Rajiv Gandhi University of Health Sciences, Karnataka.

SYNOPSIS

FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 Name of the Candidate MS. JOSEPHINE.P

2. Name of the Institution Diana College of Nursing.

No. 68, Chokkanahalli,

Jakkur Post, Bangalore – 64

3. Course of Study and Subject Master of Science in Nursing.

Psychiatric Nursing.

4. Date of Admission to Course 10.06.2009

5.

Title of the Topic

ASSESS THE EFFECTIVENESS OF

STRUCTURED DEMONSTRATION ON

KNOWLEDGE AND PRACTICE

REGARDING DRESSING AND

TOILETING SKILLS AMONG

EMPLOYED CARE GIVERS OF

MENTALLY CHALLENGED CHILDREN

IN SELECTED INSTITUTIONS,

BANGALORE.

6. BRIEF RESUME OF THE INTENDED WORK:

Introduction:

“THE RETARDED CHILDREN MAY BE THE VICTIMS OF FATE; BUT LET

THEM NOT BE THE VICTIMS OF OUR NEGLECT" - KENNEDY.

Mental Retardation is different from mental illness. lt is a handicap like blindness,

deafness or lameness, A person with visual handicap cannot use his eyes to see.

Likewise a person with mental retardation is also handicapped. Low intelligence is

their problem. They cannot use their intelligence to do their activities of daily living

satisfactorily. ln order to these activities of daily living (e.g eating, dressing,

grooming), they depend on others. We find that some person with mental retardation

cannot even attend to their personal needs like eating and dressing. But with good

training he/she can be made to attend his personal needs1. A person who is mentally

retarded is not aware of his handicap when compared to a person with a visual or

hearing handicap, who is aware of his problem. The term mental retardation is a

synonym to the term mentally challenged.2

The prevalence rate of Mental Retardation in Indian epidemiological studies range

from 12.3% -61.8%. Mental Retardation in on the rise because of decrease in the rate

of abortion and mortality in infancy and early childhood3. Scientific advancement has

helped the children to survive but making them more handicapped physically and

mentally. When we are expecting this alarming increase in mentally challenged,

mental health professionals should seriously start thinking about their rehabilitation4.

Prevalence of Mental Retardation is 2-8 times greater in low income countries than in

industrialised countries; prevalence from India provide varying estimates of psychiatric

problem in children5. Almost 75% of population diagnosed as mentally challenged have

mild mental retardation and 25%. and moderate to severe retardation. According to

National Prevalence rate for mental retardation is at range of 1.4% - 25.3%6.

Professional development is the responsibility of every nurse. Unfortunately very few

programmes give nurses the opportunity to become directly involved with mentally

challenged clients in the clinical setting as stated that in India , few specialized nurses are

available in the areas of child psychiatry, child psychology and social work; also there

are few training centres being run for teachers in the area of mentally challenged and

special learning disorders6.

Research in this area focuses in stimulating nursing interest in the field of mental health

and encourage nurses to become actively involved in demystifying the problem of mental

challenged for the public. The efforts to bring these special population out of the

institution into the society, that is from dependency to independency, needs the support of

out reach professionals like nurses, social workers and other health workers7.

In a study that has described the evaluation of a "low-key" approach to training staff in

procedures designed to increase the degree of independence of mentally handicapped

people. The amount of residents' independent activity increased prior to the introduction

of leaflets which describes a method of giving graded prompts to residents, remained

stable after their introduction and increased further when checklists were introduced in

regard to self help skills and their degree of independence. The literature review showed

that there is not much of contribution of nursing studies in this context. Thus the

researcher was interested to take up the present problem8.

Though mentally challenged children cannot be made normal, they can certainly be

trained to independently look after their activities of daily living. The key factor in

training lies in selection of priority activities in order. "clothes make a man" -when there

are large number of activities of daily living to be trained, it is rather a difficult task to do

within 4weeks of time8; Dressing and toileting skill was given the first priority and the

care givers who are in immediate contact with these special children were selected in

order to train them in the best possible manner. A sensitive professional would be a

support to the mentally challenged and their caregivers8.

