Rajiv Gandhi University of Health Sciences s72

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

ANNEXURE-ІІ PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 1 NAME OF CANDIDATE AND ADDRESS ANCY JOSEPH ST.JOHN’S COLLEGE OF NURSING, SARJAPURA ROAD, BANGALORE-34

2 NAME OF THE INSTITUTION ST.JOHN’S COLLEGE OF NURSING, BANGALORE-34

3 COURSE OF STUDY, SUBJECT M.Sc. NURSING 1st YEAR MEDICAL-SURGICAL NURSING

4 DATE OF ADMISSION TO COURSE 02-05-2012

5 TITLE OF THE TOPIC EFFECTIVENESS OF VIDEO ASSISTED TEACHING PROGRAM (VATP) ON KNOWLEDGE REGARDING OSTOMY CARE AMONG PATIENTS WITH OSTOMY.

6 BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR THE STUDY

Gastrointestinal disorders affect people of all ages. Every year there are many people who undergo ostomy surgery that alters their normal passage of elimination. An ostomy is not a disease, but a change in the way our body works. According to American Society of Colon and rectal Surgeons (ASCRS), an ostomy is a surgically created opening connecting an internal organ to the surface of the body. The most common reason for an ostomy is the cancer of the rectum or colon. Different kinds of ostomies are named for the organ involved. The most common types of ostomies in internal surgery are an ‘ileostomy’ (connecting the ileal part of the small intestine to the abdominal wall) and a ‘colostomy’ (connecting the colon, or, large intestine to the abdominal wall).

Colorectal cancer is the third most common cancer in men and the second in women.

Worldwide, an estimated 1.2 million cases of colorectal cancer occurred in 2008. Rates were substantially higher in men than in women. About 608,700 deaths from colorectal cancer occurred in 2008 worldwide, accounting for 8 percent of all cancer deaths1. According to Cancer

Registry, ICMR, India, the incidence of colorectal cancer varies from 1 to 2 per 100,000 of population.2

Ostomy frequency is increasing worldwide. There are approximately 750,000 ostomates in the United States. The number of ostomates in the United Kingdom exceeds

100,000.3Ostomy patients’ age range from newborn to 90 years of age (United Ostomy

Association of America, 2011).

According to the survey conducted by Asia South Pacific Ostomy Association and Ostomy

Association of India ,Mumbai as on June 2010-2012 , there are 3 lakh ostomates in India.(80% colostomates,10% ileostomates and 10% urostomates).As per the survey conducted by

2 Ostomates India Association from 2010 as on June 2012 ,it is reported that there are 3000 ostomates in Karnataka(80%colostomates, 10%ileostomates, 10%urostomates).

Ostomy care was an isolated field until 1950s even in developed countries. It was only in 1975; ostomy care was inaugurated in India at Mumbai by formation of Ostomy

Association of India. The association was started at Tata Memorial Hospital under the support of

Indian Cancer Society. In 1978, the first Stoma clinic came into existence at the same hospital.4

Now, there are many Ostomy Associations and Stoma Clinics established all over the country to guide an ostomate towards comprehensive rehabilitation.

Having an ostomy does not mean having a lifelong disability. Living well with an ostomy can be achieved through patient preparation, education, and planning. Nurses who are knowledgeable in ostomy care can help a patient adjust to an ostomy. Although performed to improve patient health, ostomy surgery can be a life-changing event with both physical and psychological consequences. Persons with ostomy can experience poor quality of life (QOL), along with feelings of stigmatization, degradation and isolation.5

Patients with stoma face many difficulties both physical and psychological. A descriptive study was done to assess post operative care, quality of life issues and equipment problems of the 391 patients which revealed the major stomal problems like rashes, leakage and ballooning, and also showed that majority of patients experienced some changes in the life style and more than 40% of patients had problem with their sex lives.6 Another study identified difficulties related to the stoma like periostomal skin irritation, pouch leakage, odor, reduction in previously enjoyed activities and depression/anxiety.7

A similar study was carried out in Messratta, Lypia to identify the level of knowledge

3 and self care performance of 50 colostomy patients and its effects on their quality of life. The study showed a significant relation between patient’s knowledge about self care performance and the various domains in the quality of life such as psychological well being, physical well being, body image, pain, sexual activity and nutrition concerns, in addition to patient’s satisfaction, self efficacy and teaching).The study recommended that colostomy patients should receive adequate education, simulation and counselling regarding ostomy care, life style changes and self efficacy.8

In Chandigarh, a descriptive study was done to assess the efficacy of communication by the medical personnel to the parents of children having Colostomy .The information was perceived to be complete in 6 percent, incomplete in 54 percent and virtually nil in 40 percent cases by the parents. The study concludes that health professionals should be skilled in providing adequate information and communicate with parents effectively.9 In another similar study done in Chandigarh, various educational aids such as, booklet, video film, and booklet plus video film on care of colostomy were found to be significantly effective (p<0.05).10

An experimental study was done in China to assess the effectiveness of health education approach in reducing the anxiety of patients with rectal carcinoma after colostomy.

