INTRODUCTION:

Hippocrates the father of the medicine first recognized stroke over 2400 years ago. At this stroke was called apoplexy, which means “struck down by violence”, in Greek it was due to the fact that person sudden paralysis and change in the well being, physicians had little knowledge of the anatomy and function of the brain, the cause of the stroke and how to treat it.¹ There are two main ways in which we can reduce the burden of this disease. First, we can improve outcome after stroke by providing patients with proven therapies. These therapies include the use of intravenous tissue plasminogen activator (tPA) within 3 hours of ischemic stroke onset, aspirin within 48 hours and treatment in a stroke care unit. For the first of these therapies, patients need to attend hospital within approximately 2 hours of stroke onset. Currently, only about 1% - 2% of the patients receive this treatment. The most common reasons that patients are not treated with tPA are that they do not attend hospital within the treatment time window, that there are insufficient trained staff, and that the patients are ineligible for treatment. Although the proportion receiving therapy could be improved by increasing the number of centers in which the therapy could be administered, reducing the delay to hospitalization would also considerably improve access to this therapy².

Aging population is a common phenomenon worldwide. The projected increase of geriatric population by 2030 is approximately 12% to 23.3%.In India, the population >65 years of age was 45 million in 2000, 58 million in 2010 and will rise to 76 million in 2020.Survey in different parts of India have shown that the prevalence of stroke in India is approximately 200 per 100000 population. India faces an enormous socioeconomic burden to meet the cost of rehabilitation of stroke victims as more people are now surviving to the age that coincides with the peak of stroke occurrence (55-65 years).³

India is ranked among the countries where the information on stroke is minimal. The study conducted in Eastern India concluded that the overall reaction to anticipatory stroke symptoms was very disappointing. The study highlights the lack of awareness of stroke symptoms, its risk factors and inadequate response to stroke symptoms in Indian elderly population. Stroke awareness programme should be undertaken at various levels in the community to different population subgroups, using different modes of education for this lack of knowledge. Efforts should be made to educate the public about modern concepts of stroke treatment, so that the people make more rational and beneficial health care decisions⁴

Today there is the wealth of information available on the cause, prevention, risk and treatment of stroke. Although there is no cure, most stroke victims now have a good chance for survival and recovery can all improve the quality of the life for stroke victims, the term brain attack also conveys a more urgent call for immediate action and emergency treatment by general public and staff nurses ^3.

NEED FOR THE STUDY

“I do not believe that any man fears to be dead, but only the stroke of death.”

Francis Bacon

Neurological problems are major unrecognized public health problems. With paucity of trained manpower, the emphasis till date has been on delivery of services, more so in urban areas. The distribution and determinants of neurological disorders is very vital for planning delivery of services and to develop preventive programs. Neurological disorders being chronic progressive disorders place significant burden on families and societies. As the twentieth century closes with decade of the brain, it is fitting to reflect on the revolutionary changes taking place in neurosciences and in the management of patients with neurological health problems. Stroke or brain attack is a leading cause of death and disability in the heterogeneous population. In recent years there has been tremendous expansion in both the breadth and depth of understanding of events on cellular and molecular levels that accompany or mediate ischemic brain injury, with obvious implication for medical intervention. Contemporary strategies in early interventions, include emergency thrombolytic therapy, optimal recovery is enhanced by early rehabilitation and the measurements of patient outcomes using standardized, valid and reliable tools. Nursing plays critical role in risk factor modification and the care of the stroke patient across the care continuum.⁴

Stroke, or a cerebral vascular accident, is the sudden death of brain cells due to inadequate blood flow and stroke is a clinical syndrome divided into two broad categories and they are Ischemic and Hemorrhagic strokes, Ischemic strokes are caused by either cerebral thrombosis or embolism and it accounts for 50%–85% of all strokes worldwide. Hemorrhagic strokes are caused by subarachnoid hemorrhage or intracerebral hemorrhage and account for 1-7% and 7-27% respectively of all strokes worldwide.⁵

Stroke is one of the leading causes of mortality and morbidity worldwide. Approximately 20 million people each year will suffer from stroke and of these 5 million will not survive. Developing countries account for 85% of global deaths from stroke. Stroke is also a leading cause of functional impairments, with 20% of survivors requiring institutional care after 3 months and 15% - 30% being permanently disabled. (AHA 2009) Stroke is a life-changing event that affects not only the person who may be disabled, but their family and caregivers.⁶

Morbidity and Mortality associated with Stroke Global Stroke Morbidity and Mortality

 According to the World Health Organization, 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled.

