INTRODUCTION:

“Learning is the beginning of wealth. Learning is the beginning of health. Learning is the beginning of spirituality. Searching and learning is where the miracle process all begins.”

Jim Rohn

Advancement in the science, modern technology and invention of newer drugs has changed the phase of various medical diseases. It is observed that those patients who survive an attack of disease live for long time but their active powers are badly affected. It is necessary that the patients must be informed, made aware of their responsibilities which are possible as a result of education. ⁽¹⁾Therapeutic options for treatment of patients with ESRD (End Stage Renal Diseases) include maintenance hemodialysis, peritoneal dialysis and renal transplantation.⁽²⁾The cost of each hemodialysis (HD) session in India varies from Rs 150 in government hospitals to Rs. 2,000 in some corporate hospitals. The monthly cost of HD in most private hospitals average Rs. 12,000 and the yearly cost of dialysis is Rs. 1,40,000, equivalent of $3000, which is in sharp contrast to an annual cost of $60,000 in the US and UK. So we are the cheapest in the world and yet more than 90% of Indians cannot afford it. The cost of an AV fistula construction is Rs. 6,000 to Rs. 20,000 from a government hospital to varying grades of private hospitals. The average cost of erythropoietin per month is Rs. 4,000 (bio similar) to Rs. 10,000 (the pioneer brand). ⁽³⁾ Nurses play a vital role in long term care of the client with a renal transplantation. She facilitates the client’s acceptance and understanding of the regimen as a part of his/ her daily life. For the professional nurse, the person’s ability to perform the kind of self care that promotes health is a central concern and patient education is an important aspect of the nurse’s role. Helping the patient to learn how to care for themselves has been an integral part of nursing practice since the beginning of nursing history.⁽⁴⁾

STATEMENT OF THE PROBLEM:

“A study to identify the learning needs of patients undergoing hemodialysis and prepare and evaluate the effectiveness of self instructional module for home management of patients.”

OBJECTIVE OF THE STUDY:

1. To identify the learning needs of the patient undergoing hemodialysis.

2. To prepare the self-instructional module for home management of patients undergoing hemodialysis.

3. To assess the effectiveness of SIM in terms of knowledge gained by patient.

4. To correlate the findings with selected demographic variables.

OPERATIONAL DEFINITIONS:

1. Learning needs:

According to oxford dictionary, learning is knowledge acquired by study and need is circumstances requiring some course of action or necessity. In this study, learning needs are the things that the patient should know to take care of him.

2. Hemodialysis:

According to oxford dictionary, a process for separating substances from a liquid, especially for taking waste substances out of the blood of people with damaged kidneys. In this study, dialysis is a procedure done with the help of dialyzer when a patient's kidneys can no longer function on their own.

3. Self Instructional Module:

According to oxford dictionary, “self instructional module is a book that gives instructions about how to do something.”

In this study, it is the written material based on diet modification, care of arteriovenous fistula, activity restrictions etc.

SCOPE:

1. Community Health Nursing: The community nurse can use the findings to improve her services, pay attention to patients receiving hemodialysis and teach home management and personal attention skills while living.

2. Clinical Nursing: The clinical nurse can use findings to improve services by understanding the need for lifestyle modification including diet, activity restrictions etc.

3. Nursing Research: Further researches can be done to know the caregiver burden experienced by caregiver of patients undergoing hemodialysis.

HYPOTHESIS:

H1:

There will be significant difference in knowledge score of the patients before and after the provision of SIM.

ASSUMPTIONS:

1) The patients with hemodialysis have some knowledge regarding home management, which is not adequate.

2) Administration of SIM will improve the knowledge of patients regarding home management.

VARIABLES UNDER STUDY:

Independent Variable:

Self instructional module regarding home management.

Dependent Variable:

Learning needs of patients undergoing hemodialysis.

LIMITATIONS:

1) Large sample size should have been taken to get the generalized effect.

2) The control group could be incorporated to evaluate the effect of self-instructional module.

3) Area-wise detail study can be conducted.

Ethical Aspects:

1. The study proposal has sanctioned by the ethical committee of the college.

2. Permission was obtained from the concerned authority of related hospital.

3. Study was explained to participant and informed consent was taken from the participant.

4. Confidentiality of information maintained by utilizing code numbers instead of names of sample group. The raw data was also kept confidential.

Conceptual Framework:

· The conceptual framework of the present study was developed on the basis of Orem’s theory of self care.

