CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
CANCER EDUCATION
\1
A PILOT PROJECT FOR PATIENTS AT
GENERAL HOSPITAL, VENTURA COUNTY
A graduate project submitted in partial satisfaction of the
requirements for the degree of r1aster of Public Health in
Community Health Education
by
·-
Carol Lynne Motylewski
The Graduate Project of Carol Lynne Motylewski is approved:
Michael V. Kline, Dr. P.H.
Robert M. Huff,
Waleed A. Alkhateeb, Dr. P.H., Chairman
California State University, Northridge
ii
Dedication
To
Mom and Dad
Les, David and Danny
iii
Acknowledgments
To Carol Russell and Lila Atkisson, my colleagues
and friends, whose constant
encou~agement
and support
during the past six years have gotten me to this point in
my life.
To Jean Hembree, Rita Reuben, Jo Blackburn, Ruth
Geagea and Joy Carlson who listened to me complain, curse
and cry for the past three years.
To Wally Alkhateeb and Mike Kline, whose expert
instruction and consultation actually made my graduate
studies tolerable.
Finally, but certainly not least, to Bob Huff,
whose daily
11
spirit 11 boostering made this thesis a
reality.
iv
Table of Contents
Page
Dedication·
ii
. . . .
Approval· · · · .
. . .
..
..
. . iii
Acknowledgments · . . · . . . .
. . . . .. .
Table of Contents
Abstract· · · · .
iv
v
. . . . . .
vii
Chapter
I.
II.
Introduction
........
1
Statement of the Problem . . .
Purpose of the Project .
. ..
Limitations of the Project
Definition of Terms . . . . . . .
5
6
6
8
Background of the Project . . .
9
Informal Survey of Hospital Cancer Education Programs· . . . . . . . . . . .
9
Needs Assessment . . . . .
. . . . 13
. 14
Staff Needs Assessment
. . .
-j_,ll
Introduction of the Survey . .
.
14
Methodology· · .
. ....
Survey Results · ·
. . . . . . . . 16
20
Discussion . . . . . . .
.
4
•
Medical Records Su!'vey . .
. . 22
Recommendations fo~ Program Development . . 22
Table 2: Inpatie~'1t Malignant Neoplas1r.s. . 23
III.
Program Design · · · · · · .
.
Development of the Program
.
.
.
.
.
.
.
Design of the Ivianual ·
. . .
Program Implementation · ·
.
.
.
.
Program Evaluation · · ·
IV.
. 26
. 26
. 28
. 31
. 32
Summary of Conclusions & Recommendations ·
'"'. .)~
5
Selected Bibliography · · · · · · . . . . . . . . 38
Page
Appendices . . . . . . . . . . . . . .
. 41
A.
Patient Education Department Program
B.
Patient Education Needs Assessment
Questionnaire . . . . . . . . . . . . 45
Cancer Education Prevention Program . . 50
Cancer Education Prevention Teaching
and Resource Guide . . . . . . . . . 52
Chart . . . . . .
C.
D.
. . . . .
~ri
• 43
ABSTRACT
CANCER EDUCATION:
A PILOT PROJECT FOR PATIENTS AT GENERAL HOSPITAL,
VENTURA COUNTY
by
Carol Lynne Motylewski
Master of Public Health
in
Community Health Education
The purpose of this project was to develop a cancer
education program for adult patients at General Hospital,
Ventura County.
A patient education needs assessment
questionnaire was distributed to the hospital medical and
nursing staff to
(l)
solicit updated information from
them regarding patient education programs within the hospital and (2) assess felt needs of hospital staff relative
to the development of cancer patient education programs.
An analysis of the questionnaire indicated pertinent
educational needs which were considered in the development
of the cancer education program.
A "Cancer Education
.Teaching and Resource Guide" with goals and objectives has
been developed.
The Guide sets forth the goals and ob-
jectives and teaching modules containing behavioral ob-
vii
jectives, content outlines, teaching strategies, educational resources and evaluation methodologies.
The Teaching and Resource Guide contains modules
which target major educational areas to be taught to
patients at General Hospital.
These topics include:
(1) basic cancer facts with warning signals,
cancer and breast self-examination,
and the "Pap 1' test,
(2) breast
(3) uterine cancer
(4) smoking and lung cancer--your
smoking behavior, and (5) colon-rectal cancer.
This program has been designed for implementation with
inpatients on an individual basis in a general medical/
surgical wing.
This cancer education program established
the first level of a three phase comprehensive cancer patient education program to be developed in the next t'!Jro
years.
The other two phases are:
( 1) specific cancer site
programs, e.g., mastectomy, ostomy, etc.; and (2) psychosocial aspects of cancer, e.g., living with cancer, death
and dying, and the hospice.
All patients in the pilot project will participate
voluntarily in the program.
Modules taught depend upon
the patient's interest and knowledge as determined by a
pre-education assessment questionnaire.
The Cancer Ed.ucation Program will be made available to
other interested hospitals who wish to develop a cancer
prevention program for their own inpatients.
viii
Chapter I
Introduction
Cancer is the second leading cause of death in the
United States.
In 1900, tuberculosis was the most frequent
cause of death in the United States, heart disease ranked
fourth and cancer ranked eighth.
As methods for preventing
and treating infectious diseases improved, the number of
deaths attributed to those diseases dramatically decreased
and the average lifespan lengthened.
Cancer, thought of
as a disease primarily of middle and old age, has risen to
second place partly because Americans are living longer
now then they did in 1900.
The cancer incidence rate in the United States in
1978 was 300 per 100,000 persons.
In 1978, the mortality
rate was 170.5 per 100,000 population.
According to the
American Cancer Society, nearly 55 million Americans now
living, one in four, will eventually have cancer. (1)
The nature of cancer makes education an essential
tool in the effort to control the disease.
Basic to the
doctrine that "while cancer is fatal if untreated, or if
treated late, the fact is that early cancer is among the
most curable of the major causes of death.r: (17:7)
This
year, in the United States, about 385,000 people will di.e
of the disease--over 1,000 a day or about one every 1\
1
2
minutes.
Cancer is blamed for one out of every six deaths
from all causes in the United States.
(1)
"The incidence of preventable cancer is enormous.
individual's behavior or lifestyle seems to be the
An
corr~on
denominator in most of this preventable morbidity and premature mortality."
(24:52)
The importance of lifestyle in
determining the health status of the people of the United
States is becoming increasingly clear.
A "Personal Cancer Plan" (PCP) as advanced by
Higginson, states that
11
each individual should examine his
conscience as to what he is prepared to do through personal
action to prevent cancer.
No person should rely on future
community action as an excuse for avoiding personal action
now for his family.n
(10:360)
At the same time, heavy
responsibility is placed upon research and public health
workers to investigate the nature of the environmental
factors involved, establishing priorities and gathering
data to be disseminated so the individual and community
can re-act and act.
Hochbaum has stated that, nthe main goal of health
education in cancer programs generally stated is to obtain
individual, voluntary health action." (6:26)
Can the hospital be a setting for this health education where an individual can gain the necessary knowledge
and skills to take personal action to
~revent
cancer?
The
American Hospital Association asserts that every individual
3
should share the responsibility for protecting his own
health and by taking that responsibility can help in reducing the incidence of injury, illness and death. (3:51)
People must be aware of the importance of their role as a
partner in their own care and they must be taught how to
assume that role.
The hospital has an obligation to pro-
mote, organize, implement and evaluate health education
programs.
Programs should not only be limited to the traditional
teaching of disease and trauma management, but they should
also focus on primary prevention education for inpatients
as well as outpatients. (24:54)
George G. Reader stated that:
The period of time when the patient is in the hospital
is a rich opportunity too often overlooked, to engage
the patient in a long term program of health education. During the period of hospitalization his physician and the hospital staff together can proceed to
reinforce his health education in a number of areas,
in addition to his particular illness in the hospital.
(18:36)
Fiori et al.
~vrote
that, "hospital health education
offers potentials which in view of current national health
programs and issues cannot be overlooked.
11
n •••
the com-
munity hospital should be utilized as a new focal point
for broadly based community education programs.n (5:26)
The Commission on Public-General Hospitals was established to examine how public-general hospitals carry
out their public mandates and to explore their roles in
the development of future health care delivery systems.
A public-general hospital is a comrr1unity hospital--that is,
short-term general and certain special hospitals, excluding
federal, psychiatric, and tuberculosis hospitals--that are
owned by state and local governments. (25:v)
In its June, 1978 report, the Commission recommended
that this type hospital assume a leadership role in providing or arranging for preventive care and health education programs and ensure coordination of these services
with other human services programs in the community. (25:24)
Local government health care systems like General Hospital, Ventura County are in the position to provide preventive health services, including education, to those
individuals who don't have easy access to personal health
care services through the traditional medical network in
the community, e.g. "Pap" and breast exam clinics, and
stop smoking clinics.
These services extend health educa-
tion programs beyond public health environs and into the
general hospital setting.
The hospital setting can be a unique opportunity to
present health education to a patient.
~vhen
receives care in a hospital, "he comes to get
a person
~tlell,
with
a psychological status hovering between anxious optimism
and fear of his future, thus he usually is receptive to
the offer of help with his problem." (26:99)
Inpatients do not have normal daily activities to do
5
thus they have time to receive instructions and to learn
whatever skills they may need.
In conclusion, a program of cancer control through
early detection can be accomplished without an QDrealistic
increase in patient costs.
Patients can return to their
homes and communities with knowledge, motivation and confidence to carry out the actions necessary to maintain
their health. (26:99)
Statement of the Problem
An October, 1978 patient education needs assessment
questionnaire (Appendix B), conducted by the author, confirmed that little is being done to educate either patients
or staff on the primary or secondary prevention level regarding the disease of cancer.
What was being done was
usually "on the spot," informal and inconsistent patient
teaching on the part of staff.
According to staff, mixed
messages to patients regarding their treatment and/or discharge process did more damage than no message at all--the
need for a formalized health education program in the area
of cancer control was evident.
A Patient Education Advisory Committee, whose members
represent many of the hospital's professional disciplines,
were cognizant of the fact that no organized cancer education program, either prevention or treatment oriented,
existed within the hospital.
'rhey w·ere also aware that
6
hundreds of patients could be the beneficiaries of a prevention program that would compliment existing screening
and detection programs offered through Public Health Services.
Permission was granted by this committee to develop
a "Teaching and Resource Guide" that would form the nucleus
for a cancer education program.
Purpose of the Project
The purpose of the project was (l) to assess the
current patient education program needs at General Hospital
with emphasis on cancer patient education and (2) to
develop an educational program designed to increase the
awareness and knowledge levels of the target group about
the nature of cancer, preventive measures, detection
methods and conununi ty resources, and to develop a "Cancer
Education Teaching and Resource Guide 11 that would include
modules with specific topics, behavioral objectives, content
outlines, teaching strategies, resources and evaluative
methodologies.
Limitations of the Project
The Cancer Education Program would be written as a
pilot project for general medical/surgical adult inpatients,
but excluding cancer patients.
Cancer patients were ex-
cluded because they have been diagnosed as having the
disease;
therefore, this type of prevention education did
not seem appropriate for patients at this level.
7
A second limitation of this project is that initially
monolingual Spanish speaking patients will not be included
in the teaching program until bilingual staff are thoroughly
oriented to the program.