 High blood pressure contributes to more than 12.7 million strokes worldwide.

 Europe averages approximately 650,000 stroke deaths each year.

The Stroke council of American Heart Association using evidence regarding various established and potential risk factors, established a classification for stroke risk factors which are as follows:-

• Non-modifiable, Modifiable, Potentially modifiable risk factors.

Non modifiable risk factors of age, gender, race/ethnicity, family history of stroke and transient ischemic attack (TIA) identify individuals at a higher risk of stroke than others. Stroke strikes all age groups from fetuses still in the womb to centenarians. The incidence of stroke doubles in each successive decade for people over the age of 55 years. Stroke deaths rise significantly after age of 65 years accounting for more than 40% of all deaths among persons aged 65-74 years and almost 60% of those aged 85 and older. In most age groups, more men than women have stroke in a given year. The risk of stroke varies among different racial and ethnic groups. Blacks have higher incidence of risk factors. Stroke seems to run in some families.⁶

The National Stroke Association and American Heart Association have identified ten important modifiable stroke risk factors which can be changed or controlled by the person at risk, six health status factors (hypertension, myocardial infarction, atrial fibrillation, diabetes, elevated blood lipids and asymptomatic carotid artery disease) and four lifestyle factors (smoking ,excessive alcohol use, physical inactivity, poor diet/obesity). High blood pressure is the major risk factor contributing to more than 500,000 each year. Coronary heart disease, valve defects, irregular heartbeat, enlargement of one of the heart chamber can result in blood clots that may break loose and block vessels in or leading to the brain. Diabetes has three times the risk of stroke compared to people without diabetes. Cholesterol for LDL is the main source of damaging build-up and blockage in the arteries, and for the formation of blood clots. In a study conducted in Australia, it has been reported that within 12 months of stroke, approximately 37% will die and 10% will experience a recurrent stroke. Of those who survive their stroke, approximately 51% are disabled in some activity of daily living and 50% exhibit either cognitive impairment or dementia. This represents a considerable burden to our community.⁷

STATEMENT OF THE PROBLEM:

A study to assess effectiveness of the Self Instructional Module (SIM) on knowledge regarding management of the patients with stroke among the staff nurses working in critical care units of KLE’s Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum, Karnataka, India”

OBJECTIVES OF THE STUDY:

1. To assess the knowledge regarding management of the patients with Stroke among the staff nurses working in critical care units

2. To evaluate the effectiveness of SIM on knowledge regarding management of the patients with Stroke.

3. To find the association between the pre test knowledge scores regarding the management of the patients with

Stroke and selected demographic variables among the staff nurses working in critical care units.

Hypotheses

H1: The mean post test knowledge scores of the nurses exposed to Self Instructional Module will be significantly greater than the mean pre test knowledge and skill scores regarding the management patients with stroke at 0.05 levels of significance

H2: There is statistically significant association between pre test knowledge scores regarding the management of the patients with stroke and selected demographic variables among the staff nurses at0.05level of significance.

Assumptions

The study assumes that,

1. Staff nurses working in critical care units have some knowledge regarding management of patients with stroke.

2. SIM is an effective self learning package for staff nurses working in critical care units to upgrade and update their existing knowledge in effective management of patients with stroke.

Delimitation

This study is delimited to the staff nurses working in critical care units of KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum, Karnataka.

Operational definitions

1. Assess: It refers to the statistical analysis (descriptive and inferential) measurement regarding the management of patients with stroke scores among the staff nurses working in critical care units.

2. Effectiveness: refers to the extent to which the Self instructional module(SIM) regarding knowledge of the management of the patients with stroke, has achieved the desired outcome as measured by significant changes in the knowledge scores.

