r s i n the T o t a l M e d i c a t i o n Regimen o f Bo th E x p e r i m e n t a l and C o n t r o l Groups w i t h Regard to L i v i n g A r rangemen ts 45 x i C h a p t e r 1 INTRODUCTION I. INTRODUCTION TO THE PROBLEM The g e n e r a l p u r p o s e o f t h i s s t u d y was t o e v a l u a t e the e f f e c t o f p l a n n e d t e a c h i n g on t h e s e l f - m e d i c a t i o n p r a c t i c e s o f a m b u l a t o r y c a r d i a c p a t i e n t s o v e r t h e age o f f o r t y - f i v e y e a r s , who were l i v i n g a t home. C o m m u n i t y n u r s i n g e x p e r i e n c e r e v e a l e d t o t h e r e s e a r c h e r t h a t e r r o r s i n s e l f - m e d i c a t i o n were made by p a t i e n t s l i v i n g a t home. The l i t e r a t u r e s u p p o r t e d t h i s o b s e r v a t i o n . The m e d i c a t i o n r e g i m e n p l a y s a v i t a l r o l e i n t h e t r e a t m e n t o f t h e a m b u l a t o r y c a r d i a c p a t i e n t . ^ The numbers o f o u r p o p u l a t i o n i n the age g r o u p o f f o r t y - f i v e y e a r s and o v e r a r e i n c r e a s i n g , and the l e a d i n g c a u s e o f d e a t h i n C a n a d a o f i n d i v i d u a l s i n t h i s age g r o u p i s c a r d i o v a s c u l a r d i s e a s e . T h e r e f o r e a s t u d y o f the s e l f - m e d i c a t i o n b e h a v i o r o f t h i s s e g m e n t o f o u r p o p u l a t i o n was deemed t o be a t i m e l y and w o r t h w h i l e e n d e a v o r . 'Amy B . H e c h t , " S e l f - M e d i c a t i o n , I n a c c u r a c y , and What Can Be D o n e , " N u r s i n g O u t l o o k . V o l . X V I I I , N o . 4 ( A p r i I , 1970), p . 30. p D o m i n i o n B u r e a u o f S t a t i s t i c s , C a n a d a Y e a r Book ( O t t a w a : Q u e e n ' s P r i n t e r o f C a n a d a , 1970-71), p. 307. 1 I I . STATEMENT OF THE PROBLEM 2 The s p e c i f i c purpose o f t h i s s t u d y was to compare the s e l f - m e d i c a t i o n p r a c t i c e s o f two g roups o f a m b u l a t o r y c a r d i a c p a t i e n t s , age f o r t y - f i v e y e a r s and o v e r , who were l i v i n g a t home and who a t t e n d e d an o u t p a t i e n t c l i n i c f o r m e d i c a l a t t e n t i o n . A l l o f the p a t i e n t s were t a k i n g d i g o x i n 0 . 2 5 mgm. d a i l y , and e x c e p t f o r f o u r p a t i e n t s , two f r om each g r o u p , t h e y were a l s o t a k i n g a d i u r e t i c . One g r o u p , the c o n t r o l g r o u p , was g i v e n the u s u a l r o u t i n e f a c t u a l i n f o r m a t i o n wh ich p a t i e n t s r e g u l a r l y r e c e i v e when t h e y v i s i t the o u t p a t i e n t c l i n i c . The o t h e r g r o u p , the e x p e r i m e n t a l g r o u p , was g i v e n a d d i t i o n a l p l anned t e a c h i n g r e g a r d i n g m e d i c a t i o n s , by the r e s e a r c h e r . T h i s group was a l s o encou raged to ask q u e s t i o n s wh ich the r e s e a r c h e r a n s w e r e d . The c o m p a r i s o n o f s e l f - m e d i c a t i o n p r a c t i c e s was made i n terms o f : 1 . number o f s e l f - m e d i c a t i o n e r r o r s made by i n d i v i d u a l s i n each group 2 . t ype o f s e I f - m e d i c a t i o n e r r o r s made by i n d i v i d u a l s i n each group 3 . l e v e l o f knowledge o f m e d i c a t i o n a c t i o n s o f i n d i v i d u a l s i n each g r o u p . I I I . SIGNIFICANCE OF THE PROBLEM The numbers o f our p o p u l a t i o n i n the age group o f f o r t y - f i v e and ove r a re i n c r e a s i n g . In 1956 the p o p u l a t i o n 3 o f Canada i n t h i s age group was 4 , 0 0 9 , 9 1 4 . In 1966 t h i s f i g u r e was 5 , 0 9 7 , 4 4 7 , an i n c r e a s e o f 1 , 0 8 7 , 5 3 3 i n t e n y e a r s . In B r i t i s h Co lumb ia the p o p u l a t i o n i n 1956 o f i n d i v i d u a l s aged f o r t y - f i v e y e a r s and over was 4 1 1 , 0 9 6 . In 1966 t h i s f i g u r e was 5 4 1 , 0 6 8 , an i n c r e a s e o f 1 3 0 , 9 7 2 i n t e n y e a r s . ^ The l e a d i n g cause o f dea th i n Canada and i n B r i t i s h C o l u m b i a o f i n d i v i d u a l s age f o r t y - f i v e y e a r s and over i s c a r d i o v a s c u l a r d i s e a s e . ^ " Many p e r s o n s w i t h a known d i a g n o s i s o f c a r d i a c d i s e a s e have p r e s c r i p t i o n s of d i g o x i n and d i u r e t i c s . " D i g o x i n , d e s p i t e i t s e a r l y o r i g i n s , i s an agen t whose v a l u e i s c u r r e n t l y i n c r e a s i n g r a t h e r than d e c r e a s i n g . " ^ H e a l t h w o r k e r s a re becoming i n c r e a s i n g l y conce rned w i t h the e x t e n t t o wh ich p a t i e n t s t ake t h e i r m e d i c a t i o n s , and how a c c u r a t e l y they do s o . The p a t i e n t ' s a b i l i t y to t a k e m e d i c a t i o n s a t home i s an i m p o r t a n t d e t e r m i n a n t o f the a t t a i n m e n t o f t r e a t m e n t g o a l s . ^ Those p a t i e n t s who make e r r o r s i n s e l f - m e d i c a t i o n w i l l not r e c e i v e maximum b e n e f i t f rom t h e i r p r e s c r i b e d m e d i c a t i o n s , or w o r s e , - " I b i d . , p . 2 1 2 . ^ I b i d . , p . 3 0 7 . 5 R o b e r t P . Wa l ton and P e t e r C . G a z e s , " C a r d i a c G l y c o s i d e s I I : Pha rmaco logy and C l i n i c a l U s e , " D r i I I ' s  PharmacoIoqy i n Med i c i n e . e d . Joseph R. D ipa lma (New Y o r k : M c G r a w - H i l l Book Company, 1 9 7 1 ) , p. 7 8 0 . Mary V . M a r s t o n , " C o m p l i a n c e w i t h M e d i c a l Reg imens : A Rev iew o f the L i t e r a t u r e , " N u r s i n g R e s e a r c h , V o l . X I X , No. 4 ( J u l y - A u g u s t , 1 9 7 0 ) , p . 3 1 2 . ^Norman H. B e r k o w i t z e t a I., " P a t i e n t F o l l o w - T h r o u g h i n the O u t p a t i e n t D e p a r t m e n t , " N u r s i n g R e s e a r c h , V o l . X I I , No. 1 ( W i n t e r , 1 9 6 3 ) , p . 1 6 . s u f f e r i r r e p a r a b l e h a r m . 0 P r a c t i c a l e x p e r i e n c e has demons t ra ted t h a t . . . a l e r t and i n f o rmed c l i n i c a l a t t e n t i o n i s needed a t a l l t i m e s i n the a d m i n i s t r a t i o n o f the s i n g u l a r l y p o t e n t d r u g , d i gox i n.9 E n c o u r a g i n g p a t i e n t s t o f o l l o w t h e i r p h y s i c i a n ' s o r d e r s and recommendat ions i s o f c o n c e r n t o n u r s i n g . N u r s i n g i s one d i s c i p l i n e c o n s i d e r e d e s s e n t i a l t o p l a n n i n g f o r , and i m p l e m e n t i n g ca re f o r the i n d i v i d u a l i n the communi ty . B e f o r e p l a n n i n g c a r e , the nurse must know the n e e d . S c h w a r t z s a y s , "The re i s a r e c o g n i z e d need f o r s t u d i e s wh ich w i l l p r o v i d e i n f o r m a t i o n abou t p rob lems a s s o c i a t e d w i t h s e l f - m e d i c a t i o n o f a m b u l a t o r y p a t i e n t s . " 1 0 She found t h a t 59 p e r c e n t o f p a t i e n t s i n a s t u d y o f e l d e r l y a m b u l a t o r y p a t i e n t s made s e l f - m e d i c a t i o n e r r o r s . She then a s k e d , "What abou t p a t i e n t s eve rywhere e l s e ? " 1 1 Hecht says " I t i s a m i s t a k e t o t h i n k t h a t p a t i e n t s a t home take t h e i r m e d i c a t i o n s c o r r e c t I y . 1 , 1 2 Cap Ian e t a l . s t u d i e d the rank o r d e r o f i m p o r t a n t v a r i a b l e s f o r p a t i e n t s a t i s f a c t i o n i n o u t p a t i e n t c l i n i c ° H e c h t , o p . c i t . , p . 31. ^ W a l t o n and G a z e s , o p . c i t . , p . 781. 1 ° D o r i s S c h w a r t z , B a r b a r a H e n l e y , and Leona rd Z e i t z The E l d e r l y AmbuIa to ry P a t i e n t : Nurs i ng and P s y c h o Ioqi caI  Needs (New Y o r k ; The Macmi I Ian Company, 1964), p . 109. 1 1 D o r i s S c h w a r t z , " M e d i c a t i o n E r r o r s Made by Aged P a t i e n t s , " Ameri can Jou rna I o f N u r s i n g . V o l . L X I I , No. 8 ( A u g u s t , 1962), p . 51. l 2 H e c h t , o p . c i t . , p . 30. 5 s e r v i c e s . She found t h a t the d i f f i c u l t y the p a t i e n t has i n f o l l o w i n g i n s t r u c t i o n s f o r home t r e a t m e n t ranked second among the t w e n t y - t w o v a r i a b l e s i d e n t i f i e d by p a t i e n t s . S e l f - m e d i c a t i o n i s f r e q u e n t l y the o n l y home t r e a t m e n t wh ich a m b u l a t o r y c a r d i a c p a t i e n t s must p e r f o r m f o r t h e m s e l v e s . T h i s i n d i c a t e s a need f o r p a t i e n t t e a c h i n g . " P a t i e n t s w i t h a l o n g - t e r m i l l n e s s a re r e p o r t e d l y more c o m p l i a n t i f t hey a re g i v e n c a r e f u l i n s t r u c t i o n , " 1 2 1 " s a y s D a v i s , and Malone e t a I. r e p o r t t h a t " t e a c h i n g i s g e n e r a l l y c o n s i d e r e d to be e s s e n t i a l to the s u c c e s s f u l t r e a t m e n t o f a m b u l a t o r y p a t i e n t s . " 1 ^ "The t e a c h i n g o f p a t i e n t s has been a c c e p t e d as an i n t e g r a l p a r t o f a n u r s e ' s f u n c t i o n . " 1 ^ Methods o f t e a c h i n g p a t i e n t s abou t t h e i r m e d i c a t i o n s must be e x p l o r e d . 1 7 l e a n o r Cap Ian and M a r v i n B. Sussman, "Rank Order o f Impo r tan t V a r i a b l e s f o r P a t i e n t and S t a f f S a t i s f a c t i o n w i t h O u t p a t i e n t S e r v i c e , " J o u r n a l o f H e a l t h and Human  B e h a v i o r . V o l . V I I , No. 2 (Summer, 1 9 6 6 ) , p . 1 3 5 . ^ M i l t o n S . D a v i s , " V a r i a t i o n s i n P a t i e n t s ' C o m p l i a n c e w i t h D o c t o r s ' A d v i c e : An E m p i r i c a l A n a l y s i s of P a t t e r n s o f C o m m u n i c a t i o n , " Amer i can Jou rna I o f Pub Ii c  H e a I t h . V o l . L V I 1 1 , No. 2 ( F e b r u a r y , 1 9 6 8 ) , p . 2 7 5 . 1 ^ M a r y M a l o n e , Norman H. B e r k o w i t z , and M a l c o l m W. K l e i n , "The Paradox i n N u r s i n g , " Amer i can Jou rna I o f  N u r s i n g . V o l . L X I , No. 9 (Sep tember , 1961 ) , p. 5 3 . I ^ L o i s A . M o n t e i r o , " N o t e s on 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 Fo rum. V o l . I l l , No. 1 ( 1 9 6 4 ) , p. 2 6 . 1 ' H e c h t , " S e l f - M e d i c a t i o n , I n a c c u r a c y , and What Can Be D o n e , " p . 3 1 . I V . THE NEED FOR RESEARCH 6 F o x , i n h i s a r t i c l e "A P r o p o s e d Model f o r I d e n t i f y i n g R e s e a r c h A r e a s i n N u r s i n g , " c i t e s the need f o r s t u d i e s i n the a r e a o f n u r s e - p a t i e n t t e a c h i n g . He s t a t e s : I n v e s t i g a t i o n s a re needed to i d e n t i f y the need f o r t e a c h i n g , . . . the methods of t e a c h i n g , the e f f e c t i v e n e s s w i t h wh ich i t i s l e a r n e d , and the e x t e n t t o wh ich i t i s a c t e d upon.18 The need f o r s t u d y i n g p a t i e n t s i n the o l d e r age group who a r e c h r o n i c a l l y i l l i s e x p r e s s e d by Mack . She s a y s the number o f s o c i o l o g i c a l s t u d i e s o f o l d e r p e o p l e a re i n c r e a s i n g . However , the group o f o l d e r p e o p l e who a r e c h r o n i c a l l y i l l has been l a r g e l y i g n o r e d i n the e x i s t i n g r e s e a r c h . T h i s c h r o n i c a l l y i l l o l d e r age group m e r i t s some s p e c i a l c o n s i d e r a t i o n f r om the r e s e a r c h s t u d e n t . 1 ^ The need f o r a s t u d y o f more e f f e c t i v e use o f w a i t i n g t ime of p a t i e n t s i n an o u t p a t i e n t c l i n i c i s i n d i c a t e d i n the s t a t e m e n t : S y s t e m a t i c o b s e r v a t i o n o f t h i r t y - o n e p a t i e n t s a t t e n d i n g a c l i n i c r e v e a l e d t h a t most o f the p a t i e n t s spen t f o r t y - f i v e m i n u t e s t o one hour i n the w a i t i n g room, and most s p e n t t h i s w a i t i n g t ime do ing n o t h i n g . ^ 1 Pi ' D a v i d J . F o x , "A P r o p o s e d Model f o r I d e n t i f y i n g R e s e a r c h A r e a s i n N u r s i n g , " N u r s i n g R e s e a r c h , V o l . X I I I , No. 1 ( W i n t e r , 1 9 6 4 ) , p. 3 4 . 1 ^ M a r j o r i e J . Mack, "The P e r s o n a l A d j u s t m e n t o f C h r o n i c a l l y I I I O ld P e o p l e Under Home C a r e , " N u r s i n g  R e s e a r c h . V o l . I, No. 1 ( J u n e , 1 9 5 2 ) , p . 9 . 20 E v e l y n R. H a y e s , " C l i n i c W a i t i n g Room E x p e r i e n c e : An E x p l o r a t o r y S t u d y , " N u r s i ng R e s e a r c h . V o l . X V I I , No. 4 ( J u l y - A u g u s t , 1 9 6 8 ) , p . 364 . 7 I t i s s u g g e s t e d t h a t e d u c a t i o n a l e x p e r i e n c e s c o u l d be p r o v i d e d w h i c h m i g h t be e f f e c t i v e i n i m p r o v i n g p a t i e n t c a r e . T h e r e i s a p a u c i t y o f s t u d i e s on t h e f o l l o w - u p o f s e l f - m e d i c a t i o n p r a c t i c e s o f c a r d i a c p a t i e n t s i n t h e i r h o m e s . One s u c h s t u d y o f f o r t y p a t i e n t s on d i g o x i n t h e r a p y r e v e a l s a l a c k o f p a t i e n t k n o w l e d g e . The r e a s o n g i v e n by f o u r t e e n o f t h e 2 6 p a t i e n t s who made e r r o r s o f o m i s s i o n w a s , "I f o r g e t . " 2 1 A n o t h e r s t u d y o f t h i r t e e n c a r d i a c p a t i e n t s s t a t e s t h e e r r o r o f o m i s s i o n was t h e most f r e q u e n t e r r o r made by t h e s e p a t i e n t s . The r e a s o n s t h e y gave f o r t h e o m i s s i o n s were f o r g e t t i n g and i n t e r f e r e n c e w i t h t h e i r a c t i v i t i e s . A summary o f t h i s s t u d y i n d i c a t e d e l e v e n o u t o f t h e 1 3 p a t i e n t s s t u d i e d made e r r o r s i n s e l f - m e d i c a t i o n w h i c h p l a y e d a v i t a l p a r t i n t h e i r t r e a t m e n t , o v e r a p e r i o d o f s i x w e e k s . An a b s e n c e o f h e a l t h t e a c h i n g was n o t e d . P a t i e n t s l a c k e d i n f o r m a t i o n a b o u t the t h e r a p e u t i c e f f e c t s o f t h e i r m e d i c a t i o n s . T h e y were p a s s i v e r e g a r d i n g t h e i r t r e a t m e n t , y e t had a l a t e n t d e s i r e f o r s e l f - s u f f i c i e n c y pp and i n c r e a s e d k n o w l e d g e . c-A need f o r r e s e a r c h i n t o t h e e f f e c t i v e n e s s o f t e a c h i n g a c a r d i a c p a t i e n t a b o u t m e d i c a t i o n s i s i n d i c a t e d . Pi R i t a M. B r k i c h , "A S t u d y t o D e t e r m i n e how P a t i e n t s V i e w T h e i r D i g o x i n T h e r a p y " ( u n p u b l i s h e d M a s t e r ' s d i s s e r t a t i o n , M c G i l l U n i v e r s i t y , 1 9 6 9 ) , p . 2 8 . 2 2 I r e n e E . N o r d w i c h , " C o n c e r n s o f C a r d i a c P a t i e n t s R e g a r d i n g T h e i r A b i l i t y t o Imp lement t h e P r e s c r i b e d D r u g T h e r a p y " ( u n p u b l i s h e d M a s t e r ' s d i s s e r t a t i o n , U n i v e r s i t y o f W e s t e r n O n t a r i o , 1 9 7 0 ) , p . 