RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BENGALURU, KARNATAKA.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BENGALURU, KARNATAKA.

SYNOPSIS PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING SENSORY STIMULATION IN UNCONSCIOUS PATIENTS AMONG STAFF NURSES IN SELECTED HOSPITALS, BENGALURU.”

MRS. JEEMOL VARGHEESE

1ST YEAR M Sc NURSING

MEDICAL AND SURGICAL NURSING,

SJB COLLEGE OF NURSING,

KENGERI, BENGALURU-560060

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BENGALURU, KARNATAKASYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT

FOR DISSERTATION

1

NAME OF THE CANDIDATE

AND ADDRESS

MRS. JEEMOL VARGHEESE

S J B COLLEGE OF NURSING,

BGS HEALTH AND EDUCATION CITY,

KENGERI, BENGALURU 60

2

NAME OF THE INSTITUTION

S J B COLLEGE OF NURSING,

BGS HEALTH AND EDUCATION CITY,

KENGERI, BENGALURU 60

3

COURSE OF STUDY AND SUBJECT

I YEAR M.Sc. NURSING

MEDICAL- SURGICAL NURSING

4

DATE

OF ADMISSION

25-06-2012

5

TITLE OF THE TOPIC

“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING SENSORY STIMULATION IN UNCONSCIOUS PATIENTS AMONG STAFF NURSES IN SELECTED HOSPITALS, BENGALURU.”

6. BRIEF RESUME OF INTENDED WORK

6.1 Need for the study

“Keep your body grounded on earth, but keep your consciousness high above the clouds” ― Tyler Hebert

Health is the level of functional or metabolic efficiency of a living being. In humans, it is the general condition of a person's mind, body and spirit, to get aware of their surroundings1.

Consciousness is a state of being with two important aspects, wakefulness and awareness of self and environment.2 Unconsciousness is a condition of being unaware of one’s surroundings as in sleep or of being unresponsive to stimulation.3

Unconsciousness is lack of response to sensory stimuli as a result of hypoxia; resulting from respiratory insufficiency or shock, metabolic or chemical brain depressants, such as drugs, poisons, ketones, or electrolyte imbalance, a form of pathologic condition such as trauma, seizures, cerebro vascular accident, brain tumors or infection.4 Unconsciousness can be brief lasting for a few seconds to minutes or sustained, lasting for an hour or longer2.

Unconscious patients may survive for days or months and often experience decreased quality of life. The outcomes ranges from recovery to death.5 Coma generally last a few days to few weeks, rarely more than 2 to 5 weeks .After this some patient gradually comes out of coma or some may progress to a vegetative state, and some may die. Some patients may remain in a vegetative state for years or even decades.6The outcome from coma and vegetative state depends on the cause, location, severity and extent of neurological damage. 7

Traumatic brain injury (TBI) is the major cause for unconsciousness. Approximately 60 percent will make a positive recovery, and an estimated 25 percent will be left with a moderate degree of disability. Death or a persistent vegetative state will be the outcome in about 7 to 10 percent of cases. The remainder of patients will have a severe degree of disability.8

To facilitate the recovery process, coma arousal techniques has been developed.5 Coma arousal programs operate on the belief that brain has restorative properties, previously not appreciated.9 According to coma arousal techniques there are four scientific theories that address the brain’s apparent adaptability in recovering from brain injury. These are

· Spare capacity and reorganization

· Redundancy

· Response at a cellular level

· Environmental effects

Spare capacity and reorganization refer to the brain's apparent ability to reorganize its functions following injury. The redundancy theory is refers to the brain’s apparent ability to duplicate neuronal pathways. The response at a cellular level theory revolves around the scientific fact that when cells in the central nervous system are dead, recovery does not occur. The environmental effects theory refers to the improved performance that is noted in animals and humans when increased environmental stimulation occurs.