3. Self instructional module: It refers to an educational material/information material (English), on the knowledge regarding the management of the patients with stroke, prepared by the investigator and content validated from experts.

4. Management of the patients with Stroke: It refers to the clinical care provided to the patients who are suffering with stroke i.e. a condition which is the resultant of the interrupted blood flow to the brain causing deprived or reduced oxygen supply and nutrients resulting in damage to the brain cells, which is manifested by paralysis, speech impairment, loss of memory and reasoning ability, coma or death.

5. Knowledge: Refers to the appropriate response from the staff nurses regarding management of the patients with stroke which is measured through the structured knowledge questionnaire.

6. Staff Nurses: Refers to the registered nurses with Bsc (N), GNM and PCBSc (N) qualifications and who are working in critical care units.

7. Critical Care Units: Refers to the Medical Intensive care units (MICU) Neurosurgical Intensive care units (NSICU), and Trauma of KLES Dr. Prabhakar Kore and MRC, Belgaum.

8. Demographic Variables: Refers to demographic factors of the staff nurses such as age, gender, marital status, professional qualification, total years of experience, years of experience in critical care units and exposure to in service education.

Conceptual framework:

It is a framework which provides the investigator the guidelines to proceed in attaining the objectives of the study based on theory. It is a scientific representation of the steps, activities and outcome of the study.

The present study is aimed at evaluating the effectiveness of Self Instructional Module on the knowledge regarding management of the patients with stroke among the staff nurses working in critical care units of KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum, Karnataka.

RESEARCH METHODOLOGY:

Research methodology is a way to systematically solve the research problem.⁴⁷ Research methodology is a collective term for the structured process of conducting research. It is a science of studying how research is done scientifically. It also refers to the techniques used to structure a study and gather and analyze information in a systematic manner.⁸

This study was conducted with the purpose of assessing effectiveness of Self Instructional Module on the knowledge regarding management of the patients with stroke among the staff nurses working in critical care units of KLES Dr. Prabhakar Kore Hospital and Medical Research Centre Belgaum, Karnataka, India. This chapter unfolds the description of the research methodology adopted by the investigator to study and analyze the efficacy of Self Instructional Module on management of the patient with stroke. The various steps that are undertaken to conduct the study includes research approach, research design, setting, population, sample, sampling techniques, description of the tool, description of self instructional module, procedures and data collection methods and plan for data analysis.

Research approach:

Evaluative approach is conducted to determine how well a program was implemented and how well it accomplished its purpose. Evaluation is undertaken with the aim of providing answers to the questions about the effectiveness of the programme under consideration.

Research design:

The research design used for the study was one group pre-test post test design which is a pre experimental design.

Table: Schematic representation of research design

Pre test	Intervention	Post test
O₁	X	O₂

Key:

O₁=Pretest for assessment of knowledge through structured questionnaire.

X=Intervention or Treatment through Self Instructional Module

O₂=Posttest for assessment of the knowledge through same structured questionnaire.

Variables under study:

Independent Variable:

In the present study the independent variable is Self Instructional Module (SIM) on Management of the Patient with Stroke.

Dependent Variable:

In the present study the dependent variable is the nurse’s gain in knowledge scores.

Attribute variable/Demographic variables:

Refers to demographic factors such as age, gender, marital status, qualification, total years of experience, and years of experience in critical care wards.

Research setting:

The present study was conducted in Critical Care Units of KLES Dr. Prabhakar Kore and MRC, Belgaum.

Population:

In this study, population consists of staff nurses working in Critical Care Units of KLES Dr. Prabhakar Kore and MRC, Belgaum, Karnataka.

Sample:

In the present study was the staff nurse working who have completed as degree or diploma nursing and who are working in Critical Care Units, that is Trauma, MICU, and NSICU of K.L.E.S Dr Prabhakar Kore hospital and MRC, Belgaum

Sample size:

Sampling is the process of selecting a portion of the population to represent the entire population¹⁴.The sample size of the present study was 55 staff nurses.

Sampling technique:

The sample for the present study was selected by Non probability purposive sampling technique.