The study revealed that health education for rectal carcinoma patients after colostomy via health education approach can effectively relieve the anxiety of patients, reduce the rate of anxiety and improve the effect of health education.11

One method to develop and increase ostomy knowledge among nurses is through computer-based programs in the workplace. A study was done among 103 staff nurses to assess the effectiveness of computer-based learning on staff nurse confidence in caring for patients with

4 ostomy. Nurses reported a statistically significant increase in knowledge of ostomy care (mean pretest and posttest knowledge scores are 3.8 and 4.51 respectively) and increased confidence in their ability to provide care.12 Nurses and other healthcare providers can play a key role in the perception and have a significant impact on how patients and their families adjust to the ostomy.

However, this role is successful only when nurses are supported by the required knowledge and skills. Therefore, structuring an educational program becomes necessary to improve ostomates’

Quality Of Life, decrease postoperative complications, and enhance ostomates’ adjustment to the ostomy.

The care of patients with ostomy is a complex, challenging and lengthy process. An ostomy touches on the taboos of dirt and cleanliness, lays bare the fears of cancer and death, and implies disfigurement and rejection to the person who has it. At the outset, an ostomy patient needs every opportunity and resource if he is to assume the way of life he enjoyed prior to his surgery. Managing a patient with such a deformity is not institutionalized and spills over to the home setting for economic and administrative reasons.13 Hence, the hospital stay is meant to equip and prepare the patient with knowledge and dexterity in stoma care.

At St. John’s Medical College Hospital, Stoma Clinic was established on 23rd

March, 1990. It functions from 9 am-5 pm, Monday to Saturday and the services are provided by a Stoma therapist. Every month, an estimated range of 30-50 patients visit the Stoma clinic. On an average, 3-5 patients seek medical attention on ostomy related complications in a month. The investigator during her clinical experience found that, often minimal or a little information is being provided to patients with ostomy during hospital stay. Moreover, discharge teaching on ostomy care is not given in an organized manner in hospitals. Various barriers to patient

5 education can be lack of time, lack of educated nurses on ostomy care and non-availability of patient teaching materials in the wards. People discharged home with a new ostomy often encounter stoma related difficulties and seek medical attention again. This study will help the ostomates to obtain an in depth knowledge and understanding of stoma care, irrigation, types of bag, replacement and removal of colostomy bag and care of skin around stoma which will in turn help them to improve their quality of life. Considering these, the investigator felt the need to develop and assess the effectiveness of video assisted teaching program on knowledge regarding ostomy care among patients attending Stoma Clinic in SJMCH, Bangalore. Nurses and all health team members working with ostomates can make use of the educational aid while educating the patients and family members regarding ostomy care.

6.2 REVIEW OF LITERATURE

Review of literature helps the investigator to develop deeper insight in to the problem and gives a strong foundation of knowledge.

The literature reviewed for the present study has been organized under the following:

 General aspects of ostomy care

 Effectiveness of information on ostomy care

GENERAL ASPECTS OF STOMA CARE

A co-relational survey was conducted on 50 ostomates from All India Institute of

Medical Sciences; Delhi to assess the quality of life (QoL) of ostomates and to develop guidelines to improve quality of life of ostomates for the health professionals was undertaken during the year 2005-2007. Purposive sampling technique was employed to select the sample subjects. The study revealed that majority of the ostomates’ possessed best quality of life. There

6 was a significant association between QoL score of ostomates with age, sex, duration of surgery, education, income, and occupation. There was no significant association between QoL scores of ostomates and marital status and type of ostomy. This study concludes that nurses have a great role to play in the physical, psychological, economical, social, familial, and sexual aspects in the care of ostomates and to offer psychological support and empathy, to reinforce coping skills to promote an optimal quality of life and a great role to influence and educate all the aspects of care to the patients and their relatives.14

A descriptive study to assess the knowledge regarding enteral stoma care among caregivers of children with enteral stoma on various aspects of knowledge such as anatomy and physiology, status of stoma, home care management, identifying complications and health seeking behavior was done. The study revealed that on colostomy and ileostomy care,

