RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA,

ANNEXURE-2

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1 NAME OF THE CANDIDATE AND

ADDRESS

RAJA UMA VENI

1ST YEAR MSc NURSING,

ST.JOHN’S COLLEGE OF NURSING,

SARJAPURA ROAD,

BANGALORE - 34

2 NAME OF THE INSTITUTION ST.JOHN’S COLLEGE OF NURSING

3COURSE OF STUDY,

SUBJECTM. Sc NURSING

MEDICAL SURGICAL NURSING

4 DATE OF ADMISSION 2.5.2011

5TITLE OF THE TOPIC

EFFECT OF VIDEO ASSISTED

TEACHING Vs STANDARD

TECHNIQUE ON SELF

ADMINISTRATION OF INSULIN

AMONG PATIENTS WITH TYPE II

DIABETES

6 BRIEF RESUME OF INTENDED WORK

6.1 NEED FOR THE STUDY

Diabetes affects 246 million people worldwide and is expected to affect some

380 million by 2025. Every year, 3.8 million deaths are linked directly to diabetes

related causes including cardiovascular disease, made worse by diabetes related

causes. Every ten seconds, two people develop diabetes. India has the largest diabetes

population in the world with the estimated 41 million people amounting to 6% of the

adult population. Type I diabetes which predominantly affects the youth is rising

alarmingly worldwide at a rate of 3% per year1.

In the recent years, Indians have witnessed a rapidly exploding epidemic of

Diabetes. Indeed, India today leads the world with its largest number of diabetic

people in any given country. WHO estimates that there are 32 million people with

diabetes in India in 2000, which is projected to rise to 80 million by the year 20301.

Increase in prevalence is rapid in urban areas from 2% in 1970s to 12% in 2000 and

in rural areas also, it is now beginning to increase.

The WHO has stated that the education is the corner stone of the diabetic

therapy and vital to the integration of diabetes into the society. The purpose of the

therapeutic programme in diabetes is not to cure the patient but to keep the disease

under control. If that is achieved, the life expectancy of the diabetic client is expected

to be almost the same as that of the person without the disease.

Education and training of patients and their families are the foundation of

good diabetic therapy. If planned teaching is imparted to clients suffering from

diabetes, regarding monitor diet, exercise, drugs and foot care, it will be very helpful

for clients to keep diabetes under control and prevent complications. There is a need

for patients to gain awareness, because lack of awareness among many diabetic

clients may lead to fatal complications2.

Studies suggest that improvements in health care technologies and treatments

have resulted in increased life expectancies and improved disease management

potential for individuals with Diabetes and on prolonged Insulin therapy. To a great

degree, quality of life may be determined by the ways they deal with the illness. Thus,

identifying effective ways of coping and promoting their self-dependence with these

diseases may lead to the development of efficacious interventions. Since 1980 there

has been a substantial amount of research devoted to understanding the relation

between coping with chronic illnesses and psychological adaptation.

Several studies have shown that high blood sugar (glucose) levels are

associated with diseases caused by the diabetes. Controlling the glucose may prevent

these complications. As people age, their bodies become unable to make enough

insulin to control the blood sugars. Pills used to treat diabetes may help for a while,

but many times this does not last. When the blood sugar is too high, insulin is

frequently recommended and used to treat diabetes. Enhanced support is especially

important when undertaking and sustaining new challenging self-care tasks, such as

initiating or intensifying insulintreatment regimens. Many people with type 2 diabetes

who need insulin therapyare often reluctant to start using insulin to manage their

diabetes. This may be because they are worried about giving an injection and do not

know enough about insulin to make an informed choice3.

The number of patients admitted in St. Johns hospital with Diabetes, on

average is 385 in a month, among this, the number of patients on Insulin therapy is

115. On a daily basis, the number of patients receiving Insulin injection in St. Johns

hospital is 82.

Survey, with patients with Type II Diabetes has revealed some of the practical

facts. Many patients are not aware of the correct techniques of Insulin administration.

When the patient feels that the disease is itself a curse, the act of self administration

of Insulin makes it tedious and difficult for the patient. Patients with self

administration of Insulin are not aware that the Insulin sites need to be rotated. In case

of big families, the patients feel highly insecure to administer injection, themselves.