8
Definition of Terms
Cancer:
Patient
Education:
Cancer Prevention
Program:
Inpatient Education:
Outpatient Education:
Educational
Module:
A group of diseases characterized by unrestrained cellular growth. These cells
build up into tumors that compress, invade and destroy surrounding tissues.
Those health experiences designed to
influence learning which occur as a
person receives preventive, diagnostic,
therapeutic and/or rehabilitative services, including experiences which
arise from coping with symptoms; referrals to sources of information, prevention, diagnosis and care; and
contacts with health institutions,
health personnel, family and other patients. ( 16:111)
A specific program containing educational modules written to teach inpatients
about cancer early detection and preventive measures.
Those programs or services provided for
the hospitalized patient.
Those programs or services provided for
the ambulatory patient.
A structured lesson plan adapted to a
particular setting that contains objectives for learning, teaching strategies, content, materials and resources
needed, and evaluative mechanisms.
Chapter II
Background of the Project
In 1976, a patient education/continuing education
needs assessment was carried out at Ventura General Hospital by the patient educator who initiated program development around priorities identified.
areas named were:
At that time, priority
Diabetes, Cardiovascular, Prenatal/In-
fant Care and Hypertension.
All of these plus other pro-
grams have subsequently been developed, implemented and
are now being evaluated. (Appendix A)
Analysis of the
survey also indicated that cancer patient education and
continuing education were areas of need but since that
time little has been done to meet these needs.
In September, 1978, this author's field training began
at the hospital, under the supervision of the Director of
Patient Education.
At that time, several patient education
program needs were discussed that could be developed for
a project, including the area of cancer control.
As a result, a needs assessment questionnaire was
again written and distributed to medical and nursing staff
to validate that this area was truly being neglected.
Informal Survey of Hospital Cancer Education Programs
The Investigator contacted persons around Ventura
County and Los Angeles County designated to conduct patient
9
10
health education in their hospital to ascertain if cancer
education programs were carried out on a formal or informal
basis.
St. John's Hospital, the largest private hospital
in Ventura County, with over 300 beds, has specific cancer
site programs, e.g. mastectomy, ostomy, and also has an
excellent organized hospice program for persons with terminal illnesses.
The Simi Valley Adventist Hospital education department offers a "Living With Your Mastectomy" post-discharge
program and also offers the well-knmiTn "Five Day Stop
Smoking Program" based at the hospital and aimed at the
general community.
Northridge Hospital, another large teaching hospital,
has an extensive community education department which
carries out diabetes group sessions and smoking cessation
classes.
None of the hospital educators contacted were aware
of any preventive cancer education programs for inpatients
but could name many hospitals that had specialized cancer
patient education programs.
The American Hospital Association, in its "Hospital
Inpatient Education Survey Findings and Analysis," 1975,
anticipated that a large number of education programs for
specific patient populations existed among the hospitals
surveyed.
In fact, 2,680 of the 4,669 surveyed hospitals
had inpatient education programs defined as " ... educational
11
activities with written goals and objectives for the patient and/or family during inpatient hospitalization. 11
(2:11)
Table 1 lists in order of frequency, the adult patient
education programs that were active in 1975.
Table 1
No. of Hospitals Reporting
Type of Program
Diabetes
Nutrition
Prenatal
Ostomy
Mastectomy
Heart Attack
Postnatal
Preoperative
Respiratory
Postoperative
2,097
1,453
1,426
1,337
1,275
1,263
1,200
1,186
906
894
"Other cancers 11 listed in the American Hospital Assoelation Survey as specific programs, primary or secondary
oriented were not broken down any further, thus it was
impossible from this survey to assume that any of the 378
hospitals reporting
11
other cancer" programs were doing
preventive cancer education for cancer or non-cancer
patients.
Elizabeth Lee, Health Education Specialist with the
American Hospital Association, stated that, patient education programs listed as
11
other cancer" were also targeted
12
at the secondary level of disease management, e.g. laryngectomy. (15)
However, she added that the Cleveland Hos-
pital Association has begun video-tape presentations on
"preventive 11 subjects to patients in ambulatory clinics.
Many other hospitals are also trying this approach to
patient education but strictly in outpatient settings.
She concluded by saying that most hospital Patient Education Departments don't tackle nprevention" programs for
inpatients because of:
support,
(1) a lack of administrative
(2) medical and nursing staff won't and can't do
them, i.e. lack of time,
(3) staff feel inadquate about
the subject content being taught, and (4) prevention belongs in the realm of public health and not a hospital.
Ms. Lee suggested that the results of this preventive
cancer education program be published.
Glenn Hildebrand, Vice President for Programs, American
Cancer Society, California Division, stated that he didn't
know of any formalized "preventionn programs for inpatients
in a California hospital.
He did mention several programs
conducted from a hospital directed towards the general
community at large, e.g. the Kaiser Permanente "Living
With Cancer," stop smoking programs, etc. (11)
The "First Surgeon General's Report On Health Promotion and Disease Prevention!! stated:
"It is clear that
improvement in the health status of our citizens will not
be made predominantly through the treatment of disease,
13
but rather through prevention .... Prevention is an idea
whose time has come." (22)
The hospital is one of several
places that cancer prevention and detection methods can be
learned.
Needs Assessment
To plan a hospital patient education program, staff
and patients needs must be assessed.
The design and im-
plementation of a program would be based on identified
needs.
This input is crucial to the successful operation
of a patient education program.
The information gathered_
from questionnaires can contribute to a data base for planning goals and objectives for a hospital wide program.
Therefore, a needs assessment questionnaire was designed
prior to the development of a cancer education program.
Two basic types of questions are presented in most
surveys:
the fixed-alternative and the open ended.
(27)
A fixed-alternative question in one in which responses of
the subject are limited to stated alternatives.
mat was not utilized for this project because:
This for(1) the
respondent may feel forced to make a choice that he/she
may actually have no knowledge or opinion about, and (2)
limited choices may place an artificial quality on the
range of the answers the investigator receives.
On the other hand, open-ended questions encourage
14
the respondent to freely express his/her perspectives or
beliefs regarding the issue being examined.
This is es-
pecially helpful when a new area of interest is being
surveyed, or when the issues might be complex and the relevant dimensions
unkno~m.
The open-ended format allowed Ventura County General
Hospital staff the flexibility of comment and proved very
useful to this author in the development of a new patient
education program.
Staff Needs Assessment
Introduction of the Survey
The following survey report outlines the data that
were collected as a direct result of a questionnaire which
was distributed to staff throughout Ventura County General
Hospital, including the Family Care Center and the Women's
and Children's Clinic.
The purpose of the questionnaire was two-fold:
(1) to
solicit updated information from staff regarding patient
education programs within the hospital, and (2) to assess
needs of hospital physicians and nurses specifically for
cancer patient education.
Methodology
With cooperation and support from the Director of
Patient Education, a four page questionnaire was developed
15
(Appendix B) to assess the current status of general patient programs and to ascertain specific needs for cancer
patient education.
two sections:
The questionnaire was divided into
Section I - General Patient Education and
Section II - Cancer Patient Education needs including
questions regarding continuing education.
Section I of the survey was designed to ascertain
what staff knew about patient education programs currently
being carried out within the hospital, who staff thought
was responsible for patient education activities in their
department and what new patient education programs were
needed or what current programs should be expanded.
Section II of the survey was designed to ascertain
what staff perceived to be cancer patient education needs,
including the type of cancer patients they see, and what
information cancer patients possess about their illness
and their hospital stay.
Additionally, questions regarding
staff needs for continuing education in cancer control
were addressed.
Lastly, a question looking for volunteers
to serve on a cancer patient education committee was posed.
The questionnaire was distributed to Nursing Administration, Medical Education, Outpatient Services, Women's
and Children's Clinic and the Family Care Center.
Special
instructions on where and when to return the questionnaire
were included in the introduction.
Simultaneously, inpatient medical records were ex-
1 /'
..L.O
amined to determine the number and type of cancer patients
hospitalized for a
July,
1978.
13 month period from July, 1977 through
This examination further validated reported
needs from staff versus real needs for a cancer education
program at the hospital.
Survey Results
One hundred and four questionnaires were distributed
throughout Ventura County General Hospital.
Twenty-eight
questionnaires were returned in a two week period.
With
additional calling and follow-up, four more were received
for a total of thirty-two which represents a
31% return
rate.
The returned questionnaires were representative of
staff at this hospital:
eight resident physicians, three
staff physicians, fourteen registered nurses, seven nurse
assistants, and one social worker.
The questionnaire was primarily "open-ended" in design.
Several questions included in the survey were not
discussed in this paper since they were not relevant to
the development of the project.
In section I all thirty-two respondents felt that
patient education is an important component of the toal
patient care process.
11
Compliance 11 • • • "self-responsibility
for their own care, 11 ninformed patients easier to care forn
... were typical comments given as basic reasons for doing
17
education.
Sixty percent of the respondents were involved in
daily patient teaching activities ranging from
11
on the
spot 11 teaching to two hours daily of formalized teaching
in a group or individual setting.
Barriers in carrying out patient education were (most
frequently mentioned):
(1) lack of time,
(2) language and
cultural difficulties,
( 3) patient umdllingness to learn,
(4) my (respondent's) own lack of knowledge regarding the
content.
In an attempt to identify responsibility for carrying
out patient education activities, thirty-five percent
stated that all staff share this responsibility, twentyeight percent of the survey respondents indicated that
nurses have total responsibility, nineteen percent stated,
"not sure" or
11
no response," and eighteen percent responded
that in their department, no one is responsible.
The
belief that nurses have total responsibility for patient
education has fallen to second ranking from the previous
first ranking in the
1976 survey.
This might indicate
that the establishment of a patient education department
has influenced additional staff to participate in educational activities.
Over eighty percent of the respondents could name at
least three of five currently offered patient education
programs.
All of these programs are formalized with
18
written protocols containing specific objectives, teaching
strategies and evaluative mechanisms.
The programs identi-
fied by survey respondents include (most frequently named):
(l) adult diabetes,
(2) hypertension,
(3) myocardial in-
(4) infant care, and (5) pre-natal.
farction,
Hospital staff were also asked to list new program
areas for patient education.
ty:
They were in order of priori-
(1) cancer education (prevention, detection, facts),
(2) Spanish only implementation of already established
programs (diabetes, infant care done now),
(4) pre-operative education,
and child care,
(5) pre-natal,
(3) menopause,
(6) infant
(7) juvenile diabetes.
It should be noted that numbers 5, 6, and 7 (already
formalized programs) were listed by 21% of the respondents
as areas to be added to existing patient education program
offerings.
This seems to indicate that all phases of
currently developed and operating programs are still not
readily known to some staff at Ventura County General Hospital.
Section II of the survey was specifically directed at
determining needs regarding patient education for the
cancer patient at Ventura County General Hospital.
By
diagnosis, staff ranked the following cancers as most
frequently seen:
breast,
( 1) lung,
(4) prostate,
( 2) cervical-uterine,
(5) pancreas.
( 3)
Sixty-nine percent
of the survey respondents said cancer patients know !!very
19
little to almost nothing" about their particular type of
cancer;
twenty-five percent stated patients know "some-
thing" while the remaining six percent of the respondents felt that cancer patients know "quite alot" about
their particular cancer.
None of the thirty-two surveyed would state that
cancer patients know "quite alot" about what will be done
to them while at the hospital.