9.4% of caregivers had excellent knowledge, 65.6% had good knowledge, 21.9% had average knowledge, and 3.1% had poor knowledge, whereas on gastrostomy and jejunostomy care, 10% had average knowledge, 80% had good knowledge and 10% had excellent knowledge. The study emphasizes on the need for developing educational aids for effective education of caregivers on enteral stoma care.15

A prospective clinical trial was conducted for 37 patients with loop ileostomy and 39 patients with a loop colostomy in University Hospital, Utrecht. Patients were categorized according to social restriction. The association between the degree of social restriction and the presence of stoma care problems and complications were assessed. The study found out that the more stoma care problems and complications seen, the higher the degree of social restriction, significantly, more stoma care problems were seen in the completely isolated

7 group of patients when compared with the patients who were less socially restricted (spearman correlation coefficient 1,0.35,p=0.003). It was concluded that stoma leakage, peristomal skin irritation, dietary prescriptions, retraction and prolapse of the stoma have significant impact on the patient’s daily life.16

Another study was done to describe periostomal skin complications seen by

Wound Ostomy and Continence nurses over a one-year period using a standardized data collection tool and using the periostomal complications terminology developed by the Wound

Ostomy and Continence Nurses Society.12 nurses saw a total of 89 ostomy patients over a 12 month period. The subjects had a mean age of 61 years (range, 1-91 years).The sample included

46 females and 43 males. The study found that 47 percent of the patients had periostomal complications .Of these 42 patients, 31 had irritant dermatitis, 5 had mechanical injury, 4 had

Candida infections, 1 had an allergic reaction, and one had pyoderma gangrenosum.17

EFFECTIVENESS OF INFORMATION ON OSTOMY CARE:

An experimental study was done in China to assess the effectiveness of health education approach in reducing the anxiety of patients with rectal carcinoma after colostomy.

100 patients with rectal carcinoma after colostomy were randomly divided into observation group and control group. The patients in control group were educated routinely and those in the observation group received health education approach at different periods of hospitalization. The study found that the rates of anxiety in the observation group was significantly lower than that in the control group 1 day after hospitalization, one day before operation, 3 weeks after operation and before discharge (p=0.05).This study concludes that health education for rectal carcinoma

8 patients after colostomy via health education approach can effectively relieve the anxiety of patients, reduce the rate of anxiety and improve the effect of health education.11

A descriptive study was done in Chandigarh to develop educational aid for parents of children having colostomy and test its effectiveness. Two educational aids in the form of booklet and a video film/ computer disc (CD) were developed and used to teach care of colostomy to 120 parents. The sample constituted 3 groups (n=40 each) using the booklet, video film and a combination of booklet and video film for teaching to the parents. The mean pretest and post test scores of booklet, video film, and a combination of booklet and video are

(Mean=3.53, 6.05, SD=1.62,1.24) and (Mean=3.45,5.70, SD=1.62,1.24) and (Mean=4.18,6.28,

SD=1.18,1.48) respectively. It was found that the developed education aid were significantly effective (p<0.05) in order to provide knowledge and skills to the parents.10

A randomized controlled trial compared 2 methods of ostomy care instruction, traditional nurse instruction versus 2 session nurse instruction plus DVD for teaching ostomy care, to determine their effect on patients’ knowledge, skills, and confidence related to postoperative ostomy care. Eighty-eight adults with newly created ostomies were randomly assigned to 1 of 2 groups. Of the 88 enrolled patients, 68 completed the study. There were 23 colostomy and 45 ileostomy patients in the sample and the study setting was 2 acute care hospitals in the Midwestern United States. A posttest-only experimental design was used for the study. Traditional education comprised 3 WOC nurse-led instruction sessions and the experimental intervention comprised 2 nurse-led instruction session plus DVD instruction. a written test of ostomy knowledge, a self- care skills demonstration, and a visual analog scale rating their confidence with ostomy self- care. There were no significant differences between the

9 2 teaching methods or type of ostomy with regard to knowledge of ostomy care (F 3, 64=1.308,

P=0.28), ostomy care skills (F3,64=0.163,P=0.92), or confidence in performing ostomy self- care

(F3,64=0.629, P=0.59).The study concluded that when teaching first time ostomy patients postoperative self- care, a nurse instruction plus DVD method is as effective as nurse instruction alone.18

A comparative study compared the costs and effectiveness of enterostomal education using a multimedia learning education program (MLEP) and a conventional education service program (CESP). This study used a randomized experimental design. A total of 54 stoma patients were randomly assigned to MLEP or CESP nursing care with a follow-up of one week.