Sensory stimulation programme is based on environmental effect theory for the recovery of brain.10Sensory stimulation are essential factors in stimulating the reticular activating system to maintain consciousness.6Sensory stimulation programme (SSP) is a planned series of activities aimed to stimulate the senses of comatosed patients. The aim is to arouse a patient from coma and try to awaken them. Many types of efforts are made, including showing the patient to look at, playing music, speaking, touching and offering things to the patients to smell, taste and touch.11

Sensory stimulation programs for coma patients act by increasing environmental stimulation to the part of the brain that controls levels of consciousness, attention and concentration. It has been proposed that with intense and repeated stimulation and following very precise protocols, a patient could be awakened early from coma and returned to higher level of functioning. Some patients in coma awaken slowly and begin to respond normally.12The program should commence as early as possible after development of coma. Therefore improved health outcomes would be anticipated by reducing the time a patient spends in coma8.The intensity of these programs varies. Sensory stimulation program ranges from 1 hr or 2 cycles of stimulation daily (1 hr each) to hourly stimulation cycles, lasting from 15-20 minutes for 12-14 hrs per day, six days in a week.11

Some patients in coma awaken slowly and begin to respond normally. Sensory stimulation, application of planned, meaningful, multimodality sensory stimulation has been suggested as a measure to enhance outcome from coma. Nurse is encouraged to interact with comatose patients through all their sensory system2. Nurses who work with coma patients would do well the sensory stimulation programme in their areas to see what they have to offer the comatose patients and their families.

Unconsciousness more appropriately referred to as loss of consciousness or lack of consciousness. Glasgow coma scale (GCS) is a widely used scoring system to assess coma and impaired consciousness. Patient with a score of 8 or less is moderate and score of 13-15 are mild unconscious2.

Hospital Episode Statistics for 2002-2003, Department of Health, England states that 82% of hospital consultant episodes for unconscious and coma required hospital admission, among which 47%are men and 53% are women.13 According to a survey conducted in 2005 by National Institute of Mental health and Neuro Science, the incidence of mild unconsciousness was 131 cases per 1,00,000 people,15 cases per 1,00,000 people were moderate unconscious and 14 severe cases per 1,00,000 people.14

The longer the patient remains in coma more they suffer from a long term cognitive , behavioural and emotional impairment which prevents them from pursuing active and responsible lives after injury.7 Although emergency care, diagnostic technology , medical intervention and nursing care have resulted in increased survival in individuals after traumatic brain injury, arousal and cognitive recovery are not guaranted.15

Arousal is a pre-requisite for all the selective attention necessary for recognizing and processing information. Without arousal the more complex cognitive process such as sustained attention or concentration necessary for learning cannot occur.15With the current state of knowledge related to activation of recovery mechanism immediately following unconsciousness, it can be stated that early environmental stimuli via sensory stimulation program may enhance recovery processes. The clinical use of sensory stimulation program with comatosed patients has garnered success.6

A randomized controlled trial was conducted by Karma and Rawat (2006) on 60 pediatric patients who were in a coma due to non traumatic causes. Sensory stimulation programme was given through 5 senses and the patient’s level of consciousness was measured using the Glasgow Coma Scale (GCS). The results showed that the study group demonstrated significant improvement, while the control group did not show much improvement. Thus it suggests that sensory stimulation can improve the recovery of unconscious patients.16

A quasi experimental study was conducted in U.S.A, 2003 with sample size of 24 patients and the Sensory stimulation programme was given to patients each day for up to 7days. The GCS scores were recorded as pre-test and post-test. The results showed that improvement was demonstrated in participants who receive auditory sensory stimulation. Hence it was concluded that sensory stimulation is effective in the recovery of unconscious patients.17

Considering the above facts and review of literature, investigator felt that sensory stimulation will improve the level of consciousness among unconscious patients. As a student as well as staff nurse, the investigator had that, the staff nurses can do more for unconscious patients other than care with sophisticated equipments as they are with them at all the time during hospitalization. In the view of above need, the investigator has taken the study to provide the staff nurses with adequate knowledge regarding sensory stimulation in unconscious patients.

