CALifORNIA STATE
Ur-!IVEi':3JTY~
NORTHRIDGE:
DIABf::T.IC PATIENT EDUCATIUN
II
i\.
g~~~:lriva t(>
;.·roj .;;"!c t
rct:r~.lir(;rr:¥~nts
subn1i tted i 'll
for· the
degre~
{)f
p.:~· r t i ~i L ~~.~t tiD f .e r: t 1o.n rt;? t. ht::
1-·ia..f-te:r· .~rf Ft:.lh1l<: Hr~alth in.
I.
ty
R":Jbr~rt ArtdrB~. .r Gci:.J.TH.H?r
~
June .. 1974
'~
The graduate project of Robert An·:1rB\-T :Scha.pper is approved;
Committee Chainr.an
CaU.tornia State University, Northridge
June,
.
•
Abs.trac.t •
I~
.
•
Introduction.•
•
•
.
,.
e
..
•
~
"
"
1.
,
..
II. Problem IdEntification
... l
III. Literature Review • • • • • •
I '1
\
&
Program Objectives
V ~ RE:se.arch f.lethods
VI. Study Results*
e
"
•
~
•
~
•••
• • •
•
....
~
,.
15
'!-•
.
.
..
0
.
·1
57
VI I I. Sumwary and Cone lus iot< • •
Bibliography •
Appem1i::::es
e
..
" • •
•
• • •
..
.• 18
• • • • •
VII. Interpretation of Results a
~
.
.
•
" •
B. Demogr;;.phic Data COllection
. ..
•
61
.. . .
62
. ., .
Instrun~nt.
• •
Letter Distr·ihuted \Hth Extend£d f'olit Evaluations
D. Nursing Evaluation Instructions
" 62
..
.. 70
" •
71
e
E • Cl1nictd. Data Collection Instn.u:l€nt • • •
68
..
..
!J
..
" 73
r·
INDEX OF TABLES
(by Title)
LO
Operational
Objsctiv~s
" *
Q
~
•••
e
&
•
~
.•
•
~
•
19
Out-Patient Education Program".-.content Outline
3.0
Description of Study Categori£>s.
l4,.V
"
Out:~Patient
5.0
Con~:ent
6 .. 0
Diaeram of .Proposed . In-Patient R'"search Design.
<
Areas-9Pre .. Post Evaluation
•
•
Age Distributions by Sex Within
Out-Patient Study .Population.S 4 •
s.o
19
Study Populations., •
•
*
~
e
29
Sex Distribution \Hthin Out-Pntient Study I'opule.tif.'tlE,. ..
7,.2·
17
•
•
•
•
Comparison of Age and Sex Distribution
of Out-Patient: Experimental Populations
and Non-Study Diabetic Population • • ~ • •
~
Length and Type of Education ~li thin
Out .. ra.t:Jent Study Populationse • ~ a
8
•
e
•
• " .. 3.5
~
•
•••
~
••
~
• 35
•
•
•
•
e
•
•
~
•
•
~
•
36
!--1ean Number of Correct ItelT's for Out~
Patitmt Exp€rimenta1 Group Pre Tests o
~
•
~
•
•
•
e
•
•
•
~
37
8.,1
Hean Number of Correct Items for OutPatient Experimental Group Post Tests~ . . . . . . . . . " ... 38
9.0
Compnd.son of Nean Number of Correct
Items on Out-Patient Experimental
Group Pr€ and Post Tests • • • • • • , . . . . . . . . .
~
..
~
39
10.0
Hean Number of Correct IteUJ!:) for Out-Patient
Experimental and Control Post Tests. • • • • • • • • • • • • 39
11.0
Mean Number of Correct Items for
Out-Patient Experimental and NonDiabetic Group Post Tests • • • •
tv
Q
•••
•
•
•
•
•
•
4
•
~
• 40
~-··· •. ---~--·-··--·---·-
12.,0
Mean
Numb~~r
of Correet Items for All
Out-Pa tlent Study Group Pre Tests ~ • ~ • ,, ., ~ .. • •
;13~0
••
o
~
~ ·41
Comparison of Mean Number. of Correct
Items on Follow-Up Post Test:;; for Ttoo
Extended Experimenta!. Diabetic Populations . . . . . . .
o
.,
l~l
Percent Distribution of Pre T(-:!~lt
Missed Responses by Content Area
for Ex peri menta 1 Study Groups l-4 •
~
• " ., .. ,. •
~
• • • .,.
l~2
Percent Distribution of Post Test
Missed Responses by Content Area
for Experimental Study Groups 1-L>
•
•
o
~
~
n
q
o
I
"
q~
15.0
Rate of Diabetic Drop-Out From
Out·Patient Experimental Groups
16.0
Comparison of Extendr:::d Out~Patient
Post Test Results by Test Env.ironrlK:>nt .. " • ., ...
4
••
~
..
l,.5
!>lean Number of Correct Items on
In-Patient Nursing Evaluation •
~
•
•
•
~ 47
by Content Area for Nursing Evaluation • • • • • ~ • *
8
o
•
48
Comparison of Mean Number of
Cor:cect Items on In .. Patient i'lurs.ing
Evaluations by Nursing Unit ~ . . . .
•
•
•
49
14.,0
14 .. 1
17c0
18.0
19.0
20~0
o
G
•
•
•
•
•
•
e
...
Percent Distribution of Nissed Responses
...
"
•
0
•
•
•
Frequency of Diabetic Hospital Admittances
December 1, 19"/3--Narch 1, l97t.~ ., . . . . ., ~ . . . . . . ., ., • 50
v
-
"~ 41
ABSTRACT
DIABETIC PATIENT EDUCATION
r~va.luation
in a Community Hospi t>!l.l
by
Robert Ar..dr0w Schapper
~laster
of PubBc Health in Com:nuni ty Health Education
June, 1974
To master knowledge and techniques of self=management in r:he
light of chronic illness is c.n achievable reality for rr.any persons
'-...
living with
diabetes~
abnormal secretion
the hormonf.) insulin, 1&
norn~<~lly
a cr.mtr-(;.llable
?-1;3ny variables tend to affect this d:i.SE'ase process, but
phenomena.,
rece~•t
~:;f
_,...
This !1•-.:>tabolic disorder characterized by the
research in the area of behavior modific,'ltion has found.
f.•
correlation between the knowledge level of the individual and the
degree of diseaoe stability (Stone, 1961).
Physid.an$ who work
t~lth
diabetic patients h'alped to influence
the development of an educati.on program for diabetics at Northridge
Hospital lr•
th~
San Fernando Valley.
originally designed
01.1.
Th~
creation of this program
an out-patient th.sme,
delivf~red
a
mt~ch
needed
service to busy physicians and concerned patients of the local community.
The
proc~ss
of patient referral by physician to an approved (by
the Diabetic ·Association of Southern California) out-patient program
vi
,-
i opened
a
rH.':'hT
approach to health education for the diabetic, nnd provt"d
l
l' to be a much nt>6ded community service,.
Tho? ;..<ctual instructional program, molded after th& cil'.lSign of m:1ny
, physicians c,nd lnterested community groups, entered into
;.:~
p:!:'t.1C<-~ss
ot
This program f.!valuatf,r:m) inclusive of both
. a three mcr(th evaluation.
· out-path~rt\: and il1ahospi tal
components~
was geared at mor£> closely
'defining program e!'fectiveness and involvE:d 'the author a!ld other coop-..
eratlve hospital staff members.
Specific diabetic and non-dia1;Btic
populations were studied and observations were made r.egi!rding
tional effectiveness and pe.tient&,physiclan need
i:tst:n:c~·
gratific~~tlon.
It
~>.'as
concluded from the study that diabetic populations who :::ecelved
instruction on an out-patient basis significantly nd.sed th10ir know'
ledge level;
in ... patients
sho~;·~~d
2
very little change in J.ut•OVI1edge e.nd
had a very low referral rate to out-patient sessions.
Results would
seem to indicate that in-hospital education lacks continuity in
instruction and referral, and many patients d(J not receive the i.nfor ..
mation necessary to maintaln disease stability ... Based on prelimirwry
findings and continued study, program expansion was extended to in=
hospital
pati~nts.
i
I
!....~~ - - - - - . - ---~ ~---~~-·-~·-·- -·-·-·~'"" .. ~r••--~··-•·--·- ••
'•• -·" ·~ ~- ~- •-••"-
•< · - • · • •
---••·-•·---------·-·-.-·-~-•-• -·•-«--••- •- ···-·-•
vii
INTRDDUCTIUN
:Lally for those patients ,,rho must mast(:',; l<rwvledge and tech11iqt.\GS of.
self~management
ness~s..
essuntir.d. for U ving id th long term and c.h:coni c ill"'
This typ;e of health inst.i:-uction has become an
of a comp:t:IO!hensive approach to
P~•tierct
inb<~grs.1
part
care in many local CQ'!nrl:tmity
hos pi t:a.ls.,
The patient education desc:-lbed in t:hie paper was conducbad. in
hospital with a specific
thi.s narrative
di.scus.~:es
progr~'lw
for hti<".\lth instructione
evaluati<m and
modifi~;ation
~
The body c.f
of nn existing
diabetes education program, and the process of develop1nent of
fl.
modi ...
fled unit for in-patient instruction.
The dist;.r>.m!n<d::ion of inforttlc'ltion
p~rtalning
to the mainter•.omc'=
and control of d:tsbetes hss traditionally beer. limited to physician ..
pati.ent interaction and/or intere::;ted conmr..tni ty based agencies such as
trte
DiaJy:~b'!S
As,<;cciation of Southel'n California,.
Internists ;vho spedalhe in the area of diabetes, diaheticians,
!>.ave reflected a concern. for the existing system of education avail ..
. able
tl.l
the diabstic and the community as it: relates to obtaining
knowledge of the factors involved in maintenance and control of this
1
'"'"''' "' ""' ' """" """ ""
disorcm;.·.
••'~"""'""'
·•·•-• '' •'" •• ""-""'"'""-"""_'___,, ,,_ -• •·•• '•'
""""••-•"""''"~""
-- .,.,., .. ·, ., "'"l
It is thn prevailing fe-eling of this group of physiciaxv;
th.:: facto:ns involved in control and maxntenance of diabetes.
Sf.Hu>e:t "the p<'ltient tr.ust assutte prirrary r.espnnsihiHty
ft:;;,~
!n thh3
his own
Increasing number;;; of diagnosE;d diabetics and "pott>nU.a1 dlabetics" (persons who may exhlbit some symptoms of dlabet'f?s, but who have
not yet been di.agn.osed) in the Sa11
l~ern_at1do
Valley hav.2
limitation upon the physician in terms of direct
interaction~
iR~p0t3ed
tJ
ti.tn-f"
patientMphy!~J.cian
This reduction in avallabi H ty of the physician has conM
versely af fee ted the quality and effectiveness of patient educ.:t tion ir•.
the physician;s officeo
This is a primary concern to the dh:betlcian,
for lt is important that th,;;.- patient understand his condition and be
awarf'! of the be.sic c.haracte.r.istlcs of the disorder.
Lack of patient:
comprehension of the d3sease process places a bard.el.· of c..ommunic<?ttion
between the physician and the pa tlent.
The physician cannot effec-
tively discuss the problem with t:J:w patient, the patient cannot under ..
stand what the physician is attempting to explain, and typically the
patient i.s unl-\ble t·'.l
tion~
assun~.oe·rosponsibility foJ.~
control of his condl-
This is a real problem, the solution is education.
There will be some to whom the idea of self-wanagement is foreign,
and some 1-rho may advocate physicien care as the primary force in main··
taining the health status of the patient.,
On the other hand, th1;!re
may be those who are aware that "due to the nature of the dis ease,
:
-·-----·-----*Robert Rood, N.,D., Diabetes Workshop
"' .. -~··--~-·-··-· ·--·-·-·-···~-~~-~-·..-·~- '··-
·-··-~- ~~ ·-~· --~' --~-·--
...... ··--·--- -·- ·-··1
I
is simple <md sow-;d vn beth health and econond. c
aspects~11
-:::..:m.trol, the diabcti.c ca.n live a more active and
rH th
prop~0r
normal" l!f~3.
A
dit.hetic frequently out of r.:ontr-ol m3_y find greater economic burden
placed upon himself, his family and possibly the cormnunit:y due to a
protable increase in <:tmbulant care ·visits, and possibly regular cr
greate~:·
fn~qu·2ncy
of hosf;i t:.a H2.ation.
Considering
th~:se
circum.":ltances,
educatior: seE·n:s to be a 1'-e"<lthier and l<:>.ss expensive a1t£:rnative.
The Education Commi tt£~f; of the Diabetes Association of Southern
California, hereafter referred to as DASC, became interested in an
education program for the San Ff3rnancio Valley..
They or:sanizcd int.::r-
more appropriatr: di<:1betes instru;;tion ·within the
community~
efforts of thil-l group t.vere tnmsposed into what has been
The
call~d
"protocol" for an instructional program in diabetes education,.
a
This
protocol,. or content outline 9 was adopted by the education committee
as their formal instructional package.
A number of r>.;presentatives to the Diabetes Education Committee
were also on the staff at Northridge Hospital in Northridge.
Their
pers11;rverance •..ri th the hcspi tal's Nedical Education Committee and
Board of Trustees proved to be significant when their proposal to ereate an out .. patient education program at Northridge was ratified.
It
was agreed by the hospital's Nedical Education Committee that the
, instructional package created by DASC would serve as the
fr~mework
:----------------------*Robet·t Rood, M.De, Diabetes
\~orkshop,
,_
-
1973.
"""
------------ ·----·----------·-------------·------------------'
for the Northridge
program~
A hospital sub-comrrdttee, th;,,
Steering CowJnittee 11 under the authority of the
Euuc~tlon
prograr·~
Connni ttee was organized and dB lege:. ted
r<?view..
Educat~.on
The
Northridg~
r~sponsHd
D:i.~:b£,tic
t-l!i,d:i.c.."d.
1i ty h1r
Committee of DASC followed by giving
. No:cthridge sole endorsement for thE: San Fernando Valley, and con:mi tted
DASC r·esovn;:es for duplication of educational I!k"\terials.
The author '.s i!ntry into the Northridge program came in August,.
uiOnth~'>
1973, about 18
after the original program was
that time<t the program
~Jas
implem~nt(v:l,.
At
running wl thin the original content d<::sign
suggestf.?d by DASC and no program evaluation, or modification had been
made since program inception •.
.
i
..
!.-~-~~-·-·- ---~~~---~-·N~"-·-~~-~-·---" '''''---~-•••·•--
'''''·-- _.,,,,
--·-~•>
·-·••• ·-·· •-··-•
•-·~·-··-
••• ··-
••·-~--.-••·-•··-·-···
_ _,_, _________ ,,,, ____,__
~
CHAPTER II
PROBLEH IDENTIFICATION
A
_g~;meral
expres:::.fon
p:r~.-.vide
progn'!m at Northridge is to
diabetic population
;:;f
t:he purpose of the diabetic
l':.lf.
~ducatiiJn
an edw:::ationrd. ser·vice to the
thr.: S,;m Fernando Valley..