1 2 1 . C h a p t e r 2 RESUME OF PRESENT KNOWLEDGE I. INCIDENCE OF SELF-MEDICATION ERRORS The l i t e r a t u r e r e v e a l s numerous s t u d i e s o f the s e l f - m e d i c a t i o n b e h a v i o r o f p a t i e n t s . Most p a t i e n t s s t u d i e d l i v e d a t home. Few o f t hese p u b l i s h e d s t u d i e s i n v e s t i g a t e d the s e l f - m e d i c a t i o n b e h a v i o r o f c a r d i a c p a t i e n t s . D a v i s w r i t e s , "A r e v i e w o f the l i t e r a t u r e d e m o n s t r a t e s a range of f r om 15 to 93 p e r c e n t o f p a t i e n t s r e p o r t e d l y n o n - c o m p l i a n t w i t h m e d i c a l r e g i m e n s . H e says t h e r e a r e v a r i o u s p o p u l a t i o n s and a v a r i e t y o f da ta c o l l e c t i n g methods , bu t n e v e r t h e l e s s a p a t t e r n emerges when t h e s e s t u d i e s a r e examined as a w h o l e . R e g a r d l e s s o f d i f f e r e n c e s , a t l e a s t one t h i r d o f the p a t i e n t s i n most s t u d i e s f a i l e d to comply w i t h d o c t o r ' s o r d e r s . He r e f e r s t o bo th p h y s i c i a n ' s t r e a t m e n t o r d e r s as w e l l as t o m e d i c a t i o n o r d e r s . In a s t u d y done by D a v i s h i m s e l f , he r e p o r t s t h a t no v a r i a t i o n i n p a t i e n t c o m p l i a n c e w i t h m e d i c a l reg imens can be a t t r i b u t e d to demograph ic c h a r a c t e r i s t i c s p e c u l i a r 2 3 Q a v i s , o p . c i t . , p . 2 7 4 . 8 t o the p a t i e n t such as a g e , s e x , m a r i t a l s t a t u s and e d u c a t i o n . 2 4 M a r s t o n w r i t e s t h a t a r e v i e w of the l i t e r a t u r e r e v e a l e d l i t t l e or no a s s o c i a t i o n e x i s t e d between c o m p l i a n c e b e h a v i o r w i t h r e g a r d to m e d i c a l reg imens and s e x , e d u c a t i o n and s o c i o - e c o n o m i c s t a t u s . ^ Male p a t i e n t s s i x t y - f i v e y e a r s and under w i t h c a r d i o v a s c u l a r d i s e a s e were s t u d i e d , and 30 p e r c e n t o f the s t u d y group a d m i t t e d to some d i s c r e p a n c y i n c o m p l i a n c e w i t h t h e i r m e d i c a l r e g i m e n . "A p a t i e n t g e n e r a l l y does not a c c e p t 26 e v e r y t h i n g h i s d o c t o r recommends . " R e s p o n s i b i l i t y to the p a t i e n t i s not comp le ted w i t h p r e s c r i p t i o n . A s t u d y i n v o l v i n g t w e n t y - s i x p a t i e n t s on a home ca re program r e v e a l e d t h a t s i x t e e n o f t h e s e p a t i e n t s f a i l e d t o f o l l o w the m e d i c a t i o n reg imen p r e s c r i b e d by t h e i r p h y s i c i a n s , E v i d e n c e o b t a i n e d f rom these p a t i e n t s w h i l e a t t e n d i n g a c l i n i c s u g g e s t e d the impo r tance o f c l e a r l y e x p l a i n i n g 2 7 m e d i c a t i o n reg imens to a l l o u t p a t i e n t s . 2 4 I b i d . , p . 278. 25 (v !a rs ton , " C o m p l i a n c e w i t h M e d i c a l R e g i m e n s , " P . 3 1 2 . p^r M i l t o n S . D a v i s and R o b e r t L . E i c h h o r n , " C o m p l i a n c e W i t h M e d i c a l Reg imens : A Pane l S t u d y , " J o u r n a l o f H e a l t h and Human B e h a v i o r . V o l . I V , No . 4 ( W i n t e r , 1 9 6 3 ) , p . 2 4 9 . 27 E l i z a b e t h B. C u r t i s , " M e d i c a t i o n E r r o r s Made by P a t i e n t s , " N u r s i n g O u t l o o k . V o l . I X , No. 5 (May, 1961), p. 290. 1 0 Two s t u d i e s , one o f d i a b e t i c p a t i e n t s ^ 0 and a n o t h e r o f p r e g n a n t women t a k i n g i r o n p i I I s , ^ r e v e a l e d h i g h s e l f -m e d i c a t i o n n o n c o m p l i a n c e r a t e s . No c o r r e l a t i o n was found between age and s o c i a l c l a s s and number o f e r r o r s made. Bo th r e s e a r c h e r s recommended more p a t i e n t t e a c h i n g as t o the "wha t " and "why" o f the m e d i c a t i o n p r e s c r i b e d . In the w e s t e r n U n i t e d S t a t e s a s t u d y was done u s i n g a sample o f f i f t y - n i n e p a t i e n t s who were s i x t y y e a r s o f age and o v e r . I t was found t h a t 5 9 p e r c e n t o f the p a t i e n t s made m e d i c a t i o n e r r o r s . The r e s e a r c h e r s emphas ized t h a t the consequences o f m e d i c a t i o n e r r o r s and the i n c r e a s i n g need to depend upon the p a t i e n t to t ake m e d i c a t i o n s a t home, make i t n e c e s s a r y to c o n t i n u e to c o n c e n t r a t e on ways o f i d e n t i f y i n g those p a t i e n t s who make e r r o r s , i n o r d e r t o a t t e m p t to reduce t h i s p e r c e n t a g e . 3 0 " A s t u d y o f one hundred p a t i e n t s w i t h pu lmonary t u b e r c u l o s i s , showed t h a t t w e n t y - f o u r o f t h e s e p a t i e n t s were t a k i n g t h e i r d rugs i n an i r r e g u l a r f a s h i o n . " T h i s i r r e g u l a r i t y may not a l l o w the p a t i e n t to respond to the 2 ^ J u l i a W a t k i n s , "A S t u d y o f D i a b e t i c P a t i e n t s a t Home," Ameri can Jou rna I o f Pub I i c H e a I t h . V o l . L V I I , No. 3 ( M a r c h , 1 9 6 7 ) , p . 4 5 7 . po ^ J o h n B o n n a r , A . G o l d b e r g , and J . S m i t h , "Do P r e g n a n t Women Take T h e i r I r o n ? " The L a n c e t ( M a r c h , 1 9 6 9 ) , P . 4 5 7 . - ^ E l i z a b e t h N e e l y and Max ine P a t r i c k , " P r o b l e m s of Aged P e r s o n s T a k i n g M e d i c a t i o n s a t Home," N u r s i n g R e s e a r c h , V o l . X V I I , No. 1 ( J a n u a r y - F e b r u a r y , 1 9 6 8 ) , p . 5 5 . 11 m e d i c a t i o n t h e r a p e u t i c a l l y , " s t a t e s the r e s e a r c h e r . ^ 1 He f e e l s t h a t the c o o p e r a t i o n o f the p a t i e n t i n s e l f - m e d i c a t i o n may be improved by e x p l a i n i n g the c o u r s e o f the i n t e n d e d chemotherapy to the p a t i e n t . Two d o c t o r s s t u d i e d f i f t y - n i n e c h i l d r e n a t a p e d i a t r i c c l i n i c i n New York s t a t e . The s t u d y was done by i n t e r v i e w i n g the p a r e n t s of the c h i l d r e n and by i n s p e c t i o n o f the p a t i e n t ' s m e d i c a t i o n c o n t a i n e r s . I t was f ound t h a t h a l f the c h i l d r e n on a t e n - d a y c o u r s e o f p e n i c i l l i n s topped t a k i n g the d rug by the t h i r d d a y . These r e s e a r c h e r s g i v e two p o s s i b l e r e a s o n s f o r noncomp l i ance w i t h the m e d i c a t i o n r e g i m e . They f e l t pe rhaps the t r e a t m e n t or d i r e c t i o n s f o r t h e r a p y were not u n d e r s t o o d by the p a r e n t s . S e c o n d l y , p a t i e n t s * r e l a t i o n s h i p t o the p h y s i c i a n c o u l d be a l a r g e f a c t o r i n d e t e r m i n i n g c o o p e r a t i o n i n the m e d i c a t i o n r e g i m e . ^ H a l l b u r g found t h a t 103 p a t i e n t s who were s i x t y y e a r s o l d and o v e r , r e s i d i n g i n San F r a n c i s c o , and who had m e d i c a t i o n s p r e s c r i b e d f o r the f i r s t t ime w h i l e v i s i t i n g an o u t p a t i e n t c l i n i c , had a r e l a t i v e l y h i g h noncomp l i ance w i t h p r e s c r i b e d m e d i c a t i o n r e g i m e n s . - ^ W a l l a c e F o x , "The P r o b l e m of S e l f - A d m i n i s t r a t i o n o f D r u g s ; w i t h P a r t i c u l a r R e f e r e n c e to Pu lmonary T u b e r c u l o -s i s , " T u b e r c I e . V o l . XXXIX ( O c t o b e r , 1958), p . 271. 3 2 Abraham B. Bergman and R i c h a r d J . Werne r , " F a i l u r e o f C h i l d r e n t o R e c e i v e P e n i c i l l i n by M o u t h , " New Enq I and  J o u r n a I o f Medi c i ne . V o l . C C L X V I I I , No. 25 (June 13, 1963), P . 1337. - ^ J e a n n e C . H a l l b u r g , "A D e c i s i o n Mak ing Approach as a T e a c h i n g - L e a r n i n g S t r a t e g y f o r P r e p a r i n g P a t i e n t s f o r S e l f C a r e " ( u n p u b l i s h e d D o c t o r ' s d i s s e r t a t i o n , U n i v e r s i t y o f C a l i f o r n i a , 1969), p . 53. I I . THE TEACHING FUNCTION OF A NURSE I t no l onger s u f f i c e s to have an e f f e c t i v e t h e r a p e u t i c drug i f the p a t i e n t r e f u s e s t o take h i s m e d i c a t i o n s as d i r e c t e d . E x p e r i m e n t a l programs f o r p a t i e n t s i n v o l v i n g s p e c i a l e d u c a t i o n t e c h n i q u e s a re c e r t a i n l y w a r r a n t e d . Nu rses a c c e p t t e a c h i n g as a p a r t o f t h e i r f u n c t i o n on the h e a l t h team. In our con tempora ry s o c i e t y more and more r e s p o n s i b i l i t y f o r t r e a t m e n t o f d i s e a s e i s b e i n g s h i f t e d f rom d o c t o r , t o n u r s e , t o p a t i e n t . " I t may w e l l be t h a t the s c i e n c e o f commun ica t i on i s more p e r t i n e n t t o n u r s i n g than the s c i e n c e o f d i s e a s e or p a t h o l o g y . " - ^ Kos r e p o r t s on the t e a c h i n g of s e l f - c a r e t o e l d e r l y p a t i e n t s w i t h p a c e m a k e r s . These p a t i e n t s commonly have d i g o x i n and d i u r e t i c s p r e s c r i b e d to improve h e a r t a c t i o n . Bo th t h e i r knowledge and m e d i c a t i o n - t a k i n g b e h a v i o r improved w i t h t e a c h i n g . The s t u d y p o i n t s ou t the need f o r n u r s e s * i n v o l v e m e n t i n t e a c h i n g p a t i e n t s . ^ 6 14 J D a v i d B e r r y , A l a n R o s s , and K u r t D e u s c h l e , " T u b e r c u l o u s P a t i e n t s T r e a t e d a t Home. Compar i son o f R e g u l a r and I r r e g u l a r S e I f - M e d i c a t i o n G r o u p s , " Rev iew of  R e s p i r a t o r y D i s e a s e s . V o l . L X X X V I I I , No. 6 (December , 1 9 6 3 ) , p. 7 7 1 . • ^ D o r o t h y M. S m i t h , "Myth and Method i n N u r s i n g P r a c t i c e , " Ameri can Jou rna I of N u r s i n g . Vo I . L X V I , No. I ( F e b r u a r y , 1 9 6 4 ) , p . 7 0 . 36 B a r b a r a Kos and Pamela C u l b e r t , " T e a c h i n g P a t i e n t s a b o u t P a c e m a k e r s , " Amer i can Jou rna I o f N u r s i n g . V o l . L X X I , No. 3 ( M a r c h , 1 9 7 1 ) , p . 5 2 6 . 13 S t u d i e s o f p l a n n e d i n s t r u c t i o n to p a t i e n t s i n o u t p a t i e n t c l i n i c s s u g g e s t t h a t t h i s p a r t i c u l a r a s p e c t o f the n u r s e s ' r o l e i s i d e a l i z e d more than i t i s r e a l i z e d . - ^ H e a l t h t e a c h i n g i s one e f f e c t i v e method o f a s s i s t i n g the p a t i e n t t o cope w i t h p r e s e n t and f u t u r e h e a l t h p r o b l e m s . However , e v i d e n c e e x i s t s t h a t t h i s a p p r o a c h to h e a l t h ca re has o n l y had s p o r a d i c s u p p o r t and e m p h a s i s . ^ 8 P a t i e n t s e x p e c t n u r s e s t o h e l p them meet the need f o r knowledge abou t t h e i r t r e a t m e n t . They a r e v o i c i n g t h e i r o p i n i o n s more f r e q u e n t l y and more vehement I y . ^ As long ago as 1 9 5 3 , S t r e e t e r w r o t e , "Today i t i s e s s e n t i a l t h a t depa r tmen t s o f n u r s i n g s e r v i c e conduc t a c t i v e t e a c h i n g 40 programs f o r p a t i e n t s . . . . " "The nu rse who i n c r e a s e s her t e a c h i n g f u n c t i o n w i l l a s s i s t the p a t i e n t and h i s f a m i l y t o cope w i t h t h e i r h e a l t h p rob lems more e f f e c t i v e I y . 37 jeanne 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 , " Nurs i ng C I i n i cs o f No r th A m e r i c a . V o l . V , No. 2 ( J u n e , 1 9 7 0 ) , p. 2 2 3 . -z o A r l e n e M. P u t t , "One E x p e r i m e n t i n N u r s i n g A d u l t s w i t h P e p t i c U l c e r s , " N u r s i n g R e s e a r c h , V o l . X I X , No. 6 (November-December , 1 9 7 0 ) , p. 4 9 2 . - ^ S t e l l a Hay and He len A n d e r s o n , " A r e Nurses Mee t i ng the P a t i e n t s ' N e e d s ? " Ameri can Jou rna I o f Nurs i n g , V o l . L X I I I , No . 12 (December , 1 9 6 3 ) , p. 9 7 . 40 V i r g i n i a S t r e e t e r , "The N u r s e ' s R e s p o n s i b i l i t y f o r Teach i ng P a t i e n t s , " Amer i can J o u r n a I o f N u r s i n g , V o I . LI 1 1 , No. 7 ( J u l y , 1 9 5 3 ) , p . 8 1 8 . 41 M a r g a r e t L . P o h I , " T e a c h i n g A c t i v i t i e s o f the N u r s i n g P r a c t i t i o n e r , " N u r s i n g R e s e a r c h . V o l . XVI ( W i n t e r , 1 9 6 5 ) , P . 5 . 14 A t t i t u d e s o f p a t i e n t s toward t h e i r m e d i c a t i o n s can be i n f l u e n c e d . I n s t r u c t i o n by n u r s e s canno t a l w a y s a l t e r l i f e t i m e a t t i t u d e s , but s e v e r a l s t e p s can be t a k e n . "A method wh ich i s b e i n g t r i e d out i n some h o s p i t a l s i s s e l f -a d m i n i s t r a t i o n o f m e d i c a t i o n s . " 2 1 ' 2 Such a program i s b e i n g c o n d u c t e d i n a r e h a b i l i t a t i o n h o s p i t a l i n a l a r g e urban c e n t r e on C a n a d a ' s west c o a s t . I t i s hoped t h a t t h i s p rogram w i l l g i v e p a t i e n t s i n d e p e n d e n c e , and a p r e p a r a t i o n f o r t h e i r d i s c h a r g e to t h e i r homes and the t a s k o f s e l f -medi c a t i o n . I t has b rough t t o the a t t e n t i o n o f the h o s p i t a l s t a f f , the g r e a t h a z a r d s i n v o l v e d to p a t i e n t s who a re d i s c h a r g e d to the home env i r onmen t w i t h o u t the n e c e s s a r y t r a i n i n g and i n s t r u c t i o n on the p r o p e r usage o f d r u g s .^3 F o l l o w - u p s t u d i e s on t h e s e p a t i e n t s a f t e r d i s c h a r g e home have no t been done . I I I . THE ROLE OF THE NURSE IN THE OUTPATIENT CLINIC H e a l t h s e r v i c e s a r e u n d e r g o i n g r a p i d t r a n s f o r m a t i o n . P r e v e n t i o n o f i l l n e s s and h e a l t h ma in tenance i n a m b u l a t o r y c l i n i c s and i n the p a t i e n t s ' homes a r e b e i n g s t r e s s e d . ^ H e c h t , " S e l f - M e d i c a t i o n , I n a c c u r a c y , and What Can Be D o n e , " p . 3 1 . ^ M a r y F a l c o n e r , "An E x p e r i m e n t a l P rogram i n S e l f -M e d i c a t i o n , " Canad i an Pharmaceut i ca I J o u r n a I . (May, 1 971 ) , p . 2 3 . 15 More o u t p a t i e n t ca re i s b e i n g c o n s i d e r e d T h e emphas is i s on the p r a c t i c e o f p r e v e n t i v e m e d i c i n e . ^ B e n n i s e t a l . recommend t h a t n u r s e s be a s s i g n e d t o 46 the o u t p a t i e n t c l i n i c p r i m a r i l y t o t e a c h p a t i e n t s . The n u r s i n g p r o f e s s i o n r e c o g n i z e s p a t i e n t t e a c h i n g as an i m p o r t a n t f u n c t i o n o f the n u r s e , y e t , as t h i s group o f r e s e a r c h e r s has n o t e d , "Much o f our da ta has borne ou t the f a c t t h a t p i v o t a l as t e a c h i n g i s s a i d t o b e , i t i s o f t e n a n e g l e c t e d a rea i n p r a c t i c e . " ^ F i s c h e r w r i t e s t h a t s o c i a l changes a re making o u t p a t i e n t u n i t s more i m p o r t a n t than e v e r b e f o r e and n u r s e s must a c t b e f o r e the f u l l p o t e n t i a l o f t h e s e u n i t s can be r e a l i z e d . She adds t h a t o u t p a t i e n t c l i n i c s have t h r e e f u n c t i o n s , each o f wh ich i m p l i e s a d e f i n i t e n u r s i n g r e s p o n s i b i l i t y . These a r e : t r e a t i n g the a m b u l a t o r y 48 s i c k , h e a l t h t e a c h i n g and r e s e a r c h . u ^"Es ther L u c i l e Brown, N u r s i n g R e c o n s i d e r e d . A S t u d y o f Change ( T o r o n t o : J . B . L i p p i n c o t t Company, 1970), p. 118. Ac -^Based on a l e c t u r e by D r . S t a n l e y B l o c k , I l l i n o i s I n s t i t u t e o f T e c h n o l o g y i n C h i c a g o , a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a , March 9, 1 9 7 1 . 