6.1 NEED FOR THE STUDY:

“THE NEGLECTED CHILD LACKS THE APPEAL

TO LIVE" –FERENCZI (1929).

A child who is mentally challenged will have a profound impact on the family. No one

will like to have an imperfect child. The parents may even reject the child if they cannot

accept the fact that the child has chronic disability. Some parents are so ignorant that they

believe their child is capable of only vegetable existence11. As nurses constitute an

important part of health care providers in the society, and as these are in the rehabilitation

level, there comes the direct need to educate and train the children who are mentally

challenged according to their capacity and need for personal independence.

There is a growing need to train teachers, nurses and other caretakers who are in daily

contact with the mentally challenged in an institutionalized set up. With every skill that

the child acquires, he/she becomes more like other children and this can result in a

change for the better in people’s attitude towards him12.

Service provision is grossly inadequate with most learning disability services being

directed to people of 16 years and older. Children and young people with learning

disabilities are looked after primarily by their families or foster carers in the community.

Today’s children are the pillars of tomorrow. Children are a source of pride as future

citizens of our country. India’s children population is perhaps the largest in the world.

45% of our 700 million populations comes to 315 million children9.

Children under 15 years of age constitute approximately one third of the world’s

population and between 5-15% are afflicted by mental disorders. 80% of the world’s

children live in developing countries where mental health services are meagre or non-

existent. Mental retardation has a national value of 5.3 per 1000 and 80% of the scores

fall below 10.5 / 10009.

In a survey conducted on mentally retarded children, nearly 20 million people in India are

mentally challenged and 3 of every 1000 people belong to this category. Going by the

modest estimates about mentally challenged, based on the several small scale prevalence

surveys conducted in different parts of the country, the retarded population could be

nearly 22 million and about 4,00,000 challenged are being added every year10,11.

They ideally require support with access to resources addressing the special needs of the

young person13.

There is a one word of warning which states that work does not necessarily increase self

esteem of people with learning disabilities, but there remains the need for support in

developing identity, confidence and self worth. Children and young people with learning

disabilities are at above average risk of psychiatric disorders. They require specialist

expertise in terms of assessment and management14.

There are about 300 institutions for training and teaching of mentally challenged in the

country. Where majority urban based and practically in rural areas. In India majority are

looked after by their families and small proportion are looked after in the institutions. Of

the estimated 2.514.

3 million persons with severe mental retardation in India and 4600 professionals of whom

1400 are special educators; remaining included psychologist, medical personnel, speech

therapist, occupational therapist, and physiotherapist. In the field of rehabilitation the

available trained manpower is grossly inadequate compared to the magnitude of the

problem.

There are 2 main reasons for untrained manpower in developing countries:

Lack of training facilities.

Training available is based on imported model and people trained migrate

to developed countries15.

The children should receive an education that broadens the individuals opportunities and

options for a personally satisfying and valued life style. Thus educational training

programmes for caregivers in the long run can provide opportunities for children to

develop their potential and to acquire some basic skills, that are age appropriate15. The

structured demonstrable skills on dressing and toileting should be able to make them

develop self control while facilitating mentally challenged children to be less dependent

on others (care givers) a member in the midstream of the society in which the child

lives15.

This study highlights the need for structured demonstration for employed caregivers in

rendering care for mentally challenged children. Hence the investigator had a curiosity to

teach the care givers regarding special skills especially dressing and toileting skills. The

investigator would like to assess the effectiveness of structured demonstration to the

employed care givers of mentally challenged children.

6.2. Review of literature: The term review of literature refers to the activities involved in identifying and searching

for information on a topic and developing a comprehensive picture of the state of the

knowledge on that topic.

The purpose of review of literature is to obtain comprehensive knowledge and in depth

information through systematic and cultural view of scholarly publications, unpublished

scholarly print materials, audio visual materials and personal communications15.