At the Urr.e of chce
author's entrance into the program, a number of i.nterested physlci.'li".S
and
some
~mbers
conc~rn
of the hospital
JE
diabetic steering committee demonstrated.
as to whether th.:: prt>gram was currently meeting th9 ne.,ds
of the diabatlc patient.
It vas suggested that the hospital employ a
study to evaluate the :!nstructional program.
The author was in.vi ted
to participate in the rc;viH1·iJ ar•d was delegated responsibility for
implementing
Initial
~
hospital T,;ide
rev~<:"Vi!
study~
of the existing diabetc"s education program
t:he author to identify \:'t;o separate instructional
two areas of
.in~hospital
,enahl~d
environments~
The
att0. out"'pathm.t education are independent
components of a total patient education program.
Each specific compn ...
nent is theoretically designed to meet the particular educational
needs of the patlent .at bvth an ambulatory and in .. patient level" and
both
instru\~tional
a common content outline.
programs adopted
ReSfH:>rtsiblli ty for planning, impls:mentation and evaluation of the
total program fo.n:·nuHy rests with the hospital diabetic steering
conllllf.ttee-; bu·t h.as be~Z<n informally delegated to the actual teaching
s
Specific questions regarding the actual relevance of the education pr<:•g::·am
we;:·~
physicio-ws and
of
inter~sted
recently t·aL>ed by a swe.ll number of :!ntl"n·Bst:.<::d
thE~
author*
Tht:
}.rJ'hkl.:iY
area of interest
r.est1~·d
wi.th
parties that there was no on.golng system of prograre
evaluation, t'tnd due to chi;:;) many
tiona1 eff.0ctiveness:
w~>~;
person~>
assumed that actual insn:uc···
not being assessed.
This co:1cern rel2.tes to
the general acceptance by physicians of the concept that knowledge of
diabet..;s n?lates to the patient's ability to stabilize his condL::lu,,
(Ston€, l96l)e
If the teaching team is not currently eva1uaclng
patlent learning at the cogni.t:i.V!Z' h?Ve!.,. it is not possible to as•<-1:•.:>6
that the program c·:.mtr.Hmtes to
this dis.:n·der and
thereforr::~
th~
paticntfs kno·•,rlecge of cnntrol of
the program may be irrelevant.
Closely related to this question of patient knowledge is the area
of instntcticmal
methodology~
Thn author observed that: a specific
structured content outline is fullowed in the out-patient education
sessiom-;,. but very little consist,;,ncy in in.-ho5pital instruction is
observed~
This may be accepte.bh; if p.'J!tient preas.sessment Is held
prior to individual instruction, hut thiF; t-:as not
question of whether the ctlrrent
ln~hosp!tal
done~
Here the
program actually moets the
needs of hospitalized diabetic patients is raised.
Due to the lack of
a planned program for evaluation of activities relating to the in .. hos ...
L·
7
<E.cittcation program sufi'1c1ent1y meet:s p.::.t1ent n€?eds.
I
~~Assessment of the existing diabet{;.')5 education program be;.:an:e r:h~;:
//-
'primary pr:Jblem to be studied~ VA t3£cotv:\ary area :relating to ths
rec-ords that only
10~1.
af: the tot:-11
1n.~pntie:at
attendod out .... patient instructional sessions,.
ci<:!bet:tc populflticm
A qu\?S tion ;..r2.1S :n:liS·l:?d hy
for in .. pati":nts to be referred to an out-patient progra;-r; vpoa
correlation (generally accepted by the physicians involved
~~n
ctL:;c~
the
program), and if in-hospital instruction is sufficiently successft!l .in
raising patient knowledge level, the low rate of attendance of ambulu ..
tory. patients to the out .. patient pr·ogram is not a concern..
But, if
h'w levels of success are exhlbi ted in in.,.hospi tal instruction, it is
fair to assume that diahetic in-patients need further 1nstruc.:tlon in
ordt.r to
n~int.aJ.n
rationalf;,
if;
high levels of disease stability.
Following this
is also probable that since only 10% of these patients
attend the out-patient program, the balance of diabetic ine,patients
may
r·~cei ve
little or no further instruction,
This question relates
directly to the .:?.Valuation of the current in-hospital program.
Based
on avA Uab1G !nfor.l'!lil tion, it would be lnappropria te to assume that
in .. hospital instruction sufficiently meets patient needs.
iHthout
empirical dat:a relating to program effectiveness, it is difficult to
say something about the effectiveness of the existing referral system,.
l
\~- ~'-"~ .....................................................................
- .........~-····.
_____,._ ,. ,.,.,., _____ .__, ,,.,._.,.. ----------·----·
---------------~----------------------~---
------~l--
~
1
!
land the statHC of :.'lon-r·eferred in .. patients~
1
1
'
It
\laS
cuncluded by the author and members of the diabetic
; teaching team that these questions ne£ded to be
confidence,.
ans~vered
"':U::h gr-eater
A study design l.tas developed and implemented to gather
data relating to actual prozrE!m effectiveness.
CHAPTER Ill:
LITERATURE REVIEW
~vas
The author's 1 i tera ture review
conducted in n?fe:ccnce to
specific areas involving evaluation of the existing diallBtlc education
program0
The author was interested in :ecviewing previous studies
relating to evaluation of similar diabetic prograxns, at:ti turJ~;; n:•r.;arding hospital based patient educat\on, instructional methcds and
t:he>J~-
ries of learning, and studies relating to relevance of patient knowl- c.
edge and .-:ontrol of diabetes.
An<\ly~o7is
of the structure of the trarlitionztl h0spital
nvrt~ing
department led th!Z) author to conc1lrde that patient education is not a
singular responsibility and function (Pohl, 1965).,
Research by FQhl
indicated that even though nurses acknowledge this responsib:i.litYs.
over 60% of 1.'300 nurS\:"1S studied did :<Ot have adequate knowledge of
teaching methods to carry Gut this function.
The relative Lmportance
of this is reflE:cted in Stone's findings that
kno'~<rledge
and factors related to its control has been
n.~lated
of diabetes
to the degree of
sttlbility of the di;,:ease in individual patients (Stone, 1961).
These factors, combined with the limited time available for ln.,
hospital teaching and the mo.ny Interferences associated with hospital
routine, theoretically make teaching the in-patient a difficult task,
and
L~Y
seriously
imp~de
the patient in controlling his disease due to
9
('~~~-~~~--·~~-<~-.-.~ ~-~.o·•-•••~···
-·
••••~~-·~--~v••-
<·--•·•_-~·-·•--·•"- -•Y-'~-- ··.-··--•··--•-·........-•~---•-•·••~~- ..-----···-~~-~ ... -·-,~~~-•~ ·~··~
·"'·•'
.,•
._~-·~
o• •
~--~·~- •••~
-· •
I
! his
l
lnadequu tf.':! knowledge base.
Th(; author observed that tir:te was a
i1 knowledge
s1gn.if~cant
1.avel has been correlated to degree of
fact<.::•r, ?'.nd that
dise<.t.'.'l~
stability,.
i
·Another study by Stone (1961) discussed clinical symptoms of. misn'iu·~'..
• agement and correlated this to lack of knowledge.
i 160
I
dlabet:!.c~ pa.tier.ts studied, 126 'Here rated
11
Stene found that {>f
poorly cont-roH.::d 11 as
·evidenced by m·rotic blood sugar levels, recu:t::r.ent infectior-: 11 and
· ft'equent occurence of diabetic coma and lnsuHn reaction"
126 pat{ents, 83 h.nd e.r. insufficient
adeqUE!t<?.ly manage thetr
disease~
k~w;.;:ledge
Of those
base to allov tLeiri te
!-lost of the 83 patients h1.'1d.
instructions on care while they ·iv-ere hospitalized-emethod nf
tion and instructor were not identified.
n~ceiv·~d
instx·uc~·
iHth repeated instruction.
60 of the 83 \Ycre able to attain enough information to enable t.he;n to
exercise considerable control in regulating their dlsoO!se.
The author also reviewed studies relating to knowledge of in· structors..
who
Etzweiler (1967) surveyed diabetic patients to find out
taught them» the teachers degree of knot·rledge)
sitttation.
L··
~nd
He concluded that dLibetic education was not
che teaching
opti.r,~.<itl
due
to lack of knowledge on the part of the instructor, the emotional
state of the learner, and the period allowed for lee.:r.ning to occur.
Continued study was directed toward theories of learning in an
attempt to find an acceptable model to follow in reference to an in-
patient study.
Gag!le's th>::ories were concentrated on quite heavily,.
. Gagne (1970) defines lenrning as lla, change in human disposi tlon or
capability$ which can be retained, and which is not simply ascribabl~
. to the proc~ss of growth" (p.3).
Gagne also proposE",s a hierarchy of
i
...... _____ , __ ,.. ·-·--'"-·'. ·-- - ... ···---·------·-···--· --- ···-·-···.-.-.:...----·-~·-·- ···-- ---~~
for th"''ir c-ccunmca.
If this theory of learning :i.s
&cc€pted~.
lt f.E.
necessary for the instructor tr; identify the typE? <Of lea.rning to
lH:!
. accompHsh:;:;d and the conditions necessary for its a.::complishmr.::nt.
Much of ·what the diabetic patient must learn is based on dl$crim"'
!nation learning such as differentiating signs and symptom.s of insulin
shock end rHabetic coma, testing un.ne and
intcrpr·~t.ing
rately, .:md recognizing symptoms and signs of
results accu-
infection~
Gr.,gne 0-970)
postulatr:;s that the external co:d:lUons for st1ch discriminati.:-·n
learning includes a great
dea~.
of :t"'<Jf'/;0ti tion
~u1d
reinforcement if th£'
le:arn1ng is to be accomplished und retained.
~!Xt~.?.:t>­
Gagne, as 'vell as other theorists,. also concludes th<o1t the
nal cond i. tions 'i?hich affect any learning include instruction!
reinforccnmnt, and interference factors.,
Skinnc:r (DeC.ecco,. 196B)
particularly emphasizes the role of reinforcement and
cies of reinfor·cGment in the learning sl tuation,
reinforcement nost
imrr~diately
yr·;;>.cti:~e ~
follow the p:t·oper
th~C: (:nn·ti1.1§~~.:n 6
According
n.~sponse
if
tc~
11
Skirmer,
S ...R
bonds" are to be achieved and learning to occl.lr.
According to Gagne (1966),
ence on learning, it is
tion.
~ince
neo~:;sary
instruction h.:ts a prhr.ary influ ...
to knm• Wh-At is expected of :f.nstruc ...
He proposes <.t :model of instruction which indicates tha.t it i$
necessary to:
(l) identify the terminal behavior expected;
identify the elements of the stimt.tlus situation;
level of
re~allabi li ty;
(2)
(3) establish a high
and (4) guide the thinking of the learner,.
Based on this model, instruction nust: then begin with stated
tives of learning which are
fra~ed
obj~c­
in behavioral terws so that they
{znigh·t he recogrtiZ-·-~d ··\-~l1~~ri accomp1 isht:!d.,.
~l-e}{t r 1~ t: ~.s r. ~t.~:s.~J~t~~r
1Cf;n~
.t:;:-;
j
I.
Itify
what ls to b.r,, lc:a:cned 11 the si.:irr~.d.<-lt? 1.:d.tuatiort.,
ln ::::ch:i.eving a
I
l hi.€~b.
level «;)f r~calla.bility on.e c~r\ ~1\"iSt:ulate thi'it fii~·ar=tfcf.: (r.ep,eti~
. i tion)
and :n:d.nforcement are implied and im:)ortant..,
La:.;tly, in gu:lding
I
'
In. applying Gagne's model of instruction e.nd co:aditior:.s of
learning to the diat1etic patient, especially in the in.,hospi tal
"~nvi ..
ronmt<nt, greater attention should be given to\>ar6 p:r.·ovlding more
adequate external learning c-ondi tlons.
tion can be a
consist~nt
In theory, prcg:n.nt;,:K:•d ins true~
SUIJplement to conventional
allow for mor.e faci:U tation of
ext~rnal
teaching~
and v.:J..U
condit10ti.S by providing a
great deal of repeti ti.on and reinfo1:cement, '\>Thich should result in a
higher degree of
h~arning
and recall.
According to DeCecco (1967), programned instruction provides tht~
following;
(1) rmterial is broken into 3mall steps;
responses are necessary;
provided;
(2) frequent
(3) imrr.ectiate confirmation or c·,.)rrect:ion is
and (4) content is appropriately sequenced.
Added to this
is the flexibility that such instruction also provides that it can be
utiliz~d
at any timf..: without the assistance of an instructor.
In selecting the type of programmed instruction to be used, it
would seem that a "branching" linear program would be rr.ost appropriate
slnce it is "stinulus centered".
In this type of program!J the correct
13
al.so accounts nl<-:;x·e
effectiv~ly
for th>:: .l.ndiv':.dual <lifferr::ncl'!S of the
learner (Lum.sdalne, 1962),.
A similar learning theory .eppU.E:S
tor:~
Friesen refers tc as the Adjunct Frngram:ne.
se>:ond r;rogram vhich
This program is suggested
for use when populations ere sme.ll in. m. ;mbcr, and whriir<e the
linear prog:t'iHl'ming Is too high to t-mrrant: the end
instructhm 1r.ay
tiona!
proble~s
b€~
/-.--"
:n~sult.
r~xpense
of
Y;;•t self-
clearly indicated as a means for resolving instru<:-...
(Friesen, 1973) •
. The t.mde<rlying theory in thi..s type of program is the sr.1me as that
of the linear rrog:r-am, but in adjunct programr.dng, the trainee must
construct a response and from this, the instructor can evaluate precisely what the
train.:~e
knows.
According to Friesen, "Adjunct Program-
ming is a fast, economical and productive means of achieving instruc ..
tional goals.,"
This supplemtmtax-y program is based on discrimination
learning, but allows for greater overlearning due to the added benefit
of a completion segment which allows for an overt constructed response.
Worlcing with a book, pamphlet or other material, a diabetic patient
would read the material at least once in documentation, and twice in
the adjunct programme.
This would be a minimum <.>f three times through
the pertinent infc,rmation.
After each phase of the adjunct material,
l../
. ··-·•"J•J~---~
-~····· ------~--~·-·----~
...
·--~-----~--,~---~ ~-··-~
..~--~-··--~~~~~····~
---~~·------.--.,.,.....
....____,-~-<
-·~----.
'"~1
!
~rhich
path·nts had significant p:coblems and the prograrnrn.::::r can then
.9.dd to thP dccmnentation as required to provide additional
tfon, or increase the number of questions on the
troubl~
in.str.uc·~
spots 1 as h-e
chooses (Fries{:n, 1973) .. "
The revie1f.• of the referenced H terature gave the author insight
into developing an approach toward studying the existing diabetic
education prog:rar.J,
.assessing
From the 11 t2rature,. a framework l>Jas built for·
ln-l<o~~pltal
instruction, and a· pilot study vla$ ini.tlated to
evaluate ectual levels of existing instructional effectiveness l-lithin
both i:n ... hospl t.al .and out-patient envir_onments.