46 Warren G . Benni s e t a I., The RoIe o f the Nurse i n  the O u t p a t i e n t Depar tment (New Y o r k : A m e r i c a n N u r s e s ' F o u n d a t i o n , I n c . , 1961), p . 65. 4 7 I b i d . , p . 58. 48 Mercedes M. F i s c h e r , " O u t p a t i e n t Depar tments Have a Long Way To G o , " A m e r i c a n Jou rna I o f N u r s i n g . V o l . L X I , No. 8 ( A u g u s t , 1961), p . 56. 1 6 "T ime i s c u r r e n t l y one o f our s o c i e t y ' s most v a l u e d c o m m o d i t i e s . " ^ I t f o l l o w s t h a t t ime s h o u l d be used w i s e l y . Ye t t ime s p e n t by p a t i e n t s i n w a i t i n g rooms o f o u t p a t i e n t c l i n i c s i s not b e i n g used e f f e c t i v e l y . Hayes s u g g e s t s p a t i e n t t e a c h i n g would meet the needs o f the p a t i e n t and implement a more p r o d u c t i v e use o f t i m e . ^ A s t u d e n t d o c t o r who s t u d i e d 1 5 0 p a t i e n t s a t a m e d i c a l o u t p a t i e n t c l i n i c w r i t e s t h a t 8 5 t o 9 5 p e r c e n t o f t h e s e p a t i e n t s were s a t i s f i e d w i t h the i n f o r m a t i o n and e x p l a n a t i o n t hey r e c e i v e d f rom the p h y s i c i a n r e g a r d i n g t h e i r c o n d i t i o n . He adds t h a t 6 0 p e r c e n t o f t h e s e p a t i e n t s had an e i g h t h grade e d u c a t i o n or l e s s and t hese peop le o f t e n tend to be p a s s i v e and t o a c c e p t the ca re they r e c e i v e w i t h o u t q u e s t i o n or c r i t i c i s m . ^ 1 Sussman e t a I. s t a t e the l e s s - e d u c a t e d and low-income p a t i e n t s tend to be most s a t i s f i e d w i t h the o u t p a t i e n t c l i n i c . - * 2 P a t i e n t comments do , however , i n d i c a t e a commun ica t i on b a r r i e r i n the d o c t o r - p a t i e n t r e l a t i o n s h i p . ^ j n e o u t p a t i e n t depar tmen t s t a f f ^ H a y e s , " C l i n i c W a i t i n g Room E x p e r i e n c e , " p . 361 . 5 ° l b i d . ^ 1 A n d r e w W. F i s h e r , " P a t i e n t s ' E v a l u a t i o n o f O u t p a t i e n t M e d i c a l C a r e , " J o u r n a I o f Medi caI E d u c a t i o n . V o l . X L V I , No. 3 ( M a r c h , 1 9 7 1 ) , p. 2 4 2 . 5 2 M a r v i n B. Sussman e t a I., The W a l k i n g P a t i e n t : A S t u d y i n O u t p a t i en t Care ( C l e v e l a n d : The P r e s s o f Wes te rn R e s e r v e U n i v e r s i t y , 1 9 6 7 ) , p . 7 6 . 5 3 I b i d . , p . 6 9 . 17 u n d e r e s t i m a t e the p a t i e n t s * e a g e r n e s s f o r i n f o r m a t i o n . ^ 2 ' ' These f i n d i n g s by Sussman e t a l . i n d i c a t e not o n l y the need f o r t e a c h i n g by the c l i n i c n u r s e , but a l s o the r e c e p t i v e n e s s o f the p a t i e n t t o such t e a c h i n g . "The nurse i n the o u t p a t i e n t depar tmen t i s i n a un ique p o s i t i o n t o make a s i g n i f i c a n t c o n t r i b u t i o n to the t o t a l h e a l t h - e d u c a t i o n p r o g r a m . " 5 5 Windemuth a s s e r t s two r e a s o n s f o r t h i s un ique p o s i t i o n o f the n u r s e . The f i r s t i s t h a t the p a t i e n t i s i n a s t a t e o f r e a d i n e s s . The f a c t t h a t the p a t i e n t has made the e f f o r t t o come to the c l i n i c , i n d i c a t e s t h a t he has a need wh ich he w i s h e s t o have s a t i s f i e d . The second r e a s o n g i v e n i s the p r e s e n c e o f the nu rse i n the c l i n i c a t a t ime when the p a t i e n t i s most i n t e r e s t e d i n d o i n g someth ing abou t h i s h e a l t h p r o b l e m . And Windemuth a d d s , " A d u l t s l e a r n r e m a r k a b l y we I I . "56 IV . SUMMARY A r e v i e w of the l i t e r a t u r e i n d i c a t e s t h a t the f r e q u e n c y o f noncomp l i ance w i t h p r e s c r i b e d m e d i c a t i o n reg imens by p a t i e n t s i n t h e i r homes i s r e l a t i v e l y h i g h . The numerous s t u d i e s i n c l u d e a wide range o f s e t t i n g s , and a v a r i e t y o f numbers and t y p e s o f m e d i c a t i o n s per p a t i e n t . 5 4 l b i d . , p . 130 . 55Audrey Windemuth, The Nurse i n the O u t p a t i e n t  Depar tment (New Y o r k : The Macmi I Ian Company, 1 9 5 7 ) , p . 105 . 5 6 I b i d . , p . 1 0 7 . 18 Demograph ic c h a r a c t e r i s t i c s of the p a t i e n t such as a g e , s e x , r a c e , m a r i t a l s t a t u s , s o c i o - e c o n o m i c s t a t u s , e d u c a t i o n and m e d i c a l d i a g n o s i s a re a l s o v a r i e d . On ly two o f t h e s e s t u d i e s , one by Nordwic and the o t h e r by B r k i c h , J U d e s c r i b e d p o p u l a t i o n s o f c a r d i a c p a t i e n t s and a s p e c t s o f t h e i r d i g o x i n t h e r a p y . A c o n s i d e r a t i o n o f paramount impo r tance i n most o f t h e s e s t u d i e s i s the e x p r e s s i o n o f the need f o r p a t i e n t t e a c h i n g by the n u r s e . The n o t i o n t h a t " t e a c h i n g i s g e n e r a l l y c o n s i d e r e d to be e s s e n t i a l to the s u c c e s s f u l t r e a t m e n t o f a m b u l a t o r y p a t i e n t s " - ^ cannot be o v e r -e m p h a s i z e d . I t permeates most o f the l i t e r a t u r e r e v i e w e d . I n t e r e s t i n the t e a c h i n g f u n c t i o n o f the nurse i s l o n g -s t a n d i n g , but o n l y a l i m i t e d number o f s t u d i e s o f i t s p r a c t i c e and e f f e c t i v e n e s s a re a v a i l a b l e i n the l i t e r a t u r e . The r o l e o f the nurse i n the o u t p a t i e n t c l i n i c r e i t e r a t e s a con tempora ry emphas is on p r e v e n t i v e m e d i c i n e and the impo r tance o f the t e a c h i n g f u n c t i o n o f the n u r s e . In the c l i n i c the nurse r e c e i v e s a r e c e p t i v e p a t i e n t a u d i e n c e , w i t h t ime to s p a r e . T h i s a f f o r d s her the o p p o r t u n i t y t o make a s i g n i f i c a n t c o n t r i b u t i o n t o the s e l f - c a r e o f a m b u l a t o r y p a t i e n t s i n t h e i r homes. 57f \ jordwich, " C o n c e r n s o f C a r d i a c P a t i e n t s . " 5 8 e r k i c h , "A S t u d y to De te rm ine how P a t i e n t s View T h e i r D i g o x i n T h e r a p y . " 5 9 M a l o n e , B e r k o w i t z , and K l e i n , "The Paradox i n N u r s i n g , " p . 5 3 . C h a p t e r 3 THE DESIGN OF THE STUDY I. GENERAL AIM OF THE STUDY The g e n e r a l a im of the s t u d y was to compare the s e l f - m e d i c a t i o n p r a c t i c e s o f two groups o f a m b u l a t o r y c a r d i a c p a t i e n t s who were over f o r t y - f i v e y e a r s o f a g e , and l i v i n g a t home. A l l o f the p a t i e n t s were t a k i n g d i g o x i n 0.25 mgm. d a i l y , and e x c e p t f o r f o u r p a t i e n t s , two f r om each g r o u p , t hey were a l s o t a k i n g a d i u r e t i c . The number and t ype o f m e d i c a t i o n e r r o r s as w e l l as the i n d i v i d u a l ' s l e v e l o f knowledge abou t h i s m e d i c a t i o n s were compared . One g r o u p , the c o n t r o l g r o u p , was g i v e n the u s u a l r o u t i n e f a c t u a l i n f o r m a t i o n wh ich p a t i e n t s r e g u l a r l y r e c e i v e when t h e y v i s i t the o u t p a t i e n t c l i n i c . The o t h e r g r o u p , the e x p e r i m e n t a l g r o u p , was g i v e n a d d i t i o n a l p l a n n e d t e a c h i n g r e g a r d i n g t h e i r m e d i c a t i o n s , by the r e s e a r c h e r . I I . S P E C I F I C OBJECTIVES OF THE STUDY 1. To d e t e r m i n e the number of e r r o r s i n s e l f -m e d i c a t i o n o f d i g o x i n and d i u r e t i c s made by the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p , i n a t w e n t y - f o u r -hour p e r i o d . 2. To d e t e r m i n e the t ype o f e r r o r s i n s e l f -m e d i c a t i o n o f d i g o x i n and d i u r e t i c s made by the e x p e r i m e n t a l 19 20 group as compared w i t h the c o n t r o l g r o u p , i n a t w e n t y - f o u r -hour p e r i o d . 3. To de te rm ine the l e v e l o f knowledge o f s e l f -m e d i c a t i o n o f d i g o x i n and d i u r e t i c s o f the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p . I I I . THE HYPOTHESES H y p o t h e s i s I. H 0 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 number o f s e I f - m e d i c a t i o n e r r o r s made i n a t w e n t y - f o u r - h o u r p e r i o d by members o f the e x p e r i m e n t a l group as compared w i t h members o f the c o n t r o l g r o u p . Hypothes i s I I . H 0 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 t ype o f s e I f - m e d i c a t i o n e r r o r s made i n a t w e n t y - f o u r - h o u r p e r i o d by members o f the e x p e r i m e n t a l group as compared w i t h members o f the c o n t r o l g r o u p . H y p o t h e s i s I I I . H Q 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 l e v e l o f knowledge o f s e l f - m e d i c a t i o n of d i g o x i n and d i u r e t i c s , o f members o f the e x p e r i m e n t a l group as compared w i t h members o f the c o n t r o l g r o u p . I V . VARIABLES INCLUDED IN THE STUDY The i ndependen t v a r i a b l e i n the s t u d y was the p l a n n e d t e a c h i n g by the r e s e a r c h e r . I t was t h i s v a r i a b l e 2 1 wh ich p u r p o s e l y a l t e r e d c o n d i t i o n s i n the s t u d y by i t s a p p l i c a t i o n to the e x p e r i m e n t a l g r o u p . The dependent v a r i a b l e was p a t i e n t s e l f - m e d i c a t i o n b e h a v i o r . T h i s c r i t e r i o n measured the e f f e c t o f p a t i e n t t e a c h i n g . T h i s measured e f f e c t was o b t a i n e d f r om i n t e r v i e w s w i t h the e n t i r e s t u d y p o p u l a t i o n t e n t o f o u r t e e n days a f t e r t h e i r v i s i t to the c l i n i c , by a d m i n i s t r a t i o n o f the t w e n t y -i t em q u e s t i o n n a i r e . V . DEFINITION OF TERMS S e l f - m e d i c a t i o n w i t h o u t e r r o r : p a t i e n t a d m i n i s t e r s m e d i c a t i o n : (a) o r d e r e d by h i s p h y s i c i a n (b) a t the c o r r e c t t ime (c ) i n the c o r r e c t d o s a g e . S e l f - m e d i c a t i o n e r r o r : m e d i c a t i o n wh ich i s : (a) t a k e n by the p a t i e n t and not p r e s c r i b e d by h i s p h y s i c i an (b) o r d e r e d by the p h y s i c i a n but not t a k e n by the p a t i e n t (c ) t a k e n a t the i n c o r r e c t t ime (d) t a k e n i n an i n c o r r e c t d o s a g e . Type o f m e d i c a t i o n e r r o r : the d i f f e r e n t t y p e s o f e r r o r s a r e : 22 (a) e r r o r o f t a k i n g a m e d i c a t i o n no t p r e s c r i b e d by the p a t i e n t ' s p h y s i c i a n (b) e r r o r o f o m i s s i o n (c ) e r r o r o f t a k i n g a m e d i c a t i o n a t the i n c o r r e c t t ime (d) e r r o r o f t a k i n g a m e d i c a t i o n i n an i n c o r r e c t d o s a g e . I n c o r r e c t t i m e : m e d i c a t i o n i s no t t a k e n by the p a t i e n t O . D . , B . I . D . , T . I . D . , o r Q . I . D . as p r e s c r i b e d by h i s p h y s i c i a n . I n c o r r e c t d o s a g e : m e d i c a t i o n i s not t a k e n by the p a t i e n t i n numbers o f t a b l e t s , c a p s u l e s or s p o o n f u l s as p r e s c r i b e d by h i s phys i c i a n . L e v e l o f k n o w l e d g e : i n t h i s s t u d y t h r e e l e v e l s o f knowledge a re c o n s i d e r e d : low, moderate and h i g h . These l e v e l s p e r t a i n t o knowledge o f answers t o the f o l l o w i n g q u e s t i o n s : (a) p a t i e n t knows the t r a d e names o f the m e d i c a t i o n s take n (b) p a t i e n t knows a t what t ime the m e d i c a t i o n s s h o u l d be t a k e n (c ) p a t i e n t knows the e f f e c t s o f the m e d i c a t i o n s t a k e n (d) p a t i e n t knows the p o s s i b l e s i d e - e f f e c t s o f the m e d i c a t i o n s t a k e n . A low l e v e l o f knowledge i s s i g n i f i e d by a knowledge o f z e r o t o one a n s w e r . A moderate l e v e l o f knowledge i s s i g n i f i e d by a knowledge o f two a n s w e r s . A h i g h l e v e l o f knowledge i s s i g n i f i e d by a knowledge o f t h r e e t o f o u r a n s w e r s . R o u t i n e i n f o r m a t i o n : i n f o r m a t i o n r e g a r d i n g the p a t i e n t ' s d i a g n o s i s and m e d i c a t i o n s wh ich i s r o u t i n e l y g i v e n to p a t i e n t s who a t t e n d the o u t p a t i e n t c l i n i c . A d d i t i o n a l p l anned t e a c h i n g : i n f o r m a t i o n and t e a c h i n g r e g a r d i n g h i s d i a g n o s i s and m e d i c a t i o n s g i v e n to the p a t i e n t by the r e s e a r c h e r . T h i s c o n s i s t s o f d i s c u s s i o n w i t h the p a t i e n t ove r a t h i r t y - m i n u t e p e r i o d , d u r i n g wh ich the p a t i e n t i s a l s o encou raged t o ask q u e s t i o n s . T w e n t y - f o u r - h o u r p e r i o d : t h a t t w e n t y - f o u r - h o u r p e r i o d o f t ime i m m e d i a t e l y p r e c e d i n g the i n t e r v i e w e r ' s v i s i t t o the p a t i e n t ' s home. V I . LIMITATIONS OF THE STUDY 1. The r e s u l t s o f the s t u d y a re dependent upon p a t i e n t h o n e s t y and a c c u r a c y i n r e s p o n d i n g t o the q u e s t i onna i r e . 2 . Because o f the low s o c i o - e c o n o m i c s t a t u s o f the p a t i e n t s i n the s t u d y , and the g e o g r a p h i c l i m i t a t i o n t h a t 24 t hey a l l l i v e i n the same l a r g e urban a r e a , i t i s not p o s s i b l e t o g e n e r a l i z e r e s u l t s to the g e n e r a l p o p u l a t i o n . 3 . Most s t u d i e s a re never c o m p l e t e l y f r e e o f e x t r a n e o u s v a r i a b l e s . Because o f t hese l i m i t a t i o n s t h e r e can never be a b s o l u t e c e r t a i n t y t h a t the e f f e c t s p roduced i n an e x p e r i m e n t would h o l d t r u e f o r the ^ t a r g e t p o p u l a t i o n when the f i n d i n g s a re g e n e r a l i z e d . 0 V I I . ASSUMPTIONS 1. The a s s u m p t i o n was made t h a t p a t i e n t s were w i l l i n g t o a d m i t t o m e d i c a t i o n e r r o r s . 2. The a s s u m p t i o n was made t h a t the random a s s i g n m e n t o f p a t i e n t s t o c o n t r o l and e x p e r i m e n t a l g roups would d i s t r i b u t e any u n r e l i a b i l i t y o f r e s p o n s e s randomly between the two g r o u p s . 