Criteria for sample selection

Inclusion Criteria:

Staff Nurses who are:

1. Working in Critical Care Units.

2. Willing to participate in the study.

Exclusion Criteria:

Staff nurses who are:

1. Working at the managerial level like supervisors, in charge nurses.

2. On leave during this study.

Data collection instrument:

Data collection tools are the instrument used by the researcher to observe or measure the key variables in the research problem.

In this study data collection instrument were:

a) Performa of the demographic variable.

b) Structured Knowledge Questionnaire on management of the patients with stroke.

Development of the tool:

After an extensive review of literature and discussion with the experts the structured knowledge questionnaire on Management of the Patient with Stroke was developed. The following steps are carried out in the preparation of the tool.

· Literature review

· Validity of the tool

· Pre testing

· Reliability check

Validity of the tool

The tool, self instructional module (SIM), blue print were submitted to total 8 experts from Department of Medical Surgical Nursing

All the suggestions were considered and the necessary modifications were made. The Content Validity Index (CVI) across the expert’s rating of relevance for each item was calculated. The CVI of 0.87 or better is generally considered to have good content validity. A CVI of 0.95 were found for structured questionnaire, and 0.91 for the self instructional module.

Reliability:

An instrument’s reliability is the consistency with which it measures the target attribute.¹⁴ Reliability of the tool was assessed by administering the tool to 21 staff nurses. Reliability was tested by split half method using Karl Pearson’s Coefficient of correlation. The reliability computed was r = 0.95.

Pretesting:

Pretesting of the structured questionnaire was done to check clarity, feasibility and practicability of the tool on a sample of 10 staff nurses working in Critical care units (+5ICU).It took the nurses 50 minutes to complete the questionnaire. The language and statements used in the questionnaire were well understood by them.

Pilot study:

A pilot study is a small scale version, or trial run, done in preparation for a major study¹⁴. In order to test the feasibility of the research study a pilot study was carried out at Emergency service ward of K.L.E.S Dr Prabhakar Kore hospital and MRC, Belgaum. 15/01/2013 to 27/01/2013.

The pretest was conducted on 15/01/2013 followed by administration of Self Instructional Module on Management of Patient with Stroke. The post test was conducted after 7 days on 27/01/2013.

Item analysis was done and the items were modified as per the difficulty and discriminative index values estimated . The findings of the pilot study revealed that there was an increase of the knowledge scores after the administration of the Self Instructional Module on Management of the Patient with Stroke, hence it revealed that the study is certainly feasible.

Procedure of data collection:

The investigator obtained the ethical clearance and the formal written permission was obtained from KLEU Institute of nursing sciences, formal written permission was obtained from the Medical Director of KLES Dr.Prabhakar Kore Hospital and MRC, Belgaum to collect data for the main study. The main study was conducted from 02/03/2013 to 09/03/2013..

Data analysis plan:

Statistical analysis is the organization and analysis of quantitative data using statistical procedures. For the present study the data obtained were analyzed in respect to the objectives of the study by using descriptive and inferential statistics.

RESULTS:

Analysis and interpretation of data

Analysis of data based on the objective of the study.

The data was collected through structured knowledge questionnaire on the management of the patients with Stroke among staff nurses working in the critical care units. The sample consists of 55 staff nurses of KLES Dr Prabhakar Kore Hospital and Medical Research Centre. The data was analyzed by using descriptive and inferential statistics. Collected data presented as follows.

Descriptive

1. Frequency and percentage

2. Mean, Median and Mode

3. Standard deviation and range

4. Karl Pearson’s co-efficient of correlation

Inferential

1. Paired’t test

2. Chi square test

• Majority of subjects 30(54.54%) belonged to age group 25-27 years.

• Among the 55 subjects 30 (54.54%) were Males and 25(45.45%) were Females

• Among the 55 subjects 25(45.45.18%) completed their diploma nursing and 9(13.36) were completed their degree nursing (PC Bsc).

• Majority, 43 (78.17 %) subjects had 3-4 yrs of experience.

• Majority 20 (36.36%) were working in MICU.