The review of literature is presented under the following headings:

1. Mentally challenged children and their problems.

2. Role of care givers and their knowledge.

3. Effectiveness of teaching program.

1. Mentally Challenged Children and Their Problems:

Mentally challenged/Mental retardation is defined by the deficits in general intellectual

functioning and adaptive functioning (APA 1998). General intellectual is measured by an

individual’s performance on intelligence quotient (IQ) tests. Adaptive functioning refers

to the person’s ability to adapt to the requirements of daily living and the expectations of

his/her age and cultural group. The DSM – 1V identifies criteria for mental retardation as

IQ of 70 or below, with deficits or impairments in communication, self-care, home living,

social, interpersonal skills, use of community resources, self direction, functional,

academic skills, work, leisure, health and safety16.

The DSM – IV (APA, 1998) states that the aetiology of mental retardation may be

primarily biological or primarily psychosocial or some combination of both. Among 30-

40% of individuals seen in clinical settings, aetiology cannot be determined.

Nearly 75% of Indians who are mentally challenged are only mildly retarded. About 20%

of them are moderately retarded; and about 2 – 3% is severely retarded; such children can

receive partial independence in self care, can learn acceptable behaviour and can be

economically useful within the family by taking on sheltered employment17.

In a study which stated that before developing a system for training, one must decide who

should receive training. Within a institution, many more staff generally interact with the

residents. In this case, all staff who come into contact with the residents – all professional

staff, all residential care staff, and all support staff within the unit, should be trained. The

need to educate the child to control behaviour across settings and staff demands such

extensive training program. In residential and public facilities, parents should also be

trained, but this procedure is usually far more difficult. The long -term advantages of a

well-trained staff outweighs the disadvantages of a few weeks of limited programming17.

A study which stated that the training needs of foster care providers serving mentally

challenged persons have been acknowledged for some time. This review of specific

training programs demonstrates that a variety of excellent materials and strategies for

meeting these needs are now available. A number of important tasks remain. First

existing training programs need to be implemented more widely. Second, new programs

and training materials need to be developed to address needs that are not adequately met

by existing programs. Finally, there is a need to conduct systematic evaluations of care

provider training, on a more regular basis. The results of these evaluations must then be

used to guide refinements in future training efforts. This is an essential step if these

programs are to be effective in meeting their goal of improving the quality of care offered

to mentally challenged persons by foster family care providers19.

2. Role of care givers and their knowledge.

In a study that was conducted on 11 severely mentally challenged children to find out the

efficacy of an ‘Activation programme’. During initial assessment on dressing, 6 children

were able to perform dressing skills and after 2 months of Activation Programme, 10

children were able to dress by themselves19.

A study has proved the effectiveness of a graduated guidance procedure for increasing

independence in dressing that was examined in a multiple base line analysis across

behaviours. Two multihandicapped children were trained to dress in socks, pants, and

shirt. In training sessions, subjects completed the entire sequence of steps involved in

putting on the training of each child. Trainer assistance was provided as necessary, but

was faded systematically according to a hierarchy of intrusiveness. Positive

reinforcement was delivered contingent on dressing with increased independence.

Assessment of independent responses followed each dressing behaviour19.

In a study that trained 37 mothers of mentally challenged children aged between 3 ½ and

8 years with an IQ of less than 70 by using behavioural techniques such as shaping , task

analysis, prompting and modeling, to develop independent self help functioning in these

children. The self help areas of toileting, feeding, bathing, washing and dressing. 32% of

mothers reported complete skill learning20.

3. Effectiveness of teaching program.

In a study that described like other self help skills that teaching dressing lies on

observation and functional analysis, prompting, fading, breaking down into small steps,

chaining and reinforcement21.

A study that investigated the effectiveness of behaviour modification procedure in

training personal hygiene skills in ten institutionalized, moderately mentally challenged

children of age 10 to 12 years. IQ ranged from 30-38. An individual case study design

with pre, post and follow up assessment was adopted. Results show the package to be

effective for each student. Skills were maintained over a follow up period of one year21.