60 E ugene 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 . V o l . I X , No. 4 ( F a l l , 1960), p. 205. C h a p t e r 4 METHODOLOGY I. THE SAMPLE The sample f r o m wh ich da ta were o b t a i n e d was drawn f rom a p o p u l a t i o n o f p a t i e n t s who a t t e n d e d the o u t p a t i e n t c l i n i c a t a l a r g e u rban h o s p i t a l . P a t i e n t s were randomly a s s i g n e d to g roups by a l t e r n a t e l y a s s i g n i n g t hose who met the c r i t e r i a f o r sample i n c l u s i o n , t o the e x p e r i m e n t a l and the c o n t r o l g r o u p s . The m e d i c a l r e c o r d s o f the p a t i e n t s were p e r u s e d i n o r d e r t o o b t a i n those who met the c r i t e r i a f o r i n c l u s i o n i n the s t u d y . The c r i t e r i a f o r the sample were : a d i a g n o s i s o f c a r d i a c i l l n e s s , age f o r t y - f i v e y e a r s and o v e r , b e i n g a m b u l a t o r y , l i v i n g a t home, t a k i n g d i g o x i n d a i l y , and w i l l i n g n e s s t o p a r t i c i p a t e . The e l i g i b i l i t y s c a l e f o r the o u t p a t i e n t c l i n i c l i m i t e d the i n d i v i d u a l ' s income t o $150.00 per month per p e r s o n , w i t h s a v i n g s amount ing t o l e s s t han $1,000.00. T h e r e f o r e the sample p o p u l a t i o n c o n s i s t e d o f p a t i e n t s o f a low s o c i o - e c o n o m i c s t a t u s . I I . THE BIOGRAPHICAL DATA The p a t i e n t s who met the c r i t e r i a f o r i n c l u s i o n i n the s t u d y were met i n d i v i d u a l l y by the r e s e a r c h e r as they 25 w a i t e d f o r t h e i r a p p o i n t m e n t s w i t h the d o c t o r s . A copy o f the i n t r o d u c t i o n t o the p a t i e n t i s c o n t a i n e d i n Append ix A , page 68. A f t e r a g r e e i n g t o p a r t i c i p a t e , the p a t i e n t was i n t e r v i e w e d f o r b i o g r a p h i c a l da ta i n a p r i v a t e c u b i c l e of the o u t p a t i e n t c l i n i c . A copy o f the b i o g r a p h i c a l da ta fo rm i s c o n t a i n e d i n Append ix B, page 70. A da te f o r the v i s i t t o the p a t i e n t ' s home i n ten t o f o u r t e e n days was t e n t a -t i v e l y ag reed upon . I I I . THE PLANNED TEACHING A copy o f the s e m i - s t r u c t u r e d i n t e r v i e w gu ide wh ich the r e s e a r c h e r f o l l o w e d i n p a t i e n t t e a c h i n g i s c o n t a i n e d i n A p p e n d i x C , page 72. The same f o r m a t was f o l l o w e d i n the t h i r t y - m i n u t e d i s c u s s i o n w i t h each p a t i e n t i n the e x p e r i m e n t a l g r o u p . A w r i t e - u p o f one such t e a c h i n g d i s c u s s i o n i s c o n t a i n e d i n Append ix D, page 75. The p a t i e n t s were encou raged to p a r t i c i p a t e i n the 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 by i d e n t i f y i n g g o a l s o f s e l f - m e d i c a t i o n b e h a v i o r , by c h o o s i n g a l t e r n a t i v e s and by making t h e i r own d e c i s i o n s under the g u i d a n c e o f the r e s e a r c h e r . Each p a t i e n t was g i v e n a l a r g e c a l e n d a r and a p e n c i l , and i n s t r u c t e d i n the use o f t hese i t ems f o r i n d i c a t i n g d a i l y when a m e d i c a t i o n had been t a k e n . I V . THE QUESTIONNAIRE 27 Purpose o f the Q u e s t i o n n a i r e The o v e r a l l goa l f o r the da ta c o l l e c t i o n i n s t r u m e n t was to o b t a i n o b j e c t i v e i n f o r m a t i o n abou t the r e l a t i o n s h i p between the dependent v a r i a b l e o f p a t i e n t s e l f - m e d i c a t i o n b e h a v i o r i n the home, and the i ndependen t v a r i a b l e o f p a t i e n t t e a c h i n g . From t h e s e da ta c o m p a r i s o n s were made between the e x p e r i m e n t a l and c o n t r o l g r o u p s , and the t h r e e h y p o t h e s e s were t e s t e d . A copy o f the t w e n t y - i t e m q u e s t i o n n a i r e i s c o n t a i n e d i n Append ix E , page 80. C o n s t r u c t i o n o f the Q u e s t i o n n a i r e The measurement of the r e s u l t s o f the s t u d y i n terms o f i t s o b j e c t i v e r e q u i r e d the deve lopment o f a da ta c o l l e c t i o n i n s t r u m e n t , s i n c e none t h a t c o u l d be a p p l i e d t o t h i s s t u d y was a v a i l a b l e . Some of the i tems were based on a s t u d y by S c h w a r t z , H e n l e y , and Z e i t z o f e l d e r l y a m b u l a t o r y p a t i e n t s In d e s i g n i n g the q u e s t i o n n a i r e , p r i m a r y c o n s i d e r a -t i o n was g i v e n to e l i c i t i n g o b j e c t i v e i n f o r m a t i o n r e g a r d i n g the s e l f - m e d i c a t i o n p r a c t i c e s o f the p a t i e n t s i n t h e i r homes. Other f a c t o r s t a k e n i n t o a c c o u n t i n c l u d e d the t ime and c o s t i n v o l v e d i n data c o l l e c t i o n , the a v a i l a b i l i t y o f the p a t i e n t s ' c h a r t s i n the o u t p a t i e n t c l i n i c and the e x p e c t e d c o o p e r a t i o n ' S c h w a r t z , H e n l e y , and Z e i t z , The E I der I y  AmbuIa to ry P a t i e n t . p . 3 0 7 . 28 by the p a t i e n t i n p r o d u c i n g the m e d i c a t i o n c o n t a i n e r s f o r the i n t e r v i e w e r d u r i n g the home v i s i t . The sequence o f the i t ems of the q u e s t i o n n a i r e p e r m i t t e d a f r e e - f l o w c o n v e r s a t i o n w h i c h , a l t h o u g h t h e r e was an o r d e r l y p r o g r e s s i o n o f n e c e s s a r y i n f o r m a t i o n r e c e i v e d by the i n t e r v i e w e r , a l l o w e d the p a t i e n t t o d i g r e s s t o h i s l i f e e x p e r i e n c e s wh ich f r e q u e n t l y were u n r e l a t e d to h i s m e d i c a t i o n r e g i m e n . I t was f e l t t h a t t h i s would a l s o h e l p to c o n t r o l f o r p o s s i b l e b i a s i n p a t i e n t r e s p o n s e s to the q u e s t i o n s by h e l p i n g t o put the p a t i e n t a t e a s e . The q u e s t i o n n a i r e was d e s i g n e d to a l l o w the p a t i e n t t o f e e l c o m f o r t a b l e r a t h e r t han i n t e r r o g a t e d . I t c o n s i s t s o f t h r e e p a g e s . The c h a r t on the t h i r d p a g e , wh ich the i n t e r v i e w e r comp le ted w h i l e e l i c i t i n g r e s p o n s e s to q u e s t i o n s 3 t o 1 3 , s i m p l i f i e d the data a n a l y s i s p r o c e s s . Q u e s t i o n s 14 to 20 were i n c l u d e d i n the q u e s t i o n n a i r e to add to the d e s c r i p t i v e da ta o f the s t u d y . In o r d e r t o e l i m i n a t e p o s s i b l e b i a s by i n t e r v i e w e r s , the q u e s t i o n n a i r e c o n t a i n e d no i d e n t i f i c a t i o n o f the p a t i e n t w i t h r e g a r d t o e x p e r i m e n t a l or c o n t r o l g r o u p . P r e - t e s t o f the Q u e s t i o n n a i r e The q u e s t i o n n a i r e was p r e - t e s t e d . Four p a t i e n t s were each v i s i t e d i n t h e i r homes t w i c e , one week a p a r t , i n o r d e r t o a d m i n i s t e r the t o o l . The w o r d i n g , r e l e v a n c y , p r e c i s i o n and r e l i a b i l i t y o f the q u e s t i o n s were 29 t e s t e d . ^ 2 The p a t i e n t s responded w i t h i d e n t i c a l s c o r e s upon r e - a d m i n i s t r a t i o n o f the q u e s t i o n n a i r e . P r e - t e s t i n g t h e r e f o r e r e v e a l e d t h a t r e l i a b l e da ta c o u l d be o b t a i n e d . A r e v i s i o n was made by d e l e t i n g an i t em f r o m the q u e s t i o n n a i r e . A q u e s t i o n a s k i n g i f the name o f the m e d i c a t i o n was p r i n t e d on the c o n t a i n e r was found to be u n n e c e s s a r y , s i n c e a l l p a t i e n t s o b t a i n e d t h e i r m e d i c a t i o n s a t the o u t p a t i e n t c l i n i c pharmacy wh ich r o u t i n e l y p r i n t e d the names on a I I m e d i c a t i o n c o n t a i n e r s . Any doubt a s t o the w i l l i n g n e s s t o c o o p e r a t e on the p a r t o f the p a t i e n t s was d i s p e l l e d . The f o u r p a t i e n t s wi I I i n g I y p roduced the m e d i c a t i o n c o n t a i n e r s f o r the i n t e r v i e w e r . Some d i d so b e f o r e b e i n g a s k e d . They answered the q u e s t i o n s w i t h o u t h e s i t a t i o n . Where e r r o r s i n s e l f -m e d i c a t i o n were e v i d e n c e d , the p a t i e n t s o f t e n seemed to be unaware o f them. The r e v i s e d q u e s t i o n n a i r e was r e v i e w e d by the t h e s i s commi t t e e . The p a t i e n t s who p a r t i c i p a t e d i n the p r e - t e s t were not i n c l u d e d i n the s t u d y . A d m i n i s t r a t i o n o f the Q u e s t i o n n a i r e In o r d e r to a t t emp t t o c o n t r o l f o r p o s s i b l e b i a s on the p a r t o f the r e s e a r c h e r who a l s o m a n i p u l a t e d the D £ i F a y e G. A b d e l l a h and Eugene L e v i n e , B e t t e r P a t i e n t  Ca re Through Nurs i ng R e s e a r c h (New Y o r k : The Macmi I Ian Company, 1 9 6 5 ) , p. 3 2 1 . e x p e r i m e n t a l v a r i a b l e i n the c l i n i c s e t t i n g , two o u t s i d e i n t e r v i e w e r s , one o f whom was a r e g i s t e r e d nurse and the o t h e r a p h a r m a c i s t , each a d m i n i s t e r e d f i v e q u e s t i o n n a i r e s . T h i s was done i n the p a t i e n t ' s home, t en to f o u r t e e n days a f t e r h i s v i s i t to the c l i n i c . The o u t s i d e i n t e r v i e w e r s were not i n f o rmed as t o whether the p a t i e n t was a s s i g n e d to the e x p e r i m e n t a l o r the c o n t r o l g r o u p . P a t i e n t r e s p o n s e s o b t a i n e d by these i n t e r v i e w e r s were c o r r e l a t e d w i t h p a t i e n t r e s p o n s e s o b t a i n e d by the r e s e a r c h e r who v i s i t e d the r e m a i n i n g t h i r t y s t u d y p a t i e n t s i n t h e i r homes, when the da ta were a n a l y z e d . D u r i n g the home i n t e r v i e w the i n t e r v i e w e r asked to see the c o n t a i n e r s o f m e d i c a t i o n s , and w h i l e c a r r y i n g on the c o n v e r s a t i o n , checked the l a b e l s to compare t h e s e i n s t r u c t i o n s w i t h the p h y s i c i a n ' s o r d e r s t a k e n f r om the p a t i e n t ' s m e d i c a l r e c o r d a t the o u t p a t i e n t c l i n i c . The q u e s t i o n n a i r e was a d m i n i s t e r e d i n such a way so as not to impugn g u i l t i f e r r o r s i n s e l f - m e d i c a t i o n were made. R e l i a b i l i t y , V a l i d i t y and P r a c t i c a b i l i t y o f the Q u e s t i onna i re "A measure i s r e l i a b l e i f i t i s c o n s i s t e n t l y r e p r o d u c i b l e . " ^ R e l i a b i l i t y i s the degree to wh ich a p a t i e n t w i l l r espond w i t h the same s c o r e s when a q u e s t i o n -n a i r e i s r e - a d m i n i s t e r e d . I t i s a measure o f a t o o l ' s L e v i n e , " E x p e r i m e n t a l D e s i g n , " p. 208. 31 s t a b i l i t y and c o n s i s t e n c y . ^ 4 Responses f r om the f o u r p a t i e n t s i n the p r e - t e s t o f the q u e s t i o n n a i r e were i d e n t i c a l on bo th the f i r s t and second a d m i n i s t r a t i o n . T h e r e f o r e r e l i a b i l i t y o f the t o o l was deemed h i g h . V a l i d i t y answers the q u e s t i o n , "Does the i n s t r u m e n t r e a l l y measure what i t i s supposed to m e a s u r e ? " The q u e s t i o n n a i r e d e s i g n e d f o r t h i s s t u d y d i d r e v e a l e r r o r s i n s e I f - m e d i c a t i o n and v o i d s i n p a t i e n t know ledge , wh ich i t was supposed to m e a s u r e . L e v i n e s t a t e s v a l i d i t y i s r e l a t e d to r e l e v a n c e . I f s t a t i s t i c a l t e s t s show s i g n i f i c a n t r e s u l t s , do t h e s e r e s u l t s 65 a c t u a l l y have a p r a c t i c a l s i g n i f i c a n c e i n r e a l l i f e ? I t i s f e l t t h a t a s t u d y whose d a t a - g a t h e r i n g t o o l r e v e a l s t h a t a s i g n i f i c a n t l y h i g h e r number o f e r r o r s i n s e l f - m e d i c a t i o n a re b e i n g made by p a t i e n t s , where t hese p a t i e n t s have no t been exposed to t e a c h i n g abou t t h e i r m e d i c a t i o n s , i s of p r a c t i c a l v a l u e i n r e a l l i f e . P a t i e n t t e a c h i n g i s a f u n c t i o n o f the n u r s e . T e a c h i n g a p a t i e n t abou t h i s m e d i c a t i o n s i s not n e c e s s a r i l y a d i f f i c u l t t a s k . E r r o r s i n s e I f - m e d i c a t i o n o f d i g o x i n can r e s u l t i n r e a l harm to the p a t i e n t as Wa l t on and Gazes p o i n t ou t when t hey w r i t e : Inadequate dosage commonly i s f o l l o w e d by the r e t u r n o f the c o n d i t i o n s o f h e a r t f a i l u r e . E x c e s s i v e dosage i s f o l l o w e d by t o x i c e f f e c t s w i t h a r r h y t h m i a s and as a f i n a l s t a g e , h e a r t s t a n d s t i I I . ° ° 64 A b d e l l a h and L e v i n e , o p . c i t . , p . 3 2 2 . ^ ^ L e v i n e , l o c . c i t . Wa l ton and G a z e s , " C a r d i a c G l y c o s i d e s I I , " p. 7 8 0 . And Jankowsk i s a y s , " O b v i o u s l y , the marg in between the t h e r a p e u t i c dose and the t o x i c dose o f d i g i t a l i s i s q u i t e n a r r o w , compared w i t h most d rugs i n common use t oday ."^7 Wi th r e g a r d t o d i u r e t i c s , G r o l l m a n w r i t e s : The p o t e n t , commonly used d i u r e t i c s a re no t s e l f -l i m i t e d i n a c t i o n . T h i s i s p a r t i c u l a r l y t r u e i n p a t i e n t s w i t h c o n g e s t i v e h e a r t f a i l u r e , . . . where ove ruse o f d i u r e t i c s may i n c r e a s e d i s a b i l i t y and even p rove f a t a I A c c o r d i n g t o F i s h e r : . . . the s i m p l e p r e c a u t i o n o f r a n d o m i z a t i o n w i l l s u f f i c e t o g u a r a n t e e the v a l i d i t y o f a t e s t o f s i g n i f i c a n c e , by wh ich the r e s u l t o f the e x p e r i m e n t i s to be j u d g e d .69 The sample p o p u l a t i o n i n t h i s s t u d y was randomly a s s i g n e d i n t o two g r o u p s . The above s t a t e m e n t would imp l y t h a t the t e s t s o f s i g n i f i c a n c e were v a l i d . The p r a c t i c a b i l i t y o f a t o o l i s measured by i t s r e a s o n a b l e n e s s i n c o s t , i n t ime and i n ease o f a d m i n i s t r a -t i o n . 70 The q u e s t i o n n a i r e was r e a d i l y a d m i n i s t e r e d by r e a d i n g the twen ty i tems to the p a t i e n t and r e c o r d i n g the p a t i e n t r e s p o n s e s . T h i s c o u l d be done i n l e s s than twen ty ^ N o r m a n W. J a n k o w s k i , " D i g i t a l i s : I Never Know Where I S tand Wi th I t , " P a t i en t Care C I i n i caI C o n c e p t s (March 1 5 , 1 9 7 0 ) , p . 8 9 . ^ A r t h u r G r o l l m a n , " D i u r e t i c 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 , V o l . LXV, No. 1 ( J a n u a r y , 1965), p . 89. ^ 9R. A . F i s h e r , The De s i gn o f E x p e r iments (7 th e d . ; London : O l i v e r and B o y d , 1 9 6 0 ) , p. 2 1 . ^ ° V i v i a n Wood, " U n d e r s t a n d i n g P s y c h o m e t r i c T e s t s , " The C a n a d i a n N u r s e . V o l . L X I , No. 4 ( A p r i l , 1965), p . 2 8 2 . 33 m i n u t e s . The c o s t o f the fo rms was n o m i n a l . The t ime and c o s t o f t r a v e l t o the p a t i e n t ' s home must a l s o be c o n s i d e r e d . The s i m p l i f i e d method o f da ta a n a l y s i s on page 3 o f the q u e s t i o n n a i r e makes i t an e f f i c i e n t and p r a c t i c a b l e t o o l f o r the r e s e a r c h e r . V . METHOD OF DATA ANALYSIS "An i m p o r t a n t c h a r a c t e r i s t i c o f a I I s c i e n t i f i c a c t i v i t y i s the m e a s u r e m e n t . " 7 1 Hav ing n u m e r i c a l da ta s e r v e s a u s e f u l pu rpose s i n c e q u a n t i f i c a t i o n enhances the o b j e c t i v i t y o f the i n t e r p r e t a t i o n o f r e s u l t s . Numbers a r e l e s s ambiguous than l a n g u a g e . 7 2 In t h i s s t u d y the data were d i s c r e t e v a l u e s . The c h i - s q u a r e t e s t o f s i g n i f i c a n c e was used to d e t e r m i n e the d i f f e r e n c e between the number and type o f s e l f - m e d i c a t i o n e r r o r s , and the d i f f e r e n c e i n l e v e l s o f knowledge between the two g roups o f p a t i e n t s . Y a t e s ' c o r r e c t i o n f o r c o n t i n u i t y was a p p l i e d where i n d i c a t e d . 