Graph 1: Pie graph depicts Distribution of staff nurses according to Age

Graph 2: Doughnut graph depicts Distribution of staff nurses according to Gender

Table 4: Mean difference (d), Standard Error of difference (SEd) and paired ‘t’ values of knowledge score of Staff Nurses. n= 55

Mean Difference (d)	Standard Error Difference (SEd)	Paired ‘t’ Values
		Calculated	Tabulated value
16.73	0.317	40.811	1.960

Table 4 reveals that calculated paired ‘t’ value (t=40.811) is greater than tabulated value (t=1.960). Hence H₁is accepted. This indicates that the gain in knowledge score is statistically significant at P<0.05 levels.

Therefore, Self Instructional module on Management of the patients with stroke improved the knowledge of the staff nurses

H_2.1: The calculated value (6.57) was lesser than the tabulated (9.48) value. Hence there is no association between pre-test knowledge score and age

H_2.2: The calculated value (0.37) was lesser than the tabulated (5.99) value. Hence there is no association between pre-test knowledge score and gender

H_2.3: The calculated value (4.56) lesser than the tabulated (9.48) value. Hence there is no association between pre-test knowledge score and qualification

H_2.4: The calculated value (6.01) was lesser than the tabulated (12.59) value. Hence there is no association between pre-test knowledge score

H_2.5: The calculated value (3.58) was lesser than the tabulated (9.45) value. Hence there is no association between pre-test knowledge score and area of the work.

H_2.6: calculated value (0.96) was lesser than the tabulated (5.99) value. Hence there is no association between pre-test knowledge score and in service education.

Hence table 5.1 reveals that there is no association between pre-test knowledge score and demographic variables.

DISCUSSION:

In the present study, among the staff nurses (n=55) working in Critical Care unit, most 30(54.54%) belonged to age group 25-27 years while 11(20%) belong to the age group above 27 years.

In contrast, by the study of Bagi D conducted in KLES Dr. Prabhakar Kore and MRC, Belgaum. The results revealed the majority 36(65.45%) were found in the age group 25-27 years.⁸

Section 2: Findings related to pretest knowledge scores

For pre-test the mean was 24.14, median was 23.5 mode was 23, S.D was 4.93 and Range was 23. Among the total samples (n=55), 28 (50.90%) of the Staff nurses had average knowledge and 14(25.45%) had poor knowledge and 13(23.63%) had good knowledge regarding management of stroke.

The findings of the study were supported by; a pretest post test study was conducted at the Reproductive Health Centre, USA to evaluate the effectiveness of a self-instructional module in increasing nurses' knowledge of genetics. There was a significant increase in mean knowledge score of 20.8% on the post-test (89.0% mean, SD=8%, range=67-100%) as compared to the pretest (69.0% mean, SD=12%, range=42-92%), based on Paired ‘t’ test analysis (t=11.74, SE=0.426, p< .0001).

Section3: Finding related effectiveness of self instructional module.

The post test mean value of knowledge was 40.85 with SD of 2.23, which was higher than the pretest value of knowledge was about 24.12 with SD of 4.93 was significant at 0.05 level. Hence it was concluded that the hypothesis is accepted.

Similar findings were found in the study conducted by Bagi D in KLES Dr. Prabhakar Kore and MRC, Belgaum. The results revealed that the calculated t value was 26.58 which was higher than the tabulated value 1.960.

Section 4: Findings related to the association between the pre test knowledge scores and selected socio-demographic variable:

The obtained chi square value is less than the table value for demographic variable such as age, gender, qualification, year of experience, area of work, in-service education.

The results coincide with the study done to assess the effectiveness of self instructional module on knowledge of nurses regarding Stroke management. The result of the study reveals that there is no association between the pretest knowledge scores and selected socio-demographic variables.

CONCLUSION:

The following conclusions were drawn on the basis of the present study

1. Knowledge scores of nurses working in Critical Care Units regarding Management of the Patients with Stroke were found inadequate in the pretest.

2. There was evident increase in the knowledge scores after the administration of the Self Instructional Module on Management of the Patients with Stroke. Thus it was inferred that the Self Instructional Module on Management of the Patients with Stroke was effective.