They are conscious of what the relatives would think of them. Many patients are not

aware of the mixing techniques. When it comes to changing of needles or lancets,

they are not ready to do it, owing to the cost involved. They do not understand that

the needle bore can be blocked by crystallization of Insulin. They do not comply to

the therapeutic regimen. In case they forget to take insulin at the prescribed timing,

they don’t mind taking it when they remember, even if it is hours later than their last

meal.

This study is important because it will help health care providers to

understand the feelings of the patient and provide educational support that patients

need when they are on insulin. It is the responsibility of the health care personnel to

explain the complications of the therapy like Insulin reactions, Insulin shock and

coma. This study will surely throw light on the above aspects and will be a resource

to the diabetic clients who are on self administration of Insulin. Moreover, the topic

was selected based on interest of the researcher.

6.2 REVIEW OF LITERATURE

Review of literature refers to an extensive, exhaustive and systematic

examination of publications relevant to the research project. It refers to the activities

involved in identifying and searching for information on a topic and developing an

understanding of the state of knowledge on that topic. Literature review is done for

the purpose of identification of the topic, to ascertain what is already known in

relation to a problem of interest, to develop a broad conceptual context into which a

research problem will fit and to suggest ways to going about the business of

conducting a study on a topic of interest4.

The topic was selected based on interest of the researcher. An extensive search

was done on the internet about the topic selected for similar studies. Resource

material in the form of books, periodicals, and journals was looked for in the library

of St. Johns Medical College Hospital, Bangalore. After an extensive search done on

the internet, certain studies were selected for review of literature.

The literature reviewed for this study has been categorised as under the following

headings:

Literature on Diabetes

Literature onInsulin therapy

Literature onVideo assisted teaching

LITERATURE ON DIABETES

A study was done in Karachi4on “Knowledge, Attitude and Practices of

Patients Visiting a Diabetes Care Unit” and 100 Type 2 Diabetic patients were

enrolled for the study. Knowledge was assessed by a questionnaire. Information

regarding HbA1c, Total Blood Cholesterol (TBC) and Fasting Blood Triglyceride

(FBTG) levels was obtained from medical records. Results showed that 54% had poor

knowledge about diabetes, 34% had fair knowledge about diabetes while only 13%

had good knowledge5.

A study was conducted on the management of Diabetes Mellitus on 200

diabetic patients, The results showed that 56% of Females were obese and had poor

glycaemic control. It was concluded that the interventions include not only

prescription of the appropriate nutritional and pharmacological regimen by the

physician but also intensive education and counselling of the patient. Control of

obesity and ideal body weight is important for better glycaemic control and

prevention of complications6.

A study was conducted by Indian council of Medical Research (ICMR) which

studied the pattern of morbidity amongst NIDDM individuals in the age group of 25-

65 years with 4637 subjects. Analysis of large vessel disease showed that the most

common vessel disease observed in patients with type II Diabetes is Coronary artery

disease with males showing 8.1% and the females having 4.7%, prevalence. The

findings of this study shows that nephropathy has a significant relationship with the

onset of diabetes. Duration of diabetes and hypertension are the major determinants of

both large and small vessel disease of diabetes7.

A study was conducted in Paris which focuses on recurrent comas due to

secret self-administration of Insulin in adolescents with type I Diabetes. A total of

322 cases of recurring hypoglycaemia were detected. Results showed that 7% of

patients on self administration of Insulin used to deliberately induce coma. Girls had

a higher frequency of coma than the boys. Recurrence of severe hypoglycaemia has been

related to age, duration of diabetes, glycaemic control, psychiatric problems or

socio-economic factors8.

A study was done at France on the assessment of frequency of hypoglycaemia.

Among 2679 French children surveyed, 338(13.8%) had atleast one and 123 of 338

patients had two severe hypoglycaemic comas during the six month study. The

frequency of coma in these studies was thus much lower than in the adolescents. The

study revealed that repeated hypoglycaemic comas are in insulin treated Juvenilles7.

LITERATURE ON INSULIN THERAPY

A blended Qualitative and quantitative study was done on exploration of lived

experiences and effectiveness of the teaching programme about Diabetes Mellitus

among twenty diabetic clients attending the clinic in Puduchery, When enquired about

diabetes and their attitude towards the disease and the Insulin injections, some of the

verbalization of the patients were as follows:

“I feel that I am in hell and it is very difficult for me to carry the medicine along

with me wherever I go”.