A study examined the effectiveness of a system , a graduated guidance to teach

independent skills to three children with severe and profound disabilities. Training took

place in the special class room of an integrated elementary school. Task analysis was

developing according student needs. All three children reached criterion on each skills21.

As seen in Review of literature very few studies are available on the impact of nursing,

intervention among care givers of mentally challenged children. with an appropriated

intervention most individuals who are mentally challenged can learn at least some basic

self care skills like eating, toileting, bathing, dressing etc…There for it is the nurse who

by the virtue of his or her professional knowledge , enables the mentally challenged to

achieve the mastery of self care skills. Few studies show that care givers who train the

mentally challenged children on basic self care skills enable the mentally challenged

children to acquire self care skills in an effective and acceptable manner. This inturn

makes the child on contributor to the society and supportive to the family22.

Statement of the problem:

A Study to assess the effectiveness of structured demonstration on knowledge and practice

regarding dressing and toileting skills among employed care givers of mentally

challenged children in selected institutions, Bangalore.

6.3. Objectives of the study:

1. To assess the pre-test knowledge regarding dressing and toileting skills among

employed caregivers of mentally challenged children in selected institutions, Bangalore.

2. To assess the pre-test practice regarding dressing and toileting skills among employed

caregivers of mentally challenged children in selected institutions, Bangalore.

3. To assess the effectiveness of structured demonstration on dressing and toileting skills

among employed caregivers of mentally challenged children in selected institutions,

Bangalore.

4. To find the correlation between the post-test knowledge and practice regarding

dressing and toileting skills among employed care givers in selected institutions,

Bangalore.

5. To associate the post-test knowledge regarding dressing and toileting skills among

employed caregivers with their selected demographic variables.

6. To associate the post-test practice regarding dressing and toileting skills among

employed caregivers of mentally challenged children with their selected demographic

variables.

Operational definitions:

1. ASSESS: It refers to the estimation of knowledge and practice regarding dressing

and toileting skills among employed care givers of mentally challenged children as

determined by structured knowledge questionnaire and rating scale.

2. EFFECTIVENESS: It refers to the significant gain in knowledge and practice

after structured demonstration as determined by the improvement in knowledge

scores and demonstrable skills in dressing and toileting among employed care givers

of mentally challenged children.

3. STRUCTURED DEMONSTRATION: It is the pre planned act of teaching

through lecture cum demonstration on dressing and toileting skills for the employed

care givers.

4. DRESSING SKILL: It is a process of making a child neat and tidy and

includes the activity of employed care givers in unbuttoning, removing the clothing,

and dressing up the child properly.

5. TOILETTING SKILL: It is the process of helping the child at their

elimination needs and cleaning them up, putting them dry in neat undergarments.

6. CAREGIVERS: The persons employed, irrespective of their past qualification

and those who are trained at giving care in the absence of parents in institution for

mentally challenged children.

7. MENTALLY CHALLENGED: It is a condition where the IQ of the children

is low i.e. below 70.

8. MENTALLY CHALLENGED CHILDREN: Children below the

chronological age of 14 years and who are diagnosed as mentally challenged.

9. SELECTED INSTITUTIONS: It refers to the places where the mentally

challenged children are taken care of, and those places that are selected for the study.

Hypothesis:

H1: There will be significant difference in pre-test and post-test knowledge regarding

dressing and toileting skills among employed caregivers of mentally challenged children.

H2: There will be significant difference in pre-test and post-test practice regarding

dressing and toileting skills among employed caregivers of mentally challenged children.

H3: There will be significant correlation between post-test knowledge and practice

regarding dressing and toileting skills among employed caregivers of mentally challenged

children.

H4: There will be significant association between the post-test knowledge regarding the

dressing and toileting skills among employed caregivers of mentally challenged children

and their selected demographic variables.

H5: There will be significant association between the post-test practice regarding the

dressing and toileting skills among employed caregivers of mentally challenged children

and their selected demographic variables.

Assumptions:

1. Children who are mentally challenged depend upon caregivers for their daily

hygienic needs.