Seventy-two percent re-
sponded that most patients kno'\'T "very little to almost
nothing 11 while only eighteen percent felt that these patients know
11
something."
Nine percent of the staff did
not respond to this question.
Thirty-one percent of the respondents stated that
they feel "partially" adequate when teaching patients,
twenty-eight percent stated they feel adequate, twentytwo percent do not feel adequate, and nineteen percent
did not respond to this question.
For those who said
npartially adequatett comments included, "deficient in
dealing with death, not enough education to teach cancer
facts," ttnot familiar with so many kinds of cancer,u
"need updates on present treatments, care techniques,
death and dying."
Forty-four percent of staff respondents stated that
they might take more responsibility for patient teaching
with appropriate help, twenty-five percent don't want
additional responsibility, twelve and a half percent want
20
more responsibility and twelve and a half percent did not
respond to this question.
Ninety-one percent of the respondents would like more
continuing education in dealing with cancer patients indicating a high degree of interest in continuing education.
The Educational Services Department at Ventura County
General Hospital is now planning such programs and conferences.
Discussion
Generally, the patient education survey set the scene
for the development of a formalized cancer education program at Ventura County General Hospital.
Whether it should
be initiated with a focus on primary prevention education
or with the secondary education of cancer patients remained to be decided.
It appeared that the patient education department
was well-established at Ventura County General Hospital,
in light of the fact that most staff surveyed were able to
name "formalized 11 on-going patient education programs.
Additionally, the overwhelming majority of the respondents felt that patient education is an important component
of the patient's total care indicating that the Patient
Education Department has successfully demonstrated and
clarified the role of patient education in a hospital
setting.
Higher priority was given by staff to clarifying
21
and defining the role of patient education at Ventura
County General Hospital, a need identified through the
1976 Survey.
From the results of this questionnaire, it was very
obvious that education for cancer patients had been lacking
mainly because of
(1) the lack of a formalized program,
(2) the lack of time to teach, and (3) the language barrier
between most staff and monolingual patients.
Any education
to date had been "on the spot," haphazard, with no one
person in nursing or on medical staff taking responsibility
for its consistency.
Additionally, staff also prioritized as number one the
need for a cancer education program for patients in the
area of cancer prevention and detection.
Many of those
surveyed commented that with the resources available, including screening programs for breast and cervical cancer,
that a solid prevention program could benefit inpatients
even though hospitalized with other than cancer problems.
Therefore, after lengthy discussion with the Director
of Patient Education and advice from the Patient Education
Committee, it was decided that a specific educational program for cancer patients only would be postponed in favor
of the development of a comprehensive cancer prevention
program.
Those involved in this decision felt that a
general cancer education program on the primary prevention
level for inpatients would be more practical for several
22
reasons:
(1) more patients could be reached with a general
program,
(2) the closed-circuit television system at
Ventura County General Hospital could broadcast many excellent American Cancer Society films, not only to the
target inpatients, but also to patients in ambulatory
settings such as the Women's and Children's, General Medical and Specialty Clinic facilities,
(3) the responsibili-
ty for implementation of the prevention program could be
assumed by this author, an employee of the Health Care
Agency.
Medical Records Survey
During the period in which the survey questionnaire
was being distributed, medical record printouts were examined for data to indicate the distribution of malignant
neoplasms by site for inpatients at Ventura County General
Hospital for the period, July
1977 through July 1978.
There
appeared to be some correlation between this data and the
respondents' ranking "of cancers most frequently seen by
diagnosis.
11
(See Table 2)
Recommendations for Program Development
The
1978 patient education survey revived the need
for a program in cancer patient education, both primary
and secondary.
Continuing education for staff in the area
of cancer control was also voiced.
Two major recommendations were made to the Patient
23
Table 2
Ventura General Hospital
Inpatient
Malignant Neoplasms*
July, 1977 - July, 1978
7/77
140-149
Buccal Cav. &
Pharynx
0
170-174
Bone, Connective Tissue,
Skin & Breast
0
9/77
!
10/77
11/77
'!
12/77 Totaf*
I
0
0
j
i
'::
1
0
i
I
I
150-159
Digestive Organs & Peri toneum
160-163
Respiratory
8/77
i
4
1
l
I
1
I
2
1
3
~
4
'
I
l
l'
1
1
l
l
3
!
I
iI
'
I
l
J
I
l
I
II
4
1
2
6
!
1
3
I
l
4
3
6
I
I
I
2
II
~
I
(
i
180-189
Genitourinary
Organs
J
5
2
190-199
Other & UnSpecified Sites
1
0
2
200-209
Lymphatic &
Hemo. Tissue
1
0
Total by Months 19
14
,....
!
I
'·
t
!'
!
I
I
6
3
!
TI
I
l
i
I
l
7
l
4
l
I
I
I
I
I
5
2
1
1
ll
I
I
if
0
0
0
1
13
15
16
19
:I
jl
I' I.
ll
*World Health Organization: International classification
of diseases. 1975 Revision. Geneva, Switzerland, 1977.
**For Total see continued Table 2 (page 24).
24
Table 2
(Continued)
Inpatient J.VIalignant Neap lasms *
1/78
140-149
Buccal Cav.
& Pharvnx
150-159
Digestive
Organs &
Peritoneum
160-163
Respiratory
2/78
I0 I1
I
II
1
I
I!
1
3/78
0
4/78
1
5/78
!
II
I
170-174
I 1
Bone, Con- I
nective
I
Tissue, Skinl
& Breast
''
3
2
2
!
I
7/78 Total
I0
I
3
1
1
3
2
1
3
0
I
27
37
I
4
1
2
2
i
I
I
38
3
I
!
I
i
I
'
180-189
Genitourinary Organs
'
!
4
4
I
I
2
I
0
1
;
4
6/78
1
3
6
3
3
1
i
!
i
l
1
i !
I !
:
46
iI
i
190-199
Other & UnSpecified
Sites
' !
1
1
0
3
2
0
1
I
!i
I 16
'
I
I
I
I
I
200-209
Lymphatic &
Hemo. Tissue
1
1
2
0
1
3
13
3
I
I
I
Total by
Months
I
12
l
9
13
16
11
12
12
[181
*World Health Organization: International classification
of diseases. 1975 Revision. Geneva, Switzerland, 1977.
25
Education Advisory Committee and the Director of Patient
Education:
(1) that a comprehensive cancer education
~
program be developed for inpatients at Ventura Genral
Hospital.
This program would consist of three levels of
implementation over a two year period.
These levels in-
elude:
1st Level:
General Education (cancer facts, prevention, detection and community
resources)
2nd Level:
Specific cancer site patient education
programs, e.g. breast, ostomy (treatment
and rehabilitation)
3rd Level:
Psycho-social aspects of cancer including living with cancer programs, death
and dying, and hospice resources.
The first level was the primary focus of this investigator's project.
The second major recommendation was that the Educational Services Department sponsor continuing education seminars, conferences, etc. for medical staff that would
include issues at each level of the overall cancer program.
Chapter III
Program Design
Development of the Program
This author, the Director of Patient Education and
the Education Director for the American Cancer Society,
Ventura County Unit, collaborated to formulate a program
flow plan (Appendix C).
This plan will be reviewed for
final approval by the Patient Education Advisory Committee
prior to implementation at Ventura County General Hospital.
Given the results of the patient education needs
assessment, the group concluded that there was a definite
need for preventive cancer education for our hospitalized
patients.
A program approach emphasizing basic
kno~rledge
and skills regarding cancer prevention would have several
advantages.
1.
A "pilot" phase of this program would proceed on
a trial-and-error basis in one wing of the hospital, when
different teaching strategies, content, methods and materials could be tried and modified as needed.
2.
A program of this type could be offered by the
educators during two of the three hospital shifts making
it also available to the patient's family.
3.
Since the Patient Education Department has an
excellent closed-circuit television system, 16mm filrrill
26
27
from the American Cancer Society stressing detection and
prevention could be transferred to video-tape format at
very little cost.
4.
Since the medical and nursing staff at Ventura
County General Hospital are already patient education
oriented, implementation of this type of program could be
easily facilitated.
5.
A prevention program with a detection component
could meet the needs of many patients who could subsequently receive cancer screening services available through
Public Health Services and the American Cancer Society.
The program planners and the American Cancer Society
consultant there fore suggested:
(1) that a pilot program
be developed including a teaching and resource guide to
assure consistent teaching among the instructors involved,
( 2) that this program be implemented in the general medical-surgical wing initially for at least two to six months,
with program modifications made as necessary, and (3) that
the patient response to this program be evaluated to
assess the extent to which improvements in the overall
program would result.
Before this author wrote the "Cancer Education Teaching and Resource Guide" the planning committee discussed
what should be included in a practical prevention program.
Realistically, the group felt that no more than five or
six modules would be possible for one patient to handle
28
during their hospital stay, and decided that all modules
would not be taught to all patients for one obvious reason:
most patients are not in the hospital long enough to receive the one module/day instruction.
Accordingly, the pre-education assessment questionnaire would be a valuable tool in determining the patient's
main interest, e.g. smoking, breast cancer, etc.
It was
decided that Module #1 would be taught to all patients
because of its introductory nature to the cancer problem.
Design of the Manual
A "Cancer Education Teaching and Resource Guide"
was developed from a design suggested by Kemp, and in
accordance with operating protocol utilized by the Ventura
County General Hospital Patient Education Department.
(14)
This guide includes goals and objectives that serve
as the focal points for five modules written in regard
to different cancer topics.
Each module includes a topic,
behavioral and/or educational objectives, a suggested
content outline, resource materials and teaching strategies.
Particular emphasis is placed on the teaching strategies within each module.
A one-to-one teaching method
will initially be employed for the following reasons:(13:26)
1.
It capitalizes on the warmth and understanding
and knowledge of the communication.
2.
It provides the opportunity for involvement, for
asking questions, expressing fears and learning
more fully.
29
3.
It can get people to make changes in personal
habits more readily when discussion presents
reasonable explanation for these changes.
4.
Patients contacted many be motivated to preventive action when they learn that this is being
done by many others, e.g. breast self-examination.
5.
It is more influential with average and belowaverage educational level.
A pre-post test was written for each topic to determine the patient's cancer knowledge level prior to the educational intervention.
These tests were read for com-
prehension of the questions by health education staff and
were administered to twelve lay persons not connected with
the Health Care Agency.
Modifications were made as neces-
sary.
The American Cancer Society Program Director also
checked these questions for accuracy.
Several of the
questions were taken from the American Cancer Society,
California Division Biology of Cancer Course test, though
the majority were written by this author.
(21)
Areas of cancer knowledge tested will be presented
through:
(1) audio-visual presentations,
(2) the actual
teaching program by the health or nurse educator, and
(3) pamphlets and other materials.
Audio-visual selections were determined by previewing
and examining current American Cancer Society Public Education films.
The planning committee finally selected
ten films to transfer onto video-tape for viewing within
30
Ventura County General Hospital.
Final approval for con-
version was given by the American Cancer Society California
Division Director of Public Education.
The films selected were:
(1)
nHow to Examine Your
Breasts" (Available in Spanish) and (2) "For A Wonderful
Life."
Other films include: "Man Alive" (available in
Spanish), non With Your Life,n "The Cancer No One Talks
About," "Signals," "The Time to Stop Is Nown (available
in Spanish), nwho, Me?" (available in Spanish), "Women In
the Middle Years," and "Luisa Tenia Razon" (available in
Spanish).
