RajivGandhiUniversityofHealthSciences,Karnataka,Bangalore

ANNEXURE–II

PROFORMAFORREGISTRATIONOFSUBJECTSFORDISSERTATION

Nameofthecandidateandaddress
(inblockletters) / NEETHUJOSE
IYEARM.Sc.NURSING
ATHENACOLLEGEOFNURSING
FALNIRROAD
MANGALORE–575001.
NameoftheInstitution / ATHENACOLLEGEOFNURSING
FALNIRROAD
MANGALORE–575001.
CourseofStudy,
Subject / M.Sc.NURSING
MEDICALSURGICALNURSING
DateofAdmissiontothecourse / 01.06.2012
TitleoftheTopic
A STUDY TO ASSESS THE EFFECTIVENESS OF INDIVIDUAL TEACHING PROGRAMME (ITP) ON KNOWLEDGE AND SKILL IN SELF-ADMINISTRATION OF INSULIN AMONG PATIENTS WITH DIABETES MELLITUS RECEIVING INSULIN IN A SELECTED HOSPITAL AT MANGALORE.
BriefResumeoftheIntendedWork
Introduction
“Life is not over because you have diabetes.
Make the most of what you have, be grateful”
- Dale Evans
Diabetes mellitus is a multisystem disease related to abnormal insulin production, impaired insulin utilization, or both. Diabetes mellitus is a serious health problem throughout the world.1
Diabetes is a disorder of the body's metabolism, the process of converting the food we eat into energy. Insulin is the major factor in this process, which begins when food is broken down during digestion to create glucose, the main source of fuel for the body. This glucose passes into the bloodstream, where insulin, a hormone secreted by the pancreas (a large gland behind the stomach), allows it to get into the cells. In people with diabetes, one of two parts of this system fails to work properly; the pancreas produces little or no insulin (Type I); orbody's cells do not respond to the insulin that is produced (Type II).2
In 1869, a German medical student, Paul Langerhans, found that within the pancreatic tissue that produces digestive juices there were clusters of cells whose function was unknown. Some of these cells were eventually shown to be the insulin-producing beta cells. Later, in honour of the person who discovered them, the cell clusters were named the islets of Langerhans.3
On 30th July 1921 a young surgeon Fredrick Banting and his graduate student assistant Charles Best working in Toronto in the physiology lab of professor Macleod prepared active extract of pancreas, which lowered the elevated level of glucose in diabetic dogs. The first patient who received active extract prepared by Banting and Best was Leonard Thompson a boy aged 14 years. He came with blood sugar of 500mg/dl. He received the pancreatic extract and improved.3
Insulin plays a key role in making sure that our body runs with a full supply of fuel. Insulin acts like a key that fits into little locks on the surface of the cells. It creates a series of reactions on the surface of the cell and inside the cell that allows glucose to enter. Without insulin, the sugar would back up in the blood, unable to get into the cell for use as energy. People with diabetes, is unable to take the energy or sugar from the blood stream and into the cells. That is why the first symptom of diabetes is loss of weight, thirst and frequent trips to the restroom.4
Early initiation of insulin may help more patients to achieve and maintain long-term glycaemia control through targeted titration and protection of beta-cell function. Early insulin therapy in patients with newly diagnosed type II diabetes aids the recovery and maintenance of beta-cell function, while oral hypoglycaemic agents that increase the production of endogenous insulin may speed failure of beta-cell function. The goal of insulin therapy is to mimic the way the pancreas would produce and distribute its own insulin, if it were able to manufacture it. Taking insulin simply means that your body doesn’t produce or use enough of it on its own to cover the foods you eat.5
Although insulin doesn't cure diabetes, it's one of the biggest discoveries in medicine. When it came, it was like a miracle. People with severe diabetes and only days left to live were saved. And as long as they kept getting their insulin, they could live an almost normal life.3
Self management of diabetes is of critical importance in preventing serious long term complication and it is well known that India has second largest number of diabetics globally and is expected to get dubious distinction by shortly moving to the first place in due time.6
6.1Need for the Study
Diabetes mellitus is a group of diseases characterized by high blood glucose levels that result from defects in the body's ability to produce and/or use insulin. Insulin is a hormone produced by the pancreas in response to
blood sugar levels. It is important because it helps prevent diabetes and regulates how much sugar the body needs for energy. Produced constantly by the pancreas, insulin is needed for the cells to absorb the glucose or sugar to give us the energy the body requires. Exogenous insulin is needed when a patient has inadequate insulin to meet specific metabolic needs and the combination of nutritional therapy, diet, exercise and oral hypoglycaemic agents cannot maintain a satisfactory blood glucose level.1.
Synthetic insulin helps treat and prevent complications from diabetes. There is new evidence that tight blood glucose control and earlier use of insulin can help obese patients with type 2 diabetes and reduce their risk for complications. The anti-inflammatory effects of insulin may also protect patients against blood vessel disease.3
World Health Organisation has estimated that the number of diabetics is expected to rise to 300 million by 2025. In India the number of diabetics is expected to increase from 19 million to 57 million by 2025. World health statistics shows that diabetes is directly responsible for 3.5% of non communicable disease deaths in addition to its direct role in diabetes, raised fasting blood glucose also increases the risk of cardiovascular deaths and was estimated to cause 22% coronary heart diseases deaths and 16% of stroke deaths.7
Diabetes self management education (DSME) is recognized as a fundamental component of diabetes care. The DSME is to help patients acquire the knowledge, information, self care practices, coping skills and attitudes required for the effective self management of their diabetes. Helping your patient feel positive and empowered in managing their diabetes is very important. Patients often feel that injection therapy is a sign of failure. They see insulin as a last resort and if they need to initiate therapy it means they failed to take care of themselves with other treatment options. This negative attitude can carry throughout injection therapy and can significantly impact their compliance and diabetes management in general. The negative feeling about insulin can further impact quality of life concerns surrounding administering injections.8