7 ^ The c o m p u t a t i o n s were pe r fo rmed m a n u a l l y . In o r d e r t o p e r f o r m s t a t i s t i c a l t e s t s o f s i g n i f i -c a n c e , the h y p o t h e s e s were s t a t e d i n the n u l l h y p o t h e s i s ' ' W a l t e r R. F u c h s , C y b e r n e t i cs f o r the Modern Mi nd (New Y o r k : The M a c m i l l a n Company, 1971), p. 58. 7 2 L e v i n e , o p . c i t . , p. 206. ^ D o n a l d R. Shupe , "On the Use o f C h i - S q u a r e i n N u r s i n g R e s e a r c h , " Nurs i ng R e s e a r c h , V o l . X V I , No. 3 (Summer, 1 9 6 7 ) , p. 282. f o r m . The . 0 5 l e v e l o f s i g n i f i c a n c e was a c c e p t e d as s t a t i s t i c a l l y s i g n i f i c a n t . The d e c i s i o n to a c c e p t the . 0 5 l e v e l was made b e f o r e the s t u d y was begun . Some o f the da ta were a l s o a n a l y z e d d e s c r i p t i v e I T a b l e s and g raphs were drawn to i l l u s t r a t e c o m p a r i s o n s . C h a p t e r 5 ANALYSIS OF THE DATA I. THE STUDY POPULATION A t o t a l o f f o r t y a m b u l a t o r y male and f ema le c a r d i a c p a t i e n t s c o m p r i s e d the s t u d y s a m p l e . F o r t y - f o u r p a t i e n t s i n i t i a l l y a g r e e d to p a r t i c i p a t e i n the s t u d y when they came f o r c l i n i c a p p o i n t m e n t s on Tuesday morn ings d u r i n g the months o f November, December , and J a n u a r y . Four were s u b s e q u e n t l y not i n c l u d e d i n the s t u d y . One man f rom the e x p e r i m e n t a l group was h o s p i t a l i z e d b e f o r e he c o u l d be v i s i t e d a t h i s home t e n t o f o u r t e e n days a f t e r v i s i t i n g the c l i n i c . A n o t h e r man f rom t h i s group was o m i t t e d f rom the s t u d y because the home v i s i t r e v e a l e d t h a t a c l o s e f a m i l y member a d m i n i s t e r e d h i s m e d i c a t i o n s and a l s o became h i s spokesman d u r i n g the i n t e r v i e w . In the c o n t r o l group one man was a l s o h o s p i t a l i z e d , and a woman who had i n i t i a l l y s t a t e d she was w i l l i n g t o p a r t i c i p a t e i n the s t u d y , l a t e r r e f u s e d to p e r m i t the i n t e r v i e w e r t o v i s i t he r a t her home. She was the o n l y p a t i e n t to r e f u s e t o p a r t i c i p a t e , a l t h o u g h each p a t i e n t was t o l d he c o u l d w i t hd raw f rom the s t u d y a t any t ime i f he so d e s i r e d . D u r i n g the i n i t i a l p a t i e n t i n t e r v i e w i n the o u t p a t i e n t c l i n i c , an emphas is on the p a t i e n t ' s m e d i c a t i o n s 35 was a v o i d e d by e x p r e s s i n g an i n t e r e s t o n l y i n how he was g e t t i n g a l o n g a t home. I t was f e l t t h a t t h i s app roach would h e l p to a v o i d b i a s i n the s t u d y . A f t e r c o m p l e t i o n o f the b i o g r a p h i c a l da ta f o r m , no f u r t h e r c o n v e r s a t i o n was h e l d w i t h p a t i e n t s i n the c o n t r o l g r o u p . Those p a t i e n t s who had been a s s i g n e d to the e x p e r i m e n t a l g r o u p , r e t u r n e d f o r a t h i r t y - m i n u t e p l anned t e a c h i n g d i s c u s s i o n w i t h the r e s e a r c h e r a f t e r s e e i n g the d o c t o r . The m e d i c a l r e c o r d s o f p a t i e n t s i n both groups were o b t a i n e d a f t e r the p a t i e n t s had been seen by the d o c t o r , i n o r d e r to t r a n s c r i b e the l i s t o f p r e s c r i b e d m e d i c a t i o n s to the b i o g r a p h i c a l da ta f o r m . In many i n s t a n c e s t h i s l i s t o f m e d i c a t i o n s was unchanged f rom p r e v i o u s o r d e r s , but i n some c a s e s changes were made i n o r d e r s of l o n g - s t a n d i n g . On ly o r a l m e d i c a t i o n s were c o n s i d e r e d i n the s t u d y . A M of the f o r t y p a t i e n t s were t a k i n g d i g o x i n . T h i r t y - s i x p a t i e n t s , e i g h t e e n f rom each g r o u p , were a l s o t a k i n g a d i u r e t i c . The two most commonly p r e s c r i b e d d i u r e t i c s were L a s i x and H y d r o c h l o r o t h i a z i d e . A l i s t o f the l e s s common d i u r e t i c s and a l l o t h e r m e d i c a t i o n s p r e s c r i b e d f o r t h e s e p a t i e n t s i s c o n t a i n e d i n Append ix F , page 84. N i t r o g l y c e r i n e , a n a l g e s i c s , s o m n e r i f i c s and l a x a t i v e s were r o u t i n e l y p r e s c r i b e d as p . r . n . o r d e r s and were not i n c l u d e d i n the s t u d y . A pharmacy was l o c a t e d i n the o u t p a t i e n t c l i n i c . P a t i e n t s o b t a i n e d t h e i r m e d i c a t i o n s here w i t h o u t c o s t . The names o f the d rugs as w e l l as amounts and t imes to be 37 t a k e n were c l e a r l y p r i n t e d on the c o n t a i n e r s . T h i s e n a b l e d the i n t e r v i e w e r s t o check the c o n t a i n e r s d u r i n g the home v i s i t . The p a t i e n t s i n the e x p e r i m e n t a l group r e t u r n e d w i l l i n g l y t o t a l k w i t h the r e s e a r c h e r a f t e r s e e i n g t h e i r d o c t o r s . The t ime i n v o l v e d d i d not seem to be a c o n c e r n t o them. Most t a l k e d f r e e l y about t h e i r c a r d i a c c o n d i t i o n s and appeared i n t e r e s t e d i n l e a r n i n g more abou t them and abou t t h e i r m e d i c a t i o n s . A l l t h r e e i n t e r v i e w e r s were a c c e p t e d i n t o the homes o f the p a t i e n t s . On l y one r e f u s a l was e n c o u n t e r e d . D u r i n g the home v i s i t a f r e e - f l o w i n t e r v i e w took p l a c e e l i c i t i n g i n f o r m a t i o n abou t the p a t i e n t s * s e l f - m e d i c a t i o n b e h a v i o r by f o l l o w i n g the t w e n t y - i t e m q u e s t i o n n a i r e . Most p a t i e n t s d i d not appea r to r e c o g n i z e t h a t the purpose o f the v i s i t was t o check on t h e i r s e l f - m e d i c a t i o n b e h a v i o r . They t a l k e d f r e e l y , abou t t h e i r h e a l t h , the o u t p a t i e n t c l i n i c , t h e i r m e d i c a t i o n s and o t h e r l i f e e x p e r i e n c e s . I t seemed t h a t where e r r o r s became a p p a r e n t t o the i n t e r v i e w e r , the p a t i e n t s t h e m s e l v e s were o f t e n not aware t h a t e r r o r s had o c c u r r e d , e x c e p t i n the case o f o m i s s i o n s . A l m o s t e v e r y p a t i e n t appea red r e l u c t a n t to see the i n t e r v i e w e r l e a v e , and, thanked her f o r h a v i n g come to v i s i t . I I . SUMMARY OF THE DATA D e t a i l s o f the background o f p a t i e n t s i n the e x p e r i m e n t a l and c o n t r o l g roups a re shown i n T a b l e s 1 and 2. 38 T a b l e 1 S e x , A g e , L i v i n g Ar rangement and T o t a l Number o f M e d i c a t i o n s o f P a t i e n t s i n the E x p e r i m e n t a l Group P a t i e n t Sex Age L i v i ng T o t a l number a r r a n g e m e n t * o f m e d i c a t i o n s 1 M 67 A 3 2 M 64 A 3 3 M 66 S 4 4 M 64 A 2 5 F 74 0 3 6 M 62 A 4 7 M 65 A 3 8 M 66 S 5 9 F 78 0 4 10 M 67 A 2 11 F 66 S 3 12 M 77 0 2 13 M 61 A 2 14 M 69 A 3 15 M 69 0 3 16 F 85 A 3 17 F 59 A 7 18 M 60 A 3 19 M 80 A 2 20 M 89 A 3 X = 69 .4 X = 3 . 2 *A = l i v i n g a I one S = l i v i n g w i t h spouse 0 = l i v i n g w i t h o t h e r a d u l t s . 39 T a b l e 2 S e x , A g e , L i v i n g Ar rangement and T o t a l Number o f M e d i c a t i o n s o f P a t i e n t s i n the C o n t r o l Group P a t i en t Sex Age L i v i ng T o t a I number a r r a n g e m e n t * o f m e d i c a t i o n s 1 F 6 5 S 3 2 M 59 A 5 3 M 80 0 3 4 M 78 A 3 5 M 88 0 3 6 M 82 0 4 7 F 71 A 3 8 M 56 A 4 9 F 75 A 3 10 F 77 S 4 11 M 61 S 5 1 2 F 82 0 2 13 M: 72 0 2 14 M 67 A 3 15 F 82 0 3 16 F 79 S 3 17 M 53 S 2 18 F 58 A 3 19 F 69 A 8 20 M 71 A 4 X = 71 . 3 X = 3 . 5 * A = I i v i n g a I one S = l i v i n g wi th spouse 0 = I i v i ng wi th o t h e r a d u l t s . 40 In the e x p e r i m e n t a l group o f twenty p a t i e n t s , f i v e were f e m a l e . The c o n t r o l group o f twen ty p a t i e n t s c o n s i s t e d o f n i ne f e m a l e s and e l e v e n m a l e s . The a v e r a g e age o f the e x p e r i m e n t a l group was 6 9 . 4 y e a r s , w h i l e the a v e r a g e age o f the c o n t r o l group was 7 1 . 3 y e a r s . In the e x p e r i m e n t a l g r o u p , t h i r t e e n p a t i e n t s l i v e d a l o n e , t h r e e l i v e d w i t h t h e i r spouses and f o u r l i v e d w i t h m a r r i e d c h i l d r e n or o t h e r a d u l t s . In the c o n t r o l g r o u p , n i ne p a t i e n t s l i v e d a l o n e , f i v e l i v e d w i t h t h e i r spouses and s i x l i v e d w i t h m a r r i e d c h i l d r e n or o t h e r a d u l t s . The ave rage number o f m e d i c a t i o n s p r e s c r i b e d per p a t i e n t i n the e x p e r i m e n t a l group was 3 . 2 , w h i l e i n the c o n t r o l group i t was 3 . 5 m e d i c a t i o n s per p a t i e n t . The p e r c e n t a g e d i s t r i b u t i o n o f s e l f - m e d i c a t i o n e r r o r s i n d i g o x i n and d i u r e t i c s , and o t h e r m e d i c a t i o n s , and the a v e r a g e l e v e l o f knowledge o f d i g o x i n and d i u r e t i c s , and o t h e r m e d i c a t i o n s , of bo th the e x p e r i m e n t a l and c o n t r o l g roups a r e shown i n F i g u r e 1. The f i g u r e shows the i n v e r s e r e l a t i o n s h i p between p a t i e n t s e l f - m e d i c a t i o n e r r o r s and p a t i e n t l e v e l o f knowledge abou t h i s m e d i c a t i o n s and t h e i r e f f e c t s . The e n t i r e e x p e r i m e n t a l group made a t o t a l o f t h r e e e r r o r s (wh ich r e p r e s e n t 15 p e r c e n t o f the t o t a l number o f e r r o r s made by a l l f o r t y p a t i e n t s s t u d i e d ) i n s e l f -m e d i c a t i o n o f d i g o x i n and d i u r e t i c s i n a t w e n t y - f o u r - h o u r p e r i o d , w h i l e the c o n t r o l group made s e v e n t e e n e r r o r s (wh ich r e p r e s e n t 85 p e r c e n t o f a l l e r r o r s made by the e n t i r e s t u d y p o p u l a t i o n ) . In o t h e r m e d i c a t i o n s the e x p e r i m e n t a l group l • •! 41 made a t o t a l of s i x e r r o r s (wh ich i s 2 7 . 3 p e r c e n t o f a I I e r r o r s made by the f o r t y p a t i e n t s s t u d i e d ) d u r i n g the same p e r i o d , w h i l e the c o n t r o l group made s i x t e e n e r r o r s (or 7 2 . 7 p e r c e n t o f a I I e r r o r s made by the e n t i r e s t udy p o p u l a t i o n . L e g e n d : E r r o r s i n d i gox i n and d i u r e t i cs E r r o r s o t h e r me d i ca -t i o n s Ave ra ge I eve I o f know ledge o f d i g o x -i n and d i u r e t i cs E x p e r i m e n t a l group C o n t r o l group 1 Average Ie veI o f know ledge o f o t h e r medi c a -t i ons F i gure 1 P e r c e n t a g e D i s t r i b u t i o n o f S e l f - M e d i c a t i o n E r r o r s i n D i g o x i n and D i u r e t i c s , and Othe r M e d i c a t i o n s , and Average L e v e l o f Knowledge o f D i g o x i n and D i u r e t i c s , and Othe r M e d i c a t i o n s , o f Both E x p e r i m e n t a l and C o n t r o l Groups The p a t i e n t ' s l e v e l o f knowledge was e s t a b l i s h e d by the a s k i n g o f f o u r q u e s t i o n s c o n c e r n i n g h i s m e d i c a t i o n s . T h e r e f o r e , the p a t i e n t who knew the c o r r e c t answers t o a l l f o u r q u e s t i o n s would have a l e v e l o f knowledge o f 4 . The ( 42 ave rage l e v e l of knowledge o f d i g o x i n and d i u r e t i c s o f the e x p e r i m e n t a l group was 2 .7 (wh ich r e p r e s e n t s 6 9 . 2 p e r c e n t o f the p o s s i b l e l e v e l o f knowledge o f 100 p e r c e n t ) w h i l e f o r the c o n t r o l group i t was 1.2 (wh ich r e p r e s e n t s 3 0 . 8 p e r c e n t o f the p o s s i b l e 100 p e r c e n t ) . The ave rage l e v e l o f knowledge o f o t h e r m e d i c a t i o n s t a k e n by the e x p e r i m e n t a l group was 2 . 5 (wh ich i s 69.1 p e r c e n t o f the p o s s i b l e l e v e l o f knowledge o f 100 p e r c e n t ) w h i l e f o r the c o n t r o l group i t was 1.1 (o r 3 0 . 9 p e r c e n t o f the p o s s i b l e 100 p e r c e n t ) . The number and p e r c e n t a g e o f t y p e s o f s e l f -m e d i c a t i o n e r r o r s o f m e d i c a t i o n s o t h e r than d i g o x i n and d i u r e t i c s made by bo th g roups a re shown i n T a b l e 3 . T a b l e 3 Number and P e r c e n t a g e o f Types o f S e l f - M e d i c a t i o n E r r o r s i n M e d i c a t i o n s Other Than D i g o x i n and D i u r e t i c s Made by Both Groups E x p e r i m e n t a l group C o n t r o l group Type N = 20 N = 20 o f e r r o r Number Pe r c e n t a g e Number P e r c e n t a g e o f o f t o t a I o f o f t o t a I e r r o r s e r r o r s e r r o r s e r r o r s Omi ss i on 1 1 6 . 6 4 2 5 . 0 Not p r e s c r i b e d 3 5 0 . 0 2 1 2 . 5 Improper t ime 1 1 6 . 7 7 4 3 . 7 I n c o r r e c t dosage 1 16 .7 3 1 8 . 8 To ta I 6 1 0 0 . 0 16 1 0 0 . 0 The type o f s e l f - m e d i c a t i o n e r r o r o f o t h e r m e d i c a t i o n s which was made by most p a t i e n t s i n the e x p e r i m e n t a l group was t a k i n g a m e d i c a t i o n no t p r e s c r i b e d by the d o c t o r . In the c o n t r o l group most p a t i e n t s made the e r r o r o f t a k i n g the m e d i c a t i o n s a t the improper t i m e . Both g roups made few e r r o r s i n i n c o r r e c t d o s a g e . The e x p e r i m e n t a l group made one e r r o r o f o m i s s i o n w h i l e the c o n t r o l group made f o u r e r r o r s o f o m i s s i o n . In t h i s c a t e g o r y o f m e d i c a t i o n s , some common p r e s c r i p t i o n s such as p o t a s s i u m p r e p a r a t i o n s were o f t e n o r d e r e d by the d o c t o r t o be t a k e n f o u r t i m e s a day ( Q . I . D . ) , w h i l e d i g o x i n and d i u r e t i c s were u s u a l l y o n l y d a i l y o r d e r s ( O . D . ) . However , the c o n t r o l group made a p p r o x i m a t e l y the same number o f e r r o r s i n t a k i n g d i g o x i n and d i u r e t i c s ( s e v e n t e e n e r r o r s ) as i n t a k i n g o t h e r m e d i c a t i o n s ( s i x t e e n e r r o r s ) . The e x p e r i m e n t a l group made t w i c e as many e r r o r s i n s e l f - m e d i c a t i o n o f o t h e r m e d i c i n e s as i n s e l f - m e d i c a t i o n o f d i g o x i n and d i u r e t i c s . The number o f p a t i e n t s i n both g roups who made s e l f -m e d i c a t i o n e r r o r s i n the t o t a l m e d i c a t i o n r e g i m e n , w i t h r e g a r d t o age g r o u p , and mean number o f e r r o r s per p a t i e n t i n each age g r o u p , a re shown i n T a b l e 4. In bo th g r o u p s , most e r r o r s per p a t i e n t i n the t o t a l m e d i c a t i o n r e g i m e n , were made by the 61-70 age g r o u p . None o f the e r r o r s made by the e x p e r i m e n t a l group were made by p a t i e n t s under s i x t y y e a r s o f age or over e i g h t y y e a r s o f a g e . In the c o n t r o l g r o u p , p a t i e n t s i n t h e s e two age groups d i d make e r r o r s . In each o f the f o u r age groups the Tab le 4 Number of P a t i e n t s i n Both Groups who Made S e l f - M e d i c a t i o n E r r o r s i n the T o t a l M e d i c a t i o n Reg imen, w i t h Regard t o Age Group , and Mean Number of E r r o r s per P a t i e n t i n Each Age Group E x p e r i m e n t a l Group N = 20 C o n t r o l Group N = 20 Age Number o f Number Mean number Number o f Number Mean number Group p a t i e n t s o f of e r r o r s p a t i e n t s o f o f e r r o r s e r r o r s per p a t i e n t e r r o r s per p a t i e n t . 