'
L. _~~-~-•• .~- ~~.-.,.~ ~--~---··--~·••<
··-o-•-• -- -·-
••-~•~·-·~--~·~•·-~----
••··-· -•• -- •
i
CHAPTER IV
FROGRAN OBJECTIVES
A prelininary
r~vie¥7
of the existing diabetes educ.atlon progrE>m
allowed the .author and mer.ibers of the teaching team to identify aceL;s
of concern
reg.;~rding
progra:;;;
tffe:::tiv-=n""ss~
It was
suggc~st\:'!r~
that
specific pro:grani objectives be devBloped in an evaluative for;'n:; to
all<n? thb> planning body a frr:nnework· for program expansicn., n:odlfica"'
tion and
appraisal~
The committee followed this suggestion, but took
a very passive approach toward participation in actual goal setting,.
Team members suggested that the steering committee should assume this
administrative role, and that the committee should revieH tht:O· concerns
of appropriate interest groups (medical staff, administration, DASC,
and the teaching tean.) in an attempt to centralize ideas and develop
object:lves around commcn goals.
This revie"7 never took place.
The
author observed a level of marked complacency among a majority of the
steeri.ng
comt;;itt~<.!!..
A number of the com:nittee members reflected an
interest in pursuing a goal identification session, hut active suppor.·t
was vlrtu.:.'llly non-existent.
It was their feeling that even though
they were interested in better prog:tam definition, the real responsi ..
bility for program implementation rested with the teaching team.
Based on this attitude, the author decided to organize the teaching
team to set program goals and develop an evaluation
····---------- -------·
~---·
··- ·······- -·······-- --·· -··----· ·-··-· ... . ... ... ........
--- ··-··--- -··· ····- ·-·--. ·- .....
15
study~
--·-------·-----··-·-··--··· -·-·-·---
16
The develcpme:rtt of r;r·r.>gram objectives took place at an orgnni:r,a, ..
ticmal level 9 and dealt basically with activities involvi?d in a-chi!:;v..
ing the primary goal of rwogram evaluatione
Table 1,,0 dlagrama.tically
illustrates the pril'llary and secondary objectives stated for the
, gram study.
p:ro~·
It was suggested by the author that once the prl{!![<t'Y.
objective of program evaluation was achieved,
be placed on modifying the existing
g:rent~.?.r
in.structiont~l
empha::; is should
pack;.:1ge and that
specific instructional objectives .should be developed for eaci;, content
area co
0<:~
stud i.-.:·J at both thf.' in.-.hospi tal
E~md
out=patient levels.
Once'evaluation takes place, instructional objcr;tlvcs can be developed
and
int~g:rated
into the formulation of total program
I"--- ··-··----·· ··------..- ......... _.,......................................................... ---· ...........................
goals~
!
~ ...........................................___ ,__ , ____________ ____j
on:RA 1IONf.L OBJECTIVES
Prirrary Obj£ctive:
To evaluate both ir\•hOS?ital ar;.d oatpatient !nstr-u.cticnal comi)Ortents
th<2
existing diabetic education progran at
Northridge Ho;::pital vith:i.n a six mc•:tth
ped.od.
''f
Secondary Objectives:
(1)
To organize the teaching team to dis cuss the curr>.mt
status of the diabetes education prograrne
(2)
To id<::ntlfy possible problem .n:reas within the~ existlng
instructional program at both in~hospi tal and Otlt~pat=
ient levels •
. (3)
To develop a study design for evaluation of the exist ..
ing education program.,
(4)
To identify criteria f-or evaluation ;md develop instru ..
foe .e.;;;sessing existing instructional effectiveness ..
l!'<~:mt.\';
(5)
To imp!e.mf2nt a pilot study at both instructional levels.
(6)
To collect data relating to possible problem areas
in the existing instructional program.
(7)
with~
To define areas of program weakness based on collected
data.
{8)
To devel(lp modifications for identi.fied c1re.n.s of pr•o ...
gram weakness.
(9)
To imple1'11€'nt modifications within selected pr'ugram
areas.
(10)
To re-evaluate the total program on a specific time
interval or on-going basis.
CHAPTER V
RESE..o\RCH METHODS
Evaluatio:.n. cf the existing diabr::tes
the developnil:;nt of
a
de~:dgn
~ducation
for. measuring ct·it:eria within the f.t·a1Jr.;; ...
work of the E>Xisting instrvctionitl setting,
cer<i).)Oi~.?nts,
.:valuation of th"" t:wo instruction
patient educatl.:m 11
wGlS
program cBlled for
implern~nted
A study design. b.:u.. ed on
in ... hospital and
out·~
in an attempt to gather informa.tion
pertai.ning to total. progra:m relevance and sped:Lic instru.ctivnal
effectlv02ness within each component.
Th(:'l existing out-patient education program at Northridge was
organized around the vrlginal DASC content outline.
Annually., appr:ox-
imately 18 out .. paUent education sessions are held based on content
including that Fhich is illustratDd in table 2.0.
ture of the pr.ogrant is based on five two hour
over a one
'WCi?k
int<.~rval~
The actual struc ..
ev~nin~~
$essions held
and instruction is the primary responsibil"'
i ty of the f .i ve ... member teachlng team.
Patient referral is th!O! pricr.ary mode of entr.ance into the out ..
patient program,.
Patients who are in-patients at Northridge are
gen•arally ref-arred to the out-patient sessions, hut patients do attend
from within a 10-mile radius of Northridge Hospital.
h:o
This geographic
open a greater area of the community to participa ...
18
r···--·"· ..........."·-· .
tionr but is HmJ. ted to .cenidGnts of t:hc San Ferne.ndo Valley ..
OUT-PATIENT f:DUCATJGr!
1st
St~ssion
PR(J;~-tAN .....
(2 hours)
CONTENT OUTLH1lE
:r:xpl<.'\nation of Dlabe!.:BS
}Jho Gets Di.a.bete;;
Inl~ulin am~ 0:.-;:1 Drugs
!nsulln Reactions
2nd Session (2 hours)
Diabetic Ketoacidosis
Urir,~;: Test:!ng
3rd
s~~ssion
(2 hours)
Diet
4th Session (2 hours)
Social Service
. 5th Session (2 hours)
Foot Care
Infections
Comp 1i cations
A study design ·was implemented at the out-patient level with the
objective of assessing current program activities and evaluating
patient progress toward knmrledgc
incr~<:H;e&
• upon the study of five groups categorized
aG
This dE:sign was based
ilh.1.'3trated in t<'!ble 3.0
for a three rr.onth period.
'I.4.BLE 3. 0
DESCRIPTION OF STUDY CATEGORIES
Study Category A
Out-Patient Diabetic:s (attending out ...
patient program for the first time)
Study Category B
Non-Diabetic with Relative {person
in nuclear family is a diabetic)
Study Category C
Non-Diabetic (no relative)
Study Category D
Health Professional (nurse, aide,
medical assistant, or orderiy)
Study
In-Patient Diabetics
Catego~y
E
'fable
out .. patient
L~.o
lev~l.
The
Given an average o.f: 18 form."'\1
w~re
prOC!~Ss
correlat~:;d
t:h~;
of selectf.ng the four c,xperi·"'
out~pvtient
sessions per
year~
f._AJX
randomly selected for study from t'he total of 18.
relating to age"' sex
later
·at
SelecUcn of the: out .. patient diabetic OXPE!rtme:-nt;"l
tions -of tim0 and money,.
.groups
;;tudi~~d
outlines t!w tota 1 number of populations
ar~d
Dat:3
educati(>n >;ras collected on all 18 grct:ps end
to determine whether thi2 four groups selected wera
actually a reprRscntative sample of the target population,
A Id:ninn.un
group size was set at 15 persons.
'IAB IJ:: 4. 0
OUT-PATIENT STUDY POPUlATXONS
Ex peri menta 1 Gn;up ill
Out .. patient
Ex per i n.en t.~ l Group 1fo2
Diabetic Groups-Took part in ont ..
patient instructional program
Experimental Group :f.k3
Ex peri. rr.en ta 1 Group i/:4
Non-Diabetic Comparison Group :/,1:1
Non.. Diabetic
with Relati.ve~'c
N.on~"DtabtO:tic
Non-Diabet::i.c- ..
No Relative*
Diabetic
*
Comparison Group #2
Contl~ol
Group
Diabetic Control Group
for definition see table 3.0
A diabetic control group was also selected for study.
This gLoup
consisted of diabetics who upon referral to the out ... patient program
. ··-·~-·· ·-- ·-
"•'-••
··-· ...... ·- -··-- .. .
·-""··--
··-··-· ····- .... ·-·-·-·-- ····--····--···---··-·-·· ----··-·-··-·--·-·--·······-·-·--·-----"--
f""..... ....
~
,~.~~
·-
·~-.
---·
·~-
.,
i
!did not attertd~
i
I
! t:1.nd
A total of 25 persons were tested from this grmap,
"''-8I.'E~ :c;:mdornly selected over a t:tu·ee 1110nth period,.
One group consisted .of nor;,.t!ie.botics who have diabetic
:lations.
sistcd of non .. <Habetics ldth no diabetic relatives.,
by the authe:t·c.
Th;e
non~diah12:tie
A tntal oE 48 non .. diabE:tics 'Here studied.
Colh:cthm of study data consiste.d p:drn.a.rily of denographfc
informat:h;.n including ag(?) sex, and f•.>rw.al education of group
pants, cn.d pr.e and
p~ncil
examination scores
dm·iv;~d
from a paper and
test given tc the same participants"
In
item
vos~
partie?.~
~n
pape~;o
attempt t" assess patient knowledgo <lbout
diabetes~>
a 1+0
.a:v.:l. p(.::ncil test wa1:l deG:igned for use by the author,.
(Appendix A)
This inst:rumznt ~..,a~ designed to evaluate patient knowh
program~
edge prior to ,;;.ntr.;<.nce into the instructional
t.ton of the f:iv·a cky instructional session.
and upon comph•"'
The evaluation was
designe,-d around tho£: existing content out:llne typically followed in
the instructional progran1 (Table 280) ..
All of the experimental study populations
~·Tere
administered the
evaluation on a pre-post basis and two groups were fe:'!llowed for an
extend~d
t'i-r<:. month period.
These groupe;
't~ere
administered the eval-
The diabetic control population
atl.on once upor. . discharge from
tiK~
"17as administe:::~d
hospital, and
<.t
the same evaht..,
second time one
ono week period.
Testing was done in the clas;;:room environment f1:,r all experi ..
menta! groups and was also conducted in the hm:r-2 by the
t~<o
groups
cont~i.~ol group. was condueted in the hospital envlronment prier c·~
discharge, and also '\7aS co:'"l.ducted in the home for post test t·esults.
Assessment of both non .. diabetic groups t;as limited to the home env.t ...
rt."~nment..
All p::-e and post test item.c; '\·lere randomized.
All demog1·aphic
d~:lta ~ras
collected by use of a "Dlabetic Infer ...
Ir.ation Sheet" designed by the author (Appendix B).
'~as
This instrunk::.:nt.
administered to each study participant along lolith the pre test,.
Actual collection of data was facilitat:ed by members of the
teaching team for both the experimental and control
diabetic populations ware tested by the author.
mental study groups and
hom~
populations~
Non-
The extended experi ...
evaluation of the diabetic control group
was conducted by the author by mal 1 (Appendix C).
Data relating to specific areas of patient weakness in reference
to lnstrvctlonal content
This data
lriaS
was kept for each experimE:ntal
population~
collected by developing a frequency distribution for all
missed items on pre and post evaluations.
categorized as illustrated in table
s~o.
These i terr.s were previously
r~·-·-.
· · - - -· .
CONTENT AREAS ...... PRE ... POST EVALt.1.l\.TION
!
I
I
{1.)
General lnfm:r:-.ation
(2)
Diet
(3)
Insulin, Oral Drugs and Testing
(4)
Reactions
No data was collectC!d relating to clinical symptomo!ogy or
patient ter.avior. mod:l.fication in the out; ... patient study.
mental populations
'~>tho
All other
dropped out of the prograr.J, size of .specific
study groups, and length of
t1m~~
patients h.-··we been diagnosed uia.bed.c
(not used in study results due to too little data).
InMpatient diabetes instruction G.t Northridge ls generally a
product of nursing interaction with patients.
The actual structur:e of
the program is similar in content to that of the out-patient component,
but instruction is less formal.
Diet instruction is taught as a
separate unit by a registered dietician, but the balance of instruction is presented by staff nurses, and is subject to variables such as
patient
census~
floor assignn:l(mts, nu.t'sing staffing patterns, patientsi
severity of illness, nurse's knowledge about diabetes, nursing knO\vl""
edge of and ability to perform teaching skills, and priority given to
patient education by nursing personnel.
vening
variables~
Notwithstanding these inter..
cost of actual instruction is a primary deterrent to
structured in"hospital patient education.
The current in-patient component does not evaluate specific
24
-.··-·
pat!e.nts
~:ho rf~ceive
-~ ·~·"·"·' ..-.--~-
..
-·p-··-----·~·-~···, ~- -'-~-~-~-·-
.. .,
!
instruction have benefitted frfJw th>? effort
expenrlf.lc In providing the service maybe a fe.uH:y ll.SSumption,
th"" relevance of in..,hospi tal instruction.,.
The componGn.ts :;:of th•?Se
!nstructiona.l meth()ds used ln teaching ths patient.
whethe~:-
behind these st;..:dies was to identify
t<r,;eching actually
xnaint~in
heliJ~>
The rr.a.in p1.trpose
exjsting in .. hospit.nl
the patient raise his knowledge J.evel an.d
greater disease stability, and if more
effect:iY(~
and less
expensiv"::> means of instruction can be employed to meet the sar:1e goaL
l.n.:l'!!.!1 ClJ!...2!llib:_Qes i gn
~=- A~~~~E2.'!l.Jffl t
of Nur.~ ing K~D2~£.1! bo?::!!7.
Diabet~s
Originally t•,;o areas of interest
'<~'ere
to be studied relating to
nursing expertise and diahetes instructiou, but due to the wishes of
the current nursing edministration at Northridget assessment of
nursing knowledge of educational skills was not studied.
Permission
was granted to sar.-;ple the current full-time nursing staff and assess
th~ir
knowledge level in
diab~tes.
The main intention of the author
was to evaluate "instructor 11 expertise in the subject area of diabetes
in an attempt to eliminate lack of knowledge as a possible variable
that may r9tard in-patient learning.
A random sample of 85 full time nurses
from seven hospital units.
were selected for study
The units selected for study
wer~
those
, rr.edical-surgica.l and specialty units normally charged with care of
diabetic patients.
£...-··
edge was issu(:d to aH ,study paJ:-tidpants (Appendix A)u
of distrbut:.io:r:. and collection '-'f
tlK~
on how to \:ldminister the test to theLr
ted full.
l:ions
till~
pl~ced
nursing staff
~!Orkbg
The process
evaluations viaS decided by the
subo:~:·ctins t$S:)
in these units.
and enough coples
The only n:?St.Tic•<
on the staff were that only full tinie, non .. flOElt ;:>erson ..
ncl shoulo be tested;
the evaluation should be completed
hol]l of rmtside resources;
·;.ri.