Effectiveness measures were knowledge of self care (KSC), attitude of self care (ASC) and behavior of self care (BSC). The costs measures for each patient were: health care costs, MLEP cost and family costs. The study found significantly better outcomes in the effectiveness measures of KSC, ASC and BSC in MLEP group than in CSEP group. Additionally, the total social costs for CESP patient were higher than MLEP patient. The cost effectiveness ratios in these two groups showed that the MLEP model was better than the CESP model after one intervention cycle. In addition, the Incremental Cost Effectiveness Ratio was-20:99.The study concludes that due to the better cost-effectiveness ratio of MLEP, hospital policy makers may consider these results when choosing to allocate resources and develop care and educational interventions.19

6.3 PROBLEM STATEMENT

A study to assess the effectiveness of video assisted teaching program (VATP) on knowledge regarding ostomy care among patients with ostomy who attend the Stoma Clinic

10 in a selected hospital, Bangalore.

6.4 OBJECTIVES OF THE STUDY

 To compare the pre-test and post-test knowledge scores of patients on ostomy

To determine the association of knowledge scores with selected baseline

variables.

6.5 OPERATIONAL DEFINITIONS

1) Knowledge

The information, understanding and skills that you gain through education or experience.20

In this study, knowledge refers to the awareness of patients with ostomy regarding ostomy care as measured by the scores obtained in response to items of a structured knowledge questionnaire.

2) Effectiveness

Producing the result that is wanted or intended; producing a successful result.20

In this study effectiveness refers to the changes in knowledge brought about by video assisted teaching program on ostomy care and is measured in terms of significant gain in the mean post-test knowledge scores.

11 3) Video assisted teaching program on ostomy care

The activities of educating or instructing using video; video assisted activities that impart knowledge or skill.21

In this study, video assisted teaching program (VATP) refers to the computerized disc (CD) on ostomy care prepared by the investigator for a duration of 20 minutes, to impart knowledge to the patients with ostomy regarding care of ostomy (irrigation, types of bag, replacement of bag and care of skin around stoma), prevention of ostomy complications and life style modification which include diet, clothing, exercise, sex and personal relationships.

4) Ostomy

An artificial ostomy or opening into the urinary or gastro intestinal canal, or the trachea.22

In this study, ostomy refers to either ileostomy or colostomy which can be temporary or permanent.

5) Patient with ostomy

In this study patient with ostomy refers to the individuals, both inpatient and outpatient, with colostomy or ileostomy attending Stoma Clinic of SJMCH, Bangalore.

6) Baseline Variables

In this study, baseline variables of the patients refers to age, gender, educational status, marital status, occupation, duration of ostomy, type of ostomy, source of information and

12 socio-economic status.

6.6 ASSUMPTIONS

1) Patients with ostomy may have some knowledge regarding ostomy care.

2) Video assisted teaching program is an effective method in improving knowledge of the

patients with ostomy.

6.7 DELIMITATIONS

The study is limited only to the patients with ostomy, who seek services at the Stoma Clinic in

St. John’s Medical College Hospital, Bangalore.

PROJECTED OUTCOME

This study will determine the effectiveness of video assisted teaching program in improving the knowledge of patients with ostomy .The nurses taking care of patients with ostomy can use this educational aid in imparting effective health education to the patients with ostomy. This indeed will improve the quality of care rendered. Also, patient education will reduce the incidence of stomal complications, increases patient satisfaction and in turn will bring forth a positive outcome in patients’ quality of life.

13 6.9 HYPOTHESIS

H1: There will be a significant difference between the mean pre-test and post-test knowledge scores of patients regarding ostomy care at 0.05 level of significance.

H2: There will be a significant association between the knowledge scores and baseline variables at 0.05 level of significance.

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

Patients with ostomy who attend the stoma clinic in St. John’s Medical College Hospital,

Bangalore.

7.1.1 RESEARCH APPROACH

The research approach used will be Quasi – experimental.

7.1.2 RESEARCH DESIGN

The research design used in this study will be one group pre-test post-test design.

7.1.3 SETTING

The study will be conducted at the Stoma Clinic of St.John’s Medical College Hospital,

Bangalore. St. John’s Medical College Hospital is a tertiary care teaching institute with 1200

14 beds. The total number of ostomy patients visiting Stoma Clinic is 5-7 per day.