6.2 REVIEW OF LITERATURE:

Review of literature is a key step in research process. The major goal of review of literature is to develop a strong knowledge base to carry out research scholarly activity.

The review of literature for the present study is explained under the following headings.

1. Literature related to sensory stimulation in unconscious patients.

2. Literature related to knowledge of staff nurses regarding sensory stimulation.

3. Literature related to effectiveness of structured teaching program.

1. Literature Related To Sensory Stimulation in Unconscious Patients

An experimental study was conducted to examine the effect of Sensory stimulation program (SSP) on recovery in unconscious patients after traumatic brain injury in Thailand. Forty unconscious patients admitted in hospitals were divided into control and experimental groups and 20 included in each. Response to stimulation was assessed using the modified Sensory Modality Assessment and Rehabilitation Technique score and the Glasgow Coma Scale score. The results showed that mean modified Sensory Modality Assessment and Rehabilitation Technique scores after commencing the SSP in the experimental group were significantly higher than those in the control group. Mean Glasgow Coma Scale scores after commencing the SSP in the experimental group were significantly higher than those in the control group. The results indicated that the SSP can enhance brain recovery in unconscious patients.18

An experimental study was conducted in Philadelphia to evaluate the possible therapeutic benefits of intense multi-sensory stimulation (IMS) in the management of profound coma. Two hundred hospitalized patients with Glasgow Coma Scale (GCS) scores of 6 or less were selected, outcome results are compared with 33 patients (controls) who did not receive IMS; 34.5% of the IMS group made a moderate to good recovery based on Glasgow Outcome Scores (GOS), 9% have remained in PVS, 56.5% are still severely disabled with marked psychomotor deficits, but are out of coma and some are continuing to show progress. A total of 91% are out of coma; 33 patients in the control group (100%) remain in coma. The results shows that the outcome in acute and chronic coma conditions can be markedly influenced by IMS.19

A meta-analysis was performed on data from 24 single-case experimental studies evaluating the immediate effects of sensory stimulation treatment on patients in vegetative state following traumatic brain injury. Response to treatment was evaluated by time sampling behavior pre and post-treatment, and examining for changes in behavior that suggested increased arousal. Analyses showed that multimodal stimulation produced greater behavioral changes than unimodal stimulation and the use of personally salient stimuli in multimodal stimulation the greatest changes of all.20

2. Literature Related To Knowledge Of Staff Nurses Regarding Sensory Stimulation

A descriptive study was conducted by Batool A Jaddoue, and Ali A Ghanim, in Bagdad, in 2009, to assess the knowledge and practices of nurses regarding caring of unconscious patients in intensive care units. The study included 50 staff nurses, and the tool was structured knowledge questionnaire.28 (56%) of nurses revealed that the inadequacy of knowledge and skills for nurses in the field of airway care, observation and record level of consciousness, and the application of sensory stimulation. Thus it can conclude that there is a need for improving knowledge of staff nurses in application of sensory stimulation for unconscious patients.21

A descriptive study was conducted in selected hospitals of Mangalore to assess the knowledge of staff nurses regarding care of unconscious patients .The study sample was 60, the results showed that the knowledge of staff nurses was found to be adequate but in certain areas like safety needs of unconsciousness and sensory stimulation it was found to be inadequate. This study shows a need for educating staff nurses who are taking care of unconscious patients regarding sensory stimulation.22

A systematic literature search study was done in the Royal Surrey County Hospital, Guilford, to assess the researchers interpretations regarding importance of touch and verbal communication while caring unconscious patients. Ashworth (1980), one of the authors of a literature recognizes nurses often experience difficulties in communicating with unconscious patients, because the patient is unable to respond. It is recommended that nurses evaluate such studies and aim to strike a balance in providing physical and psychological care by focusing on touch and verbal communication while ensuring that any clinical needs are met. Nurses need to analyze their patient’s responses to communication and be aware of physiological signs that may indicate stressful reactions. Nurses who are involved in the care of unconscious patients should identify further evidence to ensure best practice. This concludes that the staff nurses who give care for unconscious patients require more knowledge regarding importance of verbal communication. 23

3. Literature Related To Effectiveness Of Structured Teaching Programme:

A quasi experimental study was conducted to assess the effectiveness of structured teaching programme on knowledge and practice of staff nurses regarding body mechanics in selected nursing interventions on 30 nurses who are selected by convenient sampling technique .The improvement in mean percentage for overall knowledge was 38.6% with‘t’ value 14.68 which was highly significant showed the effectiveness of structured teaching programme (STP) on body mechanics in selected nursing interventions. Thus it can conclude that the STP is effective in improving knowledge of staff nuses.24

A quasi experimental study was conducted to assess the effectiveness of planned teaching program for the care givers in the family, on prevention of pressure sores among spinal cord injured patient in selected hospital on thirty samples revealed that improvement mean score was 51.8 with‘t’ value 41 which shows the effectiveness of structured teaching program in improving the knowledge. This shows that the planned teaching programme can be used to educate the care givers effectively.25

PROBLEM STATEMENT:

“A study to evaluate the effectiveness of Structured Teaching Programme on knowledge regarding sensory stimulation in unconscious patients among staff nurses at selected hospitals, Bengaluru”.

6.3 OBJECTIVES OF THE STUDY:

1. To assess the pretest knowledge score regarding sensory stimulation in unconscious patients among staff nurses.

2. To evaluate the effectiveness of structured teaching programme among staff nurses regarding sensory stimulation in unconscious patients.

3. To find the association between pre test knowledge score and selected demographic variables.

6.3.1 Hypotheses:

H1: There will be a statistically significant difference between mean pre-test and post-test knowledge scores regarding sensory stimulation in unconscious patients among staff nurses.

H2: There will be significant association between the pre-test knowledge score and selected demographic variables among staff nurses.

6.3.2 Variables:

1. Independent variable: Structured teaching programme regarding sensory stimulation

2. Dependant Variable: Knowledge of staff nurses regarding sensory stimulation in unconscious patients.

3. Demographic Variable: Age, Gender, Educational Background, Working experience and attended any continuing nursing education on sensory stimulation in unconscious patients.

6.4 Operational Definitions:

1. Effectiveness: In this study it refers to desired gain in knowledge as determined by significant difference in pre-test and post-test scores on the structured knowledge questionnaire among staff nurses.

2. Structured Teaching Programme: In this study it refers to a planned teaching and learning process between the investigator and study subjects that helps the study subjects to change his or her knowledge regarding sensory stimulation in unconscious patients.

3. Knowledge: In this study it refers to the correct facts regarding sensory stimulation in unconscious patients.

4. Staff nurses: In this study it refers to registered nurses who are giving direct patient care in hospitals.

5. Sensory stimulation: In this study it refers to the introduction of different stimuli such as auditory, visual, tactile, olfactory and gustatory to the human body.

6. Unconscious patients: In this study it refers to persons who are admitted in hospitals with Glasgow coma scale score of 4-7, incapable of responding to sensory stimuli and of having subjective experiences.

6.5 Assumptions:

1. Staff nurses will have some knowledge regarding sensory stimulation in unconscious patients.

2. Structured teaching programme will improve the knowledge of staff nurses regarding sensory stimulation in unconscious patients.

6.6 Delimitations:

The study is limited to;

1. The staff nurses who are present at the time of data collection.

2. 60 staff nurses who are working in selected hospitals.

7. Materials and Methods:

7.1 Source of Data: staff nurses who are working in selected Hospitals, Bengaluru.

7.2 Method of Collection of Data

7.2.1 Research Approach: Evaluative Approach.

7.2.2 Research Design : Pre experimental one group pre-test post-test design.

7.2.3 Setting : selected hospitals, Bengaluru.

7.2.4 Sample And Sample Size: 60 staff nurses.

7.2.5 Criteria For Data Collection

7.2.5.1 Inclusion Criteria:

Staff nurses who are;

· Present at the time of data collection.

· Willing to participate in the study.

7.2.5.2 Exclusion Criteria:

Staff nurses who are;

· Sick at the time of data collection.

· Not involved in direct patient care

7.2.6 Sampling Technique: Non probability convenience sampling technique.

7.2.7 Tool of Research: The research instrument will include two parts.

Part I – Demographic data

Part II –Structured knowledge questionnaire regarding sensory stimulation in unconscious patients.

7.2.8 Collection of Data:

1. The formal permission will be obtained from the hospital authority.

2. The informed consent will be taken from the staff nurses.

3. Investigator collects the data from staff nurses through self administered

Structured knowledge questionnaire followed by structured teaching programme.

4. Post test will be done after seven days.

7.2.9 Duration Of The Data Collection: Four weeks.

7.2.10 Method Of Data Analysis And Presentation:

Data obtained from the sample will be organized and analyzed with the use of both descriptive and inferential statistics.

a) Descriptive statistics:

1. Frequency and percentage distribution will be used to describe the demographic variable of staff nurses.

2. Mean, median, mean percentage range, and standard deviation will be used to describe the knowledge regarding sensory stimulation in unconscious patients among staff nurses.

b) Inferential statistics

1. Paired‘t’ test will be used to evaluate the effectiveness of structured teaching programme on knowledge of staff nurses regarding sensory stimulation in unconscious patients.

2. Chi square test will be used to find the association between knowledge regarding sensory stimulation in unconscious patients among staff nurses and selected demographic variables.

Analyzed data will be presented in the form of tables, diagrams and graphs based on findings.

7.3 Does the study require any investigation or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.

Yes, the study will include an intervention in the form of Structured Teaching Programme. However there will be no other invasive or non invasive investigation on participants in the study.

7.4 Has ethical clearance been obtained from your institution?

1. Yes, Consent will be obtained from concerned subjects and authority of institution.

2. Privacy of subjects, Confidentiality and Anonymity of the data will be guarded.

3. Scientific objectivity of the study will be maintained with honesty and impartiality.

8. LIST OF REFERENCES:

1. Wikipedia [online]. 2012 Nov 19[cited 2012 Nov 22]; Available from: URL:.http://en.wikipedia.org/wiki/Health.

2. Black JM, Hawks JH. Medical Surgical Nursing. 8th ed. Philadelphia: Saunders; 2009. P. 1792-3.

3. The Oxford concise medical dictionary. 6th ed. Oxford: Oxford University Press; 2002.unconsciousness

4. Anderson KN, Anderson L, Glanze WD. Medical nursing and allied health dictionary. 4th ed.Missouri: Mosby; 1994. P. 1612.

5. Dancer S, Brown AJ, Yanase LR. National Institutes of Health Stroke Scale. Jneuronurs [serial online] 2009 february [cited 2012 OCT 23]; 41(1) Available From: URL: https:// www.Nursing center.com/pdf-aspx?an =01376517.

6. Gruner ML,Tehrang D. Multi modal early onset stimulation(MEOS) in rehabilitation after traumatic brain injury. Brain inj 2000; 14(6):584-94.

7. Stern JM, Sazbon L, Becker E ,Costeff H. Severe behavioral disturbances in patients with prolonged coma. Brain Inj 1988;2(3):259-62.

8. American Association of Neurological Surgeons [online]. 2011 Mar 24 [cited 2012 Nov12]; Availablefrom:URL:https://www.aans.org/Patient%20Information/ Conditions%20and%20Treatments/Traumatic%20Brain%20Injury.aspx.

9. Lasden M. Coming out of coma. The NYTimes Magazin 1982 Jun 27;6(1):28-35,38,40 ,54.

10. Baker J. Coma Arousal Theory and Practical Considerations. [online]. 2010 [cited 2012 oct 31];Available from: URL: http://www.comacare.com/cgi-bin/giga.cgi?cmd=cause_dir_news_item&cause_id=1784&news_id=84750&cat_id=0.

11. Mitchell S,Bradley VA,Welch JL,Britton PG. Coma Arousal Procedure: a therapeutic Intervention in treatment of injury. Brain Inj 1990; 4:273-279.

12. Sosnowski, Ustik. Early intervention; coma stimulation in the intensive care unit. jneuro nurs 1994 dec ; 26(6):336-46.

13. Hospital statistics for Coma [online]. 2012 Feb 1 [cited 2012 Nov 6]; Available from: URL:http://www.rightdiagnosis.com/c/coma/hospital.htm.

14. Gururaj G, Kolluri SVR, Chandramouli BA, Subbakrishna DK and Kraus JF. Traumatic Brain Injury, NIMHANS,Publication no. 61, Bangalore - 560029, India. 2005 p :9

15. Dalvice,Alice. Cognitive –behavioural recovery in comatosed patients following auditory stimulation, J Neuro nurs 1995 sep;12(3):351-61.

16. Karma D, Rawat AK. Effect of Stimulation in Coma. [online]. 2006 [cited 2012 oct 23]; Available from: URL:www.indianpediatrics.net/oct2006/oct-856-860.htm

17. Davis AE, Gimenez A. Behavioral recovery in comatose patients. J NeuroNurs 2003 Aug;35(4):202-9,214.

18. Urhenjaphol P, Jitpanya C, Khaoropthum S. Effects of the sensory stimulation programme on recovery of unconscious patients with traumatic brain injury. JNeuro nurs 2009 jun;41(3):10-6.

19. Doman G, Wilkinson R, Mihai D , Pelligra R.The effect of intense multi-sensory stimulation on coma arousal and recovery. Neuro psych rehab 2007 oct 24; 3(2):203-12.

20. Wilson SL, Powell GE, Brock D, Thwaites H. Vegetative state and responses to sensory stimulation: an analysis of 24 cases. [online]. 1996 [cited 2012 nov 14 ];Available from: URL:http://www.ncbi.nlm.nih.gov/pubmed/8905159.

21. Jaddoue BA, Ghanim AA. Assessment of Nurses’ Practices for Neurological Unconscious Patients in Intensive Care Units. Iraqi national j.nurs spec [serial online] 2011 [cited 2012 Nov 7]; 24(1): Available from: URL:http://www.iasj.net/iasj?func=fulltext&aId=3475

22. Basava-Yellanagowda P. A study to assess the knowledge of the staff nurses regarding care of unconscious patients 1998

23. Leigh K, Dip H E. Communicating with unconscious patient. N times 2001 Nov 29;3(1):33-5.

24. Salome P. A study to Assess the Effectiveness of Structured Teaching Programme on Knowledge and Practice of Staff Nurses regarding Body mechanics in Selected nursing interventions at MSRM Hospital, Bangalore. 2006.

25. Siddharth SN. API Textbook of Medicine.7th ed. Mumbai: Association of Physicians of India Publications; 2003. P. 1263-77.

9.

SIGNATURE OF THE CANDIDATE

10.

REMARKS OF THE GUIDE

The study is feasible and of genuine interest of the student.

11.

NAME AND DESIGNATION OF

11.1. GUIDE

Mrs. MANIMOZHI.R, MSc(N).

Professor,

HOD, Medical and Surgical Nursing,

SJB College Of Nursing,

Kengeri, Bengaluru-60.

11.2. SIGNATURE

11.3. CO-GUIDE

Ms. JESNA JOSE MSc (N).

Lecturer,

SJB College Of Nursing,

Kengeri, Bengaluru-60.

11.4. SIGNATURE

11.5. HEAD OF THE DEPARTMENT.

Mrs. MANIMOZHI.R, MSc(N).

Professor,

HOD, Medical and Surgical Nursing,

SJB College Of Nursing,

Kengeri, Bengaluru-60.

11.6. SIGNATURE

12

12.1. REMARKS OF THE PRINCIPAL

The topic for the study is relevant and forwarded for needful action.

12.2. SIGNATURE

1

16