Uv:n..tt th€
anJ that eoch evaluativn must be identl=
fiiE!d by giving the? nurses' title (RN, LVN, Aidet Orderly) and tho:ir
unit (medical-surgical, or specialty unit such as
i tat:l.on, ICU, or CCU).
Pediatrics~ R£.?hab.il~
All evaluations were to b~? completed ttnd
returned to the author by the date indicato;;d on th() inst::cuction she:.et
(Appendix D).
Nursing results were to be compared to similar results collected
from diabetic-: and non-diabetic groups.
The purpose of such
r:!
co:mpari··
son would be to identify nursing level of expertise in comparison to
that of non ... medical groups and diabetics.
A freqtJency distribution of missed i terns vms kept of the nurses
tested f.;:•r the purpose of este.blishing baseline c::.-i teria for future
inservice education of nursing personnel on diabetes.
Literature research in the area of diabetes instruction and
theories of learning inspired the author to implement a study whereby
existing in-patient instructional methodology can be assessed and
-~:.-...-~--~-·~ ~-
,__v_,_ Ji
.
~~~-~;\~:~:·· ~~···Stl::~.~:p,~r~;,R·I·~·~··· ;~Jr~---~~- ··~n:·~-~-~~-~-~~~~~- ~··;~~,~:;;~~····:~~-:,~,~····1
J sea:::·chers
{Friesen;; 1973), the use of programmed instruction &s
I
I supplementary
J
! helpful$
H
resource for shot t term 1E:arning si tuatio:n;~ is very
especially in areas ~~hf)re continued reinforcemt:nt is 11~~~~ded
'to attain higher dr::grees of rec.:1ll.
A pilot study was designed by the
• ment of
e~<isting
cuthor~•
·that included assess ...
instructional methods by comparing in-path:nt dia ...
bedc popl:tlaticns receiving conventional ins-truction with those
receiving supph'li'fcn.tal reinforcem<.::nt th!('ugh use of progr&mmcd
in.str·uction.
·The study h.'ls not bef-'!n completed in its totality I> but is
included in this narrative t:o emphasize current activitieso
In-patient education generally begins \d th the diagnosis of the
disease which very frequently occurs ld thin a hO!'jpi tal s i
tu~tion.
'l'tH<J
discover·y of the disease process hits the pa.ti!:<nt ,;rith a tremendous
impact and knmdedge about the disease can be both reassuring and
helpful in coping with the life changes
successfully manage the illness.
~Yhich
must occur i f he is to
Considering the interference factors
presented by the patient's emotional reaction as well as those pro-
vided by the t:eaching•learning e:nvironment of the hospital, one can
· assume that neither the internal conditions of the learner nor the
external conditions of learning are optimal for adequate learning to
occur.
The teaching team noted that most in-house diabetic instruction
*Original design suggested by Mary Lou ~larkovich, RN, currently
'1-lorking as a volunteer in the area of mental health at Northridge Hospital.,
.,
")"}
r-··---~-
...- ............ .
I
!occar·tS'
i
i 11.
t~e
patient's room, using conventional teaching
of !:Hsc~.m:;;ion cmd re<!<rling Hli:tterials.,
strate~les
Instruction is froqu(mti.y inter•'"
i
i
!t rvpt12.rl
by
hospi taJ r-outine and this ws:cessl tat.;s tbe.t the patfen.t read
-...
Although this
lir~thod
d: lea.r:nin.g is not questioned by the euthor, in
rr. o::; t .situations, the patient frequently 1rdsse:s ! mpor t::m.t
H'ltl t:er la l ~
ment., Ltll of which .seem to be necessary for learning with a higi1
degree of rec&ll tc occur.
In addition to the above factors, the learning which needs to
· occvr involves a great degree oi' discrimination, and is Jnost: often.
totally neH for the
patient~
Com::.idering all these
difficult: to see ut,y the patimlt
tion and
S£;'2:ms
wh~)
factor·s~
it h; not
has been able to repeat .infc::-·n;.:1 ..
to have le;;.T.ned it, is u:1atle to recall it, Etnd there ..
fore utHize it after leaving the hcspi taL
In addition tc· this w.::
.<nust add the re<>listic tin;e limit lmpozed on the learner and tn.struc ..
tor.
It
l~"Ot\ld
therefore seem that supplementing a conventional
teaching program with programmed instruction won1d facilitate a
greater degree of
learning~
provide a more adequate knowledge base,
and because of the knowledge bo.se, would enable the patient to better
manage his illness after discharge.
O_Eer~tional
Definitions
Conventional teaching indicates an instructional program which
utilizes
lecture~
discussion, literature, and charts.
Content will
include basic physiology, diet n:.anage:ment, use of insulin and oral
drugs, exercise, diabetic coma, insulin reaction, prevention of comIL.......,__, __
,•L-.•----··•- -----·-·-------<~-"~~-·---···~··•·-----·•~·-•• -~--~· •~••••--•-
-•••
0 -·~----""_, __ -~•·-·-•·--·--···~-··•••-··-----~m•-ne ~--
··-~~·
•-··~~ ~•·~~-· ~~-
•' _,.,,.,,_
-~~·~'-'
...
,
~•
·-•
.,-·h•~···••
----"
,~
.. ~., ,,_
.-.-.-.-• ,.
~-
~·•••••
~-
,., , "' .
~
.... ·•-·, ,,.
•"-~- ·-~_,,
•··-••- ,,,. .......... ~~u-~
"•-•JY~ <,•
~'•-~·---~-• ,_..,~,.-
~~···~~~·
•~
'"""" ~·
~t
I
'
inf;;~ct.:ion,.
and
L--··
! follo>-7
the trct:ltment regl:me as ev:i.d~;;ru~~?d byz
(1) kc:8ping clinic
• ~1prointxw:mts for· routine checks!> (2) r-elativ€<'-Y stable levels of blood
sugar at .;;! inlc appointments,
en
use
(>f
u;edicaticm as
pn~scrihed,
(£,) ;;;:onsistency in urine test:ir,g, ;,mcl (:-,) no oc-:::urr.;;nce of cmr:pHce, ...
t:i.c•.ns such as lnsvlin
pre end post
reaction~ <.H~bt.,.,tic
instr~ctional
cor:io::i, or jnf!C!ction.
test~
The instructional pe;:riod tvi 11 be Umi ted to a 4 day span sjnce
this most closely represents the usual lce.ngth of' hospi L.:d stay after
diagnostic W\.;rk has been completi2rl..
c;.H::h day during the afternoon.
Formal
in~t·ruction ~dJ.I
br: given
Afternoc:·l is chosen because it
. not interfere with doctor visits, visiting hours., and less so
dOBS
\.;i
th
hospital routine end schedolese
Problem Sta ternET\t~
Does the method of instruction affect
'
.
"
.~;.earnlng~
Hypothesis to be Testr.:d:
Diabetic pat.::icnts receiving both
conventional P.~nd programmed instruction will score higher on postinstructional tests than will those
receiving only conventional teaching.
The hypothesis will be tested on two groups of patients, each
having the same nurse instructor.
Since the method of Instruction is
being tested, it is necessary to keep as rr:any extraneous variables
possible, and using the same i.nstructor will at least
,
....
··-·-· ···" ······················"
.•.. ···•··· ........................,
......................................................................._""'·--· -·-····--.--·--·-·'"" ...... ..
!
1 eUmlnat;t; thw individual instructor differences which could affect the
!
!1 ..,."'f-... udy
i ...~s' ..
,_.~ esu .•
Table 6.,0 is a diogramatic repx-esentation of the
!
I
The content presented to each group vJ'lll be cont{lS"'
) research design
..
.
l
i
! tent so that the only instructional differences
programmed instruction for the
e~.cperimental
l\1 il1
group..
be ·that of the
Both g:r·,>ups tr.cn
'ilave €·qual opportuni·ty to learn, but the experimental group
fiC\S
· greater opportunity to increase learning and recall by increased rnn::"'
feedback~
tice,
and reinforcement, the
.:~xternal
conditions 't-lhich havi:>
been ic:entified as necessary to learnir.g and p<lrtJeulad.y import.:1nt
to discrimination
learning~
D!AGRA:i'-l OF PROPOSED
Study
IN~PATIENT
Independent
RESEARCH DESIGN
D.ependent
.J:~~~!lsm.§.______ _vaJ.: iab 1£.~·---,----~±.2-·-----~·
Ex peri n;en ta 1
CnnV0t1tional tea.ching
and programmed ins true ..
tion
Greater degree of. learning
(higher post test scor.~s)
Control
Conventional teaching
Lesser degree of lear·ning
(lor·rt?r post test scores)
--------------------------·-------The subjects chosen for participation in the study wi 11 be sel-:;>c··
ted from hospi talizod adult patients with newly ciagnosed diabetes
mellitus.,
Any such .i-Ja.tiBnt between the ages of 20 and 50 and without
any knoh'l:l he;arrdng dL<i?.bi 1i ties or language problems wi 11 be pre"'
tested fct· inclusion in the study.
Any patient who scores over 60%
en the pre-test will not be considered for the sample to be studied.
This arbitrary restriction is placed because higher test scores imply
prevlotts learning
.,~·hich
cou1d throw off the study results.
At this time i.t ls not felt by the autho:;;:· that sexual, cu1t:ural
cultural
difference~
cr marital status variables 't?U.l seriously con ...
found the study, t:nd these extraneous variables will
controlled.,
!
tt:~refore
Educa t.icn. level also .inf 1uences abiU ty to learn, so the
assignment of subjects to control or exper1rrl{;!nta1 groups
en
a raPdom
not be
basis in the hope thi.'l.t this::. as
·~,~ell
~.vill b·~
done
as the effects of
other extraneous variables, \d 11 be 0qually <.! istri'.buted between the
two
each
groups~
The total sam?le size will be jC,
~Jth
25 subjects in
group~
All teaching and testing 't.Ylll be done in a classroom setting.
For the experimental group, the use of. the programuied instruction -,;,•.ill
take place within the patient's hospital t'Oom.
§~guence
of
Data
Co!l££!i2n
All patients will be pre-tested before inclusion in the study3
They wi 11 then experience the instructional prograln, and on completion
of the fourth day of instruction, ,;'fi 11 be given the same randomize:;;
post .. test.,
A second instrument used in data collection wi 11 be com..
pleted one month after discharge from the hospital.
pa t~_f£1l.ection
Instruments
There will be two data collection instruments utilized in measuring the dependent variables (table 6.0).
A paper and pencil test
r.as been devised to measure both the entering behavior and the
of learning attained.
degr~e
This instrument can be found in the appendix
of this paper (Appendix A).
The test is composed of 40 multiple
31
r .......... ---·--·}
.............. - ......... - ...............................
~
lchoice quOJ?st:ionr:~
..--..-......... --------.......- ...........................------..·--··---------......................... .._"' ..
!~eliability for the- test will bfJ establish~.?.d ort ,,
!test ... retN;t ba:;Jr:: during
!t
!
pre .. test of the instrument and prlor
t~'
2 t:s
juse in thE; actua:! study.
!l
The second
".. ill be used to
instrument~
li'lea~ure
also found in the appemHx (Appendix E),
the patient's ability to manage hh; illness
as evidenced by his attendance <':t each scheduled appointment, consis ...
ttency of urine testing as indicated by a self kept
record~ Bt<~bility
of blood sugar lP-vels recorded at each apf!ointme:nt, frequency cf
repcrted insulin re:.;cti')a, tmd frsquency of infection.
~etf
The V<:11idlty
for this instrument is based on content valirli ty in that a
surv<~Y
of
the 1i tere.ture :teveals that these factors indi•::atE: degree of control
of the disease.
The study by Stone also reveals theS(l f.actor.s to be
related to the knowledge of the individual about his disease and its
managem~nt.,
and therefor"',.
!;Orne
construct valid:i ty could be clairned.
Again, the reliability of this instrument will be
test .. retest procedure to be
the studyo
conduct~?d
establi~hed
by a
before use c.£ the instrument in
It must be noted that even \-l.ith the assumed t:laims of
validity and reliability, the instrument has
S.t"~me
degrE;e of limitation,
since it asks for self reported data in four areas and wJst therefore
rely ultim<:!telv on the
hon~sty
of the patient.,
As outlined previously, the intervention or independent variable
to be introduced is the addition of programmed instruction to the
present instructional program.
This program will be consistent in
content and sequencing with the conventional program, and wi H be of
.an adjunct type (FJ:"iesen, 1973), to hopefully increase discrlmination
-------~----·----~- ...·--· ___________ __]
r··~-----------·
·-· ···-·· ... __..._... _______... -... --..--.
I
j learning and
I
!ing
be<~aus~
recalL
.............. ·--- --·- . --·-···---·--·-··- .... --········· ------ ·----·----·-'-···-------·-;
'I'he prograrcc!lf:d instruction should enrumcc learn ..
of the type of learning rcqt;ired ancl because 1 t
i
!a good deal of guid~d repetition and reinforcement.,
allo~.;rs
for
Actual usc of th~
!
px-ogrammed instruction would be encou:ragcd for at le<'<St a one hom:·
·period daily, .ru:;d a record of actual tim<2 spent i.n using the prog;:-mn
Impl.:oFrentation of the pi lot study began with
control grct\p.
It Has decided that: due to
prograrr:IT.et.:l i.nstructi-on .~1
pts.ckagc~
trK~
tf.;:~:>Li.ng
of the
lc.;ck of an appropriate
at ttte begi11rr.ing of pr(Jgraxu inlpleinen.-
tation, the author, w·ith thE: help of the teach:i.ng
team~
should dev\?:!lop
an appropr.iette l:tst>:uctio:n£:ll packag.: based on the Northridge content
outline.
This package :ls currently under development and wi 11 be
implemented as soon as it is refined$
r ___,.___ " _______________ ------------- ----
---~-
"'-----
j
'
CH:.\PTER VI
STUDY RESULTS
T\m s2parate studies \oJerP
undertak~.~n
by the teaching team at
Northridge Hospital in an attempt to eva!:uete the current diabetic
education program.
As outlined in the previous chapters 1 a study
-design involving diabetics who attended the
ol.l~:El:l.:~.!-~rt.t
educatio:t
prog1·am was implemented in an attempt to gather data relating to
th>~
(
effectiveness of the program as demonstrated by increase lin patient
knov7ledge about diabetes.
A second study involved the evaluatl:;n of
the existing in-padsat program and was designed to test
in educational merhods used for in-patient education.
dlff~·rf?nces
Both studies
were concerned with defining existing program effectiveness and
collecting
d;~ta
whereby appropriate modificatio-.:ts coule be made to
offer the diabetic patient an educational program that meets his needs.
~:Patient
Study Results
r;xperimental and control diabetic population samples used in the
outwpatient
~tudy
were selected by a re1ndom process.
Data was collec-
ted in reference to sex, age and educational characteristics to deterM
mine if these populations
~ould
be ger•erally described as representa-
tive samples of the diabetic population who use the facilities of
; Northridge Hospital.