7.1.4 POPULATION

The population for this study comprises of the patients with ostomy (colostomy or ileostomy) who receive services at the Stoma Clinic of St John’s Medical College Hospital, Bangalore.

7.2 METHOD OF DATA COLLECTION

7.2.1 SAMPLING PROCEDURE

The samples for the study are selected using non – probability purposive sampling technique.

7.2.2 SAMPLE SIZE

The sample size will consist of 50 patients with ostomy who seek services at the Stoma Clinic of

SJMCH, Bangalore. This sample size is based on previous studies sample size of 68 and 80% power analysis, 0.05 level of significance and alpha error of 5.

7.2.3 INCLUSION CRITERIA FOR SAMPLING

Patients who can understand and communicate in English, Kannada, Tamil, or Hindi.

7.2.4 EXCLUSION CRITERIA FOR SAMPLING

Patients not willing to participate in the study

15 7.2.5 INSTRUMENT INTENDED TO BE USED

The instrument to be used for data collection will have 4 sections.

SECTION 1- A structured interview to obtain the baseline variables of the patients.

SECTION 2- A structured interview to assess the knowledge of patients regarding ostomy care which will include aspects like anatomy and physiology, status of stoma, home care management, identification of complications and life style modification.

SECTION 3- Video assisted teaching program regarding ostomy care.

SECTION 4 – A structured opinnionaire to assess the opinions of patients regarding video assisted teaching program.

7.2.5 DATA COLLECTION METHOD

After obtaining permission from the Administrative authorities and Head of Department of Surgery, the samples will be identified as per inclusion and exclusion criteria using purposive sampling technique. Initial rapport will be established, the purpose of the study will be explained to the subjects, and informed consent will be obtained.

A structured interview will be conducted to obtain baseline data and the pre-test knowledge of patients. This will take about 30 minutes. On completion of pre-test, researcher will give video assisted teaching program (duration of 20 minutes) to patients on ostomy care on the same day on a one-to-one basis. This video assisted teaching program will include aspects like care of ostomy (irrigation, types of bag, replacement of bag and care of skin around stoma),

16 prevention of ostomy complications and life style modification which include diet, clothing, exercise, sex and personal relationships.

Post-test will be conducted on their next visit to the Stoma Clinic which will be between

10-12 days. A structured interview (duration of 30 minutes) will be used to obtain post-test knowledge scores. At the end of post- test, a structured opinnionaire will be used to assess the patient’s opinions about the video assisted teaching program on ostomy care.

7.2.6 DATA ANALYSIS PLAN

The investigator will analyze the data obtained by using descriptive and inferential statistics.

The plan for data analysis will be as follows:

Organize the data in a master sheet.

 Frequency and percentages to show the distribution of subjects according to

baseline variables.

 Findings will be presented in the forms of tables and figures (mean, median and

 Effectiveness of video assisted teaching will be analyzed by using paired’t’ test.

 Association of knowledge scores with baseline variables will be done using the chi-

square test

Does the study require any investigations or interventions to be conducted on patients or

other humans or animals? If so, Please describe briefly?

17 No, the study does not involve any investigation or intervention.

7.2 Has ethical clearance been obtained from your institution in case of 7.3?

Yes. Administrative and ethical clearance with regard to the study will be obtained from research committee of St. John’s College of Nursing, Bangalore prior to the study.

REFERENCES

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Aug 22];Available from: http://www.icmr.nic.in/ncrp/cancer_reg.htm

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[Unpublished dissertation].

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20 22) Stedman’s medical dictionary.[internet].26th ed. Baltimore : Williams & Wilkins; 1995.

Ostomy; p250-51. [cited 2012 Aug 28]. Available from: http://www.stedmans.com

SIGNATURE OF THE CANDIDATE

REMARKS OF THE GUIDE

21 NAME AND DESIGNATION OF MRS. MADONNA BRITTO PROFESSOR AND HOD 10.1 GUIDE: DEPT OF MEDICAL-SURGICAL NURSING ST. JOHN’S COLLEGE OF NURSING.

10.2 SIGNATURE:

10.3 CO-GUIDE: DR. ANTHONY ROZARIO PROFESSOR AND HOD DEPARTMENT OF SURGERY ST.JOHN’S MEDICAL COLLEGE HOSPITAL

10.4 SIGNATURE:

11.1 HEAD OF THE DEPARTMENT MRS. MADONNA BRITTO PROFESSOR AND HOD DEPT OF MEDICAL SURGICAL NURSING ST. JOHN’S COLLEGE OF NURSING

11.2 SIGNATURE

12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.2 SIGNATURE