“It is a life saving measure like helmet during bike riding”

“They should find out the vaccine for diabetes to control it”

“Psychologically I am feeling that I am ill after acquiring Diabetes Mellitus”

The study revealed that early screening and appropriate therapeutic intervention is the

first step in the cure of Diabetes.2

A study was done on the effectiveness of planned teaching programme on

management of Diabetes mellitus among clients attending the diabetic clinic at NIMS,

Hyderabad. Thirty diabetic clients were included in this study. Assessment was done

on based on Dorothea Orem’s theory. One group Pre test and Post test design was

used. There was a significant increase in post test scores which showed that Nurses

role in managing Diabetes is pivotal and Education is the greatest support in the cure

of Diabetes1.

Association of Diabetes Control and Complications Trial (DCCT) shows that

studies have revealed Intensive blood glucose control with Insulin reduces risk of Eye

disease by 76% , Kidney disease by 50% and Nerve disease by 60%9.

Group of Epidemiology of Diabetes Interventions and Complications(EDIC)

reveals that the Intensive glucose control with Insulin therapy reduce the risk of any

cardiovascular disease event by 42% and non-fatal heart attack, stroke, or death from

cardiovascular causes by 57%9.

A randomized controlled trial was conducted on 169 adults by Diabetes dose

adjustment for normal eating (DAFNE) group. Results showed that at 6 months,

HbA1c was significantly better in immediate DAFNE patients (mean 8.4%) than in

delayed DAFNE patients (9.4%). Conclusion was promoting dietary freedom,

improved quality of life and glycaemic control without worsening severe

hypoglycaemia or cardiovascular risk. This approach has the potential to enable more

people to adopt intensive insulin treatment and is worthy of further investigation in

“present quality of life”10.

LITERATURE ON VIDEO ASSISTED TEACHING

A study was conducted on the effect of videotape to increase the accessibility

of low Income and Spanish speaking families to the Poison Control Centres. A

videotape intervention was used to address the barriers. Two eighty nine parents of

children below six years of age attending educational classes were the samples. It was

found that Poison control centres reduce the health costs for childhood poisonings by

providing telephone advices for home management of most cases. Because of lack of

knowledge and misconceptions about it, people were not availing it. Results revealed

that the video group showed increase in knowledge about Poison Care Centres, its

functions, its hours of operation and staff qualification, which concludes that the

video tape intervention was highly effective in changing knowledge, attitude and

behavioural interventions11.

A study was conducted on the value of debriefing during crisis management,

by American Society of Anaesthesiologists during simulation and to compare the

educational efficacy of two types of feedback, oral feedback and videotape-assisted

oral feedback against control (no debriefing). Forty-two anaesthesia residents were

enrolled in the study. After completing a pre-test, participants were randomly

assigned to three groups, oral feedback, or videotape-assisted oral feedback and

control group. The debriefing focused on nontechnical skills performance guided by

crisis resource management principles. The videotapes of all performances were later

reviewed. Findings showed that the participants' nontechnical skills did not improve

in the control group, whereas the provision of oral feedback, either assisted or not

assisted with videotape review, resulted in significant improvement (P< 0.005). There

was no difference in improvement between oral and video-assisted oral feedback

groups. Valuable simulation training can therefore be achieved even when video

technology is not available12.

An Interventional Study was conducted on the effectiveness of Internet

Insulin Education at Kansans with the collaboration of National Institute of Diabetes

and Digestive and Kidney(NIDDK). Forty patients were taken as the sample. The

primary purpose of the study was demonstration of insulin administration in small

groups of type 2 diabetes patients in 4 weekly "live" Internet sessions. Findings

showed that there was cost effectiveness of the Internet intervention and Internet

teaching of basal insulin therapy was comparably better to traditional insulin

management with respect to safety and effectiveness8.

Hence, it is important that that the patients are made aware of the correct

technique of Self administration of Insulin and therefore this study is selected as a

means to it.

PROBLEM STATEMENT

A comparative study to assess the effect of video assisted teaching vs standard

technique on self administration of Insulin among patients with type II diabetes in a

selected hospital, Bangalore.

OBJECTIVES

To compare the effect of video assisted teaching and standard technique on

knowledge of self administration of Insulin

To compare the effect of video assisted teaching and standard technique on

practice of self administration of Insulin

To determine the association between practice of self administration of Insulin

with selected baseline variables.

6.5 OPERATIONAL DEFINITION

Effect: Effect refers to the result produced by an action

Dorlands medical dictionary.