I
Tables
7~0~7.3
represent a brief demographic
groups included in the out-patient study.
33
..... ...........
··--·······--·- ............. __ ..... .. ·------·-••-'• .......... ~----- -- ----····------------~---------------"--· ~-~
,_.
SEX DISTRI?..iJTION WITHIN OUT··PA'f!EN'J' STlJDY POPULATIONS
TABLE 7.0
E}~perimental
Diab;;-::1 ~
52.2%
36
Groups . (N:::-:69)
33
· Control Die.betic
. Group
13
1.2
(N::::25)
i Non~Diabet:ic
Grouos
_ _ _ _ _.,]].~-----45.8%
(N""48)
---~-~
1'able 7 .o i Uustrates the distTibution of sexes ld thin the cii,c.h-<-: ...
tic experimental and control groups, a.nd the non-diabetlc study
lation.
Results of this
revie~v
indicntes that there was nearly
sex distribution "7 ithin all study populations.
~Klptl~
~~
50";f;
The study distribution
is belc'i-7 that 'tvhich nort118.lly is reported tor state and national stat.istics
(52%-60~~
male),* but the size of the sa.Mple, location of the
study., and a variety of other intervening variables may restrict tniB
randomization of patients.
It is also f'OSsible that these statistics
might not correspond to national figures due to differ.ences in sampHng techniques, and localized population cha:>.:acteristicse
Table
7~1
illustrates an age distribution by sex for the same
three study populations.
Data collected in reference to group
~ge
distributf.on finds similar statistics exhibited by all th:t"ee groups.
In all instances male representatives
~lere
older than female represenM
tatives, and in the diabetic populations this range was from.four to
Association of Southern California
l
- ·---«~-~~"'-• --· -·• --·· -· ·•• ••• ~•----, •·•-·•·-.··~-~~
r---<··-·-•-•••••-•••••••
1
six
!
CE1nt •
-~·~••"•··•·"·
,.,.,., -~~-~-----~~~
~~
-•• ·n•-• •
''
,,·-~-
-->
-Noo~~~ -~~
• "·'"'
~
1
i
··-H~~-··---~--~-~-
<
years~
I'
!
TABU:: 7 .1
_______Group____
--
AGE DISTRIBUTIONS BY SEX WITHIN
OUT~PATH:tH STUDY POl)UlATIONS
Noan Age
Hean Age
!vlal.;,s
Females
Tota 1 fJe.:m.
th{~
---------------·-----------·-·---·--·-~-";;,·-~----·~
Experimental Diabetic
Groups (N=69)
49
43
Control Diabetic
Group (N~:25)
55
51
Non-Diabetic
Gr<.;ups (N:::!J,.8.)
43
42
43
----------·---------------Total
(N::::l42)
Not
TABLE 7.2
Siq,nificant
AND SEX DISTRIBUTION OF cu:· ...
PATIENT EXPF.R U!ENTAL POPUL\ TIONS AND NON~·STUDY
DIABETIC POPULATION
CONPAR ISON 0F AGE:
*Consists of all diabetic groups who attended the out-patient program
over a twelve month period, but were not included in the study.
(ll~ groups)
**Consists of the four study populations used who attended the out•
within the same twelve month period.
i
patient program
L______ --- --·--- ---··-· ··--·- ··-··----- -------
.
imental diab-etic population
~nd
the populati,o:"i of rliabetics from 'Hhich
the experimental sample was extracted (non .. study :population) ..
Review of the data compiled regarding the two population:~ lndicates that bc1th age and sex characteristics for both groups are shii.w
lar in nnture 7 tmd both populations exhibit a t>vo
male
n~jority.,
ThesG figu::.·cs closely
'IABIE 7. 3
LENGTH
Ai'~D
OU'L'~PATI.St•:T
corr.elat~::!
tG
five p•ar r:•:mt
lvith national ratGS.,
TYPE OF ZDUCA TI00l '~ITHHl
STUDY PCPUIATH:t\S
Nean Years
of Education
?v1ode
'"I"~.,rpe
of
Educati()n
Experimental Diabetic
Population (N=59)
Grade 13
Control Diabetic
Population (N=25)
Grade 1.2
High S:hool
Non-Diabetic
Population (N := (;.8)
Grade 12
High Scho:<t
Grade 12
Hi_g_!!. School
Table 7,.3 illustra.tes a comparison of length and typ,e of formal
education of study participants.
All three study groups depict: simi-
lar formal educational preparation with all study groups experiencing
at least a high school education.
Collection of demographic data on a.ll .study populations allo¥7ed
the team to identify specific population characteristics.
Statistical
testing indicates no significant differences between study antl nonoo
study populations, and it was concluded that the diabetic experimental
populeition base:i en the deta collected.
This data is nc.t conclusive
due t0 lack of: screercing of socio .. economic variabl0s such as lncwn:c!s
religion~
place of residence, race, family siz:?, and
but pr01iminary study provides
medic~;.).
hh:;tcryl'
a fo•;:ndation upon l•rhich mol:·s ir.tt:nsi·;,·.::
, study of demography can be done.,
ThcJ results of this study allov7S the author to
r<~Gults
that study
ass;:lm>:l
are not confounded by significant differencf:s in grcup Bdv.c.r'-
The out-p<:itient study design primarily consisted of analysis of
pre and post examination scores on a randomized knowledge
test~
NEAN NUNBER OF CORRECT ITE!vlS F'fjR OUT ..
TABLE 8.0
PATIENT EXPERH1ENTAL GROUP PRE TESTS
.
Group
_.,_..,_....,_,
__
N
""
XT
at
'"
1n
20
25.8
64.5%
Experimenta 1 Group #2
20
24el
60.3i~
Experimental Group ;\t3
14
27 ,.0
67.5%
Experimental Group it4
15
26.!;.
66.0%
69
25.8_
64. 5~.(,
Experimer.tal Group
-.....!2!al
F::::.-. 78•
- ,__ df=3,6);
Tables 8.0 and 8.1
P1'. OS
illustrat~
Not.~ficant
variance in experimental group
test results on both pre and post evaluations.
Analysis of data
suggests that all four experimental groups scored consistently close
to one anoth?r in. both pre and post evaluations.
Statistical testing
TABLE 8,.1
r1F~N HUi>iBER OF CORRECT ITEHS FOf~ OUTPATIENT CXPERIHENTAL GROUP POST TESTS
Grot~-----
13
36,4
91.0%
15
36.1
90.31,
Experimental f.roup #3
14
34.8
87 uO/~.
Experimer.tal Group ;If!•
8
35.0
87. S'i~
Experimental Group #1
---------··-----_ Total
______- 2 £ ___.____....;;3~5..:!.,;:,6_ _ __
Table 9.,0 compares the mean scorils of the out-patient experin!f;n~
tai group on pre and post 8Valuwtions.,
Results of this study ind:ic.ate
that s ignifi can<: differences were recorded by experimenta 1 populz;. tio::u:;
when comparing pre test scores with post test results.
This suggests
that the instructional program did afffoct levels of patient knowledge
about diabetes.
The diabetic groups that attended the educational sessions we:re
identified as experimental diabetic populations.
The diabetic group
that did not receive .any health instruction,beyond that which they
might normally pick up through daily contacts "'71th their environment,
was id£,ntified as a control population.
Comparison of the total group
mean score of all four experimental populations was lMde with the
diabetic control group to determine if those diabetics who attended
the educational sessions scored significantly higher on
th(.~ir
post
f-'--·---~·---·~~-~~
.......
~- ~-~~-~-~·'-~-~~
-~·.~
·-·-A~-·---~~,-~~-
.. ---~-~···'"~~-~·-··-,_~-.
~·-~-~
0•
---·-·-~,_,_
• ._.-•• _....... ~~-~--~~-......-.--~~-........-.. --u·N-•"' •O ••
-~--
.. ·~
~·.
0 -~---
1
!·&x::·unina tio:rw than the ;,;ontrol populationu
i
l!
CONPARISON OF HEAN NUM'liER OF CORRECT
!TENS ON Olrf-.PATitNT EXPERH·lE:NTAL
GROUP PRE AND .POST TESTS
TABLE 9.0
25.8
. Pre Test (N=69)
Post Test (N=50)
TABLE 10.0
SB,9%
35.6
f.-lEAN NU::1BER OF ~ORRECT ITEHS FOR OUT .. PATENT
EXPERUJENTAL AND CONTROL POST TESTS
Groun
Post Test XT
%
-~-~~------------·--------------~~~~~~~--------------~
Expe:rimental Diabetic
35.6
89%
26.0
65%
(N::50)
:control Diabetic
(N=25)
------------------------------------------------------------------------Total
Table lOvO illustrates-the results of a comparison of group mean
post test scores for experimental and control diabetic populations.
Statistical analysis of test scores indicate that significant differences exist between the
t'Vm
groups;
which further indicates that
persons who participate in the instructional program increased their
• knowledge level significantly greater than those persons who'do not
j
: receive instructif.?n.
L~(i
r-·-----..
-·---~·-·---
......,... ---- ............ -
-~.-
... ------·-·----- .......................................
--------"--·--~
I
·
I
I
TAfiU~ 11.0
..-- ·----------···------ .. -------..
.
-
------··-·--~
·
I
I
!•JEAN NUloiBER OF CORRECT ITENS FOR
'
OUT .. PATlENT EXPER Dif.N".CAL AND NCNw•
DIABETIC GRCUP PC:ST TESTS
Experim~ntal
Diabetic
35.,6
(N:=50)
Notl;;t,Diabt?.ti c
58.5%
I<:>')
( ''1
h~u.. o
D<.)ta collected r.elatlng to non-diabetic testing also strengthens
the assumptlon that the instructional progr&m positively affects
patient
kno~.;rledge'>
expf~rimenta1
for comparison of non-diabetic post scores with
group scores {table 11.,0) show significant diffe:cences
in group knowledge levels as exhlbited by higher experimental group
post test scor<:Se
the author
b~tes
tr:r~.de
Based on comparison of study group post evaluations,
the assumption that those persens who received dia"'
instruction significantly raised their knowledge level above
those who
r.e~eived
no health instruction.
This assumption is also
supported by comparing group cumulative pre test scores as illustrated
in table 124 o.
This coiDp<:n:·:lson of study group pre test scores indi""
cates that study groups did not differ significantly in their knowledge level prior to any planned health instruction.
From this data
one might suggest that out-patient :instructi,on does affect the
patient's level of knowledge.
Further study o.f two diabetic experimental groups was initiated
for the purpose of evaluating group retention of instructional
r·-·~- ·-~ ~
I
1
I
-·"·------- · - ·-· · · ---·· --· ·-· --··· --.. ,. · · · · · · · . . . · -· . . . . -·· · · - . . . . -.. ---·-· . . . . . . . .
~_
f';ontent ~
·-~----·-·---·-··
.
--..·----..-.. . . .l
The groups w-::re retested at one :month intervals for .a
!
ttl??
I
mor1 th
period.
TABLF: 12.0
HEAN NUf.'illER OF CORRECT ITENS FOR ALL
OUT.. PATIENT STUDY GROUP PRE TESTS
Experimental Diabetic
(N::69)
25.7
64.,3%
Control Diabetic
24.6
(N=25)
N<'n-Di.abetic
22.6
(N:;;48)
--~--------·--------------------------
TABLE 13.0
Group
Ex peri men ta.l
Group 112 (N=20)
Ex peri n:<en ta 1
, Group #3 (N=l4)
Post
Test #1
·----~---
CO}JPA!USON OF l'T:.AN NUi,illER OF CORRECT
ITEt-"5 ON FOLLO\.J .. UP POST TfS.tS FOR T\W
EXTENDED EXPER HJENTAL DIABETIC. POPUlATIONS
%
Post
}'est {ft2
%
Post
Test #3
%
36.1
90.3%
36.3
90"8%
35.3
88.,3%
34.8
89.0%
35.8
89.5%
34.3
85.0%
T.;;.o..;;t;.;;;;a;.;;l'--_.(.,;;.N;...~..;;3;...4:...~.2'---....;3;;..;·5;..;~~6;___8_~_
.. _0_%_ _ _
3,g.• l
---------=t;....=-=.1~·7;...;1;;_;~..._..;;;ci.=.f=-.::.17:......._ _:.t=...::•.98;
Pi'.OS
Not Significant
9~0~·~3~%____]4.~9--~8~7~·~3~%~
d f=8
P')., 05
Not Significant
t=1.32; _,df=l7
P).OS
Not Significant
Table 13.,0 illus:trates test !:('!Sttlt:s fol"' thE-: extendetJ
perlode
t¥70
xronth
Statistical analysis of post test scores indicate that both
groups retained 9ti% of the pertinent information imparted during the
instructional program as determined by scort•s obtained from thE; ext~nded
post test:. and no significant differences bctl<een group r(!sult8
ware observ6d.
Evaluation of
the teaching t«)am.
evaluate areas of
least have
outline<
mis~ed
test respon!;;es lvas an area of concern tor
It was felt that if an instrument
con~~nt
~..ras
strengths and weaknesses, the team would at
sop1e baseline data to use when evaluating the
Tables 14.0 and
avai lab]s to
14~1
instructional
gave reference to areas of instruction-
al cont\'mt: and the corresJ)onding rate of missed responses by per cent
on both pre and post test situations for the out-patient experimental
study gro:.tps ·~
TAULE 14.0
PERCENT D IS'~1:1UBUT!ON OF PRE TEST
MISSED RESPOt~SES BY CONTENT AHEA
FOR EXPERINENT.AL STUDY G.t{OUPS 1-4
Study
Group
2
Study
Group
3
Study
Group
4
(N=20)
(N~l4)
(N"=lS)
9.8%
8.1%
7. 7i~
7.8%
8.6'1.
Diet
31. 0/~
31 .. 91,,
25.1%
2.5. 0'1~
28.9%
Insulin, Oral
Drugs and Testing
30.2%
30.4%
33.3~(,
33.4%
31.5%
Reactions
29.0%
29.,6%
33.9%
33.8%
31.,0%
Total
100%
100%
100%
100%
100/~
Content
Area
Study
Group
_ _.....L.,
(N=20
General
Information
Per Cent
Missed
(9U!i1UlaJj~) -
--
, ...
,t,~..}
L.l\BLE 14.1
PERCENT DISTRIBUTION OF POST TEST
MISSED RESPONSES BY CONTENT ARF.A
FOR EXPERIHENTAL STUDY GROUPS 1-l:.
Study
Study
Study
Study
Per Cent
Corttent
Group
Group
Group
Group
tHssed
.Area
,
__________
1
_
_2___._-'3;..,_,
_
_
4,
___
(cumula_t.i'{;;iL
,_
General
Information
(N=l2)
(N:;-::13)
2,.6%
7,.7%
Diet
Insulin, ura 1
Drugs and Testing
(N=l6)
(N=8)
5.3%
7.2%
11.6%
33M3%
37 c2%
42.1%
43. 5~{.