A listing of these selected films with a brief
synopsis of each will be included in the Department of
Patient Education's T.V. Guide.
Additionally, a pre-education assessment form has
been designed by this author, incorporating cancer teaching
needs in the form of questions to the patient.
The educa-
tor can also subjectively assess the patient's frame of
mind prior to the educational experience.
This type of
assessment prior to the educational intervention is included in all of the presently operating patient education
programs at Ventura County General Hospital.
The educator can transfer demographic information
about the patient from the medical chart before entering
his room and then complete the pre-education assessment
form if the patient volunteers to participate in the cancer education prevention program.
l
31
The modules have been designed to give the patient a
maximum educational experience within a limited amount of
time;
the shortest module will take approximately twenty-
five minutes and the longest about thirty-five to forty
minutes.
Of course, if further discussion is needed or
desired by the patient, the program's flexibility allows
the educator to stay with the patient longer.
Program Implementation
Implementation of the Cancer Education Program is
contingent upon the approval of the Patient Education
Advisory Committee of Ventura County General Hospital.
Approval will be sought during a regular meeting when the
proposed program will be presented to the members and a
vote taken for approval.
Following approval, the program will be implemented
beginning with hospital staff orientation to program
goals, objectives, teaching strategies and evaluative
mechanisms.
Physician orientation will be carried out
through the Department of Medical Education at two of
their weekly meetings and nursing and other professional
staff will be oriented through the Department of Educational Services.
Since the patient care staff will not be
directly responsible for the actual teaching during the
pilot phase, it will be necessary to review the health
educator's role with them and to instruct staff on how to
32
make referrals to the program through the Patient Education Department.
A video-tape of the orientation session
will run every hour for twenty-four hours on channel
eight, the staff education channel, prior to actual implementation.
Immediately following sufficient hospital staff
orientation to the program as determined by the Patient
Education Director and Director of Staff Development,
the program will be put into effect in the general medical/
surgical wing at Ventura General Hospital.
Program imple-
mentation will be the primary responsibility of this
graduate student under the direction of the Patient Education Department staff.
Implementation will be initiated by the physician's
written order on the Patient Education Care Plan specifying
the module(s) desired and any special instructions the
educator is to follow.
and
--
Once the order has been written
the patient desires participation, the instructor will
-
teach the patient using the guidelines established in the
teaching modules and will carry out evaluation procedures
as written in the Teaching and Resource Guide.
Program Evaluation
The evaluation of this program will be based on
knowledge level increases of patients in the following
manner:
...,3
.)
1.
A pre-test questionnaire will be distributed
to the patient before each module is taught to measure
the learner's knowledge level before the educational
intervention.
2.
A post-test will be given to the same patient
after the educational intervention to measure the knowledge
level attained following completion of instruction.
The difference in scores between the pre-test and
post-test measures the actual knowledge gained.
A control
group composed of patients who did not participate in the
educational process will be asked to answer a pre-test
questionnaire before discharge.
pared to the post-tests of the
Their scores will be com11
educated 11 patient to de-
termine if the educational intervention was indeed effective.
Evaluation should be an on-going process and should be
a continuous effort of project staff, therefore, a followup satisfaction questionnaire will be mailed (approximately
3 _to 4 weeks after discharge) to patients who participated
in the cancer education program to assess their feelings
about the program.
Approximately six months later, a
long-range mail-out survey will determine if patients have
utilized any of the community resources available to him
or family members.
It is expected that on-going evaluation will:
(1) reveal where progress has or has not been made in
terms of the overall program goals,
(2) indicate the
reasons for success or failure of the program, and (3) identify areas needing improvement.
Chapter IV
Summary Conclusions And Recommendations
The primary purpose of this project was to develop a
practical cancer education teaching curriculum for use in
a hospital setting.
Since very little information existed
in the area of patient education prevention programs,
this investigator responded to the needs assessment results
by developing such a prevention project.
The major part of the preparation involved the setting
up of operational objectives for the program, the selection
of already existing materials and development of new materials to be used in the teaching process and the writing
of strategies for using them.
The hospital health educator is in a unique position
to fill educational gaps in the patient education realm.
When a realistic attempt is made to provide education to
the patient increasing his knowledge and skills in a short
period of time, the results of these efforts can help motivate the patient to be more aware and to take responsibility for his own care in disease detection.
In 1978, the Health Officers Association of California
suggested initiatives and potential program directions for
the California Department of Health Services (DHS), including the development of meaningful, integrated strate-
35
36
gies toward the prevention of morbidity and mortalitycausing chronic disease and environmental hazards.
(9)
Priority programs must address high-magnitude problems,
including cancer, focusing on primary prevention but continuing to strengthen existing DHS screening programs.
The
Association emphasized strategies for intervention that
would include 'model program development' with funding
going to agencies addressing focused priorities. (9)
The hospital is one of the primary settings for
approach to prevention education.
And the Cancer Education
Program developed for Ventura County General Hospital will
be a new and positive step in the direction of disease
prevention through health promotion.
Recommendations
Continuation and expansion of the Cancer Education
Program will be a priority of this author, the program's
coordinator.
The following recommendations from the planning
committee will be presented to the Patient Education Advisory Committee in the coming year:
1.
That efforts will be
ma~e
to (a) train bilingual
community workers, and (b) involve Spanish speaking nurses
in the teaching program.
2.
That the entire Cancer Education Program be
video-taped in Spanish and English for use \'rhen teaching
37
staff are not available, i.e. weekends.
3.
That patients who received the educational pro-
gram be surveyed to ascertain other areas of interest for
possible development by the Patient Education Department.
4.
That Phase II and III of the Comprehensive Cancer
Education Project be developed and implemented by July,
1981.
Selected Bibliography
1.
American Cancer Society. 1979 Cancer Facts and Fig~' New York, New York, 1978.
2.
American Hospital Association. Hospital Inpatient
Education: Survey Findings and Analyses, 1975,
U.S. Department of Health, Education and Welfare,
Public Health Services, Center for Disease Control
Bureau of Health Education, Atlanta, GEorgia,
1977.
3.
"An Ounce of Preventionn. Hospitals, 50:51, May, 1976.
4.
Christen, A.G. and K. Cooper. nstrategic Withdrawal
from Cigarette Smoking," CA -A Cancer Journal
for Clinicians, 29 (2): 96-107, !!larch/April, 1979.
5.
Fiori, F.B., r-1:. Dela Vega and M. Vaccaro. "Health
Education in a Hospital Setting: Report of a
Public Health Service Project in Newark, New
Jersey," Health Education Monographs, 2(1): 1129, Spring, 1974.
6.
Green, Lawrence \If. "Should Health Education Abandon
Attitude Change Strategies? Perspectives from
Recent Research,n Health Education Monographs,
Number 30:25-48, 1970.
7.
Grubb, E.D. "Hospital Takes Systematic Approach to
Educational Programs," Hospitals, 52:78-81, Dec.
16, 1978.
8.
Haggerty, H.J. "Changing Lifestyles to Improve
Health," Preventive Medicine, (6):276-289, 1977.
9.
Health Officers Association of California, "Report to
the Office of Statewide Health Planning and Development: Reco~~endations developed by the
'Creating Initiatives for Promoting Health'
Conference (May 23-25, 1978) for'Inclusion in the
State Plan," August, 1978.
10.
Higginson, J. "A Hazardous Society? Individual versus
Community Responsibility in Cancer Prevention, rt
Rosenhaus Lecture. American Journal of Public
Health, 66(4):359-365, April, 1966.
38
39
11.
Hildebrand, Glen.
Personal
12.
Hinthorne, R. .A. and R. Jones. "Coordinating Patient
Education in the Hospital," Hospitals, 52:85-88,
June 1, 1978.
13.
James, W. "Conduct of a Public Education Programme,"
Health Education Theory and Practice in Cancer
Control, A Collection of Original Papers, Geneva,
Switzerland, 21-27, 1974.
14.
Kemp, J.E. Instructional Design: A Plan for Unit
and Course Development, Fearon, Inc., Belmont,
Ca., 1977.
15.
Lee, Elizabeth.
16.
Phillips, John. "Patient Education: A Beginning, 11
Health Values: Achievinry Hi ,h Level Wellness,
3 2 :110-112, March/April, 1979.
17.
Read, C.R. 11 Introduction: Objectives and Scope,"
Health Education Theory and Practice in Cancer
Control, A Collection of Origj_nal Papers, Geneva,
Switzerland, 7-13, 1974.
18.
Reader, G. 11 The Physician as Teacher,n Health Education Monographs, 2(1):34-38, Spring, 1974.
19.
Redman, B.K. Patient Teaching, Contemporary Publication, 6(1), Spring, 1978.
20.
The Process of Patient Teaching In Nursing,
C.V. Mosby Co., St. Louis, Mo., 1976.
Co~~unication,
May, 1979.
Personal Communication, Hay, 1979.
21.
Renneker, H. and S. Lieb. Understanding Cancer,
Bull Publications, Palo Alto, Ca. 1977.
22.
Report to Surgeon General, ~H~e~a~l~t~h~P~r~o~m~o~t~i~o~n~~a~n~d
Disease Prevention, Part II. Insittute of
Medicine, National Academy of Sciences, Washington
D.C., January, 1979.
23.
Skiff, A. V.l. "Experience with Methods for Patient
Teaching from a Public Health Service Hospital,"
Health Education Monographs, 2(1):48-53, Spring,
1974.
Somers, .A.R. "Consumer Health Education--To KnO\i
Or To Die, 11 Hosnitals. 50:52-56, May 1, 1976.
24.
40
25.
"The Future of the Public-General Hospital, An Agenda
for Transition," Hospital Research and Educational
Trust, Chicago, Il., 24, June, 1978.
26.
Ulrich, Marian R., "The Hospital as a Center for
Health Education," Health Education Monographs,
31:99-108, 1972.
27.
Warheit, G.J., R. Bell and J.J. Schwab. Needs
Assessment Approaches, Concepts, and Methods, U.S.
Department of Health, Education and Welfare,
Publication No. (ADM) 77-472, 1977.
28.
Weiss, C.H. Evaluation Research: Methods of Assessing Program Effectiveness, Prentice-Hall, Inc.,
Englewood Cliffs, N.J., 1972.
Appendices
41
Appendix A
Patient Education Department
Program Chart
42
l
PATIENT EDUCATION PROJECTS
I
/~ient Educat~
Com~-.--:=J
1__
~
[AQYJJlQr
Jon-Goin!;Pr~jeet'
--e--- .. ·-··. _ !_
'.
l
APRIL, 1979
,
1· ---1
1
-J-
. Pro~l
Cancer Education Patient
& Staff 7/79
_J___
\V
Production
'l'eam
'rralning
1
Diabeti~--. Inpt., I
Prog. 3/78\.
:;r
Bedside-Disease,
Snecific 3/78
__ t: J-~-
lffl;~;~~§tl~uth I
--------\11.-------J
Hypertension
l
__ ___j_L/'.L.Ol
·--- 8'r--,c;
j;re-Natal 10/781
------::v---·
l
-First- l'lr~e
Parent Support Group
1
~-
3rd Party Payment
Project
,
-=-----=-----_...,_st
C. C. Pati.ent Education Services
!
F-:-
Pre/Post
Operative
I
f
~·elc1g_
[
Gon~~ion-servi
ce:> to P.H., V.G.H.
.Q!J.Q___Q_Q.!nm.~c 1 e a
~nard -Dia-
betic Teach..
ing
;~:;
___1_J
'
!
--·"-1
1
\Developin~
_____
.
Cardiac Teaching
Program 10/77
!-.Outpt.
--
I
1
I
1
__ L _____
Data
~lis
Project Write
Up, Re-Design,
etc.
!- - - 1 "\L_______
tvi
de o~'rapel
froduction
1
C1rcui t
Staff Inservice,
Cont. Education
Channel 8
lo~led
1
1. __________
frant Writing _
1
t31-;-aduate Student
Field Placement
Patient Educa_-f
tion Librar~_l
..!::"
V)
~
Appendix B
Ventura County General Hospital
Patient Education Needs Assessment Survey
September 1978
44
Ventura County General Hospital
Patient Education Needs Assessment Survey
September 1978
In an effort to assess patient education needs generally and cancer patient education* needs specifically,
the following questions are being asked of all hospital
nursing and medical staff. It would be appreciated if you
would fill out the survey and return it to either Nursing
Administration, Medical Education or Patient Education
offices by Monday, October 23. If you have any questions
please call Carol Motylewski at extension 3358. Your
input and expertise are needed if our endeavors are to be
successful.
DEPARTMENT/SERVICE: _____________________________________
POSITION:
/~Sr.
R.N.
/~R.N.
/~
I I Staff ril. D. I I Resident
SHIFT:
I.
I~
A.M.
L.V.N.
/~
/~Nurse's
Asst.
Other _ _ _ __
I I P.M. I I Days I I Nights
GENERAL PATIENT EDUCATION
A.
Do you feel patient education is an important
component of the total patient care process?
(Please explain your answer)
/7 Yes I I No
*Even if you don't provide care to cancer patients please
·respond to Part II with your own feelings and attitudes.
45
46
B.
Are you involved in patient teaching activities
on a day-to-day basis?
/~Yes
/~No
... If yes, what kind of teaching
are you carrying out and how much time daily do
you spend on these teaching activities? _________
C.
What problems do you have in carrying out patient
education? Please list most difficult problems
first.
1.
2.
3.
D.
In your department who is responsible for carrying
out patient education activities?
----------------
Are these patient teaching efforts documented in
patient records?
/~Yes
/~No
If yes, how?
E.
What patient teaching programs are you aware of
that are currently being carried out in the
hospital?
F.
Are there patient education programs already in
existence that you would like to see expanded?
I I Yes
1.
/~No
... If yes, what are they?
-----------------------
,2. _______________________
3·--------~-----------
4. __________________
5. _________________
6. __________________
47
G.
What new patient education programs would you like
to see developed? (Please list in order of
highest priority and be as specific as possible)
1.
2. ______________________
---------------------3. _____________________
4.
II.
----------------------
5. ___________________
6.
7. ___________________
-------------------
8. __________________
CANCER PATIENT EDUCATION
A.
B.
C.
How much do you think patients know about their
particular cancer?
/~
Quite Alot
/~
Almost Nothing
Something I I Very Little
How much do you think cancer patients know about
what will be done to them while in Ventura General
Hospital?
/~
Quite Alot /~ Something I I Very Little
/~
Almost Nothing
Do you think the \'Tell-informed cancer patient is
more cooperative during the treatment period
than the poorly informed patient?
/~
Yes
/~
not?
D.
/~
No /7 No Difference ... If no, why
In your professional experience who tells the
patient about his/her cancer condition? (Please
check all answers that apply)
/~
Private Physician
/~
Resident
/~
Other Hospital Employee (please specify) _ _
/~
Other (i.e., Family
ate)
---------------------------------------------
/~
/~
Staff Physician
Nurse
r~Iember,
Religious Affili-
48
E.
Do you think most cancer patients (and/or their
families) are prepared to take care of themselves
when they go home?
I I Yes I I No ... If yes, who
instructs them?
I I
F.
M.D.
I I
Nurse
I I
Other (Please specify) _ _
What kinds of questions do your cancer patients
ask you? (Please rank in order, most frequently
asked first)
/~
About their illness or condition?
/~
About what is being done to them in the hospi tal?
--
I I About when they will go home?
I I About what to do when they go home?
/~About
I I Other?
G.
their medications?
(Please specify) _____________________
Are you usually able to answer their questions?
;-;Most of the time ;-;No ;-;Answer some,
refer others ... If you-refer them to someone
else, why?
.H.
Do you feel your background and/or education has
adequately prepared you to do patient teaching?
;-;Yes;-; No;-; Partially ... If you answered
No, or partially-in what ways and in which particular areas do you feel deficient when dealing
with the cancer patient?
1. __________________________________________________
2. __________________________________________________
4.
_______________________________________________
3·---------------------------------------------
5---------~----------------------------------I.
Would you like to have more responsibility for
49
patient teaching?
appropriate help.
I I Yes 1-; No I I Maybe, with
J.
Would you like more continuing education in
dealing with cancer patients?
I I Yes 17 No
K.
Have you experienced communication problems
between yourself and other professional staff
that hinder your activities in patient education?
1-;
L.
Yes 17 No ... If yes, please describe ________
What kind of cancer patient do you most frequently
see? (List in order of most seen, etc.)
1.
2. ___________________
-----------------------3. _____________________
M.
--------------------6.--------------------
In developing and implementiang a cancer patient
education program, what cancer patient education
programs do you feel are most needed?
1. ________________________
4. ____________________
2.
6.
5·--------------~---___________________
3. -----------------------_____________________
N.
4.
5.
Would you be willing to participate on a cancer
patient education planning committee?
1-; Yes I I No ... If no, would you designate
another person to be on the committee?
NAME: _____________________________EXTENSION: _____
POSITION:
Appendix C
Cancer Education Prevention Program
50
51
.
'
Cancer Education Program Flow Plan
1. Patient Education
Advisory Committee
~----------------~2. Hospital AdminisSTAFF ORIENTATION*
tration
IMPLEMENTATION
\~
TEACH MODULES
If patient is willing
to participate
EVALUATION*
(carried out in all
phases of program)
1. Knowledge Level
2. Behavior Change
3. Program Evaluation
~
DISCHARGE~
OF
PATIENT
FOLLOW-UP OF PATIENTw
I 1.
Short Range
(2-3 wks.)
(Satisfaction
Questionnaire)
2. Long Range
(6-12 months
later)
*EVALUATION WILL OCCUR DURING ALL PHASES OF
IMPLE~ffiNTATION
Appendix D
Cancer Education Prevention
Teaching and Resource Guide
52
Health Care Agency
General Hospital Ventura County
Cancer Preventive Education
Teaching and Resource Guide
Developed by
Carol Motylewski
November, 1979
Program Goals and Objectives
Health education has as its ultimate goal the improvement of health, socially, mentally and physically;
and its means to attain optimal health is by a change in
behavior.
A basic assumption to achieving behavioral
change is to work through an increase in knowledge and
change in attitude.
A cancer education program would
offer an opportunity for patients to acquire knowledge in
cancer control, and to develop a positive attitude towards
cancer prevention and detection techniques.
Program Objectives
1.
Ultimate Objective
To improve the individual's health by reducing
_cancer morbidity and mortality through an organized patient education program.
2.
Intermediate Objective
To increase knowledge about cancer prevention and
detection in patients.
3.
Immediate Objective
53
54
To plan, implement and evaluate a cancer education prevention program for patients who are
hospitalized in the general medical/surgical
wing at Ventura County General Hospital.
Educational Objectives
1.
To increase interest in the basic cancer facts,
and develop fear-free attitudes regarding cancer
in patients.
2.
To increase the basic knowledge about cancer-prevention, symptoms, methods of detection and
the hopeful side of cancer to patients.
3.
To demonstrate ~rhy certain actions, including
periodic health check-up, breast self-examination,
the "Pap" test, facilitate early detection and
diagnosis.
4.
To discuss healthful behavior with patients which
may prevent precancerous conditions, especially
the advisability of not smoking, avoiding overexposure to the sun, etc.
5.
To provide a list of community resources regarding
cancer control and detection, e.g., American
Cancer Society or Public Health Services, to
hospital staff and patients receiving the education program.
Patient Teaching Modules
Introduction
The following five teaching modules contain informawhich the health or nurse educator should familiarize
themselves with prior to working withthe General Medical/
Surgical patient.
It is imperative that all staff and the instructor
provide the patient with a supportive environment in which
the program can be presented.
Hand out reading materials recomn1ended in the Teaching
Guide and request that both the patient and his family
read them.
When possible, present video-tapes at times
when the patients and their families can view them together.
Record teaching progress on the teaching checklist
attached to the patient's chart.
Before beginning each module, check the Patient
Education Care Plan in the patient 1 s chart for any additions or deletions the primary physician may have made.
A goal of the modules is to assure that consistent
messages are received by the patients.
If instructions
are based on these modules, there will be less ambiguity.
55
Module #1
TOPIC:
"Basic Cancer Facts and Warning Signals"
Objectives
1.
The patient will be able to correctly list five
of the seven warning signals of cancer.
2.
The patient will be able to locate and name at
least five common sites of cancer on a large diagram of
the body.
3.
The patient will be able to state at least four
advisable practices to prevent pre-cancerous conditions.
4.
The patient will be able to define the difference
between a "benign" and "malignant" tumor.
5.
The patient will understand and be able to dis-
cuss the difference between "localized," "regional" or
"invasive" cancer.
Materials/Resources Needed
1.
Large diagram of the human body
2.
Pre/post test
3.
Video-tape:
American Cancer Society's ttMan
Alive" or "Signals"
4.
Handouts--"Listen to Your Body, 11 "Cancer Facts
for Men," "Cancer Facts for Women,n "Answering your
Questions about Cancer"
56
57 '
5.
Health Educator or Nurse
Teaching Strategy
This introduction to the educational program must be
presented in a non-threatening atmosphere with the patients
consent to participate.
Explain the purpose of the pro-
gram and that this is a very new approach to prevention and
early detection, soliciting the patient's cooperation.
If
the patient consents to participate, ask him to take the
pre-test;
introduce the video-tape over closed-circuit
television.
After the film, discuss their immediate ques-
tions or concerns if any.
If none, using the large dia-
gram of the human body, discuss the
corr~on
cancer sites.
Ask them for their understanding of the cancer terminology
introduced in the film, e.g. malignant, invasive, etc.
As in all modules, complete the pre-education assessment
if the patient decides to volunteer in the program.
Let
them know when you will return to teach the next module.
Content Outline
A.
Signs and Symptoms
1.
Time is the most important factor in cancer
control;
it is essential that a warning
signal be recognized early.
2.
There are Seven Warning Signals which may or
may not indicate cancer.
If any of these
last longer than two weeks, go to a doctor.
58
The warning signals are:
a.
Changes in bowel or bladder habits
b.
A sore that does not heal
c.
Unusual bleeding or discharge
d.
Thickening or lump in breast or elsewhere
e.
Indigestion or difficulty in swallowing
f.
Obvious change in size or color of a
wart or mole
g.
3.
Nagging- cough or hoarseness
Prompt action by the individual is important
when a warning signal is noted because there
is the best possibility of a cure if the
growth is treated while localized in one
part of the body.
B.
Seven Safeguards of Prevention of Cancer (leading
sites of cancer)
1.
Lung cancer:
don't smoke, lung cancer is
difficult to detect and treat, but easy to
prevent.
2.
Skin cancer:
avoid over-exposure to the suns
ultraviolet rays.
At least 95% of skin can-
cer could be cured if sores which did not
heal were reported early to a doctor.
59
3.
Breast cancer:
leading cause of cancer
deaths in women;
tection;
monthly BSE is best pro-
95% of all lumps found are detected
by woman herself.
4.
Oral cancer:
(mouth) not as
cancers mentioned.
corr~on
as other
Easily detected during
a thorough oral exam by a dentist or doctor.
Oral self-exam is also taught and can be
performed by the individual.
5.
Cervical cancer:
periodic Pap
ing a pelvic examination;
test~
includ-
almost 100%
curable when detected and treated early.
6.
Colon and rectal cancer:
most common form
of cancer in both men and women in the United
States.
The key to early diagnosis is
proctoscopy--passing of a small lighted tube
into the lower part of the rectum and colon.
Three out of four patients might be saved if
a "procto" was done annually for people over
forty years of age.
7.
Regular check-ups:
a most important safe-
guard against cancer.
The six cancer sites
just named add up to 50% of annual cancer
deaths.
**Emphasize the low or no-cost services available--breast
and "Pap" exam clinics, oral detection, Stop Smoking
60
programs.
C.
Definitions
1.
Cancer:
A large group of diseases character-
ized by uncontrolled growth and spread of
abnormal cells.
2.
Tumor:
A swelling or enlargement; an abnor-
mal mass, either benign or malignant, which
performs no useful body function.
a.
Benign - an abnormal swelling or
growth that is not a cancer is usually
harmless.
b.
Malignant - a tumor made up of cancer
cells.
These tumors continue to
grow and invade surrounding tissues;
cells may break away and grow elsewhere.
3.
Localized:
Cancer cells that remain for a
time on the surface of some tissues at the
site of origin, i.e. surface of the uterus,
lining of the mouth, stomach, etc.
This
is also called cancer "in situ."
4.
Regional:
Cancer cells that become detached
or "metastasized" and are carried through
the blood or lymph systems to other body
organs.
The spread of the disease is some-
times retarded for a while in a lymph node.
61
5.
Advanced:
Cancer cells that eventually
spread to other parts of the body because of
no treatment for the disease.
Death is
almost inevitable at this point.
62
Module #1
Pre/Post Test
True/False
T
1.
Most types of cancer are curable in the early
stages, before growth spreads to other parts of the body.
T
2.
Cancer is a disorderly, uncontrolled growth of
3.
There is scientific proof that cancer in
cells.
F
h~~ans
T
is contagious.
4.
C~ncer,
in its earliest curable stage, usually
has no symptoms, but cancer at this stage often can be
detected by a physician.
F
5.
Cancer is a condition of the elderly.
T
6.
One out of every four persons living in the
United States today at some time in his/her life will
develop cancer.
F
7.
All cancer is caused by nutritional deficiency.
T
8.
Lung Cancer is largely a preventable disease.
F
9.
Cancer cells ordinarily do not stop multiplying
once they start.
T
10.
Benign tumors are usually harmless--examples of
benign tumors are warts, cysts and moles.
11.
There are 7 Warning Signals for cancer (Mark
an x in front of a Warning Signal)
----a.
Extreme tiredness, no energy
63
x
b.
Unusual bleeding or discharge
x
c.
A lump or thickening in the breast
or elsewhere
x
d.
_____e.
Change in bowel or bladder habits
Pale skin tone and coloring
X
f.
Hoarseness or persistent cough
X
g.
Change in a wart or mole
X
h.
A sore that does not heal
X
i.
Indigestion or difficulty in swallow
ing
----~j.
Persistent pain at the site, at the
onset of symptoms
12.
There are 7 Safeguards against cancer (Mark an
x in front of a Safeguard)
x
a.
Don't smoke cigarettes
x
b.
Avoid overexposure to the sun
x
c.
Have a "Papn test for cervical
cancer periodically
x
d.
Perform monthly breast self-examination
_____e.
x
f.
Eat only lean meats
Regular oral examination by dentist
or doctor
x
g.
"Procto" exam for colon-rectal cancer if over 40 years of age
-----·h.
Drink at least 8 glasses of water a
64 '
day.
X
i.
_ _,j.
Annual health check-up
Exercise at least 15 minutes daily
,,
--------
Module #2
TOPIC:
"Breast Cancer and Breast Self-Examination"
Objectives
1.
The patient will be able to state when to do
breast self-examination.
2.
The patient will be able to demonstrate the
correct way to do breast self-examination.
3.
The patient will be able to name two places to
. go for a breast examination if she finds a lump or other
condition.
4.
The patient will be able to explain the purpose
of breast self-examination.
5.
The patient will be able to state at least two
risk factors associated with breast cancer.
Materials/Resources Needed
1.
Breast model
2.
Video-tape;
American Cancer Society 1 s "How to
do Breast Self-Examination"
3.
Handouts;
"How To Do Breast Self-Examination,"
"Progress in Breast Cancer," "If You Find A Lump In Your
Breast"
4.
Pre/post test on breast cancer
5.
Instructor
65
66
Teaching Strategy
Initially, only female patients will be asked to
participate in this teaching module.
After an intro-
duction to the prevention program in cancer by the educator, the patient will be asked to take the breast cancer
pre-test.
As in all modules, complete the pre-education
assessment for each patient.
patient to view.
Introduce the video-tape for
After viewing, discuss the film and then
ask patient to demonstrate breast self-examination using
the breast model.
Administer the post-test.
Share re-
sults with the patient discussing any concerns they might
have about the BSE procedure or breast cancer.
Give the
patient the breast cancer brochures and a community resource list for their future reference.
This is a good
one-to-one or small group teaching module.
Content Outline
A.
Key Facts
1.
Breast cancer is the most
cow~on
internal
site of cancer among women, striking 1 in
11 women.
It is the leading cause of death
for all women ages 37 to 55.
2.
Women are still their own best protection
against a fatal breast cancer.
They are in
the best position to find suspicious lumps,
through breast self-examination, and to
67
report them.
Over 90% of diagnosed breast
cancers are found by women, not doctors.
B.
Early Detection
1.
Steps in early detection might include:
a.
Personal exam, detection of mass
(lump) through systematic self-exam
procedure vs. accidental palpation
of lump at early state.
Eight out
of every ten lumps discovered during
BSE are not cancerous.
(1)
Shower or bath, fingers slide
easily, skin slippery.
Keep
fingers flat and touch every
part of breast, feel for lump
or thickening.
(2)
Sit or stand, look at breasts
in mirror.
Any changes?
Size and shape?
Puckering
or dimpling of skin? Discharge or change in nipples?
Raise both arms behind head
and look ahead.
(3)
Lie down after shower or
bath, hand behind head, pillow or
ro~led
towel under
68
shoulder, flattened fingers,
small circular motions;
feel
all parts including nipple.
Start at upper outer corner
of breast (many lumps are
found here) .
(4)
Tips:
by examining yourself,
you get to know your breasts
and can detect changes more
easily.
Examine your breasts about
one week after each period.
Breasts change before and
during menstruation--glands
are more tender, etc.
Pay attention to the upper
outer section of each breast.
The lower ridge along bottom
of breasts is normal.
Menopause, hysterectomy pick specific date once a
month, i.e. 1st, 15th.
C.
Risk Factors Associated With Breast Cancer
1.
Over 35 years of age (risk increases with
age).
69
2.
A woman who has never had a child.
3.
A woman who had her first child after the
age of 25.
4.
A woman whose
mother~
sisters or other
maternal relatives have had breast cancer.
5.
A woman who experienced early menarche
(first period) and/or late menopause (change
of life) .
D.
Other Beliefs
1.
Some evidence that breast feeding prevents
breast cancer (especially in very young
mothers).
2.
Little evidence that the use of birth control pills increases the risk of breast
cancer.
3.
Breast cancer is not cause by a
burr~
or
blow to the breast.
E.
Reasons \ihy Women Fail to Report Breast Changes
1.
Fear that all lumps are cancerous and all
cancers fatal.
2.
Modesty.
3.
Ignorance of the meaning of changes.
4.
Lack of confidence in breast self-examination.
70
Module #2
Pre/Post Test
Breast Cancer and Breast Self-Examination
True/False
T
1.
Breast cancer is discovered by the woman her-
self in 95% of the cases.
T
2.
One in every 11 women born today will at some
time in her life develop cancer of the breast.
T
3.
The most
corr~on
cancer in women is cancer of
the breast.
T
4.
Monthly breast self-examination for females
should be started at the beginning of breast development
and practiced throughout life.
T
5.
The majority of the lumps found in the breast
are benign.
F
6.
A bloody discharge from the nipples indicates
breast cancer.
T
7.
Women who breast feed their babies have a
lower risk of developing breast cancer.
T
8.
If a woman has a tumor in one breast, the
probability of developing a tumor in the other breast is
doubled.
F
9.
The breast self exam should be done before each
menstrual cycle.
71 '
F
10.
It doesn't matter if you use a towel under the
shoulder during breast self-examination.
F
11.
It is abnormal to feel a ridge in the lower
part of the breast.
T
12.
Any abnormal discharge from the nipple is
something to see your doctor about.
F
13.
Almost all breast lumps are cancerous.
T
14.
Heredity and/or other factors may influence
the likelihood of any woman developing breast cancer.
For example, a woman whose mother or sisters had breast
cancer increase the risk for her.
Multiple Choice (Circle the co-rect answer)
15.
What part of the breast is most frequently
the site of a breast cancer (or malignancy)?
B
16.
c
Why should you look at yourself in the mirror
as part of your breast
(A)
self-exa~ination
process?
To be sure you're doing it properly.
(B) /Some abnormalities can be seen./ (C)
To
check your muscular development.
17.
\Alhy is it important to go to your doctor
immediately if you discover a lump or other abnormality?
(A) /Early treatment could save your life./
72
(B)
long.
You may forget about it if you wait too
(C)
Doctors need the business.
Module #3
TOPIC:
"Uterine Cancer and Components of the Pap Test"
Objectives:
1.
The patient will be able to locate and name all of
a woman 1 s reproductive organs.
2.
The patient will be able to discuss the purpose of
a "Papn test.
3.
The patient will be able to state 3 warning
signals of uterine cancer.
4.
The patient will be able to state the difference
between cervical cancer and endometrial cancer.
5.
The patient will be able to name at least one
place to go for a "Pap" test.
Materials/Resources Needed
1.
Pelvic model
2.
Pre/post test
3.
Video-tape;
American Cancer Society's
11
For A
Wonderful Lifen
4.
11
Pap-Pak, n plastic spatula, and speculum
5.
Handouts;
"Stay Healthy, Learn About Uterine
Cancer," and "Cervical Cancer Screening Clinics 11
6.
Instructor
Teaching Strategy
73
As in Module #2, only female patients, initially, will
be introduced to this module.
It is important to stress
the painless nature of a "Pap 11 test and the availability
of facilities within the Health Care Agency that provide
low-cost "Pap" tests.
Emphasis on the utilization of women
practitioners at our RCA clinics also increases the comfort
level of our women patients.
Content
A.
Reproductive Organs
1.
Cancer of the sex organs is more common to
women than to men.
The sex organs include:
a.
Ovaries--egg for reproduction is made
b.
Fallopian tubes--close to ovaries and
form a path to the womb or uterus
c.
Uterus--receives the fertilized egg and
nourishes the embryo during development
prior to birth;
site of endometrial
cancer
d.
Cervix--opening from the uterus into
the vagina, most frequent site of cancer in female reproductive organs
e.
Vagina--female organ of intercourse and
the birth canal.
2.
If a woman's uterus (all or partial) is removed, this is called a hysterectomy.
It
75
is still advised that she have a "Pap"
test.
Although very unlikely, cells sloughed
off from the vagina could be abnormal.
Also,
hormone levels can be determined from the
"Pap'' smear.
B.
Purpose of the "Pap" test
1.
The Pap test is a screening test for cancer
of the cervix.
It is a simple painless test
that can detect various conditions of the
cervix (mouth of the womb or uterus)
2.
Cells and mucous are wiped from the cervix
using a small plastic spatula.
The cells
and mucous are put on a glass slide and
sent to the laboratory.
Here the slide is
looked at through a microscope to see if
there is any inflammation, infection or abnormal appearing cells.
NOT NECESSARILY
3;
~ffiAN
ABNO~ffiL
CELLS DO
CANCER.
The Pap test is done periodically because
cervical cancer is highly curable (almost
100%) if detected early and treated promptly.
4.
The Pap test is limited in detecting cancer
of the endometrium.
If other symptoms appear
only a thorough pelvic examination by a
doctor can tell for sure.
Endometrial can-
cer is most frequently diagnosed in women
76
who have passed the menopause.
C.
Warning Signals of Endometrial Cancer
1.
Unusual bleeding or discharge from the
vagina
D.
2.
Bleeding between periods
3.
Bleeding after menopause (change of life)
A Factor That Maybe Associated with an Increased
Risk of Cervical Cancer:
1.
Early sexual activity and/or multiple sex
partners, i.e. early exposure of the cervix
to intercourse may somehow injure normal
cells.
77
I
Module #2
Pre/Post Test
Uterine Cancer and Components of the Pap Test
True/False
T
1.
The "Pap" test is a detection test for cervical
cancer that should be taken periodically by every woman
when sexual intercourse becomes part of her life.
F
2.
Periodic health exams including cancer detec-
tion tests such as the "Papn test are not necessary for
young adult women.
T
3.
Cervical cancer and endometrial cancer (body
of the uterus) are two different kinds of cancer.
F
4.
A positive Pap Smear definitely means a woman
has cancer.
5.
Women with intra-uterine devices (IUD's)
experience a higher rate of cervical cancer.
F
6.
\ITomen who have had a hysterectomy do not need
to have a periodic Pap test.
T
7.
Cervical cancer is almost 100% curable if de-
tected early and treated promptly.
Circle the Correct Answer
8.
Cervical cancer in the United States is most
common among
(d)
(a) Whites
Mexican-Americ~~s.
(b) Blacks
(c) Orientals
'
78
9.
The only effective mass screening program
currently in use for cancer is for cancer of the
(a) colon
10.
(b) lung
(c) skin
(d) cervix
Deaths from uterine cancer have dropped in
recent years, probably due to:
rate
(e) prostate.
(a) the drop in birth
(b) the decrease in nuclear test explosions
ly detection through use of "Pap" tests
(£) ear-
(d) increased
sales of prophylactics (condoms).
11.
The chief warning signals of endometrial
cancer are: (Fill in the blanks)
a)
c)
b) _______________
--------------------------------
(Unusual bleeding from the vagina, bleeding between periods, and bleeding after menopause)
Module #4
TOPIC:
"Smoking and Lung Cancer:
Your Smoking Behavior"
Objectives:
1.
The patient will be able to name three types
of cancer cause by cigarette smoking.
The patient will be able to name three reasons
2.
why he started to smoke and continues to smoke.
3.
The patient will be able to discuss what smoking
type(s) he is from the fixed smoking types as described
by Horn.
4.
The patient will be able to list at least three
obstacles to quitting.
5.
The patient will be able to state at least three
smoking cessation programs available to him in Ventura
County.
Materials/Resources Needed
1.
American Cancer Society's smoking machine (option-
2.
Video-tape;
al).
M.e?"
American Cancer Society's film n\llho,
Or nThe Time to Stop Is Now."
3.
Pre/Post test
4.
The Smoker's Test
5.
Handouts;
"The Decision Is Yours," "If you Want
to Give Up Cigarettes," "I Quit Kit"
79
80
6.
Instructor
Teaching
Strateg~
This module should be directed towards the smoking
patient although non-smoking patients should also be
considered since most people have smoking friends/relatives.
Emphasis of this module should be directed to the
patient's awareness of her smoking behavior and not to the
clinical aspects of lung cancer.
The object is not to
scare the patient with facts and figures, though some of
this type information must be presented.
Their knowledge
of their smoking behavior or "type 11 might encourage discussion on modifying or quitting their habit.
As in pre-
vious modules, introduce the topic, followed by a pre-test
and the video-tape.
If the patient wants to further dis-
tinguish his smoking behavior, administer the "Smokerrs
Self-Test," followed by discussion and the post-test.
Leave any "stop smoking" materials, kits, etc. if patient
desires.
Content Outline
A.
Smoking and Lung Cancer
1.
Lung cancer is the leading killer among
cancers, killing an estimated 90,000 people
this year.
2.
Over 100,000 new cases this year will be
found.
81
3.
Lung cancer kills about 6 times as many men
as women, although recent statistics have
shown the rate of increase of lung cancer
among women has been greater than in men.
4.
90% of all lung cancer occurs among smokers.
5.
Risk factors for lung cancer are increased
with:
a.
the number of cigarettes smoked per
day
6.
b.
the duration of smoking (over years)
c.
the depth to which smoke is inhaled
d.
the early age of onset of smoking
90% of lung cancer patients die within 5
years of their diagnosis.
7.
Smoking is also causally related to cancer
of the larynx, oral cavity, urinary bladder,
and esophagus.
8.
Occupational exposure to uranium ore, asbestos and nickel increases the risk of
lung cancer, but more so for smokers than
for non-smokers.
B.
Smoking and Cardiovascular Disease
1.
Smoking is causally related to coronary
heart disease for both men and women in
the United States.
2.
Smoking is one of the major risk factors
82
in fatal and non-fatal myocardial infarction and sudden cardiac death in adult men
and women.
3.
Stopping smoking dramatically reduces the
incidence of heart disease and additionally helps damaged lung tissue return toward
more normal limits.
C.
Social Effects of Smoking
1.
Smoking is almost entirely a learned behavior, primarily in response to direct
and indirect social pressure.
Two major
influences are:
2.
a.
smoking by one or more parents
b.
peer pressure
Smoking becomes a social requirement
during adolescence.
3.
After one starts to smoke, the reasons
he/she continues to do so may not be related to the initial cause.
D.
Six Psychological Reasons for Smoking (Horn's
Test, 4:97)
1.
There is no truly ntypical" smoker.
2.
Smokers fit roughly into one or more of
six smoking types, depending on how their
habit has developed.
83
a.
Stimulation- (10%), i.e. helps the
smoker wake up in the morning, organize energies, keeps him going.
b.
Handling- (10%), enjoys manipulating the cigarette with hands, watching the smoke curl, etc.
c.
Pleasurable Relaxation- (15%),
smoker gets real honest pleasure
from smoking, especially after a
meal or with a cocktail.
This
person is smoking under positiveaffect circumstances.
d.
Crutch:
Tension Reduction- (30%),
uses cigarettes as tranquillizers
in moments of stress, fear, shame,
discomfort, etc.
Cigarette used
as a tool to help him cope with
problems.
(Negative-affect circum-
stances).
Needs to learn how to
manage situations producing bad
feelings before substitution of
cigarette can be made.
e.
Craving:
Psychological Addiction -
(25%), feels totally dependent upon
cigarettes, and is constantly aware
when not smoking;
begins to crave
84
for the next cigarette when one
just put out.
Tapering off does
not seem to help;
solution to
quitting is usually ''cold turkey."
f.
Habit- (10%), usually gets very
little satisfaction from the habit and performs it automatically.
A minimal amount of awareness
accompanies this pattern of smoking.
E.
To Quit or Not to Quit
1.
For those who refuse to quit, five steps
can be taken to lessen the hazards:
a.
smoke fewer cigarettes each day
b.
take fewer puffs on each cigarette
c.
reduce the depth of inhalation
d.
smoke less of each cigarette
e.
choose a brand low in tar and
nicotine (give patient brand
list if he/she desires)
2.
Quitting can best be considered not as a
single, isolated event but rather as a
continuing, extended process.
Persistent
effort is required and many obstacles are
met to get an individual "off the hook."
Listed as obstacles are:
( 4:101)
a.
social pressure
b.
lack of a plan
c.
alcohol
d.
psychic defenses;
e.
feared loss of control
f.
expectation of failure
g.
secret smoking
h.
stressful situations, actual or
mobilized denial
planned
F.
i.
weight gain
j.
nicotine dependence
k.
self-pity;
"mourning"
Smoking Cessation Programs
1.
"Cold turkey 11
-
sudden cessation by indi-
vidual alone
2.
American Cancer Society's "Stop Smoking
Clinics" - $15.00/person for sixteen hours,
group sessions led by facilitator (exsmoker)
3.
Schick Program - aversion therapy and behavior modification for one week - $400$500/person
4.
"Smoke-enders" - similar to Schick
5.
Seventh Day Adventist Church's "Five Day 11
86
Smoking Program - group session;
health-
ful living and diet control approach,
$15.00
87
Module #4
Pre/Post Test
Smoking and Lung Cancer:
Your Smoking Behavior
True/False
T
1.
Cigarette smoking causes at least 80% of lung
2.
A chest X-ray often detects lung cancer when
cancer.
F
it is highly curable.
T
3.
The most common cancer in men is cancer of the
4.
Only about ten out of every 100 cases of lung
lung.
T
cancer live five years after diagnosis.
T
5.
There are known carcinogenic (cancer causing)
substances within our environment that can be avoided to
help prevent cancer, i.e. cigarette smoke.
T
6.
The rate of lung cancer has increased at an
alarming rate over the past 40 years.
F
7.
If lung cancer has spread to the lymph nodes,
the 5-year survival rate is 40 to 50 percent.
T
8.
A 30-35 year old, two-pack-a-day smoker has a
life expectancy eight to nine years shorter than a nonsmoker of the same age.
T
9.
Cigarette smokers lose more work days per year
and have more hospitalizations than persons who never
smoked.
88
T
10.
Quitting smoking reduces the risk of death
from coronary heart disease and after 10 years off
ciga~
rettes this risk approaches that of the nonsmoker.
T
11.
Children of parents who smoke are more likely
to have bronchitis and pneumonia during the first year of
life.
F
12.
Parents do not influence their children's
decision to start smoking.
Module #5
TOPIC:
"Colon-Rectal Cancer"
Objectives
1.
The patient will understand that colon-rectal
cancer is the most common cancer in the United States,
excluding skin cancer.
2.
The patient will be able to name two major symp-
toms of colon-rectal cancer.
3.
The patient will be able to locate the site of
this type of cancer using a large diagram of the human
body.
4.
The patient will be able to explain the function
of the colon and rectum.
5.
The patient will be able to discuss at least two
methods used to protect themselves against colon-rectal
cancer.