· Self care is the practice of activities that individual’s personality initiate and performs on their own behalf in maintaining life, health and well being. (Orem, 1980)

· Orem views human beings as self care agents. Self care requisite is an additional concept incorporated within the theory of self care.

Self-Care :

In the present study, self care was patient’s current knowledge related to care of dialysis fistula, prevention of infection and prevention of rupture of fistula and diet modification.

Self-Care Agency :

In the present study, demographic variables such as client’s age, sex, occupation, monthly income, diet, number of hemodialysis sessions per week were self care agency factors.

Therapeutic Self-Care Demand:

Health promoting behavior and Compliance with life style modifications and diet modification were considered as self care demands. These demands can be met with help of relatives also.

Client’s learning needs i.e. self care ability was assessed using administration of self structured questionnaire. After administration of questionnaire it was found that there are various learning needs of the clients. and they have less knowledge to take self care. Thus self care deficit is found.

Self-Care Deficit:

In the present study, lack of knowledge related to dialysis procedure and expected outcome, Perceived risk for infection at site of fistula, rupture of dialysis fistula and compression of fistula, Perceived lack of knowledge related to modification in diet are self care deficit.

Nursing Agency:

After identification of learning needs, the prepared self instructional module was administered by the nurse investigator.⁽¹³⁾

RESEARCH DESIGN:

Descriptive and quasi experimental design in which one group pre and post-test design was used.⁽⁵⁴⁾

RESEARCH APPROACH:

Descriptive evaluatory approach

SETTING OF THE STUDY:

Dialysis unit of selected hospital of the city.

SAMPLING TECHNIQUE:

Non probability convenient sampling

SAMPLE SIZE:

60 patients undergoing dialysis in dialysis unit

CRITERIA FOR SAMPLING:

INCLUSION CRITERIA:

1. Patients who are undergoing hemodialysis treatment on day care basis.

2. Patients who are undergoing hemodialysis from less than three months.

3. Literate Patients who can understand English and Marathi.

4. Those patients who are willing to participate in the study.

Exclusion Criteria:

1. Patients receiving peritoneal dialysis.

2. Patients receiving continuous hemodialysis in ICU.

Preparation of Tool:

A knowledge questionnaire was developed to assess the learning needs and to assess the effectiveness of SIM by following below steps.

a) Extensive review of literature

b) Preparation of blueprint

c) Consultation with experts

d) Validation from experts

Validity and Reliability of the tool:

Validity:

Validity of the questionnaire and module was established in consultation with experts. The questionnaire and module was sent to 19 experts in the field of nephrology, medical surgical nursing, community health nursing and statistics. Modifications were done as per recommendations. Validated tool was translated into Marathi.

RELIABILITY:

Reliability of the tool was found to be 0.83.⁽¹³⁾

Plan for Data Analysis

The ‘Man Whitney’s U’ test and ANOVA test was used to find out the association between demographic variables with pre test knowledge scores.

Organization of Study Findings:

The collected data was tabulated, analyzed, organized and presented under the following headings.

Section I

Analysis of the demographic variables.

Section II

Description of learning needs of patients undergoing hemodialysis

Section III

Description of comparison of pre and post-test knowledge score in study group.

Section IV

Description of association between selected demographic variables and pre test knowledge score.

Section I: Analysis of The Demographic Variables of The Samples:

30 (50%) of cases were from the age group of 41-60 years, whereas 18 (30%) of them were in age group of <=40 years and 12 (20%) of the cases belonged to age group of 61-80 years. 37 (62%) of the cases were male and only 23 (38%) were female. Majority 26 (43%) of them were having secondary education. 15 (25%) of them were educated up to primary level, 12 (20%) of them were graduate, 4 (7%) of them were educated up to higher secondary level and only 3 (5%) were post graduate. 18 (30%) of them were doing service, 15 (25%) of them were housewife's, 12 (20%) of them were doing business, 12 (20%) of them were retired and only 3 (5%) of them were student. 37 (62%) of them were living in joint family and 23 (38%) were living in nuclear family. 25 (42%) of the cases were having monthly income in between 10,001 to 15,000, 20 (33%) of them were having monthly income in between 5000 to 10,000. Whereas 9 (15%) of the cases were earning between 15,001- 20,000 and only 6 (10%) of them were having monthly income >20,000. 34 (57%) of them were having mixed diet and 26 (43%) of them were taking vegetarian diet. Majority of the cases i.e. 39 (65%) were undergoing dialysis twice a week. 18 (30%) of them were undergoing hemodialysis thrice a month and only 3 (5%) of them were undergoing hemodialysis twice a month.

Section II: Description of Learning Needs of Patients Undergoing Hemodialysis:

73% of the total cases scored in between 6-10 i.e. they are having average knowledge, 18% of them scored in between 0-5 i.e. poor knowledge and 8% of the total samples scored in between 11-15 which shows that they are having good knowledge.

Section Iii: Description of Comparison of Pre And Post-Test Knowledge Score of Cases in Study Group

Table 1: Comparison of Pre and Post-Test Knowledge Gained by Cases in Study Group N=60=100%

Knowledge score on		Pre test	Post test	Wilcoxon Z	P Value
		Mean ± SD	Mean ± SD	Wilcoxon Z	P Value
	Dialysis	3.22 ± 1.04	4.77 ± 0.43	6.17	<0.0001
	Fistula and care of fistula	4.37 ± 1.37	6.48 ± 0.68	6.25	<0.0001
	Diet	2.45 ± 1.21	5.97 ± 0.99	6.77	<0.0001
	Complication and coping mechanism	2.47 ± 1.23	5.22 ± 0.90	6.61	<0.0001
	Total	12.50 ± 2.87	22.43 ± 1.61	6.74	<0.0001

Table II, shows that there is high significance between pre and post-test knowledge gained in area of dialysis, fistula and care of fistula, diet, complications and coping mechanism and overall i.e. P<0.0001. Post-test knowledge score was more than pre test knowledge score in area of dialysis, fistula and care of fistula, diet, complications and coping mechanism and overall.

Section IV: Description of Association Between Selected Demographic Variables and Pre Test Knowledge Score:

Results shows that there is no significant association in pre test knowledge score and demographic variables as P>0.05. This means that knowledge gained in pre test was not associated with demographic variables such as age, gender, educational qualification, occupation, type of family, Monthly income, diet and frequency of dialysis.

CONCLUSION:

There is high significance between pre and post test knowledge gained in area of dialysis, fistula and care of fistula, diet, complications and coping mechanism and overall i.e. P<0.0001. Post test knowledge score was more than pre test knowledge score on dialysis, fistula and care of fistula, diet, complications and coping mechanism and overall. It shows that the SIM was effective.

IMPLICATIONS:

NURSING PRACTICE:

Study can contribute in the areas of nursing practice, by helping the nursing personnel to prepare a teaching program for the patients undergoing hemodialysis at their clinical area or health institute. This study will help the nurses dealing with clients needing knowledge regarding various areas such as diet, prevention of infection, care of fistula and coping for complications.

NURSING EDUCATION:

Study will contribute in development of the curriculum, so that the nursing students can develop the necessary skills and knowledge to aid in taking care of patients undergoing hemodialysis. Nursing educator also can use the evidence of this study, to prepare teaching plan on hemodialysis and care of patients undergoing hemodialysis.

NURSING ADMINISTRATION:

Findings of this study can be used by the nurse administrator to make policies and plans for benefit of patients undergoing hemodialysis in their health care institute, so that they gain maximum benefit during their visit keeping in mind the preventive, promotive and curative aspect of health.

NURSING RESEARCH:

The research is the only possible method to generate evidence for carrying out holistic nursing care. Nursing research is an essential component of today’s nursing education. The findings of the study have added to the existing body of knowledge in the nursing profession.

RECOMMENDATIONS:

The following recommendations can be made based on the findings of the present study:

1. A study can be replicated on a larger population.

2. A survey to assess knowledge, practices and coping strategies of patients undergoing hemodialysis can be done.

3. A study to assess the effect of planned teaching on home management of patients undergoing hemodialysis can be done.

4. A study can be conducted to identify the existing knowledge and attitude of nurses working in dialysis unit regarding care of patient undergoing hemodialysis.

5. A Study can be done to aeess the caregiver burden experienced by caregiver of patients undergoing hemodialysis.

ETHICAL CLEARANCE:

Taken from College level committee consisting 6 members including experts from medical field.

SOURCE OF FUNDING:

Self

CONFLICT OF INTEREST:

Nil

REFERENCE:

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Received on 11.10.2016 Modified on 21.12.2016

Int. J. Nur. Edu. and Research. 2017; 5(2): 131-135.

DOI: 10.5958/2454-2660.2017.00027.8