Reactions
-----------~-----------~,-----------------------
100%
Total
1 oo/._{,___1oo~_. ____Jj.)_o_~-~_____l_o_o...,;..,%_
General comparison of the
differencc~s
in group percet'\tages
indicate that questions most frequently missed deal with contf::nt
relating to the administration of
Comparison of post test results
insulin~
-.;~ith
oral drugs and
testing~
pre test d,istributions
~:<HH1
to
indicate that there is a gradual reduction of missed responses in the
area of diet control.
This is only a brief comparison st:udyo
The
author does not feel that the information here is of the validity to
make concrete stateme;.-itS about content in the program.
But, if one
looks at the minimal degree of variance between content areas as
illustrated in the data, it is possible that this
inforn~tion. m."ly lH~
reliable and can be used as a basis for future study.
L.·-·------·--·~-·-··-- -·-------·- '·-·--·· ··- ---- -··----......________ -----'----------··---------.....------·-·-..-· .... --··- -- -'" --~-··-·-· --·--·--·--'"______]
•"•••••
~-~•<c<O" -····~
·-·~-V~
<'
~---~--~-·-•..V•·~---~·.
-.-~
_, ___
..,,~~~
-~~-·~~-~-~ --~--~"·~,>.~•-•
.......
~"H>V_
j
....
!
TABLE 15.0
RATE OF DIAbETIC DROP~OUT FRO!.,!
EXPERIHt:NTAL GROUPS
OUT~FATIE!·lT
Number
.
Crou n
--~----
Number
___. ___l'_r:.tt..~If.S~ __ _____Eos t
·--
T(:.~~
Ra t(l oi'
ted ----~2-f:ftO~.!.
Ex per i me:-t ta 1 Group ifl
20
13
35.0%
Experimental Group #2
20
15
25o0%
Expe:l:"imental Group #3
14
14
oo.m~
Ex peri menta 1 Group f/-4
15
8
t1.6 ~ 7%
-·-------..r--..-..
50 _________lL._'}Z.-____
6<)
_____Iota.L,_~·---
- - - - -..·~•'60•
~-----~·
'ie1bl2 15.0 diagrammatically displays a bd.ef analysis of t:hc rate
of drop-out by diabetic patients from the out-patient diab(c·tlc progr.:un.
The au tho::- discovered a. 27.
c:xper.imental test
groups~
'5-;~ circ-p-~out
rate awong diabetics: in. th0
It is possible that this rate rr..:'1Y
.n·:~flect
a situational problem in the sense that the patient may not be able to
cope with the idea of sharing the informatJon that he or she is a
diabetic.
It is suggested that a
of dropmot.:ts to
St?e
clo~er
look be taken at this group
why they do not continue in the programo
It is
felt by the author that a variety of variables may be at the root of
this proble:m D.nd to make assumptions at this point \.Ji thout further
study would be pointlE:ss.
T"ro other areas of inter-est in the out-patient study include
methods used to collect data and the evaluation of the test instrument.
As mentioned in an earlier chapter, two methods of data colle'ction
were used in _following the study groups.
L____________ ·-·---· ·-----····-··----....:.. _.........______ --··- ______:. . ·--·- -·---- -- -- ·-
Follo'f..r-up on the two out-
r..
"--~---~--~---
. . .·---- - - - - - -·- - . . . .
~---------
·- · ·- - - - - -·- -·- - -·- - - - . . - - . . . - :- · · - "·- ·- · - - - - - ·- - - - ------·----·----- --··-------l
---~
patient diabEtic experimental groHps- that w-;;:;:e given the rerandomiz<1d
post test for ;;m
scon~s,
in test
~xtended
two month period indicated eoFw: difference
depending upon lihere the examination was c:)mpleted$
'
''
, F~xpe:dn;-.::mte.l groups two and three were each rPailed copies of the poBt
·. test wl th a letter of intr-oducU.on (Appendix E), and instruct5 on::; f:or.
completing the
evaluation~
Table 16 .. 0 illustrates the speciO,c groups
that "'ere instructed to complete the test by· return maiL
It can be
obs<'::rved that on the first month evaluation,. both groups scnr.;o,d higher
th~
i.n their t:or.:-e {-mvironnltento> than \i'hen t:he:y \·le:ce tested
at
th~
Aeconcl rnonth
hospital, but this difference was not statistically significant.
TABl.E 16.0
Cot--:PA~ISON
OF EXTENDED OUT-PATIENT
POST TEST .RESULTS BY TEST ENVIROI-·H·lENT
Home
GrO}lE.
~--~-----_j£~.!.2~-·-·,!_
_
Experimental Group #2
(N:::20)
36~3
90.8%
35.8
89. 5~~
35."3
88.3%
34~3
85.8%
Experimental Group 413
(N=l4)
-
-~-
Total
(N==34)
v2
_::_=..., 002 L
.!Lt=J....i
35.9
P).OS
35.2
89.8%
Not
88,.0%
Signific~nt
The author is not sure why this happenedl'l especially since the
mean scores of both groups "i;vere higher one month following original
instruction.
The only conclusion thut could be made at this time is
that the hospital environment might tend to leave the patient more
nervous, tense-. or unrelaxed than in the home.
These variables are
difficult to measure and should be studied further.
The point of
.-----·--· . · --- -.- - ---...... --·-· . . -- ...,. :-.. . --·------ ------------------------· --------- ------------T
r·----- ····----··------·------'-----------·----·
--~
l tnterest
that bec:ame a concern for the teaching group was the radical
i
i
; tHfferenc~ in return rate' -vrhen the t~Z;St was to be returned by nldil.
i
:Of 29 evaluations
i
s·~nt
out 11 only 11 't-Tere returned for a rate of ret:xcn
· of only 37. 9%.
Evrd.uetion of the test
in~trument
has not been done e.s of yetQ
d•~sign,
But, tho author does feel that with the multiple choice test
all possible st'?h<ctions of a correct ar>.swer ·should be of reasonable
diff !culty;,
tion, a
In each of the 40 questions which makes up th<::
c~:oicc;
of "I Don't Know" is left t:o the student4
~;•vnh!a~·
:t
ic the
opinlon of the author that by taking a test question with four p<)ssible correct answers and J.eavh-lg onE: as an automatic "incorrE,ct
the t(:st
becom~?S
choic~;,"
unreliable b,ased on the idea that with decreaseci
chance to select a 1o1rong
ansuet'~
more students will guess at a
question rather than to admit to hlmself that he doesn't know the
ans,o~e:r.
This type of guessing helps to confound test results, unless
the test is designed with this in mind.
The author
~'as
interested in (::V<."!luating the frequency of
guesses made per evaluation.
possibV~
A Sn'.all random sample of 20 pretests was
taken and results indicated that 71% of all missed responses 1-rere
questions where the student failed to mark the selection, "I Don't
Jr.now".
It is hoped by the au th(Jr that the teaching team wi 11 develop
interest in roodifying the current instrument used for knowledge base
evaluation.
In-Patient Studv Results
Data collected in the in-patient program has been limited to an
evaluation of nursing expertise on diabetes, and the pilot study
~-;:~1~~:-::~,.~~~~:-:;~:.:-~~:::n~~:::l~~~~::.:~::~:~-::~~~.~~-·:0
j
in~house
!
.l
education with e supplemental instructional learning program~
The nursing evaluation was implemer.ted prior to planning for the
J
i pilot study on instructional methods.
Table 17 .,0 outlines the t·tvo
• categories of nurses tested and the mea!1 scores for each group.,
Frcnt
the do). ta it can. be observed that the RN 's knowledge base is svperior
to
th~t
of the nurse aide, which was to be expected.
1~<\BLE
17. 0
>J:AN
!"Wr•~[)2R
IN~PATIENT
CF CORRECT ITE1·:S Or\
NURSING p;vALUA TION
%
RN Group
34.7
86.8%
(N:::3l)
68.5%
NA Group
(N=l7)
~---------------------·----------
_ _ _ _ _ _. .:T;,.,;.o__tal (1<::::48)
_________t=~~97;
32.1
df=46;
80e3%
1'<.05
Table 18.0 illustrates the differences in total nursing performance on the evaluation.
rates of
it~:ms
miss~:d
It can be observed that by looking at the
ln specific areas of content, the professional
staff missed a greater proportion of questions in regard to diet than
did the nurse aides.
This was an interesting observation, for it was
the opinion of the teaching team that this is not an unnatural phenomena in hospitals.
dietician~
Traditionally, diet instruction is handled by the
and therefore nurses do not become as familiar as one would
expect with the area of diet control.
The author thought this a
suppl.em(o:!nt;'~l
worthwhile discovery) and it ·wgs recommended that a
service program be developed for the nursing;
staff~
PER CENT DISTRIBUTION OF NXSSr:D RESPONSES
BY CONTENT. AREA FOI-; NURSING EVALUATION
Total Populati.on Sampled
General Infor:rr.atie>!l.
·------:=~
Diet
Insulin,
Ur~l
38.5%
Drugs, Testing
27.3%
100%
RN Group
General
..
Inforit~ationlt---:~:?
Diet
1
4L5%
1-----
Insulin, Onll. Drugs, Testing 1--~.--=-::J
Reactions._________...]
24.• 4%
25.6%
100%
NA Group
General Information
Diet
Insulin, Oral Drugs, Testing
::::J
r-----·~-----.....1
--,
- ~--------~·-----~--~
Reactionr-: .___ _ _ _ _ _ ___.I
27 .?%
-
28.7%
100%
36.2%
:tn...
Data relatlng to nursing units
'tt7a.s
also collected ir!
' to identify any weak areas among the nursing st~ff.
·of 83 nu:>:"ses Has taken.
and graded~
From this sample
t:~n 8tt~:-:rn.t>t
A total SDirtple
Sl~ evaluatlon~ v~:,:r;;; r·f:h:r:nf.;d
Of the evaluations r'-"tu:::J.H;!d:. .21
(65.1% return rate)
nurses identified their ·work n.rea as a medical-surgical sr.::a ~:md 26
m..tri'H~S
identified themselves as specialty unit ntn·ses;
seven failed to identify themsc-.lve.s C\S instructed.
a brief sununary of
u!\its.
U1.:~
tht;> rerr.ain~ng
TabJ,e 19.0 givef3
differences in mean test scores by th\-;!
As can be observed, there
~•'as
no
significa~1t
t~vo
difference i.n
test results between tested hospital nursing units.,
TABLE 19.0
COf>iPAR ISON OF f.iE:AN NIJNBER OF
CORRECT I TENS ON IN-PATIENT NUR.S ING
EVALUATIONS BY NURSING UNIT
Unit
Medi·cal - Surgical
(N=21)
31.3
78.3%
31 .. 1
77.8%
Specialty (Rehabilitation,
ICU, CCU 1 Pediatrics)
__________________ __
(N:::26)
,.
---·~1~;~--~q~f~=-4~;~--~P~)~·~O~S~--- Not Significant
The implementation of the pilot study comparing
th£~
use of
prograrror:ed instruction to tho existing conventional approach of inpatient education just recently
began~
It is not possible at this
time to ana.lyze data derived from this study, for the experimental
group has not yet been testeda
The implementation of the programmed
5(J
instructional unit is
projc<~ted
June~
for early
and at present has not
Some research into the control diabetic population
.h~s
been dun•?.
and much information has been obtained regarding the present status
of in-hospital diabeticse
EarHer in this narrative th€; auth•::-1·
alluded to the possible weakness In in-patient referrals to the outFurth..:~r
patient program.
research into this area ht1s allowed the
author to :more clearly identj.fy the communication probhnns curr·ently
existing with this referral system.
TABLE 20.0
fREQ'L'ENCY OF DIABETIC HOSPI'1AL ADfHT1ANGE.3
DE.'CENBER 1,. 1973 •• !'lARCH 1~ 1.9i4*
December
-!il-nuau_·
Februar_y_
Primary Diagnosis
10
6
8
24
Secondary Diagnosis
12
7
21
40
13
29
64
--~JQ}OSiS
----
Total
"---·---
----~--------------...--
22
......
Table 20.0 is <• bd.>':f comparison of the number of in-house diabetics ;,•ho
·~;rere
adnlitted to Northridge over the past three months.*
It is interesting to note that the actual
nut~cr
of diabeiics admitted
who we·re diagnosed diabetic by e secondary diagnosis during this peri ..
od was nearly 22 per n:onth.
Of a total 64 diabetics, only 9 patients
were identified as receiving in-hospital diabetes instruction.
is an average of only
ll~%
(Group Nean Pre Test 23.8;
This
Post Test 25,5).
*Report taken from Diagnosis Index, supplied by the Northridge
Hospital Foundation, Nedical Records Department.
51
Aprmr~ntly,
the balanc".:l of the, 86% of the diabetic ptttifm.t!< ,"1dmi tt:ed.
vre1·e either given informal instruct:ion on the nut:·s!'ng flo(.•r ;utd no one
was a\vare of i t: 1 or proper conunurd.cation wl th attending physicians is
not ta!dng placeo
If this is the case, this may b8 the greatest
attributing factor to the low rate of referral and att(mdanct'l of :anpatients to the current out-pl<.tient program.
The at.lthor's discovery of the actual corrununications breakdown
significantly affects the structure of the
in~pathmt
program.,
has recently b(;,en suggested by tlle author that the teaching
1~
te~'m
organize anrl review the problem prior to complete implemeat;.:n::i-:nl of
the in-patient: pi lot s tudyo
The in ... patient pi lot study
l?as
recently implemented and screening
of diabetics for the in-patient control
group~
conventional instruction., has recently begun.
those to receive ovly
Based on the <:U'bi trary
limit of a maximum 60% pre test score to be included in the study
(24 correct ans\>Ters out cf 40 questions), of six in-patients tested,
thr:et:; ''ere included in the sample of 25 to be used as a controle
Planned data analysis for the pilot study will include evaluation
of actual po.st test scores for both groups? and differences between
pre and post test scores will be snbjected to a chi-square analysis
to ascertain significant differences in datae
relating to collection
statistical testing.
or
Analysis of data
clinical information wi 11 also be based on
A proposed approach to this data review is to
record variances in blood sugar levels and other measurable phenomena
and compute an average deviation from a baseline level which·will be
indicated by measured levels recorded on day of hospital discharge,.
'These varionc(JS will be tested for signifi.cance and
pos.s:U):t:~'
cor:n;la""
tional procedures can be applied to det""rndning sigrdt:l;;;;;mce of
:i:'{3lf.l""
tionships bet,<Teen learning and management.
It !.s fully expected that the results of this study will
produc~
data uhich w·§.ll support the hypothesis in that the experimental
group~
those diabetics receiving both convent:l.onal teaching and programmed
instruction, ·uiU. be able to demonstrate a greater degr·ee of leat'ning
exhibited by achieving higher test scores,
BasEd on such uata, it
may e.von be possible to say something about a correlation b•""'tw·e;;;n_
knowl,edge~
\. ..
and c:.bHity to manage dise;:.,se "t-rith grec.ter stability,
.«. . .
~,,~
··~-··----""«-·
~~·-~--------~·~-
.....
-~.
·-
-~--·-~
..........
···--~---··------•'""""'
.
-··- ---"' ·---.
~
)
·~-----~ -~-
'""'""'"-"'"""-
--------~-------·-·------·--··-·-
------- -----·-1
i
l
I
I
CHAPTER VII
INTERPRET.A.TION OF RESULTS
The impleme:tit.&tion of this study at both the
in~patient
i'.'l.nd
oat~
patient levels of the diabetic program 'wns the first step toward
definition of pr-ogram t!ffectiv?ness <it Northridge$
The tesutts of
data collected relating to the two main out-patient study popv.lath•ns
indicated that a significant difference in patient knowledge loevel had
been exhibited between those pathmts taking part in the instructional
program and those diabetics who did not.
Comparison of in-patient
statistics to those of out-patients indicate that significant differences in patient learning took place among out-patients in relation to
in-patients receiving conventional instruction, and of those diabetic
ln~patients
in the hospital during the three month study period, only
14% were kncrwn to have received instruction.
This would reflect the
posslble need for a better out-patient referral system i f instruction
is desired.
The author feels that many variables affect in-patient learning
that were not tested thoroughly dt1ring this study period.
One area
of interest for the author is methods used for in-patient instruction.
The in-patient pilot study utilizing adjunct instructional programming
, as a supplew&nt to conventional instruction hopefully will give the
; teaching team greater insight into modifications needed for in-hosi..........- ........................... __,................ --
.......................................................... ____ ....,_..... .
53
~--~-------------- --~---------·
-·· · ·---·-· · · ----------------------------- ··-·· - - ----- ---------------------------
------------.-----------------------~-------- ----~-l
! pital instructions
I
The rationale tor ool<>cting program instruction
a£
a
sup;>lcr.•cn~•!
i approach to diabetic :h:struction was subsequently due to its flexa ...
I
' bi li ty for short te:rr>1
i
1
t:he m-1-jor
var.·ie-1blc~s
instn.~-:::Uon.
The author obser-ved that one of
affecting the quality and quantity cf pal-::ient_
·.education ·was the cost of providing the
1
sex·vice~
At
No:rthridg~),
the
pre·\lf.liUng fed.ing in regard to the n:spoCl.sibllity of affnrding the
cl<.lrl AHd s.:H.:ondt-!l'lly >·>ith the patient care tt~am.
This secondary
eApproach to pq.tlen.t educ.aU.on may 'include diet instructi-oi1 frorr. a
V(~ry
t'•?gistered dietician, or possibly a
provided by a member
~>f
time-consuming
thE: n1.;rB:ing staff.
f.lE:s~:dor~(s)
Unfortunately, the c,:;st cf
providing this servic€ .and tho difficulty in coordinating such a
program e.t the level of nursing service is vi.ew-ed, at least at No:rt11.-.
ridge, as inconceivable.
Considering tr:e advantages of programmed
instruction as referred to in the literature revieH, it is quite conceivable that by supplementing the
11
-conventional instructional ap-
proach" currently utilized with programmed i.nstruction, costs can be
reduced l;hi le effectiveness can be increased.
If this proves to be true, low incid€nce of patient referrals to
out-paUent instructional sessions will be more likely to occur.
But,
it would be safer to assume that the diabetic was given a significant
amount of information regarding health maintenance prior to hospital
discharge.
\o1h.at needs to be done is a patient follow-up for both in-
patient and out ... patient components in an attempt to evaluate if knowledge actually affects disease stability in diabetics, and if signifi-
v
Data collected in reference to non-diabetic populations indicated·
that those persons wh.v have prolonged contact '.rit:h diabetics usually
have a greater knowledge about
diabetes~
but it was also interesting
to note that differences in pre test rcsultz shor.·md non..-diabetic
scores (X=23.0) to
(::<-:::25,2).
b~
slightly lower than diabetic pre test scores
Thls i.s not a statistically significant
is identi f:lablc~
diffcn.mc0~
bu·t it
The author is not sure whether knowledge r:l iffer•:c;nces
are actually significantly different between diabetic and
non~-dLdct:t:lc
groups and suggests that a more accurate instrument should be devised
to more closely assess this area.
Data collected relating to nursing expertise ln
diab~tes
tl~
area of
allowed the author to assume that lack of knowledge Has not
.s variable affecting low in-patient: learning.
But, it was concluded
1--
by the author that nursing knowledge of teaching methodology should
be conside1:-ed a possible area open to future research at
Northri.dge~
It is the author's feeling that subject area €Xpertise is a pn•requ:J. ...
site for instruction, but many kno-w·ledgeab le instructors are poor
teachers.
The author questions the teaching ability of some nurse
instructors and feels that future research into this area may find
this variable a possible weakness in t:he in-hospital instructional
program.
Evaluation of instructional content is an area that was not
closely looked at.
Brief analysis of content areas indicated that
""_...-
diet information Has lacking in most study populations, but ti:ic hCtual
content was not assessed as to whether it was appropriat6 for th<2
knowledge level of the study populations, and whether
neC€!S!;,:u:-y for disease stability.
compr·,~b::n";lon
1s
The author suggests that futtlre
study include evalu.;<tion of the instrucU.m'ial cont€nt, the premiee for
i
l1hich such content is imparted to the patient, and the valid! ty behind
it.
CHAPTER VHI
SUW.lf\RY AND TOllCLUSIONS
Baslcelly, the author's interaction with the various interest
groups involved in the Nortbringe diabetic education prog:<wn "tt:s quite
f~vorable.
The organizational goals origlnatlv outlined by the author
·as a frame\orork for working with the instructional team
and results of working
program
\fl
~<rcre
fol1ow.?d,
th th0 team led to a closer deflni tion of
effectiveness~
It is the honest: opinion of the aut:hor that many areas t?.sua.lly
considered as part of progran1 planning <:vere ignored by the planning
body when deve:loping the study appr.::,aches for both the
out .... patient program,.
in-~pa
tient and
This lvas felt to be a structural weakness in the
programt espacially in the area of objective settinge
But, the author
does feel confident that much valuable information has beent and is
still being collected to enable the teaching team to modify areas of
program weakness.
This group activity, even though minimal, was a
significant happening in the group process..
This has bt:Hm the first
attempt by this group., or any other group to evaluate the existing
instructional program.
What is even more important, what has been
done by the group is the beginning of actual assessment of program
viability.
57
58
!
I
Before the sl-udi<~s were implemented:!> both the ;mthor 2nd the
l
teaching
te;~m. 'Were
curious about the a\-':tual effect this prog1·am had on
II
i members of the diabetic populatioa.
Curt·tmtly, th<:! group is at least
I
i
:able to say with a great
i
dea~
of confidence t:l:"tat those
pE>:::'~Or;s
who do
take part in the educational program .;;t the out .. patient level <h.1
c~,;s;;n~
' strate an .:.ncrease in knowledge 1:elated to the control and rn<odnl:l::nance
of
dlabetes~
level of
Further study paralleling that of Stone relating to the
knoHledg~
as .s di:rect correlation to stab!. l i ty in contp:)l of
ct!abetes can also be done now that the teaching
g~oup
has begun to
evalua t~ r.he tenc:hing program.
l'-1uch vmrk is sb 11 needed in the areas of program dev<:lopnx:n.t b
of the
t~aching
group wi 11 lead to e.n expanded
evo h\ation of the various corHpone:nt::< of the
l~vel
program~
of interest for
Ver·y liml ted
a ttentiou vras paid to the actual area of· instructional C\mtent:, and
the evaluat1.on G·f tc·aching methods v:as touched on very lightly.
greatl';·r team i.rd t!.::.tive toward evaluation of the total program
~nth
exhi~
bi ted, it is hoped that these areas of program evaluation ·will be more
closely scrutinized in the future •
.If ther;;;:! vas cnc sp"~cific area of concentration that the author
would liked to have seen more effectively exhibited 11 team organization
would be it..
The author feels strongly that the greatest weakness in
the program is the team's
total group.
~1ch
con~ is
tent inability to work together as a
can be accomplished if the interest is present and
this 1s, in the author's opinion, the key to successful program plan ..
ning..
Th~:!
diabeti.c teaching team did not 't>Tork together as a group.
r-·--·····-·······--···· ------·- ··-·------···----- ................................_ ---·-·-----··· ··-·············-··--·- -- -- ----·---
l
1Specific i:cdivid-uals had to work
in::h~!pendently
······~---------·····
t.iina~~t
and
___ ......... ·-"......... _..i
Fhnnlng
·;q,~s
I
Ivery
I
!!
spa:css ..
It 1s felt by the author that many variables intervene with incH ...
1 vidual
and group moti vn tion for
l~orking
\\1'1 th the education program .•
· .Nany of these variables are imposed from outside sources such as atti··
tudes cf specific hospital departments, adrninist:r.at:lon and th(" c:nrnmt
• definition of program need by many key individuals..
All the author·
can suggest is that by exhibiting skills in program planning$ and by
actually justifying the advantages gained by the target population
from having an educntion program, no. one can claJ.m that the very
presencB of such education programs is a waste of: time and
:n;~SO'i.H~ces:,
especially to the physician and his patiente
In conclusiont' it was felt that a foundation
'(on',S
set for
t11e
teaching teem to evaluat'c current program effectiveness e.nd hopefully
modify areas of
w~aknesso
One such area that is beginning to be
studied is that_of coordinating tealil
I•Jernbers~
nursing and the physi·"'
ciar1 in a syst'Z!m of referral and in ... patient instruction.
Hopefully,
the jn-patient pilot study soon to be implemented in its totality will
lay the frame¥1'ork for program modification.
The authortB concern throughout this study was to identify a need
for patient education.
The authorDs rationalization in this concern
was that t:her·e may exist an undefined need for patient education in
diabetes and other disease areas, and that even though a system. of
educational referral may exist, a significant amount: of pertinent
information should be made available to the patient regarding. health
maintenance
t~
ass:ure that patient control can be maintained between
;
i ~ -"--~- ".. ---·· -·--· --·----~-······-~·--~-- -~----··· --~-- -----·- .. ··---· ·--·---· •.
!
r. ---·--------------------- · · ·----- -··-·-----·-- -.. . . . -----------.. ----.. . . ------ ---------·--·- - . . . . . . . -..
I
!I the time of discharge <md attendanc-e at ambulatory educational ses"'
j·
l sions.
i
i! 14%
Looking back to the diabetic referral statistic that quoted
out-patient session attendance from all ref·:'!!Tcd
h<~h0us-e
diabe ..
i
i tics allows us to assume that many diabBtics w.ay have left thto hospi ...;
tal without proper education.
As vieT,;>,i::!d by the author, it is the
responsibility of the hospital to provide a necessary educational
ser·vice to the c:olnlTtunity$ unless the- physician deems it unn;;:;csst>ary.
BJJ3LI08RAPHY
DeCecr:o 7 Jr)tm~
lbs._t:'.!:YSJ'o1,£f'~"'-gf Jj~arnin];i_.§l1SL In~uctis:~n·
Nevr York~
McGraw-Hill Book Companyj 1967.
Donnel~
Et:z1d ler,
2:
uuho 's Teaching the Diabetic:,"
l9f.:7.,
111-11'7.
F:r· l t-,3~?·n ~
P1.1.t1l
~iller
A •.,
I~s.:sL1llL1Bk.-.In.f~J:.:~~,S:_...t~i2Ll.,
11~f:£•
Santa :<on i cal> Call f{Y!"·:n ia:
Publishing Co., Educulture Incu, 1973.
Gagrw~
Roher:: N8 Jhe Cot:tditions of. Learning.•
Rin(.:-httrt,. and iHn.ston, Inc.~ 1970.
New York:
Holt.,
"Th(! Acquisi tlcn of I~earning, 11 in Re~~~i}:!.-11:!:.
J!::J::..£h~~og,Y...J2.f C£gni tion..
Anderson .and . ~us,ubel eds. ~e~·l York:
Bolt, Rinzhart!.? a.nd \Hnston, Inc., 1966. p. 116-132.
Ce)rt'2r. Hobert H.
GJ:."{.'en:> I..aHrence H., ~nd 1T21'V-" Figa~Tat<'l.irtB.71ca. "Suggested Design.!'.: for
l:i:valuation of. PB.Uent EducntJ.on Progrc\!r.s," in Jiealth Education
. lJi:I12fLtE..E!~@.~ '/oL 2, No., 1, Spring 1.97!:.•
Pohl1o ~.brgaret:,
"Teaching Activities of the Nurse
14: 4-~11;, 1965n
Practition(,jr~"
.~J-l~;D.£.,.I?.sa~~rst.
Stc•r:e~
H.,~·
~'A
Study of the Incidence and C,:,mses of Poor Control in
PGJ t i .r;-n t.s ,,•i th D i a be u~s Ee 11 i tus," b._mer ~£::1~..!22-ill:n~..l.SJ~ls..~!
.~J.£E:.cq.
241 ~
436-4!;.1.
1963,.
APPCNfHX .A
WHA; 00 YOU KtlO\v A!JOUT DIAO£TES?
l.
When a diabetic feels any of the 5ymptoms of low b1ooci iugar
r~actio,,"
the
a. Take fruit
b.
Ask"
first
~~ing
he should do
is~
ivi.:e ot a Goncentrated S\lcct
to cdll for <Jn ilmbulance.
immediat·ely"
rcl,:,ti_'ll·c
c. Drink some black coffee.
d.
2.
I dc.n't know.
Tho insulin which the body produces ls chiefly responsible for:
.;,. Slo·r~>ng up the appetite for sugar.
b. Helping the body use its glucose.
c. Making the aigestlYe juices effective.
d.
).
i
don't knov1.
One unit of U-100 !nsul in has the same action in the body as:
a. 10 units of U-40
b. 1 unit of u-~0
c. 5 units of U-80
d. i don ' t kr.m•
4.
Cottage cheese is a:
a.
Heat excha,ge
b. fat
exchans~
Hilk CX::hJn~:Jc
d. I d0n 1 t knovl
c.
,),
If you star.t feeling very thirsty, drcH,sy, and develop a headache:,
ni:lusea, vomiting,. and frequent urination, you.1·10uid fir~_:
a. Te<.:: your urine for sug<Jr and acetone and cvll the doctor.
b. Stop taking insulin or the diabetic pills until the vomiting
SHipS.
c. Eat some canay or
d.
6.
&weetc~~d
drink.
I don't kno11.
Some oral diabetic tablets:
a. Are ora! insulin.·
b. Stim~ila::e the r~ncreas to secrete more insulin.
c. Cure diabetes.
d•
1.
I don 1 t
k n o•.-1 .
when your urine test
a. Still
is
usually negative,
tc;;t after every meal
you would:
and at bedtime to make sure.
b. Keep testing as often as ordered by your physician.
c. Test only when you su!rpect some sugar in the urine.
d,
i don't know
P.age 2
B.
9.
All food that you eat is at
body to glucose.
<::.
Tr(1e
b.
c.
False
I don't
least pHtially broken C:own Jn you;·
kno~1
Some typical
symptoms of
Insulin reaction ate:
lack of appetite, diarrhea, fever.~
he'lJ'.lche, fever, drm·1sincss"
c. Trembling, 1rritability, S\vuat!n9, hunger.
d. I don't know.
a. Hausea,
b.
lO.