2. Care givers may exhibit their best skills in teaching the mentally challenged

children regarding the skills of dressing and toileting, after the structured

demonstration.

Limitations:

The study is limited only to the caregivers employed in caring mentally challenged

children in selected institutions, Bangalore.

7. Materials and methods:

7.1. Source of Data Employed care givers.

7.2. Method of Data

collection

Research Design

Pre experimental design with

One group pre-test post-test design.

Setting The investigator conveniently selects the residential Institutions rendering care to mentally challenged

children.

Population Employed care givers of mentally challenged children.

Sample Employed Care givers in selected Institutions, Bangalore.

Sample size 40 employed care givers.

Sampling techniqueThe sampling technique adopted By the investigator

will be convenient sampling.

Inclusion Criteria 1. Employed caregivers who are willing to participate in the study.

2. Employed caregivers who know Kannada/ English.

Exclusion CriteriaEmployed care givers who are less than 18 years of

age.

ToolThe tool that will be used for data collection by the investigator consists of Three sections viz.,

Section A: A Structured questionnaire to assess the demographic data of care givers.

Section B: Structured Knowledge questionnaire to assess the knowledge of employed care givers.

Section C: Observation checklist to assess the practice of employed care givers on dressing and toileting skills.

Section D: Structured demonstration tool.

Data Collection As a part of the study, permission will be obtained from the head of institutions where such mentally challenged children are taken care of. The sampling will be convenient in nature. Caregivers will be interviewed and relevant information will be provided in regard to the confidentiality of the information that will be obtained from them, and the need for the information in regard to the study.

Consent will be obtained from the caregivers prior to the conduction of the study.

Data will be collected personally by the investigator by identifying the demographic variables of caregivers using structured questionnaire. The investigator will assess the knowledge and practice regarding dressing and toileting skill of the care givers ensuring privacy.

Later the investigator teaches the dressing and toileting skills by means of lecture cum demonstration to the employed care givers who are the selected sample for the study.

Again the investigator will assess the knowledge and practice regarding dressing and toileting skill of the care giver.

Data analysis, Data Presentation

The collected data will be organized by

1. Descriptive statistics: Frequency distribution,

percentage, mean, and standard deviation will be

used to assess the demographic data, knowledge and

practice regarding dressing and toileting skills among

employed care givers.

2. Inferential statistics:

Paired t-test will be used to compare the pre-

test and post-test value among the employed care

givers.

Coefficient of correlation will be used to

correlate the post-test knowledge with the

practice.

Chi-square test will be used to determine the

association of knowledge and practice of

employed care givers with their selected

demographic variables.

Analyzed data will be presented in the form of tables,

diagrams, graphs based on the findings.

7.3. Yes, Pre test and post-test will be conducted among employed care givers before and

after demonstration regarding dressing and toileting skills.

7.4 Yes, informed consent will be obtained from concerned authority of institution and

subjects prior to study. Privacy, confidentiality and anonymity will be guarded. Scientific

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

Ethical Committee:

Title of the topic A Study to assess the effectiveness of

structured demonstration on knowledge and

practice regarding dressing and toileting

skills among employed care givers of

mentally challenged children in selected

institutions, Bangalore.

Name of the Candidate Ms. Josephine.P

Course of the subject M.Sc. (N) 1st year

Psychiatric Nursing.

Name of the guide Prof. Mrs. Kalai Selvi.S

Head of the Department

Department of Psychiatric Nursing,

Diana College of Nursing,

Bangalore – 64.

Ethical committee Approved.

Members of Ethical committee:

1. Prof. Veda Vivek

Principal and HOD

Department of Community Health Nursing

Diana College of Nursing, Bangalore – 64.

2. Prof. Ms. Elizabeth Dora

Head of the Department

Department of Child Health Nursing

Diana College of Nursing, Bangalore – 64.

3. Prof. Mrs. Kalaivani

Head of the Department

Department of Obstetrics and Gynecological Nursing

Diana College of Nursing, Bangalore – 64.