3. The socio demographic variables of nurses in gender and total years of experience were found to have no significant association with pre test knowledge scores. Conversely age, qualifications, total years of experience and area of work did not have association with the pretest knowledge scores.

NURSING IMPLICATIONS:

1. Nursing Services:

Nursing services can be improved by regular upgrading of the knowledge of staff nurses using Self Instructional Module on Management of the Patients with Stroke.

2. Nursing Education:

Findings of the study can be used by nurse educator for educating on Management of the Patients with Stroke for the staff nurses. It is essential for all the staff nurses to have adequate knowledge on Management of the Patients with Stroke.

3. Nursing Research:

Nurses are the key personnel who provide health care to the patients extensively. Therefore these nurses should conduct various projects and research studies in the hospital to provide an evidenced based care to the patients. Investigator can use the methodology as reference material as it provides various approaches for further studies in this area. The findings of this study can be used by the future researchers.

4. Nursing Administration

The study finding can be used by the hospital administrator to convince the hospital staff that the Self Instructional Module can be used for the staff nurses to improve the knowledge on Management of the Patients with Stroke. The nurse administrators can conduct in-service education on Management of the Patients with Stroke based on the result of the present study.

LIMITATIONS:

1. The study was confined to a small sample selected by purposive sampling technique and limited area of the setting which restricts the generalization.

2. The study was delimited to staff nurses working in only Critical Care Units of K.L.E.S Dr Prabhakar Hospital and Medical Research Centre.

RECOMMENDATIONS:

1. A Similar study can be replicated with a large sample in order to generalize the data.

2. A study can be done on effectiveness of video instruction on knowledge regarding Management of The Patients With Stroke

3. Comparative studies can be conducted in different settings.

4. The research tool can be updated and can be used as evaluation criteria for the nurses working skill in the Critical Care Units.

REFERENCES:

1) Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarths text book of Medical surgical nursing(I).11^thed. New Delhi. Lippincott Williams and Wilkins; p.1887-95

2) Nicol MB, Thrift AG. Knowledge of risk factors and warning signs of stroke; National Stroke Research Institute, Australia. Vascular Health and Risk Management 2005:1(2) 137-147.

3) Das K, Mondal GP, Dutta AK, Mukherjee B, Mukherjee BB. Awareness of warning symptoms and risk factors of stroke in the general population and in survivors’ stroke. J Neuroscience 2007; 14:12-16.

4) Truelsen T. Heuschmann PU, Bonita R, Arjundas G, Dalal P, Damasceno A, et.al. Standard method for developing stroke registers in low-income and middle-income countries: experiences from a feasibility study of a stepwise approach to stroke surveillance (STEPS Stroke). Lancet Neurol [online] 2007 Feb [cited 2012 Nov12]; 6: 134-9. Available from URL: http:// www.neurology.thelancet.com.

5) Fiona C Taylor. Stroke in India, South Asia Network for Chronic Disease. [Online] 2010[cited 2012 Dec10]. Available from URL: http:// www.sancd.org/uploads/pdf/factsheet Stroke.pdf

6) Sturm JW, Dewey HM, Donnan GA. Handicap after stroke: Stroke. how does it relate to disability, perception of recovery, and stroke subtypes? The North East Melbourne Stroke Incidence Study 2002 (NEMESIS), 33:762-8

7) Kathleen A, Julie J. Stroke Knowledge: How it is impacted by rural location, age and gender? Journal of rural Nursing and Health care spring [Online] 2010 .10(1).

8) Bagi D. A study to evaluate the effectiveness of Self Instructional Module(SIM) on knowledge of Arterial Pressure Monitoring(APM) among the nurses working in critical care units of KLES Dr. Prabhakar Kore Hospital and MRC, Belgaum, Karnataka.[Unpublished MSc Theses].Belgaum: Rajiv Gandhi university of health sciences; 2009

Received on 05.11.2014 Modified on 18.11.2014

Int. J. Nur. Edu. and Research 3(1): Jan.-March, 2015; Page 20-29

DOI: