Evaluation of a ‘Supportive Educative Intervention’ on self care in patients with bronchial asthma

http://doi.org/10.33698/NRF0096 – Sukhpal Kaur, D Behera, D Gupta, S K Verma

Abstract : Bronchial asthma is a common chronic respiratory disease. It affects people of all ages. Various problems in asthma can be minimized, provided these patients are made aware of the disease. The present study was conducted to develop, implement and evaluate a ‘supportive educative intervention’ in the form of ‘Self Care Manual’ based on the concepts of Orem’s theory (supportive educative system). An experimental research design was employed. Total 523 consecutive diagnosed asthma patients were studied, of which 260 were included in study group to whom ‘self care manual’ was provided and 263 were enrolled in control group to whom no specific instructions were given. After initial interview (0 week), follow up of all patients was carried out at two weeks, six months and one year. Using an elaborative interview schedule various parameters evaluated were knowledge of the disease, their symptomatology, emotional reactions, triggering factors and indices of asthma morbidity. Knowledge scores were significantly high and emotion scores were significantly less at all the visits in the study group (p<0.001). In both groups symptom score decreased at all the follow up visits (p<0.001). There was a significant decrease in severe attacks, emergency visits and need of injections during last one year in both the groups though difference was more marked in the study group. Number of hospital admissions and absence school/job decreased significantly only in study group at one year. Thus the intervention was beneficial in improving self care abilities of asthmatic patients.

Key words :

Bronchial asthma, Patient education, Orem’s theory, Self care.

Correspondence at :

Sukhpal Kaur

National Institute of Nursing Education PGIMER, Chandigarh

Introduction

Conceptual foundations of professional nursing practice comprehensively explore issues and concepts that influence professional practice and the delivery of nursing care. Theories and conceptual frameworks provide direction and guidance for structuring professional nursing practice that assist nurses to guide assessment, intervention and evaluation of nursing care.1 Through the theoretical constructs of self care, self care deficits, and nursing systems, Orem defines the complementary relatio- nships between nursing and individuals.2 Nursing in the past two decades has relied heavily on self care as a pre requisite for healthy behavior. Bronchial asthma, a common chronic respiratory disease, is influenced by biological, environmental, psychological and social factors. Despite of growing awareness and understanding of the underlying pathogenic mechanisms it remains grossly underdiagnosed and undertreated.3 An effective control and prevention of the disease requires a combination of adequate medical treatment, environmental control, education and self-management training.4 The International Consensus Repor t on the Diagnosis and Treatment of asthma describe asthma management as having six inter- related parts, of which the first is “to educate patients to develop a partnership in asthma”.5 In fact patient education gives the patient an insight into his problems and leads to a closer relationship between the patients and the ‘involved staff’ at the clinics.6 Principle aim of nursing is to help patients to manage their lives and to live as fully and independently as possible. In bronchial asthma, patient education is central to achieve this.7 Bronchial asthma being a chronic ilIness needs to be managed by patients themselves at home and at their place of work. So educating the patients about the disease and self care practices will help them to attain and maintain adequate disease control compatible with desired quality of life. Several studies have shown that positive results can be achieved with nurses as educators although it is important that to be effective the nurse should have special training and an interest in asthma.

In one study a nurse who was herself an asthmatic was more effective in educating the patients than a non-specialist nurse.8 Another such study showed improved morbidity, reduced stigma and increased confidence in the patients attending the clinic after introduction of a nurse run asthma clinic.9 The present study was conducted with the objective to develop and evaluate an intervention i.e. a ‘self care manual’ (a booklet of 26 pages) on bronchial asthma based on the concepts of Orem’s general theory of nursing, specifically the self care deficit nursing theory and the theory of nursing system. As it has been reported that written material are by far the most frequently used tools for educating patients despite evidence suggesting that they are inappropriate for a significant number of consumers who can’t read or comprehend the information.10,11 Thus an attempt was made to prepare the self care manual in Hindi (a regional language) and also to make it more pictorial so that all the persons could understand it easily.

Orem’s Self Care Deficit Theory and Bronchial Asthma Orem’s self care deficit theory (SCDNT) is expressed in three nursing theories i.e. theory of self care; theory of self care deficit; and theory of nursing system.12 Self care is the human regulatory function that individuals must perform themselves to maintain life, health, development, and well being. A self care system is usually sufficient unless the person is faced with a new health care situation requiring adaptation or alternative health behaviors. When the self care system is limited, the deficit in the self care results and nursing assistance is required. Thus Self care deficit is a term that expresses the relationships between the capabilities of individuals and their demands for self care. It provides guide for the selection of methods for helping and understanding patient’s roles in self care. Through Nursing system the nurse assesses the individual’s self care deficits and plans, implements and evaluates nursing actions directed towards supplement- ing them. The system proposes that the nurses are required to be well educated and experie- nced to plan care for the individuals. Depen- ding upon the capabilities of the individuals the nurses’ action could be wholly compen- satory, partly compensatory and supportive- educative.12 In the current study the ‘suppo- r tive educative system’ is taken into consi- deration.

Most investigations into the level of understanding of patients with asthma about their condition have found a very poor level of knowledge regarding the disease and its management.13,14,15 There is a great variation in asthma symptoms during the day, from day to day and from week to week, and asthma treatment needs to be adjusted accordingly.16 These patients often need special knowledge and skills to meet the therapeutic self care demands in order to promote their own health and well being. Nurses can help patients to prepare themselves for the future enhanc- ement in self care requirements. Thus an education for asthmatics should include information about the disease, precautions and treatment of asthma attacks and bronchial infection, physiotherapy, and training of self- management of airflow limitations.17 Special efforts must be made to explain the benefits of corticosteroids therapy. Inappropriate over emphasis of the side effects of corticosteroids is a recognized risk factor contributing to the deaths of some patients from acute asthma.7 Moreover there are essential technical skills to be learned by the bronchial asthma patients mainly the correct use of metered-dose aerosol and regular measurements and documentations of peak expiratory flow rate which is much more a matter of demonstration, coaching and practice. 18 They also need to learn what steps are appropriate or safe for them to take on their own and when to communicate with the health professionals in case of emergency situation. The various triggering factors and how to avoid them is also an important aspect to be known by the patients. In our country, ignorance, superstition and social stigma associated with asthma and its management can only be controlled by constant discuss- ions, encouragement and prolonged edu- cation program. 19,4,3

Method of development and evaluation of Intervention

As per Orem’s theory12, to maintain healthy systems the nurse must assess each patient’s self care needs and on the basis of these deficits an appropriate plan of care should be developed, implemented and continuously re-evaluated. Thus to assess the knowledge of the patients regarding the disease bronchial asthma, a preliminary study on 45 patients was undertaken. The mean knowledge score of the patients was 57. 7± 10.17 (Range 31-80). The results indicated that the asthmatics lack knowledge in almost all the spheres of the disease like etiology, symptomatology, treatment and prevention of bronchial asthma etc.20 Based upon these findings, after reviewing the relevant literature and under the guidance of experts in the related fields, an intervention-a ‘Self Care Manual’ (a booklet of 26 pages) in Hindi (the National Language of India and is the most common spoken language in this part of country) was prepared. The text contained the information like ‘What is asthma, how it develops, the various triggering factors, signs and symptoms, control of emotions, use of inhalation devices, measurement of peak flow rate, management according to traffic lights, home management of acute attack and preventive measures of asthma etc. The educational intervention was developed with an aim to improve the knowledge of the patients regarding various aspects of bronchial asthma in order to reduce the morbidity and mortality due to the disease. As per Balkina et al 21 one of the reason of increasing morbidity and mortality due to asthma is unsatisfactory compliance of the patients. Thus to understand the disease and doctors effort better the patients need detailed knowledge about their disease.

To evaluate the usefulness of the developed self care manual the study was conducted in the out patient department of pulmonary medicine at Post Graduate Institute of Medical Education and Research, Chandigarh, India. The total 523 enrolled subjects were randomized using random number table into two groups i.e. 260 and 263 each in the study and control group respectively. After the initial interview at 0 week the patients included in the study group were given the ‘self care manual’ which was thoroughly explained to them because to perform self care a person needs an adequate self care agency. However the control group patients were not given any specific instructions. The dependent variables (knowledge of the patients, their symptoms, emotional reactions, various triggering factors, self-care in acute attack, and indices of asthma morbidity) were measured four times i.e. pre test (0 week) and three post tests at 2 weeks, 6 months and year. A detailed interview schedule to evaluate the said parameters was developed and used at each visit in both the groups. Data was analyzed using descriptive and inferential statistics. (Figure 1)

Findings

As shown in table I, in the study group the mean knowledge scores were higher at all the follow up visits as compared to the pre test.  (F=633.98,  p<O.OOl).  However  in control group, there was small increase in the knowledge scores at first follow up visit but there after it decreased. In both the groups, the symptom scores decreased at all the follow up visits. (F=71.78, p<O.OOl in the study group and F=24.19, p<O.OOI in the control group) The mean emotion score in the study group was 8.08±5.50 at 0 week and 5.89±4.88, 1.44±4.63 and 1.19±4.01 at 2 weeks, 6 months and I year following up (F=72.28, p<O.OOI). In the control group, the mean emotion score was 8.50±6.30 at 0 week and 7.88±6.21, 7.35±6.03 and 5.97±5.81 at 2 weeks, 6 months and 1 year follow up visit (F=6.03, p<O.OOl). The detail of emotional aspects of bronchial asthma is published else where.22 On comparing both the groups with each other, it was observed that the knowledge score of study group

Figure 1 : Conceptual Framework based on orem’s theory

 Self care agent                    Patient with bronchial asthma

Self care deficit                    Lack of knowledge Disease Triggering factors Signs/symptoms Management

Preventive measures

Lack of Skill

Use of inhalation devices Use of peak flow meter

Assessment of knowledge Development of ‘Self Care Manual’

Implementation and evaluation of ‘Self Care Manual’

Study group No = 260

Awareness of disease Severity of symptoms Controls of Emotions Avoidance of Triggers Number of severe attacks Number of Hospitalizations Absence from school / work

Control group N=263

Follow up at 2 weeks, 6 months, 1 year subjects was significantly higher than that of control group subjects at all the follow up visits. Similarly there was significant difference in both the groups as per the reduction in symptom and emotion score was concerned. (Table 1) As far as the triggers of bronchial asthma were concerned the number of patients whose symptoms were precipitated/ triggered by a par ticular triggering factor reduced serially on each successive follow up visit in study group. In control group, a significant reduction in number of patients ftom first to subsequent visits occurred for cigarette smoke, hot and humid weather, pollens and cold weather, whereas there was no significant difference for other triggers. But even this significant reduction was more for study group patients as compared to control patients. Regarding the various measures adopted (including drug treatment and general measures) by patients during an acute attack there were no significant changes in these attitudes during the follow up year in either group, although the number of patients who had acute attack(s) during the year before enrolment in the study became significantly less during the study year. Also significantly more patients from study group at 1 year practiced breathing exercises during an acute attack as compared to control patients. There was statistically significant decrease in the number of severe attacks, number of emergency visits and need of injections during last 1 year (study year) in both the groups, though the differences were more marked in the study group. However there was significant decrease in the number of hospital admissions and number of days of absence from work in the study group at 1 year as compared to control group.

Table 1 : Mean scores of knowledge, symptoms and emotions

  Knowledge (Max score=34) Symptoms (Max score=44) Emotions (Max score=24)
  Mean ±S.D. ‘t’ Mean ±S.D. ‘t’ Mean±S.D. ‘t’
0 Week Study 13. 04±4. 06 3.94** 18. 14±1O. 10 0.60 8.08±5.50 0.69
    Control 11.44±4.0   18.76±1O.42   8.50±6.3  
2 weeks Study 26.91:8.6 40.85** 10. 97±9. 63 4.13** 5. 89±4.48 3.57**
    Control 12.29±3.6   15. 19±1O. 71   7.88±6.21  
6 Months Study 27.75±15.46 46.85** 13.01±3.78 4.88** 1.44±4.63 8.52**
    Control 10. 18±3.06   12.07±9.95   7.35±6.03  
1 Year Study 28.13±15.70 48.71** 12.61±2.97 5.2** 1. 19±4. 01 7.67**
    Control 9. 74±2. 89   10.69±9.43   5.97±5.81  
F Value Study 633.98**   71. 78**   72.28**  
    Control 22.39**   24.19**   6.03**  

S.D. = Standard deviation, **p<O.OOI

Discussion

Education is an essential part of the management of patients with bronchial asthma. The best of medical treatment and care provided to patients may not help much if enough information in not given about the disease, its management, preventive and control measures and self care activities. The information infact should be imparted in such a manner that will have a lasting impact on the patients. In the present study an intervention i.e. a booklet on bronchial asthma based on the concepts of Orem’s theory is developed and evaluated. Many studies have shown that providing written material helps the patient to recall information.23 Findings of the current study suggest that the information provided a systematic and comprehensive approach to patient’s self care deficits. The supportive educative intervention was effective in improving the knowledge, decreasing the severity of symptoms and the emotional reactions, enhancing the self care measures the patients adopt during an acute attack and decreasing the indices of asthma morbidity. These finding have been supported by many other studies. In one of the study by Hiromoto and Dungan24, Orem’s supportive educative system was used to teach self care activities among chemotherapy patients. It was concluded that four of the subjects were able to recognize symptoms, could weigh options for actions, initiate self care behaviors and evaluate the effectiveness of self care activities. Jaarsma et al 25 in another study have reported that a supportive educative intervention which consisted of an intensive, systematic and planned education by a nurse for patients with heart failure has resulted in significant increase in self care behavior both in hospital setting and at home. In one more study by Jaarsma et al 6 it is reported that education enhanced self care behaviors significantly at one and at three months after discharge. In another study by Jaarsma et al 7 in the journal of Heart Lung, it was concluded that a supportive educative intervention was effective in improving self care behavior in patients with advanced heart failure. It is further added that self care behavior was higher in study group subjects than the control group, however there was no change in self care abilities even in the study group subjects and also there was difference between the two groups in decrease in symptom frequency and symptom distress during the 9 months of follow up. Fujita and Dungan28 also used supportive educative nursing system in their study. It is emphasized that comprehensive teaching of patients supported by therapeutic nurse- patient relationship was found to be the most impor tant factor in the promotion and maintenance of a prescribed medication regimen among patients with congestive heart failure.

Thus to conclude it can be said that the self care manual has helped the patients with bronchial asthma irrespective of their socio- demographic background. Their knowledge regarding the disease, symptoms, emotions, and indices of morbidity have improved significantly as compared to their control counterpar ts. Thus the intervention has reinforced and supplemented the management of asthma patients. It helped them become more aware, less symptomatic, and emotionally more stable with reduced morbidity.

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