5 0 - 6 0 2 0 0 4 8 2 . 0 0 61-70 12 7 0 . 5 5 4 9 2 . 5 0 71 - 8 0 4 2 0 . 5 0 8 12 1 . 2 5 81 - 9 0 2 0 0 4 4 1 . 0 0 T o t a l 20 9 X = 0 . 5 2 20 33 X = 1 .68 45 e x p e r i m e n t a l group made fewer ave rage e r r o r s per p a t i e n t than d i d the c o n t r o l g r o u p . The p e r c e n t a g e d i s t r i b u t i o n o f s e l f - m e d i c a t i o n e r r o r s i n the t o t a l m e d i c a t i o n reg imen o f bo th e x p e r i m e n t a l and c o n t r o l g roups w i t h r e g a r d t o l i v i n g a r r a n g e m e n t s , i s shown i n F i g u r e 2 . Most e r r o r s i n s e I f - m e d i c a t i o n i n the t o t a l m e d i c a t i o n reg imen i n bo th groups were made by p a t i e n t s who l i v e d a l o n e . In the e x p e r i m e n t a l group 5 5 . 5 p e r c e n t o f the e r r o r s made by the group were made by p a t i e n t s who l i v e d a l o n e . They made f i v e o f the t o t a l o f n i ne e r r o r s made by t h i s g r o u p . O n l y I I. I p e r c e n t o f e r r o r s made by the e x p e r i m e n t a l group were made by p a t i e n t s who were m a r r i e d and l i v e d w i t h t h e i r s p o u s e s , w h i l e 3 3 . 4 p e r c e n t o f t o t a l number e r r o r s made were made by p a t i e n t s who l i v e d w i t h m a r r i e d c h i l d r e n or o t h e r a d u l t s . i _ o i _ i_ OJ H-O CD CD CO -H c CD o l _ CD L e g e n d : yy '  / 'yy Vy A I one E x p e r i m e n t a l group C o n t r o l group Spouse O t h e r s F i g u r e 2 P e r c e n t a g e D i s t r i b u t i o n o f S e l f - M e d i c a t i o n E r r o r s i n the T o t a l M e d i c a t i o n Regimen o f Both E x p e r i m e n t a l and C o n t r o l Groups w i t h Regard to L i v i n g A r rangements In the c o n t r o l g r o u p , t hose p a t i e n t s who l i v e d a l o n e made 5 1 . 5 p e r c e n t o f a I I e r r o r s made by the g r o u p . They made e i g h t e e n o f the t o t a l o f t h i r t y - t h r e e e r r o r s made by the c o n t r o l g r o u p . Those p a t i e n t s who l i v e d w i t h t h e i r spouses made 2 4 . 4 p e r c e n t o f a l l e r r o r s made by the c o n t r o l group w h i l e 24.1 p e r c e n t o f a l l e r r o r s were made by p a t i e n t s who l i v e d w i t h m a r r i e d c h i l d r e n or o t h e r a d u l t s . The sex o f the p a t i e n t was not a s i g n i f i c a n t f a c t o r i n s e l f - m e d i c a t i o n e r r o r s i n e i t h e r the e x p e r i m e n t a l o r the c o n t r o l g r o u p . Ma les and f e m a l e s made s i m i l a r numbers and t y p e s of e r r o r s . P a t i e n t s who had a l a r g e number o f m e d i c a t i o n s p r e s c r i b e d f o r them by t h e i r p h y s i c i a n s made no more e r r o r s than d i d p a t i e n t s w i t h o n l y two or t h r e e m e d i c a t i o n s . T h i s was t r u e i n bo th the e x p e r i m e n t a l and c o n t r o l g r o u p s . Most p a t i e n t s were not v i s i t e d by p u b l i c h e a l t h n u r s e s i n the communi ty . Two p a t i e n t s s t a t e d t hey r e c e i v e d week l y i n j e c t i o n s f rom a community n u r s e . The r e a s o n most f r e q u e n t l y g i v e n by p a t i e n t s f o r f o r g e t t i n g t o take m e d i c a t i o n s was, "I ge t busy d o i n g some th ing and then I f o r g e t . " They d i d not appea r t o d i s l i k e t a k i n g t h e i r m e d i c a t i o n s , but many p a t i e n t s s t a t e d t hey would l i k e to know more abou t the e f f e c t s o f the medi c a t i o n s . In summary, p a t i e n t s i n the c o n t r o l group made more s e l f - m e d i c a t i o n e r r o r s than t hose i n the e x p e r i m e n t a l group and t hey had a lower l e v e l o f knowledge abou t t h e i r 4 7 m e d i c a t i o n s . In both g r o u p s , the two c a t e g o r i e s o f p a t i e n t s who made the most e r r o r s were those i n the 6 1 - 7 0 yea r age g r o u p , and t h o s e who l i v e d a l o n e . In o r d e r to check f o r p o s s i b l e b i a s o f the r e s e a r c h e r , who a l s o m a n i p u l a t e d the i ndependen t v a r i a b l e o f p l a n n e d t e a c h i n g o f the p a t i e n t s i n the e x p e r i m e n t a l g r o u p , one f o u r t h o f the t o t a l sample home i n t e r v i e w s were c o n d u c t e d by two o u t s i d e i n t e r v i e w e r s . T a b l e 5 shows t h a t s i x t e e n o f the 2 0 p a t i e n t s i n the e x p e r i m e n t a l group were i n t e r v i e w e d by the r e s e a r c h e r . Three o f t h e s e p a t i e n t s ( 1 8 . 7 5 p e r c e n t ) made e r r o r s i n s e l f - m e d i c a t i o n o f d i g o x i n and d i u r e t i c s . Four o f the 2 0 p a t i e n t s i n t h i s group were i n t e r v i e w e d by the o u t s i d e i n t e r v i e w e r s . None o f t h e s e p a t i e n t s ( 0 p e r c e n t ) made e r r o r s . In the c o n t r o l g r o u p , the r e s e a r c h e r i n t e r v i e w e d f o u r t e e n o f the 2 0 p a t i e n t s . N ine o f t h e s e p a t i e n t s ( 6 4 . 2 9 p e r c e n t ) made e r r o r s . The two o u t s i d e i n t e r v i e w e r s v i s i t e d s i x o f the 2 0 p a t i e n t s . Fou r o f t hese p a t i e n t s ( 6 6 . 6 7 p e r c e n t ) made e r r o r s . I I I . ANALYSIS IN RELATION TO HYPOTHESIS I The e x p e r i m e n t a l s t u d y was d e s i g n e d to t e s t t h r e e h y p o t h e s e s . The f i r s t h y p o t h e s i s was : H 0 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 number o f s e l f - m e d i c a t i o n e r r o r s made i n a t w e n t y - f o u r - h o u r p e r i o d by members o f the e x p e r i m e n t a l group as compared w i t h members o f the c o n t r o l g r o u p . The c h i - s q u a r e t e s t o f Tab le 5 Number and P e r c e n t a g e o f P a t i e n t s i n Both Groups Who Made S e l f - M e d i c a t i o n E r r o r s i n D i g o x i n and D i u r e t i c s as E v i d e n c e d by the Three I n t e r v i e w e r s E x p e r i m e n t a l Group N = 2 0 C o n t r o I ' Group"N = 2 0 I n t e r v i ewer Number i n t e r v i e w e d Number who made e r r o r s P e r c e n t a ge who made e r r o r s Number i n t e r v i ewed Number who made e r r o r s P e r c e n t a g e who made . e r r o r s -R e s e a r c h e r 1 6 3 18.75 14 9 64 . 2 9 O u t s i de i n t e r v i ewers 4 0 0 6 4 66.67 CO 49 s i g n i f i c a n c e emp loy i ng a 2 x 3 c o n t i n g e n c y t a b l e and Y a t e s * c o r r e c t i o n f o r c o n t i n u i t y was a p p l i e d to the data on number o f e r r o r s t o d e t e r m i n e the s i g n i f i c a n c e o f the d i f f e r e n c e between the number o f e r r o r s made by the e x p e r i m e n t a l g roup -as compared w i t h the c o n t r o l g r o u p . The s t a t i s t i c a l f o r m u l a i s c o n t a i n e d i n Append ix G, page 8 6 . T h i s f o r m u l a was a l s o a p p l i e d i n t e s t i n g h y p o t h e s i s I I I . Tab le 6 Number o f S e I f - M e d i c a t i o n E r r o r s o f D i g o x i n and D i u r e t i c s Made Per P a t i e n t by Both Groups Number o f e r r o r s E x p e r i m e n t a l group C o n t r o l group per p a t i e n t 2 0 4 1 3 9 0 17 7 T o t a l number o f p a t i e n t s 20 2 0 . N = 40 d . f . = 2 OC l= 7 . 7 2 P < . 0 5 A c h i - s q u a r e v a l u e o f 7 . 7 2 was o b t a i n e d . T h i s r e s u l t p e r m i t t e d the r e j e c t i o n o f the n u l l h y p o t h e s i s a t the . 0 5 I eve I. There was a s i g n i f i c a n t d i f f e r e n c e between the number o f s e l f - m e d i c a t i o n e r r o r s o f d i g o x i n and d i u r e t i c s made by the e x p e r i m e n t a l and c o n t r o l g r o u p s . 50 I V . ANALYSIS IN RELATION TO HYPOTHESIS II The second h y p o t h e s i s was : H 0 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 type o f s e l f - m e d i c a t i o n e r r o r s made i n a t w e n t y - f o u r - h o u r p e r i o d by members o f the e x p e r i m e n t a l group as compared w i t h members o f the c o n t r o l g r o u p s . Tab le 7 A . Number o f S e l f - M e d i c a t i o n E r r o r s o f T a k i n g N o n - P r e s c r i p t i o n M e d i c a t i o n Made by Both Groups N o n - p r e s c r i p t i o n e r r o r E x p e r i m e n t a l group C o n t r o l group Yes 1 2 No 19 18 T o t a l number of p a t i e n t s 20 20 N = 40 d . f . = 1 % z = 1 .40 p ^ .05 The c h i - s q u a r e t e s t o f s i g n i f i c a n c e e m p l o y i n g a 2 x 2 c o n t i n g e n c y t a b l e and c o r r e c t i o n f o r c o n t i n u i t y was a p p l i e d t o the da ta on a I I f o u r t y p e s o f e r r o r s made by bo th groups o f p a t i e n t s . The s t a t i s t i c a l f o r m u l a i s c o n t a i n e d i n Append ix G, page 8 6 . A c h i - s q u a r e v a l u e o f 1.40 was o b t a i n e d . T h i s r e s u l t d i d not p e r m i t the r e j e c t i o n o f the n u l l h y p o t h e s i s a t the .05 l e v e l . There was no s i g n i f i c a n t d i f f e r e n c e between the number o f e r r o r s o f t a k i n g a n o n - p r e s c r i b e d 51 m e d i c a t i o n made by the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p . T a b l e 8 B. Number o f E r r o r s o f O m i s s i o n i n S e I f - M e d i c a t i o n o f D i g o x i n and D i u r e t i c s Made by Both Groups E r r o r o f o m i s s i o n E x p e r i m e n t a l group C o n t r o l group Yes 0 No 20 6 14 T o t a l number o f p a t i e n t s 20 20 N = 40 d . f . = 1 %* = 4 . 9 0 p < . 0 5 There was a s i g n i f i c a n t d i f f e r e n c e i n number o f e r r o r s o f o m i s s i o n o f d i g o x i n and d i u r e t i c s made by the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p . T a b l e 9 C . Number o f E r r o r s o f Improper Time o f D i g o x i n and D i u r e t i c s Made i n S e I f - M e d i c a t i o n by Both Groups E r r o r o f improper t ime E x p e r i m e n t a l group C o n t r o l group Yes 2 No 18 6 14 T o t a l number o f p a t i e n t s 20 20 N = 40 d . f . = 1 0t a = 1 .-41 P > . 0 5 52 There was no s i g n i f i c a n t d i f f e r e n c e between the number o f e r r o r s o f t a k i n g d i g o x i n and d i u r e t i c s a t the improper t ime made by the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p . T a b l e 10 D. Number o f E r r o r s o f I n c o r r e c t Dosage i n S e l f - M e d i c a t i o n o f D i g o x i n and D i u r e t i c s Made by Both Groups E r r o r o f i n c o r r e c t dosage E x p e r i m e n t a l group C o n t r o l group Yes No 0 20 3 17 To ta I number o f p a t i e n t s 20 20 N = 40 d . f . = 1 P > .05 There was no s i g n i f i c a n t d i f f e r e n c e between the number o f e r r o r s o f i n c o r r e c t dosage o f d i g o x i n and d i u r e t i c s made by the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p . V . ANALYSIS IN RELATION TO HYPOTHESIS I I I The t h i r d h y p o t h e s i s was : H Q 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 l e v e l o f knowledge o f s e I f - m e d i c a t i o n of d i g o x i n and d i u r e t i c s , o f members o f the e x p e r i m e n t a l group as compared w i t h members o f the c o n t r o l g r o u p . 53 Tab le 11 L e v e l o f Knowledge o f S e l f - M e d i c a t i o n o f and D i u r e t i c s o f Both Groups Di gox i n L e v e l o f knowledge E x p e r i m e n t a l group C o n t r o l group Low 3 Modera te 5 H igh 12 14 4 2 T o t a l number o f p a t i e n t s 20 20 . . N = 40 d . f . = 2 y?= 11 .66 p < .01 There was a h i g h l y s i g n i f i c a n t d i f f e r e n c e i n the l e v e l o f knowledge o f s e l f - m e d i c a t i o n o f d i g o x i n and d i u r e t i c s , o f the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p . V I . SUMMARY OF RESULTS OF DATA ANALYSIS E x a m i n a t i o n o f the da ta r e v e a l e d t h a 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 e x i s t e d between the e x p e r i -menta l and c o n t r o l g roups o f a m b u l a t o r y c a r d i a c p a t i e n t s , i n the number o f s e l f - m e d i c a t i o n e r r o r s i n d i g o x i n and d i u r e t i c s made i n a t w e n t y - f o u r - h o u r p e r i o d , and i n the l e v e l o f knowledge abou t t h e s e m e d i c a t i o n s . T h i s was d e t e r m i n e d by c h i - s q u a r e a n a l y s i s , u s i n g the . 05 or b e t t e r l e v e l o f s i g n i f i c a n c e as the f i x e d l e v e l . The p a t i e n t s i n the e x p e r i m e n t a l group made s i g n i f i c a n t l y f ewer e r r o r s i n s e l f - m e d i c a t i o n and t h e i r l e v e l o f knowledge was s i g n i f i -c a n t l y h i g h e r , i n c o m p a r i s o n w i t h the c o n t r o l g r o u p . Hypo theses I and I I I were t h e r e f o r e r e j e c t e d . The d i f f e r e n c e i n e r r o r s o f t a k i n g n o n - p r e s c r i b e d d r u g s , t ime and dosage was not s t a t i s t i c a l l y s i g n i f i c a n t , a l t h o u g h the e x p e r i m e n t a l group d i d make fewer e r r o r s o f t h e s e t h r e e t y p e s . The o n l y t ype o f e r r o r wh ich 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 between the two groups was the e r r o r of o m i s s i o n . S i g n i f i c a n t l y f ewer p a t i e n t s i n the e x p e r i m e n t a l group made e r r o r s o f o m i s s i o n . H y p o t h e s i s I I was r e j e c t e d o n l y i n p a r t B and a c c e p t e d i n p a r t s A , C , and D. C h a p t e r 6 SUMMARY, IMPLICATIONS FOR NURSING PRACTICE, AND RECOMMENDATIONS FOR FURTHER STUDY I. SUMMARY T h i s e x p e r i m e n t a l s t u d y was d e s i g n e d to e v a l u a t e the e f f e c t o f p l a n n e d t e a c h i n g on the s e l f - m e d i c a t i o n p r a c t i c e s o f a m b u l a t o r y c a r d i a c p a t i e n t s over the age o f f o r t y - f i v e y e a r s . These p a t i e n t s were a l l t a k i n g d i g o x i n , and a l l e x c e p t f o u r were a l s o t a k i n g a d i u r e t i c . They l i v e d a t home and r e c e i v e d m e d i c a l a t t e n t i o n a t an o u t p a t i e n t c l i n i c i n a l a r g e h o s p i t a l i n w e s t e r n C a n a d a . They were f r om a low s o c i o - e c o n o m i c l e v e l o f our s o c i e t y . The t o t a l sample c o m p r i s e d f o r t y male and f ema le p a t i e n t s d i v i d e d randomly i n t o a c o n t r o l g r o u p , who r e c e i v e d o n l y the u s u a l r o u t i n e i n f o r m a t i o n d u r i n g t h e i r v i s i t t o the o u t p a t i e n t c l i n i c , and an e x p e r i m e n t a l g r o u p , who were g i v e n a d d i t i o n a l p l anned t e a c h i n g r e g a r d i n g t h e i r m e d i c a t i o n s by the r e s e a r c h e r . A r e v i e w o f the l i t e r a t u r e was conduc ted i n r e l a t i o n t o i n c i d e n c e o f s e l f - m e d i c a t i o n and t o t a l m e d i c a l reg imen e r r o r s o f a m b u l a t o r y p a t i e n t s i n t h e i r homes; the t e a c h i n g f u n c t i o n o f the n u r s e ; and the r o l e o f the nu rse i n the o u t p a t i en t c l i n i c . The da ta were c o l l e c t e d i n the p a t i e n t s ' homes