4. Prof. Mrs. Vasantha Chitra.D

Head of the Department

Department of Medical Surgical Nursing

Diana College of Nursing, Bangalore – 64.

5. Prof. Mrs. Kalai Selvi.S

Head of the Department

Department of Psychiatric Nursing.

Diana College of Nursing, Bangalore – 64.

6. Prof. Rangappa

Biostatistician GKVK,

Jakkur International Airport Road, Bangalore.

8. LIST OF THE REFERENCES:

1. Peshawaria Reeta, S. Venkatesan. “Behavioral approach in teaching mentally

challenged children – A manual for teachers”, Secuderabad, Farah Printers. 2007.

2. Bhatia M.S, “Essentials of psychiatry”,1st edition, Newdelhi, Goyal offset works.

1999.

3. Aniah U, Kumaraiah V and Mistra H. behavior modification in self help skills of

mentally retarded children. Journal of personality and clinical studies.7(5)15-20.

4. Aniah U, Kumaraiah V and Mistra H. behavior modification in self help skills of

mentally retarded children. Journal of personality and clinical studies.7(5)15-20.

5. Girimaji.R. family intervention in mental retardation. Nimhan`s journal.11(2).

6. Reese GM, Snell ME, “Putting on and removing coat and jackets, the acquisition

and maintenance of skills by children with severe multiple disabilities”, Education

and training in mentally challenged. 1999.

7. Repp C Alan, “Teaching the mentally retarded”. New Jersey, Prentice Hall. 1998.

8. Kapoor Bimla, “A text book of psychiatry Nursing”, New Delhi. Kumar

Publishers.

9. K.Rangaswami. Parental attitude towards mentally retarded children. Indian

Journal of clinical psychologist.

10. Malin Nigel, “Services for people with learning disabilities”, Routledge, London.

11. Hill Maholm, “Effectiveness ways of working with children and their families”.

London Jessia Kinsley Publishers.

12. Johnson M. Vecki, “A step by step learning guide for retarded children”, 1st

edition, New York, Syracuse.1997.

13. Goven P. Faber T; Priss S, Mangold B, “The use of sensory stimulation in

teaching mentally students”.

14. Hallas H. Charles et al . The care and training of the mentally handicapped.2nd

edition.vol-1.texas.1995.

15. Robinson lisa. Psychiatric Nursing as a human experience.3rd edition.

philadelpia.1993.

16. Robinson lisa. Psychiatric nursing as ahuman experience. 3rd edition .lippincott

publishers.philadelphia.1993.

17. Maddison david, Kellehear. Psychiatric nursing .5th edition. edinburg, Churchill

Livingston.2006.

18. Polit F. denese, Hungler. Nursing research – principles and methods. Lippincott

publishers.philadelphia.2007.

19. Kaplan I. Harald., J.Sadock Benjamin. Comprehensive text book of

psychiatry.volume 2. 5th edition. William and wilkins publishers. Maryland.1999.

20. Rowitz. Mental retardation in the year 2000.springer verlag. Newyork.

21. Yule W. Carr J. Behavior modification for the mentally handicapped. Croom

Heem Ltd. London 1997.

22. Padma Embar. The effect of activation therapy on severely subnormal children.

Indian journal of clinical psychology.

9.Signature of candidate

10. Remarks of the guide

THERE IS A GROWING NEED TO TRAIN

TEACHERS, NURSES AND OTHER CARE

TAKERS WHO ARE IN DAILY CONTACT

WITH THE MENTALLY CHALLENGED

CHILDREN. HENCE THE RESEARCH TOPIC

SELECTED BY CANDIDATE IS SUITABLE.

11.Name and designation of guide Prof. Kalai Selvi.S

Head of the Department

Department of Psychiatric Nursing,

Diana College of Nursing,

Bangalore – 64.

Signature

HOD

Prof. Kalai Selvi.S

Head of the Department

Department of Psychiatric Nursing,

Diana College of Nursing,

Bangalore – 64.

Signature

12. Remarks of the Chairman & Principal

The topic selected for the candidate is researchable and feasible and forwarded for needful action.

Signature