6.
The patient will be able to name at least three
"high fiber 11 foods supplying bulk to their diet.
Materials/Resources Needed
1.
Video-tape;
ACS's "On With Your Life" or "The
Cancer No One Talks About"
2.
Handouts;
"Two Ways to Protect Yourself Against
Colorectal Cancer," "Facts On Colorectal Cancer"
89
90
3.
Pre-post test
4.
Tray of high-fiber foods (samples)
5.
Instructor
Teaching Strategy
Colon-rectal cancer, traditionally, is the cancer
that is avoided in discussion.
The educator should con-
vey the very basics about this type of cancer to the
patient, putting it in its true perspective--the #1 internal cancer in the United States, occuring equally in men
and "mmen.
Administer the pre-test;
let the patient view the
video-tape and then follow with a discussion including the
"procto" exam, self-guiac test, high fiber diet.
Stress
the high curability of this disease, if detected early.
Explain the new terms introduced carefully--e.g., polyp,
high-fiber diet, etc.
Show patient the tray v'li th samples of
11
high fiber
foods 11 and explain simply how these goods help in the
digestion process.
Administer the post test.
If the patient raises questions regarding colostomy,
etc. be prepared to answer them or get answers back to the
patient quickly.
Content Outline
A.
Key Facts
91
'
1.
Colon and rectal cancer are the most prevalent internal cancers in the United
States;
about 100,000 people, divided
equally between males and females, are diagnosed each year.
2.
More than 90% of those diagnosed are over
40 years of age.
3.
If detected early, 75% of colon-rectal
cancers are treated successfully.
4.
Major warning signals or symptoms are:
a.
change in bowel habits, diarrhea,
constipation, etc.
b.
blood in stools, rectal bleeding can
never be assumed to be the result of
hemorrhoids alone
c.
B.
unexplained anemia
Function of the colon (or large bowel) and rectum:
1.
To extract liquid from the remains of digested food and to hold the solid waste
matter until ready to be expelled from
the body.
C.
Food Fiber and Colon-Rectal Cancer:
(This is
only a theory but is included in much professional
literature and accepted by many physicians and
other researchers relative to colon-rectal cancer).
'
92
1.
Dr. Dennis P. Burkitt has theorized that
bulky, undigested food residues make a
quick passage through the intestines,
thereby reducing the time in which bacteria, or other cancer causing substances
can be in contact with intestinal tissues.
2.
He contends that the American diet, high
in refined foods with low fiber have contributed to the high incidence of this
kind of cancer.
3.
Foods 'Ni th "high fiber" content include:
a.
unrefined cereals, e.g. bran, rice,
certain breads
b.
D.
leafy green vegetables
Detection Methods.
1.
A proctosigmoidoscopic exam, also·known as
a "procto. 11
This one foot long instrument
is used to examine the loHer 12" of the
bowel, where the majority of cancer occurs.
This exam can be uncomfortable for the
patient, but is highly recommended for
persons over 40 years of age.
Polyps can
also be easily removed with this instrument.
2.
A colonscope can examine the entire colon,
giving an excellent view of tissue;
can
93
also remove polyps or other suspicious
growths.
This procedure is less uncom-
fortable for the patient.
3.
X-ray detection can also detect tumors as
a bump or obstruction, however, X-ray
doesn't show whether a tumor is malignant
or benign.
4.
"Do-It-Yourself Guiac" test:
purpose is
to find hidden blood in the stool;
a
very small stool specimen is smeared on a
slide or tape.
Sample is mailed or
brought to a lab and is analyzed for
blood.
The physician will explain results
to the patient.
E.
Definition of Terms
1.
Colon - The lower five to six feet of the
intestine, also called the large bowel.
2.
Rectum - The last five to six inches at
the end of the colon, leading to the
outside of the body.
3.
Polyp - A mass of swollen mucous membrance
projecting into the colon or another cavity of the body;
4.
possibly pre-cancerous.
Colonscope - A highly flexible instrument
used for examination of the colon.
94
5.
Proctosigmoidoscope - A tube through which
the physician examines the lower 10-12
inches of the intestine.
6.
Fiber - The residue of plant cells after
digestion by alimentary enzymes.
95
Module #5
Colon-Rectal Cancer
Pre/Post Test
True/False
T
1.
When statistics are combined for both men and
women, colon-rectum cancer becomes the number one cancer
killer.
F
2.
The procto examination can be used to detect
stomach cancer.
T
3.
The PROCTO exam is particularly valuable for
those in the over 40 year age group.
F
4.
All cancer is caused by the chemicals added to
our foods.
~ .....
F
5.
If you watch what you eat, you won't get cancer.
F
6.
Americans have a lower number of colon cancer
cases as compared to the rest of the world.
T
7.
If diagnosed early, cancer is largely a pre-
ventable disease.
T
8.
Almost three out of four patients with colon
and rectal cancer can be cured by early detection.
F
9.
An X-ray of the colon and rectum can detect a
malignant (cancerous) tumor.
F
10.
Only hemorrhoids cause rectal bleeding.
T
11.
Diets composed of more refined foods (sugar,
white bread, white flour) have been indicated as a factor
96
in cancer of the colon.
Program Forms
And
Evaluation Tools
97
98 '
C~ncer
Education
Progr8~
Pre-Education Assessment-New Patients
Interviewer
Checks One
Criteria
(Ask Patients Questions Belew)
ll.
Clear
II
Unclear
Education Completed
Na;ne of
Time
Date
-Cosp. Educator Spent
I
What do you think are
some ;.,·arning signs for
r-.qnc~:r
?
2.
What do the words "benign"
"tumor" and "malignant"
tumor mean to you?
3.
How have you been told
to do BSE? Can you
show me?
4.
Do you understand what is
the purpose of a "Pap"
test?
s.
How do you think smoking
affects your body? Do
you smoke?
6.
'n"hat is the purpose of
a "urocto" exam?
INITIAL OBSERVATIONS
Frame of Mind:
(Circle 1 or more) Anxious Depressed Puzzled
Inattentive Angry Fearful Nonchalant Attentive Friendly Cooperative
Verbal Comurehension:
(Circle One) Excellent Good Fair Poor
Other Como.ents:
Patient's Name~~------------------~--~-----------Age __________________
Last
First
Address
Phone #
~~--~--------------~~~----------~-------
.Street
City
Zip
--------------
Chart fl
Room #
Hospitalization Days Expected _____________
Major Diagnosis __________________________________________________________
Physician ________________________________________________________________
~
Interviewer
Modules Corr.p~l-e~t-e~d-:--~(~C~i-r-c~l~e-r)-l~--~2----~3~--~4~---.5~------------------Pre-Post Test Scores:
___/ ___/ ___/ ___/
___/
99
MAJOR MEDICAL PROSLEMS:
3. _____________________
1.
2. ________
4.
PATIENT EDUCATION NEED (Chech Drsired Program):
D
0
D
D
Myocardial Inil!!ction
0 P.T.
*D O.T.
D Angina
D CHI<'
[ ] Pacemaker
D Cardiomyopa:.hy (Specify)
0
D
D
D
0
D
Rheumatic Heart Disease
Hypertension
Diabetes
Prenatal
Infant Care
Family Planning
D
c
Diet
Medications
Mental Health
Videotape Programs
0 Diabetic Series .
Prenatal Series
Jpfar.t Care
0
ro
.__, Death a!!d Dying
D Cardiac Series
Pre{Po>t Operative Teachbg
Other (Specify)
0
D
*When ordering A/.1. Program also check 0. T. and P. T. and specify activity levels under special instructions.
SPECIAL
PHYSICI.~'-1
/
INSTRUCTIONS: __ _
-------------- --------·
APPROXI!-.lATE DATE OF PATIENT DISCHAil.GE:
EXPECTED DISCHARGE 11EDICATIONS: - - - - - - - - - - - -
EXPECTED DISCHARGE DIET:
PH'\'SICIAN SIGNATURE:--------·
PATIENT EDUCATION CARE PLAN
GENERAL HOSPITAL VENTURA COUNTY
PATIENT EDUCATION PROJECT
BOS!'-505-24 (3/1YI
DATE:--
100
TEACHING CHECKLIST
(PLEASE DATE Al\fD INITIAL TEACHING AS CO!'rfPLETED)
2. DIABETES
1. BASIC CARDIAC PROGRAM
Insulin Admin. ·.....••••......•••••
Diet in CCU ................•.....•
D
D
D
Patient Reporting ....••.••.•.•••..•
D
Etiology ...........•.•.••.· •.•.•.•
Transfer Prep ...............••..•••
D
Diet. ........•.•..•.....•...•.••.
0
Heart A & P ..•.•.•..•••••••••.•.••
D
Exercise .............•••....• ·.••.•
D
Pathophysiology ......•...•..•.•.•.
D
Sick Day/TraveL .•....•......••••..
D
Angina ........••.....••.. ~ •••.•.•
0
0
D
Diet (Post CCU) ...•....•••.....•.•
D
D
Personal Hygiene .•.•••..•••••••••... _ __
Medications ....... : ••..•..•.•.••..
D
Other:------------
D
Sexuality .............•....•....••
D
Atherosclewsis ................... .
D
Community Resources ............. .
0
D
D
D
D
Orientation to CCU ................ .
Supportive Care .............•••....
Urine Testing ...••..••....•.••...•.
Hyper/Hypoglycemia .•..••....• - .•
Foot Care ....•...•.•...••..••.•.•
Risk Factors ..............•.....••
/
3. INFANT CARE PARENT EDUCATION
Additional:
CHF ..............•..•........•.
D
0
RHD .............•.•......•....•
D
Infant Nutrition •..................
D
Pacemaker .........••.••.•.••.....
D
Preventive Health Measures .......... .
D
Cardiomyopathy ...............••••
D
Community I Agency Resources ....... .
D
Physical
0
Basic Infant Care ................•..
4. PRENATAL CARE
Ch3.Dg~s/Common
Complaints ..
D
P.P. Care/Family Planning.: ......... .
D
Nutrition; Exercise, ).!eds, Hygiene .....
D
Basic Infant Care(Signs of Il1'1ess ...... .
D
A and P of Pre;;nancy ..............•
D
Infant Nutrition .................. .
D
Labor·and Delivery .........••.•... ·.
0
Prev. Health Measures/Com Resources ..
5. OTHER TEACHING (Please Specify)
D
D
D
D
INSTRUCTOR COMMENTS:---------~--------------------
101
Ventura General Hospital
Patient Education Program
Follow-Up Questionnaire
Dear
-------------- ,
You have participated in our cancer prevention education program during your stay in the hospital. This
questionnaire will help us to evaluate this program and
make changes to improve it. We would appreciate your
answering the questionnaire below and returning it in the
self-addressed, stamped envelope provided.
1. Since leaving the hospital, have you found the
information you received about cancer prevention and
detection of value to you or members of your family?
'
2. Do you feel that the information given was too
much or too little? Please explain.
3. Do you feel that the cancer education session(s)
progressed too fast or too slow?
4. Were the pamphlets and other printed materials
given to you useful and easy to understand? Or difficult?
Please explain.
102
5. Has the information you received in the session(s)
helped you to take better care of yourself?
6. Have you used any of the community resources
available to you and your family since leaving the hospital?
7. Do you have any suggestions for how we might improve our program?
Thank you for taking the
time to fill out this
survey.