ten t o f o u r t e e n days a f t e r the v i s i t t o the o u t p a t i e n t c l i n i c , 55 5 6 by means o f a t w e n t y - i t e m q u e s t i o n n a i r e d e s i g n e d t o r e v e a l i n f o r m a t i o n r e l a t e d t o the t h r e e h y p o t h e s e s o f the s t u d y . The c r i t e r i o n measure o f s e l f - m e d i c a t i o n b e h a v i o r was based on the number o f d e v i a t i o n s i n s e l f - m e d i c a t i o n , the t y p e s o f d e v i a t i o n s , and the l e v e l o f knowledge o f the p a t i e n t s . The r e s u l t s i n d i c a t e d t h a t t h e r e was 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 i n the number o f s e l f - m e d i c a t i o n e r r o r s i n d i g o x i n and d i u r e t i c s made i n a t w e n t y - f o u r - h o u r p e r i o d by p a t i e n t s i n the e x p e r i m e n t a l g r o u p , as compared w i t h the c o n t r o l g r o u p . The e x p e r i m e n t a l group made s i g n i f i c a n t l y f ewer e r r o r s . A l t h o u g h the p a t i e n t s i n the e x p e r i m e n t a l group made fewer e r r o r s o f the f o u r t y p e s o f e r r o r s s t u d i e d , t h e r e was not 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 i n e r r o r s o f t i m e , dosage and n o n - p r e s c r i b e d m e d i c a t i o n s made i n a t w e n t y - f o u r - h o u r p e r i o d by p a t i e n t s i n the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p . There was , however , 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 i n the f o u r t h t ype o f e r r o r — t h a t o f o m i s s i o 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 was shown i n the l e v e l o f knowledge o f p a t i e n t s i n the e x p e r i m e n t a l group as compared w i t h the c o n t r o l g r o u p . The e x p e r i m e n t a l group had a h i g h e r l e v e l o f knowledge about t h e i r m e d i c a t i o n s . I I . IMPLICATIONS FOR NURSING PRACTICE The r i s i n g i n c i d e n c e o f c h r o n i c and l o n g - t e r m d i s e a s e s r e q u i r e s t h a t p a t i e n t s have an u n d e r s t a n d i n g o f t h e i r c o n d i t i o n s and t r e a t m e n t s . U n d e r s t a n d i n g by 5 7 p a t i e n t s can lead to i n c r e a s e d c o o p e r a t i o n w i t h the t h e r a p e u t i c reg imen . . . 7 4 The r e s u l t s o f t h i s s t u d y r e v e a l e d an i n c r e a s e d c o o p e r a t i o n w i t h the s e l f - m e d i c a t i o n reg imen by t h o s e p a t i e n t s who had been g i v e n p l a n n e d t e a c h i n g abou t the e f f e c t s o f t h e i r m e d i c a t i o n s . Because m e d i c a t i o n s p l a y a v i t a l r o l e i n the t r e a t m e n t o f a m b u l a t o r y p a t i e n t s l i v i n g a t home, the p r a c t i c e o f n u r s i n g s h o u l d c o n s i d e r a g r e a t e r i n v o l v e m e n t i n p a t i e n t t e a c h i n g . H o s p i t a l i z e d p a t i e n t s may be g i v e n i n s t r u c t i o n s on s e l f - c a r e and m e d i c a t i o n reg imens as a p r e p a r a t i o n f o r d i s c h a r g e home. The s t u d y may p r o v i d e some d i r e c t i o n f o r p a t i e n t t e a c h i n g i n o u t p a t i e n t c l i n i c s . The t e a c h i n g o f p a t i e n t s i n t h e i r own homes by community h e a l t h n u r s e s may d e r i v e some impetus f r om the s t u d y . I t i s not i m p l i e d t h a t p a t i e n t s a re no t p r e s e n t l y b e i n g i n s t r u c t e d i n s e l f - c a r e and m e d i c a t i o n r e g i m e n s . I t i s however s u g g e s t e d t h a t a g r e a t e r emphas is m igh t be p l a c e d on t h e s e a r e a s o f n u r s i n g p r a c t i c e . In d i s c u s s i n g the i m p l i c a t i o n s o f the f i n d i n g s r e p o r t e d i n t h i s s t u d y , i t i s i m p o r t a n t to emphas ize the l i m i t a t i o n s o f the s t u d y g r o u p , both g e o g r a p h i c a l l y and s o c i o - e c o n o m i c a I I y . The s t u d y g r o u p , i n t h i s c a s e , was r e s t r i c t e d t o r e s i d e n t s o f a l a r g e u rban a r e a , and they were o f low s o c i o - e c o n o m i c s t a t u s . A l l were over the age o f ' Mary Lock 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 rma l P a t i e n t T e a c h i n g , " The Nurs i ng C l i n i c s o f Nor th  Amer i c a . V o l . V I , No. 4 (December , 1 9 7 1 ) , p. 6 6 9 . f o r t y - f i v e y e a r s and had a d i a g n o s i s o f c a r d i a c c o n d i t i o n s . C o n s e q u e n t l y the s t u d y has l i m i t e d g e n e r a l i z a t i o n p o t e n t i a l . N e v e r t h e l e s s , the f i n d i n g s a r e o f c o n s i d e r a b l e i n t e r e s t t o n u r s i n g , and c o u l d s e r v e t o s t i m u l a t e i n members o f the n u r s i n g p r o f e s s i o n a g r e a t e r s e n s i t i v i t y and c o n s c i o u s n e s s o f the r o l e o f the nu rse as a p a t i e n t t e a c h e r . P e r h a p s no l e s s i m p o r t a n t than the s t a t i s t i c a l s i g n i f i c a n c e o f the p a t i e n t s e l f - m e d i c a t i o n b e h a v i o r r e p o r t e d i n t h i s s t u d y , was the r e w a r d i n g p e r s o n a l e x p e r i e n c e e n c o u n t e r e d by the r e s e a r c h e r . Most p a t i e n t s were i n t e r e s t e d i n d i s c u s s i n g t h e i r m e d i c a t i o n r e g i m e n , and t h e y a l s o seemed most a p p r e c i a t i v e o f the i n t e r e s t e x p r e s s e d i n t h e i r h e a l t h p r o b l e m s . The e x p e r i e n c e s u g g e s t s t h a t a g r e a t e r i n v o l v e m e n t i n p a t i e n t t e a c h i n g can lead t o i n c r e a s e d job s a t i s f a c t i o n f o r n u r s e s . I I I . RECOMMENDATIONS FOR FURTHER STUDY " . . . One o f the h a l l m a r k s o f r i g o r o u s r e s e a r c h i s the s t r i c t c o n t r o l ove r v a r i a b l e s . " 7 - ^ i n b e h a v i o r a l s c i e n c e r e s e a r c h , the human s u b j e c t can c o n t a m i n a t e the r e s u l t s . Yet s t r i c t c o n t r o l s can a l t e r the " r e a l l i f e " s i t u a t i o n . As A r g y r i s p o i n t s o u t , " R i g o r o u s r e s e a r c h has i t s own b l i n d s p o t s . " 7 6 ' - ^ C h r i s A r g y r i s , " I s s u e s i n E v a l u a t i n g L a b o r a t o r y E d u c a t i o n , " i n M a r v i n D. D u n n e t t e , John P . C a m p b e l l , and C h r i s A r g y r i s , "Sympos ium: L a b o r a t o r y T r a i n i n g , " I n d u s t r i a I  Re I a t i o n s . V o l . V I I I , No. 1 ( O c t o b e r , 1 9 6 8 ) , 1 - 4 5 , p . 3 3 7 6 I b i d . , p. 3 6 . 59 . . . we have to d i s c r i m i n a t e between the we igh t t o be g i v e n t o s c i e n t i f i c o p i n i o n i n the s e l e c t i o n of i t s me thods , and i t s t r u s t w o r t h i n e s s i n f o r m u l a t i n g judgments o f the unders tand ing.77 A n a l y s i s o f the da ta i n t h i s s t u d y r e v e a l e d t h a t p a t i e n t knowledge was i n v e r s e l y r e l a t e d t o s e l f - m e d i c a t i o n e r r o r s . T h i s would i n d i c a t e t h a t p l anned p a t i e n t t e a c h i n g d e c r e a s e s s e l f - m e d i c a t i o n e r r o r s . A l t h o u g h s e l f - m e d i c a t i o n e r r o r s d e c r e a s e d as p a t i e n t knowledge i n c r e a s e d , t h e r e may have been o t h e r f a c t o r s i n v o l v e d . The l i n g u i s t , Hayakawa, s a y s , "The meanings o f words a re not i n the w o r d s , t hey a re i n J J S . " 7 ^ Warmth, or l ack o f i t , and a t t i t u d e toward the p a t i e n t a r e p o s s i b l e e x t r a n e o u s v a r i a b l e s . The c o n t e n t o f the p a t i e n t t e a c h i n g must a l s o be c o n s i d e r e d . The amount o f c o n s i d e r a t i o n g i v e n to the p a t i e n t ' s u n d e r s t a n d i n g o f , and a t t i t u d e t o w a r d , h i s i l l n e s s i s i m p o r t a n t . H i s h e a l t h b e h a v i o r i s c o n d i t i o n e d by h i s s u b j e c t i v e p e r c e p t i o n o f the s i t u a t i o n based on h i s needs and g o a l s . In t h i s s t udy each p a t i e n t g i v e n i n s t r u c t i o n was a l s o g i v e n a c a l e n d a r and a p e n c i l i n o r d e r to gu ide h i s s e l f - m e d i c a t i o n b e h a v i o r . T h e r e f o r e the r e s e a r c h e r does not f e e l j u s t i f i e d i n c o n c l u d i n g t h a t p a t i e n t t e a c h i n g a l o n e reduces e r r o r s i n p a t i e n t s e I f - m e d i c a t i o n . 77 C h r i s A r g y r i s , "A R e j o i n d e r t o Dunne t te and C a m p b e l l , " i n M a r v i n D. D u n n e t t e , John P . C a m p b e l l , and C h r i s A r g y r i s , "Sympos ium: L a b o r a t o r y T r a i n i n g , " I n d u s t r i a I  R e l a t i o n s . V o l . V I I I , No. 1 ( O c t o b e r , 1968), 1-45, p . 45. I. Hayakawa, Language i n Thought a nd A c t i on (New Y o r k : H a r c o u r t , B race & W o r l d , I n c . , 1949), p . 292. 60 The f o l l o w i n g recommendat ions a re made f o r f u r t h e r i n v e s t i g a t i o n : 1. R e p l i c a t i o n o f t h i s s t u d y i n o r d e r t h a t s u p p o r t f o r the f i n d i n g s abou t the e f f e c t s o f p a t i e n t t e a c h i n g might be g a i n e d i f a c o n s i s t e n t d i f f e r e n c e between the two groups of p a t i e n t s were o b t a i n e d . 2. S t u d i e s o f p a t i e n t s e l f - m e d i c a t i o n c o m p l i a n c e wh ich c o n s i d e r v a r i o u s a p p r o a c h e s to p a t i e n t t e a c h i n g . A t t i t u d e s and p a t t e r n s of commun ica t i on may h e l p t o e x p l a i n c o m p l i a n c e and n o n c o m p l i a n c e . The t h r e e h y p o t h e s e s o f t h i s s t u d y a re wor th t e s t i n g i n b r o a d e r s t u d i e s . 3 . S t u d i e s o f the e f f e c t o f p a t i e n t t e a c h i n g on the s e l f - m e d i c a t i o n b e h a v i o r o f g roups o f p a t i e n t s o t h e r than c a r d i a c p a t i e n t s . 4 . S t u d i e s o f the e f f e c t of p a t i e n t t e a c h i n g on p a t i e n t s e l f - c a r e b e h a v i o r i n a r e a s o t h e r than t h a t o f s e l f - m e d i c a t i o n . 5 . A s t u d y o f the e f f e c t i v e n e s s o f group t e a c h i n g a s compared to i n d i v i d u a l p a t i e n t t e a c h i n g . 6. A s t u d y o f the e f f e c t i v e n e s s o f i n f o r m a l t e a c h i n g as compared to f o r m a l p l anned p a t i e n t t e a c h i n g . BIBLIOGRAPHY 61 BIBLIOGRAPHY A . BOOKS A b d e l l a h , Faye G . , and Eugene L e v i n e . B e t t e r P a t i e n t Care  Through N u r s i ng R e s e a r c h . New Y o r k : The Macmi I Ian Company, 1965 . B e n n i s , Warren G. e t a l . The RoIe o f the Nurse i n the  Ou tpa t i en t D e p a r t m e n t . New Y o r k : Amer i can N u r s e s ' F o u n d a t i o n , I n c . , 1 9 6 1 . Brown, E s t h e r L u c i l e . N u r s i ng R e c o n s i d e r e d , A S tudy o f  Change . T o r o n t o : J . 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New Y o r k : The Macmi I Ian Company, 1964 . S n e d e c o r , George W. S t a t i s t i caI M e t h o d s . 5 th e d . Iowa: The Iowa S t a t e U n i v e r s i t y P r e s s , 1956 . Sussman, Ma rv i n B. e t a I. The WaIk i ng P a t i e n t : A S tudy i n  O u t p a t i e n t C a r e . C l e v e l a n d : The P r e s s o f Wes te rn R e s e r v e U n i v e r s i t y , 1967 . Windemuth, A u d r e y . The Nurse i n the O u t p a t i en t Depa r tmen t . New Y o r k : The Macmi I Ian Company, 1957 . 62 63 B. PUBLICATIONS OF THE GOVERNMENT Domin ion Bureau o f S t a t i s t i c s . Canada Year Book . O t t a w a : Q u e e n ' s P r i n t e r o f C a n a d a , 1970-71. C . PERIODICALS Bergman, Abraham B . , and R i c h a r d J . Werne r . " F a i l u r e of Chi Id ren to R e c e i ve Pen i c i I I i n by M o u t h , " New E n g l a n d  J o u r n a I o f Medi c i ne . V o l . C C L X V I I I , No. 2 5 ~ T J u n e 13, 1 9 6 3 ) , 1334 -1338. B e r k o w i t z , Norman H. e t a I. " P a t i e n t FoI Iow-Through i n the O u t p a t i e n t D e p a r t m e n t , " N u r s i n g R e s e a r c h , V o l . X I I , No. 1 ( W i n t e r , 1963), 1 6 - 2 2 . B e r r y , D a v i d , A l a n R o s s , and K u r t D e u s c h l e . " T u b e r c u l o u s P a t i e n t s T r e a t e d a t Home. Compar i son o f R e g u l a r and I r r e g u l a r S e I f - M e d i c a t i o n G r o u p s , " Rev iew o f R e s p i r a t o r y D i s e a s e s , V o l . L X X X V I I I , No. 6 (December , 1 9 6 3 ) , 7 6 9 - 7 7 2 . B o n n a r , J o h n , A . G o l d b e r g , and J . S m i t h . "Do P r e g n a n t Women Take T h e i r I r o n ? " The L a n c e t ( M a r c h , 1 9 6 9 ) , 4 5 7 - 4 5 8 . C a p l a n , E l e a n o r , and M a r v i n B. Sussman . "Rank Order o f Impor tan t V a r i a b l e s f o r P a t i e n t and S t a f f S a t i s f a c t i on w i t h O u t p a t i e n t S e r v i c e , " J o u r n a l o f H e a l t h and Human  B e h a v i o r . V o l . 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"The P r o b l e m of S e l f - A d m i n i s t r a t i o n o f D r u g s ; Wi th P a r t i c u l a r R e f e r e n c e to Pu lmonary T u b e r c u l o s i s , " T u b e r c l e . V o l . XXXIX ( O c t o b e r , 1958), 269-274. G r o l I m a n , A r t h u r . " D i u r e t i c s , " A m e r i c a n Jou rna I o f N u r s i n g , V o l . L X V , No. 1 ( J a n u a r y , 1965), 84-89. H a l l b u r g , Jeanne 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 , " Nurs i ng  C l i n i c s o f No r t h A m e r i c a , V o l . V, No. 2 ( J u n e , 1970), 223-231. Hay, S t e l l a , and H e l e n A n d e r s o n . "A re Nurses M e e t i n g P a t i e n t s ' N e e d s ? " Amer i can Jou rna I o f N u r s i n g . V o l . L X I I I , No. 12 (December , 1963), 96-99. H a y e s , E v e l y n R. " C l i n i c W a i t i n g Room E x p e r i e n c e : An E x p l o r a t o r y S t u d y , " N u r s i n g R e s e a r c h . V o l . X V I I , No. 4 ( J u l y - A u g u s t , 1968), 361-364. 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Ma l o n e , M a r y , Norman H. B e r k o w i t z , and M a l c o l m W. K l e i n . "The Paradox i n N u r s i n g , " Ameri can Jou rna I of N u r s i n g , V o l . L X I , No. 9 (Sep tember , 1961), 52-55. M a r s t o n , Mary V . " C o m p l i a n c e Wi th M e d i c a l Reg imens : A Rev iew o f the L i t e r a t u r e , " N u r s i n g R e s e a r c h , V o l . X I X , No. 4 ( J u l y - A u g u s t , 1970), 312-322. 65 M o n t e i r o , L o i s A . " N o t e s on 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 Forum, V o l . I l l , No. 1 ( 1 9 6 4 ) , 2 6 - 3 3 . N e e l y , E l i z a b e t h , and Max ine P a t r i c k . " P r o b l e m s o f Aged P e r s o n s T a k i n g M e d i c a t i o n s a t Home," N u r s i n g R e s e a r c h , V o l . X V I I , No. 1 ( J a n u a r y - F e b r u a r y , 1 9 6 8 ) , 5 2 - 5 5 . P a l m , Mary L o c k . 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New Y o r k : M c G r a w - H i l l Book Company, 1 9 7 1 . 