In this study, effect refers to a change in practice of self administration of Insulin,

after the teaching given by video assistance or standard technique, as scored on an

observational checklist.

Video assisted teaching: Video assisted training is a technique of teaching with the help of a video tape

Wikepedia

In this study, it is a pre recorded video demonstration of the procedure of self

administration of Insulin by a patient herself as a model, by syringe and vial method

and pen device, with a running commentary which will be projected to the patient

using a laptop.

Standard technique: The action or process of showing the existence or truth of

something by giving proof or evidence.

Oxford dictionary

In this study, standard technique refers to the act of teaching patients with type II

diabetes, the correct technique of self administration of Insulin by the investigator on

a one to one basis.

Self administration of Insulin: Self administration of Insulin is defined as

dispension of Insulin by the patient, himself/herself.

Brainy

In this study, it refers to subcutaneous injection of insulin taken by the patient on

himself/herself, using either an insulin pen or a vial and syringe method.

Knowledge: Knowledge is defined as comprehension or understanding

Oxford dictionary

In this study, knowledge refers to the level of understanding of patients regarding self

administration of Insulin as measured by scores obtained to items using structured

questionnaire.

Practice: Practice means action or rehearsal.

Dorlands dictionary

In this study, practice refers to the correct steps of the procedure of self administration

of Insulin adopted by patients as observed and scored on the items of an observational

checklist.

Patient: Patient refers to a person receiving medical treatment

Oxford dictionary

In this study, patient refers to an individual who is a type II diabetic and on self

administration of Insulin.

Baseline Variables: In this study, baseline variables refer to age, sex, education,

occupation, income, type of family, place of residence, duration of illness, duration of

set findings of insulin.

6.6 ASSUMPTION

Patients with type II diabetes on Insulin administration may not be aware of

the correct technique of Insulin administration.

Video assisted teaching will have an impact on practice of self administration

of Insulin.

6.7 DELIMITATION

This study is limited to patients with type II diabetes who are on Insulin

therapy.

This study is limited to medical, surgical, neurosurgery nephrology and

private wards of SJMCH, Bangalore.

6.8 PROJECTED OUTCOME

This study findings will reveal the effectiveness of both video assisted teaching and

the standard practice as a teaching method for self administration of Insulin. This

information will help to implement the interventions in the clinical setting. The study

focuses on the improvement in knowledge and practice of self administration of

Insulin to the individual, family and the community. The video of the practice will

serve as a tool for the patients with type II diabetes, on self administration of Insulin,

at the primary health care centres, OPD and wards.

HYPOTHESIS

H1: There will be a significant difference in knowledge scores of two groups

receiving video assisted teaching and standard technique of self administration of

Insulin at 0.05 level of significance.

H2: There will be a significant difference in practice scores of two groups

receiving video assisted teaching and standard technique of self administration of

Insulin at 0.05 level of significance.

H3: There is a significant association between the practice of self administration

of Insulin and selected baseline variables.

7 MATERIALS AND METHODS

7.1 SOURCES OF DATA

7.1.1 RESEARCH DESIGN

The research design selected for this study is Quasi Experimental design.

7.1.2 SETTING

The setting for this study includes the Medical, Surgical, Neurosurgery Nephrology

and private wards of St. John’s Medical College Hospital Bangalore, which is a

tertiary care hospital with 1250 beds. The number of patients admitted in St. Johns

hospital with Diabetes, on average is 385 in a month, among this, the number of

patients on Insulin therapy is 115. On a daily basis, the number of patients receiving

Insulin injection in St. Johns hospital is 82.

7.13 POPULATION

The Population in this study refers to the patients with type II diabetes on self

administration of Insulin.

7.2 METHOD AND DATA COLLECTION

7.2.1 SAMPLING PROCEDURE

Purposive Sampling technique

7.2.2 SAMPLE SIZE

Total sample size will be 70. 35 for Video assisted teaching and 35 direct

demonstration

7.2.3 INCLUSION CRITERIA

Patients with type II diabetes who are on self administration of Insulin.

Patients who are willing to participate in the study.

7.2.4 EXCLUSION CRITERIA

Patients who are unconscious

Patients with documented mental illness and anxiety disorders

Children

7.2.5 INSTRUMENT USED

SECTION A: Interview Schedule for the collection of baseline variables.