Polyu1 ia (frequent 'Hination) is a symptom of diabetes.
is the result of the body 1 5 attempt:
a.
b.
c.
d ,'
11.
Nausea,
To get the sugar to the body areas that need it.
To replace fluid~- lost through the kidneys.
To get rid of the excess sugar In the blood.
I don't knO\J.
v/hen the diabetic has
results is:
a..
b.
Thi;;
too much
insulin,
the complication ti;at
Diabetic coma
Hyperglycemia
c~ Hypoglycemia
d. I d·on't know
12.
Proper amounts of insulin can:
a. Allow you to cat anything you like.
b. Cure diabetes.
c. Control diabet~s.
d. I don't know.
13.
The person most responsible for good control of your diabetes is:
Yo~:r doctor
b. Yourself
c. Your family
o.
14.
Illness. or infection can cause the blood sugar
a.
Increase
b. Decrease
c. Go into the hypoglycemia
d. I don 1 t kno11
IS.
to:
range
For en insulin deoendent diabetic, excessive exercise without
changes may cause~
a. Insulin reaction
b. Acidosis
c. Diabetic coma
d • I don 1 t know
di~t
and insulin
Page
16.
3
A diabetic must give special care to his feet
beca~~e:
a. A diabetic must walk a great deal.
b. Tight gartcr5 and shoes incrc~se blood circulation to the feet.
c. Diabetes may slow blood circulation in legs and feet.
d. I don't know.
17.
If you becon:e i nvo 1ved in unexpected exercise such 9:; a tennis match,'
you should:
a. Increase your food intake ~nd eat something extra before
VOIJ play.
b. Take an extra dose of i~sulin before you play.
c. ~ot do anything out of your ordinary routine.
d. I don t kno•.-1.
18.
When tcstin9 urine for suqar before breakfast, use:
a. The first urine that you pass upon rising.
b. The ~econd urine t~at you.pass upon rising.
c. The urine passed on the previous evening.
d. I don't know.
l9•
Cuts and o the ,. wounds w i 1 1 he a l · s 1 ow 1 y i n t h c u nco n t r o 1 1e d
diauetic because:
a.
Th~
h.
The excess of
excess sugar in the blood decreases th.o healing properties.
insulin interferes \-lith the hc<ding process.
c. The blood is slow to clot.
d,
don't know.
20.
Blood
rel~tlves
of most diabetics:
a. Inherit diabetes.
b. Inherit a tendency to get cliabete5.
c. Always get d!abetes.
d.
21.
I
don't
k01ow.
The action of llPH or Lente i11sulin lasts:
a. 4-6 hours
b. 20-30 hours
'-. Z8- 36 hours
d.
22.
I
don't
kno1-1
The obese person may develop diabetes because:
a. He has e.:• ten too m11ch sugar.
b. The pancreas gets exhausted trying to supply sufficient insulin for
the excessive food intake.
c. The kidneys have collected excessive fat and can't
metabolize ctlucose.
d. I don't know.
6 _,;;:
Page 4
23.
In caring for his feet, a diabetic snould:
a. Use sharp scissors and razor blade to cut toenails, corns
and callouses regularly.
b. Bathe his feet daily in hot water 1vith a ::.trong soap.
c. Inspect his f~et every day ·and report any irritation or
injury to his doctor.
d. I ·don't know.
'21+.
1
The !nsuiin· injection should be given:
a. In the same spot as the last injection.
b. Right n'!xt to the last injection.
c. At least one inch away from the last infection.
d. I don't kno~t.
25.
Some foods do not have to be measured because:
·a. They contain no carbohydrate,
but many calories.
b. They conrain very few calories.
c •. They are all fat and have no effect on diabetes.
d. I don't know.
26.
One bread exchange provides approximately:
a. 50 calories
b. 70 calories
c. I 0-C ca lor i e s
d. I don't kncn·1
2 I' •
\i h i
c h of the f o l 1o vJi n g g roup 5 o f food i s cons i de red f r e e?
a. Group A vegetables
23.
b.
Fresh frults
c.
Dietuti~
d.
i
cnndies
don't know
The reading of one plus (1+) in any urine sugar test usually means that
the url~e contains:
a. fxcessive amount of sugar.
29.
b.
Some
c.
l~o
d.
I don't knoH.
SU(JiH.
sugar.
Regular or crvstalline insulin will be circulating in the bloodstream and re~dy to begin action in about:
a. 15·20 minutes
b. 2-3 hour·s
c. 30-60 minut~?s
d. I don't know
30.
Ail
foods
labelled "Dietetic" are all
a. True
b.
c.
False
I don't knn'''
right for diabetics to use:
Page 5
3l.
Which oi' the following
is not
included in th.;:·breacJ exchanges?
a. Popcorn
b.
c•
d.
e.
32.
Sncrbct
Pea n v t but t.e r -. ·
Pops!cles
I tlon't know
Carbohydrates are:
a. fats and oils
b. Sugars and starches
c. Vitamins and minerals
d.
33.
I
don't knol-l
An adequate supply of insulin is necessary for:
a.
b.
Body preparation in a fea:· situation.
to use the blood sugar.
The cell:;
c. Good bone and tooth development.
d.
3L1.
I don't know.
~.'hlch
body
food grour acts primarily to build and repair y.:><Jr
tissues'/
a. Protein
Carbohydrate
c. Fats
d. I don't know
b.
35.
Which of the following groups of food may be used whenever a
d i abe t i c I< i s h e s :
a. fresh fruit
Canned soup, tomato sauce, ketchup
c. Coffee, te.;, bouilion
d. I don't know
b.
36"
A diabetic diet is:
•! t
t h c who i e fa mi I y c. an use •
system of special foods that are not. included in
regclar diets.
d. i don't knov;.
a • l\ we 1 l - ba I anced d i
b. A
37.
plan~ed
A diabct!c may
go
into diabetic acidosis
(also called diabetic
coma) •,then he:
b.
Takes too r.1uch insulin, or has an infection or other illness or
stress.
Does not take enough insulin, or has an infection or other illness or stress.
c.
Eats too little and has an infection or other illness or stress.
d.
I don't know.
·a.
Page 6
38.
If your me:al
plan calls for
I milk exchange you may:
a. Use a glass of fru1t JUice instead.
b. Eat cheese in place of it.
c. Drink part of it and use the remainder in cooking.
d. l don't know.c·
Canned fruit
a.
b.
...
d.
40.
laballed "Dietetic" is
fruit
preparl~d:
\nth extra sugar.
Without sugar, but perhaps with an artificial sweetener •
ln the same ~Jay as other canned fruit.
f don't KnO\v.
A diabe;;ic may get
lo1-l blood suga.r
reaction
(also called insulin
reacti~Jn):
a. When he cats tOO much foo.d.
b. \ihen he does not eat enough food, or eat at the proper
c. When he docs not take his 1 ns u, 1 n on time.
d. I don't know.
•
I
•
time"
68
APPENDIX b
011\BETES INFORMATIO!l SHE:ET
I.
Name_·- - - - - - - Name of your p;hydcian_-'---
II.
Forrnc.1 Educati<.>n
Please check the numbered box be low that corresponds to y(;LJr la5t
year of school completed. Check the box labeled t~A if you have
never attended school.
Q
0
[!]
Q
0
GJ
Senior High School
~·
@]
@]
College, Un i ve rs i ty ,
or Technical School
fDl
G.
~
Elementary School
Junior High Schooi
L.~,.--
Post Graduates;
Second Bache 1o rs
H!!st.er's
Doc.torate
tiA
G
1.
Sex:
2.
Age Last Birthday:
3.
Height:
.
D
Ill.
Male
o·
,,
4.
26
Weight:
feet
29
0 0 0
,_.. 22
Zl
Female
0
0
Z3
26
[j
24
27.
[_j
30
po'-!nds
LJ
inches
IV.
(To be ccnpleted by a member of the teaching t•1am dl" a nurse s:..~pervi scr).
1.
Nursing Floor:
031
032
Second
Thl rd
DJJ
Fourth
3(
Length of Stay:
J.,-2 days
3-4 days
5-7 days
).
~9
8-10 days
More than
10
da1s
0
Ll
,-4G
Was admission primari 1y due to a condition relating to diabetes?
Yes
ilo
4.
0
037
038
o•s
Pediatrics
36
2.
o·
Pavi 1 ion South
0
0
41
42
A diagnosis of diabetes was made:
~ii
thin
month of this hospitalization.
Within 6 months of this hospitalization.
Within
to 5 years of this hospital izatioo.
Greater than 5 years of this hosp ita 1 i zat ion.
5.
Control is maintained by:
Diet alone
Diet and oral agent
Diet and insulin
Nc special manner
6.
047
048
049
050
Does the patient have any relatives who have been diagnosed diabetic?
Yes
No
51
0 sz
O
70
NORTHRIDGE HOSPITAL FOUNDATION
18300
ROSCOE:
SOULE:VARO
•
NOF<1'HRIOGE, CALII'ORNIA
91324
SE:IS•SSOO
Dear
All of the staff involved with t:he Nc11·thridge Hospital Diabetes Education
Program wish you well. It is our concern that those persons who look to
us for information regarding the control of their diabetes be given perti-nent information that can be utilized for the rest of their lives.
Enclosed is a copy of our program evaluation fvrm. This evaluation is in
the form of a test similar to those you took on the first and last nigi1ts
of the session you attended. The purpose of this evaluation is to help us
discover areas of strength and weakness in our program. It would be difft ·
cult for us to offer a program that meets the personal neilds of each individual unless we have feedback <tbout the prograr.1. This evaluation is de-signed to help us identify areas that may need t8 be aJ. tered, left out, or
more closely discussed during the course of the program.
At your convenience, please complete the enclosed evaluation and return it to
·us by mail. A self-addressed stamped envelope has been enclosed for your
convenience.
i'le want to thaPk :;ou for your participation and concern for making oar
Diabetes Program a truly worthwhile experience.
We will be looking fonvard to hearing from you soon.
Sincerely,
Jan Willia:ns
Program Coordinator
JW/bj
APPENDIX
·o
INTROOUCTION
Patient education is an important aspect of health care, especially for those
patients ·who must master knowledge and techniques of self-management essen[ial to
Jiving with long term and chronic illnesses. Patient education has also beer recognized as a .nursing responsibility and function, and it is ther~fore essc~tial
for nursing to utll ize instructional methods which best facil!tate paiient learning.
The attached evaluation is designed to assess the level of expertise an individual
may exhibit 1vhen working v<ith di,1betic patiE>f'tS. This evaluation is formulated
around specific educational objectives used ln teaching patients about diabetes.
This evaluation is not designed to assess ci inical knowledge but to evaluate cornprehension of specific information common to the control and maintenCJ;Jce of di<:1beres.
In an attempt to evaluate the many variables that may effect patient learning, !t is
essential to b~ able to make some valid statement about the level of expertise
available to the patient. This study is. designed to derive data upon which such a
statement may be justified.
OBJECTIVE
To assess the current level of expertise among nursing personnel at Northridge
Hospital relating to the control and maintenance of diabetes mellitus.
METHODS
1..
Each and every member of th<! nursing team
evaluation on diabetes to complete.
2.
The evaluation will be distributed by the Directo~ of Nursing and upon ccmple··
tion should be returned to the nursing office by March 20.
3.
Instructions for completion of the evalu<1tion \•lill be att<'lched to. the evaluation
itself. It -is not necessary to identify individual evaluations by name. The
purpose of this study is not to assess specific levels of knowledge, b~t is to
gai.n insight into total staff expertise.
4.
The only identification that must appear on the evaluation is the job classification, or position held by the person who completed the evaluation.
5.
The evaluation is to be completed without the aid of resource materials, friends,
or colleagues. The use of such help would invalidate any results and would
therefore make interpretation virtually impossible.
~~;
1! be given a copy of a fo1·ty item
EVALUATION
The completed evaluations will be studied and compared to gr,)up results obtained
from previous testing. The data will be analyzed by staff position, (N.A., R.N.,
Head Nur5e, etc.), and will be classified as "control group results."
APPLI CAT! ON
The application of this data may be felt in the future or possibly not at all.
With empirical data, logical assumptions about program effectiveness can be made.
Without such data, no objective conclusions can be made. It is hoped that th~ data
collected will be used for a practical purpose.
72.
INTROf.\UCTION
The atiached evaluation is designed to assess the le~er of expertise ~n inJl~idual
may exhibit 1-1hen v1orking with diubetic patients. This evalu2tion is f'ormula:::'!d
around specific educational objectives used in teaching patients about diabetes.
This evaluation is not designed to as~ess clinical knowledge but to evaluate comprehertsion of specific information common 1:0 the control' and maintenance of diabetes.
INSTRUCTIONS
1.
There is a total of 40 Items on this evaluation. For each Item circle the
letter preceding the statement that you feel best reprEsents the correct answer
in each item. If you don't know the correct answer, or you are not sure of the
correct ansv1er, circle the letter directly to the left of the selection, I Don't
Kn6w. Please complet~ all forty items.
2.
Return the completed evaluation to the nursing office by March 20.
3.
Be sure that you have labeled your evaluation according to your job title or
position, (N.A .• , L.II.N., R.N., Head Nurse, or Nurse Supervisor). It is not ner:e·;sary
to identify yourself by name.
4.
Please identify whether you work in a medicat~surglcal· unit, or in a specialty
unit such as ICU, CCU, Pediatrics, or Rehabilitation in the space below. It is
not nece.ssary to identify your specific unit or floor.
Please check the
work in a
appropria~e ~tatement
~!edical-Surgical
below. Check only one.
Unit.
work in a Specialty Unit such as ICU, CCU, Pediatrics~ or Rehabil !tat ion.
APPENDIX E
To be compl"t~td cne ~r.ontll aftE>!' discharge from ho.spitllla
Jo!arital Status.•. _...
_No•
<~f
ap'l) 1 ts. sr.:hedv;lEd since disch£1rg:a._ _ _ _ _ __
No. of app•ts, kept since discharge______ _
:&lood Sugar
<Jn. e;;~y
·Of M.scharge from h.:>spJtal .::are._ _ _ _ _ ·-----~-----·
-----------·-----Pre.'l'crifrled progT<ll!! <~f urine testing:
Tirocs JX?r
------~--------
Ncthod'------·-----·
d~y___ •••.:...._
No. of thr>2s pat:le:H: teses urine (fH>m self kept rec.,rd) Include date cf ap;>rt
and number of urine t;;sts p'Z:J.:fpr:r.ed bvt'f.l~'en app•ts.
Note any changes in no. t:of
times patient is itlt:tt·ucted. t:o complete urinu testing)_-'---·-----·---~--------------·-
No. of self-rf:pcx:ted cccurences of inStllln reactiansince
discharge·---~---
No. and type cf self o.r doctor report12d :Infections since discharge_ _ _ _ _~-
Please note s.ny type of additional instruction patient has received on diabetic
eare since dlsch<;t"ge from hospital.
(note type and by ·whom instructed)_