66 E . UNPUBLISHED MATERIALS B r k i c h , R i t a M. "A S tudy to De te rmine how P a t i e n t s View T h e i r D i g o x i n T h e r a p y . " U n p u b l i s h e d M a s t e r ' s d i s s e r t a t i o n , M c G i l l U n i v e r s i t y , 1969 . H a l l b u r g , Jeanne C . "A D e c i s i o n Mak ing Approach as a T e a c h i n g - L e a r n i n g S t r a t e g y f o r P r e p a r i n g P a t i e n t s f o r S e l f - C a r e . " U n p u b l i s h e d D o c t o r ' s d i s s e r t a t i o n , U n i v e r s i t y o f C a l i f o r n i a , 1969 . N o r d w i c h , I rene E . " C o n c e r n s o f C a r d i a c P a t i e n t s R e g a r d i n g T h e i r A b i l i t y t o Implement the P r e s c r i b e d Drug T h e r a p y . " U n p u b l i s h e d M a s t e r ' s d i s s e r t a t i o n , U n i v e r s i t y o f Wes te rn O n t a r i o , 1970 . I l l i n o i s I n s t i t u t e o f T e c h n o l o g y , C h i c a g o . A l e c t u r e g i v e n by D r . S t a n l e y B l o c k a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a , March 9 , 1 9 7 1 . APPENDIX A INTRODUCTION TO THE PATIENT 67 68 INTRODUCTION TO THE PATIENT My name i s G e r t r u d e Goodman. I am a r e g i s t e r e d n u r s e . I n f o r m a t i o n i s b e i n g c o l l e c t e d f rom p e o p l e who v i s i t the o u t p a t i e n t c l i n i c t o see how t h e y a re g e t t i n g a l o n g a t home. T h i s i s an e f f o r t t o p r o v i d e improved c a r e f o r y o u . I f i t i s a l l r i g h t w i t h y o u , e i t h e r I or a n o t h e r p e r s o n w i l l v i s i t you a t your home i n two weeks or l e s s . We w i l l ask you q u e s t i o n s abou t how you a re g e t t i n g a l o n g . From t h i s v i s i t we hope to l e a r n how we can improve the h e a l t h c a r e you r e c e i v e . W i l l you he Ip? APPENDIX B BIOGRAPHICAL DATA FORM 69 70 BIOGRAPHICAL DATA FORM Name E , C, A d d r e s s ( n e a r ) Te Iephone_ S e x . M F_ M a r i t a l S t a t u s . S_ L i v i n g A r r a n g e m e n t s . a l o n e _ Age B i r t h Da te Re I i g i on M spouse_ W D / S _ ch i I d r e n o t h e r a d u I t s E d u c a t i o n . E l e m e n t a r y _ Ra ce H i g h s c h o o l . Co I I ege_ Emp I oyment_ o r R e t i r e d D a t e o f O . P . D . v i s i t P l a n n e d d a t e s f o r home v i s i t P r e f e r r e d t i m e o f day f o r v i s i t _ L i s t o f m e d i c a t i o n s Amount p r e s c r i b e d Time p r e s c r i b e d 1 . 2. 3. 4. 5. 6. 7. 8. APPENDIX C SEMI-STRUCTURED INTERVIEW GUIDE FOLLOWED IN PATIENT TEACHING 71 72 S E M I - S T R U C T U R E D INTERVIEW GUIDE FOLLOWED IN P A T I E N T TEACHING I n t r o d u c t i o n : Do y o u f e e l h e l p e d a f t e r v i s i t i n g t h e o u t p a t i e n t What do you t h i n k h e l p s you t h e most? Do y o u r m e d i c i n e s h e l p ? You f e e l t h e n t h a t t h e y a r e an i m p o r t a n t p a r t o f t r e a t m e n t ? Is i t i m p o r t a n t t o t a k e them r e g u l a r l y ? Type o f M e d i c a t i o n E r r o r : Do you f i n d you t a k e them a t a s p e c i f i e d t i m e , o r does t h i s t i m e v a r y ? Do you o f t e n f o r g e t t o t a k e them? Do you t a k e y o u r m e d i c i n e s i n t h e e x a c t a m o u n t s o r d e r e d by t h e d o c t o r a n d a s p r i n t e d on t h e c o n t a i n e r s ? A r e t h e r e m e d i c i n e s w h i c h you t a k e w h i c h h e l p y o u , and w h i c h were n o t o r d e r e d by t h e d o c t o r ? Di s c u s s i o n : S o m e t i m e s p e o p l e f e e l t h e y w o u l d l i k e t o be t o l d more a b o u t t h e i r c o n d i t i o n . Do you? Do you f e e l you w o u l d l i k e t o d i s c u s s i n more d e t a i l y o u r h e a l t h a s w e l l a s y o u r m e d i c i n e s w i t h a n u r s e ? What i n p a r t i c u l a r i n t e r e s t s you i n t h i s r e g a r d ? ( D i s c u s s p a t i e n t ' s c o n d i t i o n w i t h h i m / h e r . ) Know l e d g e : Do you know t h e names o f y o u r m e d i c i n e s ? (Go o v e r them wi t h p a t i e n t . ) Do you know what t i m e o f day t o t a k e them? A r e y o u i n t e r e s t e d i n how e a c h one a c t s on y o u r b o d y , i . e . what i t d o e s f o r you? ( R e v i e w a c t i o n s w i t h p a t i e n t . ) c I i n i c ? y o u r 73 Do you t h i n k some of t hese m e d i c i n e s may have s i d e e f f e c t s i f not t a k e n as d i r e c t e d ? What a r e some of t h e s e ? ( D i s c u s s s i d e e f f e c t s w i t h p a t i e n t . ) P a t i e n t Feedback and D e c i s i o n - M a k i n g by P a t i e n t Under Gu idance o f N u r s e : ( I n c o r p o r a t e a l l above c o n v e r s a t i on ) I d e n t i f y the g o a l s ; e . g . To take m e d i c i n e s as p r e s c r i b e d . C o n s i d e r the r e l e v a n t d a t a ; e . g . Does he f o r g e t ? E y e s i g h t . Impor tance o f t a k i n g med i ca t i o n s . I d e n t i f y and e v a l u a t e a l t e r n a t i v e s ; e . g . Se t a l a r m . Use c a I e n d a r . Keep m e d i c a t i o n s on t a b l e . S e l e c t a l t e r n a t i v e ; e . g . T h i s i s done by p a t i e n t . APPENDIX D A TEACHING DISCUSSION WITH A PATIENT 74 A TEACHING DISCUSSION WITH A PATIENT 75 KEY: P = p a t i e n t R = r e s e a r c h e r R: Do you f e e l h e l p e d a f t e r v i s i t i n g the o u t p a t i e n t c l i n i c ? P: Y e s , I t h i n k s o . R: In what way a r e you h e l p e d ? P : I d o n ' t know. W e l l , the p i l l s h e l p me. R: You f e e l t h e n , t h a t the m e d i c i n e s you t ake a re an i m p o r t a n t p a r t of your t r e a t m e n t ? P : Y e s , I d o . R; Is i t i m p o r t a n t t o t ake them r e g u l a r l y ? P : I guess s o . R: Why do you t h i n k so? P : I d o n ' t know. R: T a k i n g your m e d i c i n e r e g u l a r l y would mean t h a t your body has a c e r t a i n amount o f the m e d i c i n e i n i t a t a l l t i m e s . Then i t h e l p s y o u . T h i s i s d e s i r a b l e . P : Y e s , I suppose i t i s . R: Do you f i n d t h a t you t ake your m e d i c i n e s a t the same t ime e v e r y d a y , o r does the t ime va ry? P : I t v a r i e s s o m e t i m e s . R: Why? P : I d o n ' t a lways get up a t the same t ime i n the m o r n i n g . R: Y e s , t h a t ' s u n d e r s t a n d a b l e . Do you o f t e n f o r g e t to take them? P : No. I would say no . I ' ve f o r g o t t e n abou t t h r e e t i m e s s i n c e l a s t Sep tembe r . T h a t ' s not o f t e n . R: What abou t the amount you t a k e . Do you t ake the e x a c t amounts o r d e r e d by the d o c t o r , and wh ich a re p r i n t e d on your c o n t a i n e r s ? P : Y e s . 76 R: Do you read the l a b e l s on the c o n t a i n e r s ? P : Y e s . R: Are t h e r e m e d i c i n e s wh ich you t ake wh ich h e l p y o u , wh ich the d o c t o r d i d no t o r d e r ? P : We I I, I d o n ' t know. I t a k e wheat germ p i l l s . Are they good? R: Y e s , I t h i n k p r o b a b l y t hey a r e . However , i t wou ld not be w ise t o take p i l l s o t h e r than v i t a m i n s , m i n e r a l s or l a x a t i v e s u n l e s s you d i s c u s s e d t h i s w i t h your d o c t o r and he o r d e r e d them. P : No. R: Somet imes peop le f e e l t hey would l i k e t o be t o l d more abou t t h e i r c o n d i t i o n . Do you? P : No. I 'm o l d . I 'm e i g h t y y e a r s o l d . I t d o e s n ' t ma t te r abou t me. R: But i f you r e a l l y b e l i e v e d t h a t you w o u l d n ' t come here would you? P : We I I, I guess n o t . R: Would you l i k e t o know more about your h e a r t c o n d i t i o n ? P : No, no t rea I Iy . R: No? P : No, the d o c t o r s know what t h e y ' r e d o i n g . R: What abou t the n u r s e s ? Do you ever ask them? P : No, I never h a v e . R: I t h i n k t h e y m igh t answer q u e s t i o n s abou t your m e d i c i n e s i f you had any q u e s t i o n s . I t may be good to know f o r y o u r s e l f , s i n c e the d o c t o r canno t a l w a y s be w i t h y o u . Is t h e r e a n y t h i n g you would l i k e to ask me abou t them? P: No. (Pause) R: Do you know the names o f your m e d i c i n e s ? P : There i s " d i - o x y g e n " f o r the h e a r t and then a wa te r p i l l . 77 R: Y e s , the l i t t l e w h i t e p i l l f o r the h e a r t i s d i g o x i n . I t ' s l i k e t h r e e l i t t l e words put t o g e t h e r ; d i g ox i n — d i gox i n . ( P a t i e n t r e p e a t s t h i s s e v e r a l t i m e s w i t h d i f f i c u l t y . ) Do you know what the water p i l l i s c a l l e d ? P : No, I have i t he re i n t h i s b o t t l e . R: H y d r o c h l o r o t h i a z i d e . ( P a t i e n t never does maste r the p r o n o u n c i a t i o n o f h y d r o c h l o r o t h i a z i d e . ) What does d i g o x i n do f o r you? P : I t h e l p s the h e a r t work . R: Y e s . In what way? P : I d o n ' t know. R: W e l l , i t s l ows the h e a r t bea t and i t s t r e n g t h e n s the h e a r t b e a t . Those a re two i m p o r t a n t t h i n g s d i g o x i n does, P : A h a . R: And the h y d r o c h l o r o t h i a z i d e — t h e water p i l l ? P : I t makes me go to the ba th room. R: Y e s , you pass more w a t e r . W i th the wa te r you a l s o l ose s a l t . T h i s can t ake away any s w e l l i n g o f your f i n g e r s or a n k l e s . Have you had t h i s ? P : Oh y e s , my a n k l e s used to be b i g g e r , ( p u l l s up p a n t l e g s ) and now t h e y a re O . K . The p i l l s r e a l l y h e l p e d me. R: Do you t h i n k your m e d i c i n e s c o u l d have bad e f f e c t s i f you d i d not take them as o r d e r e d ? P: I d o n ' t t h i nk s o . R: I f a p e r s o n took t w i c e as many as he s h o u l d , would n o t h i n g happen? P : W e l l , maybe. I never would do t h a t . R: No, I 'm su re you w o u l d n ' t . But s u p p o s i n g a n o t h e r pe rson d i d , what m igh t happen? P : Ah—go to the bathroom a l l the t ime? 78 R: Y e s , and he migh t f e e l s i c k t o h i s s t o m a c h , or ve ry s l e e p y , or ve ry weak. T a k i n g too much d i g o x i n f o r o n e ' s sys tem c o u l d a l s o make a p e r s o n f e e l s i c k t o h i s s t o m a c h . I t c o u l d a l s o make wh i t e c o l o r s look y e l l o w i s h or b l u r r e d . Has t h i s eve r happened to you? P : No. R: I f i t eve r d o e s , you w i l l know the c a u s e . Then you c o u l d get i n t ouch w i t h your d o c t o r . P : Y e s , t h a t ' s good to know. R: Y e s , I b e l i e v e i t i s . I f one u n d e r s t a n d s bo th the good and bad e f f e c t s o f a m e d i c i n e , one can t e l l when he s h o u l d see h i s d o c t o r . P : Y e s . R: We were s a y i n g e a r l i e r t h a t your m e d i c i n e s p l a y an i m p o r t a n t p a r t i n k e e p i n g you f e e l i n g w e l l . Would you t h i n k t hen t h a t t hey s h o u l d be t a k e n as p r e s c r i b e d — as w r i t t e n on the c o n t a i n e r s f o r you? P : Ye s . R: What t h i n g s can you t h i n k o f t h a t c o u l d keep you f rom t a k i n g them a t the r i g h t t ime and i n the r i g h t amounts? P : I do as i t s a y s . I d o n ' t o f t e n f o r g e t them. R: I have a l a r g e c a l e n d a r , w i t h a p e n c i l , h e r e . I f you f e e l i t would h e l p you remember, you can w r i t e your m e d i c i n e s i n on each day and t i c k o f f when you have t a k e n them. P : Thank y o u . I d o n ' t t h i n k I need i t . R: We I 1 , keep i t anyway. I g i v e one to each p e r s o n I t a l k to h e r e . I f you eve r f e e l i t m ight be o f h e l p , then y o u ' I I have i t . P : Thank y o u . You know, I keep my p i l l s on the t a b l e and I a l w a y s know where they a r e . R: Y e s . I have e n j o y e d t a l k i n g w i t h y o u . I w i l l see you then on Monday, i n two weeks , a t your home. P : Y e s . I ' l l be home. APPENDIX E THE QUESTIONNAIRE 79 80 QUESTIONNAIRE 1. What m e d i c i n e s do you take r e g u l a r l y ? 2 . May I see the c o n t a i n e r s o f m e d i c i n e s ? I need to check the l a b e I s . 3 . How o f t e n do you t ake each one? (Go over each m e d i c a t i o n s e p a r a t e l y f o r Q u e s t i o n s 3 , 4 , 6 , 9 , 10 , 12 and comp le te t a b l e on page 3 . 4 . A t what t ime d i d you take t h i s one today? 5 . I f " n o " - why d i d you not t ake i t ? 6 . A t what t ime d i d you t ake i t y e s t e r d a y ? 7 . Do you t ake i t a t t h e s e t i m e s e v e r y d a y , or does the t ime a t wh ich you t ake i t va ry? 8 . Why does the t ime va ry? 9 . How much do you t ake each t ime? 1 0 . Does e v e r y m e d i c i n e you t ake h e l p you? What do you t h i n k i t does f o r you? 1 1 . C o u l d any o f t h e s e m e d i c i n e s have any s i d e e f f e c t s ? 1 2 . I f " y e s " - c o u l d you t h i n k o f s i d e e f f e c t s wh ich would cause you to c o n t a c t the d o c t o r ? 1 3 . Do you t a k e any m e d i c i n e s not p r e s c r i b e d by the d o c t o r ? 1 4 . Somet imes p e o p l e f o r g e t to t ake t h e i r m e d i c i n e s . Do you eve r f o r g e t to t a k e your m e d i c i n e s ? 1 5 . I f " y e s " - why? 81 Page 2 16 . Does anyone a s s i s t you i n t a k i n g the m e d i c i n e s ? 1 7 . Are you v i s i t e d by a p u b l i c h e a l t h nu rse? 1 8 . What t h i n g s do you not l i k e abou t t a k i n g your m e d i c i n e s ? 19 . Do you f e e l t h a t you a r e t o l d as much as you want to know about each m e d i c i n e ? 2 0 . I f " n o " - what k i n d s o f t h i n g s would you l i k e t o know abou t your m e d i c i n e s ? Name: A d d r e s s : Date V i s i t e d : I n t e r v i ewer : QUESTIONS Page 3 6 9 10 12 Name of Amount Time How Time taken m e d i c i n e P r e s c r i b e d o f t e n Today Y e s t , t aken Amount What t aken does i t do? S i d e A n a l y s i s o f R e s u l t s e f f e c t s A . D i g o x i n & D i u r e t i c s B . O ther A R D I A C 0 T H E R 1 . 2. 3. 4. 5. 6. 7. 8. 9. 10. Name: A d d r e s s : Date v i s i t e d : In te r v i e w e r : 3,4,6. O m i s s i o n A . B . 4,6. I n c o r r e c t t ime A . B. 9. E r r o r i n amount A . B . 13. Not p r e s c r i bed A . B . T o t a l Number of E r r o r s : A . B . P a t i e n t Knowledge 1. Name o f m e d i c a t i o n A . B . 10. E f f e c t o f m e d i c a t i o n A . B . 12. S i d e e f f e c t s A . B . 3. When m e d i c a t i o n s h o u l d be t aken A . B . L e v e l o f Knowledge A . B . APPENDIX F L IST OF ALL MEDICATIONS PRESCRIBED FOR THE STUDY POPULATION 83 84 LIST OF ALL MEDICATIONS PRESCRIBED FOR THE STUDY POPULATION* a 1 dac tone h y d r o d i ur i 1 a 1 dome t h y g r o t o n a 11opur i no 1 KC1 e l i x i r amesec 1 a s i x bemi na1 p l u s p a r a m e t t e s ch1oropropami de p e r i t r a t e co1ch i c i ne phenobarb Coumadin propana1o1 d i amox s 1 ow K d i coumero1 t e t r a e y e 1i ne d i gox i n t h y r o x i ne d i 1 an t i n t o 1 butami de d o n n a t o l qui ni d i ne e 1 a v i 1 va 1 i urn h y d r o c h l o r o t h i a z i d e * L i s t i n c l u d e s g e n e r i c and t r a d e names. M e d i c a t i o n s a r e l i s t e d as the p h y s i c i a n p r e s c r i b e d them. APPENDIX G STATISTICAL TREATMENT OF THE DATA 85 86 STATISTICAL TREATMENT OF THE DATA 1. The c h i - s q u a r e t e s t o f s i g n i f i c a n c e f o r H y p o t h e s i s I employed the f o r m u l a : = £ [ ( o - e ) - . 5 ] 2 The l e v e l o f s i g n i f i c a n c e o f . 05 or b e t t e r was f i x e d as s t a t i s t i c a l l y s i g n i f i c a n t f o r a l l t h r e e h y p o t h e s e s . 2. The c h i - s q u a r e t e s t o f s i g n i f i c a n c e f o r H y p o t h e s i s I I employed the f o r m u l a : - V 2 _ 4 ( a d - b c ) - f ] 2 (a+c) (b+d) (a+b) (c+d) 3 . The c h i - s q u a r e t e s t o f s i g n i f i c a n c e f o r H y p o t h e s i s I I I employed the f o r m u l a : = ^  C(o-e) - . 5 ] 

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