SECTION B: A structured questionnaire to assess the knowledge

SECTION C: An observation checklist to assess the practice

7.2.6 DATA COLLECTION METHOD

Formal permission will be obtained from the Associate Director of St.John’s Medical

college Hospital. Purposive sampling technique will be used; subjects are selected

based on inclusion and exclusion criteria. The samples will be randomly allocated

into two groups. Group I and Group II, based on previously prepared random

allocation table. The purpose of the study will be explained to the participants and

informed consent will be obtained. An interview schedule will be used to elicit the

baseline variables. An observational checklist will be used to assess the practice of

self administration of Insulin, followed by a pretest with a structured questionnaire.

Depending on the device they use for self administration of insulin, either pen device

or vial and syringe, the checklist and observational checklist will have the respective

responses. After which, Group1will be given a video assisted teaching on self

administration of insulin and Group II will get a direct demonstration of insulin

administration by the investigator. The Post test knowledge and practice scores will

be assessed after 5 days.

7.2.7 DATA ANALYSIS PLAN

Descriptive statistics and Inferential statistics will be used to analyse data.

Frequency and percentage for baseline variables. Paired ‘t’ test for comparing for comparing knowledge and practice scores. Chi-square for association.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION AND

INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER

HUMANS OR ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY.

Yes, it requires an intervention of training on the correct technique of Insulin

administration, with syringe and vial and pen device, which is a part of the

therapeutic regimen.

7.4 HAS ETHICAL CLEARANCE OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3

Administrative clearance and ethical clearance with regard to the study will be

obtained from the research committee of St. Johns college of Nursing, Bangalore,

prior to the study.

REFERENCES

1. T.V.Satyanarayanamma. Management of Diabetes mellitus by diabetic patients.

Nightingale Nursing times 2010 November; 6(8): 53-56.

2. VadivukkarasiRamanadin. Effectiveness of teaching programme about Diabetes

Mellitus among Diabetic Clients attending the clinic. Nightingale Nursing times.

2010 October; 6(7): 27-30.

3. http://diabetes.niddk.nih.gov/dm/ap.htm

4. Polit D. Nursing Research Principles and Methods. Lippincott Williams and

Wilkins, Philadelphia. 2003;1: 583-600

5. Rafique G. Diabetes knowledge, beliefs and practices and among people with

diabetes. Health Journal of India. 2006; 7:42-44

6. Green A.J. Knowledge, attitudes and behaviours towards health, diabetic diet and

exercise. International Journal of Clinical Practice. 2007;8:144-146

7. http://www.pubmed.com

8. http://www.cinahl.com

9. Srivastava M.C. Diabetic mellitus – A challenge on to 21st century. Healing for

the Millions.1998; 2(24): 22-25

10. Stephanie, Amiel, Sue, Beveridge, Clare. Training in flexible, intensive insulin

management to enable dietary freedom in people with type 1 diabetes: Dose

adjustment for normal eating (DAFNE) randomised controlled trial, DAFNE

Study Group. British Medical Journal. 2002 October; 5(325): 1-6.

11. Nancy.R.Kelly, MD, Lynne C Huffman, MD, Fernando.S.Mendoza,MD and

Thomas. N.Robinson MD. Effect of videotape to increase the use of Poison

control centres by low income and Spanish speaking families- A randomized

control trial. American Academy of Paediatrics. 1996 Nov-Dec. 21-26.

12. http://www.medicaljournals.com

13. Rao P. Biostatistics And Research Methods. Banarsidas Bhanot Medical

Publishers. Jabalpur. 2005; 4: 48-52

8 SIGNATURE OF THE CANDIDATE

9 REMARKS OF THE GUIDE

10 NAME AND DESIGNATION OF

10.1 GUIDE

10.2 SIGNATURE

10.3 CO-GUIDE

10.4 SIGNATURE

MRS. MARY WALTONASSOCIATE PROFESSORMEDICAL SURGICAL NURSINGST JOHNS COLLEGE OF NURSING

DR. VAGEESH AYYARASSOCIATE PROFESSOR & CONSULTANTENDOCRINOLOGY DEPARTMENTST JOHNS MEDICAL COLLEGE HOSPITAL

1111.1 HEAD OF THE DEPARTMENT

11.2 SIGNATURE

MRS. MADONNA BRITTOPROFESSOR & HODMEDICAL SURGICAL NURSINGST JOHN’S COLLEGE OF NURSINGBANGALORE.

12 12.1 REMARKS OF THE CHAIRMAN AND THE PRINCIPAL

12.2 SIGNATURE