A cross-sectional study was conducted on level of knowledge regarding diabetes among community members in rural and urban areas of Kenya to determine how this impacts on attitudes and practices towards diabetes. Sample size of 1982 diabetic patients was selected randomly. A face-to-face interview was performed for selected respondents using a structured questionnaire for data collection. Out of 1982 respondents, 1151 (58%) were female and 831 (42%) were male and age ranged from 13 to 65 years. There were 539 (27%) with a good knowledge of diabetes; of these 52% had tertiary education; 25% had secondary education, and 14% and 9% had primary and no education, respectively. Only 971(49%) of the respondents had a positive attitude towards diabetes, while 813 (41%) demonstrated good practices towards diabetes. This study indicated that the level of knowledge of diabetes was poor. It also indicated poor attitudes and practices of the community towards diabetes. A comprehensive nationwide diabetes education programme is necessary to improve this situation.9
A study was conducted on health literacy, complication awareness, and diabetic control in patients with type 2 diabetes mellitus in china. Study group constituted 149 patients who had undergone diabetic complication assessment. Health literacy (p< 0.001) and patient awareness scores were negatively correlated to diabetic control (p=0.035), but management of treatment in the summary of diabetes self-care activities measure (p=0.030), gender (p=0.02) and duration of diabetes (p<0.001) were positively correlated to HbA1c. To develop effective patient education and improve patients diabetes control and own complications, educational strategies need to consider patient health literacy levels and self – care skills.10
The main goal of insulin therapy is to limit the progression of long term diabetic complications with either type1 or type2 diabetes mellitus. Insulin treatment programme requires effort from both the individual with diabetes and those responsible for diabetic care. There is no insulin dose that works well for everyone, insulin doses changes as per the requirements of the
patient’s need, based on the blood glucose level and also it depends upon the type of insulin used. Therefore, insulin treatment must be individualised to fit the lifestyle of metabolism of each and every patient with diabetes.11
Studies conducted in different parts of the world showed the evidence of inadequate knowledge and poor practice level on self insulin administration among diabetic patients. There is an increasing amount of evidence that the patient education is the most effective way to lessen the complications of diabetes and its management.8-10
During clinical experience the investigator came across a number of insulin-requiring diabetic patients and found that they have less knowledge regarding diabetes as well as insulin administration and they face difficulty especially when they go home. They have to wait for a person to administer insulin before food and they also find difficulty to locate a person to administer insulin. These problems can be well addressed by educating them regarding self-administration of insulin. Review of literature shows that individual teaching programme is an effective strategy in improving the knowledge and skill in self-administration of insulin. Therefore the investigator felt the need to educate the insulin requiring diabetic patients regarding self administration of insulin.
6.2Review of literature
A pre-experimental study was conducted on effectiveness of individual planned teaching on self-administration of insulin for patient with diabetes mellitus receiving insulin in selected hospital at Mangalore. Sample sizes of 30 diabetic patients on insulin therapy were selected by purposive sampling technique. The result of the study revealed that the mean post test knowledge score(x2=80.86) was higher than mean pre test knowledge score(x1= 66.86). The computed t value (t=12.98, p<0.05) showed a significant difference suggesting that individual teaching programme was effective in increasing the knowledge of diabetic patients on self-administration of insulin and the mean
post test ability score was found to be significantly higher(x4=19) than the pre test ability score(x3=16). There was a positive correlation(r=0.74) between knowledge and ability level on self-administration of insulin.12
A non experimental descriptive study was conducted on knowledge and practice regarding self insulin administration in Tamilnadu. Sample sizes of 60 diabetic patients under insulin self-administration were selected by convenient sampling technique. Knowledge assessment on self insulin administration revealed that majority [41(68%)] of the subjects had inadequate knowledge and least [19(32%)] had moderate knowledge on self-administration of insulin. Assessment of the practice regarding self insulin administration revealed that majority[13(72%)] of the subjects had poor practice and least [17(28%)] had good practice. There was a positive correlation between knowledge and practice on self insulin administration (r=0.62; p<0.05). The results of the study revealed that, patients on self insulin administration did not have adequate knowledge and hence the practice skill on self insulin administration was poor.13
A pre experimental study was conducted on effectiveness of structured teaching programme (STP) on home care management of diabetes mellitus in Chennai. Purposive sampling technique was used to select 50 samples. Study revealed that majority of the participants (60%) had inadequate knowledge and least (36%) had moderate knowledge on home care management of diabetes mellitus in pre test. Whereas, in post-test majority of the participants (70%) had adequateknowledge and least (30%) had moderate knowledge. The participants had obtained a higher post-test mean score (M=30.06, SD = 3.45) in comparison with the pre-test mean score (M=19.50, SD= 4.67) and it was significant at P<0.001 level. So the structured teaching programme was found to be effective.14
A descriptive study was conducted on the knowledge and self management practice of diabetic patients in Karnataka. A sample size of 100 diabetic patients who were attending the diabetic day programme of selected rural areas of Nitte in Karkala taluk were selected as samples using non-
probability purposive sampling. The level of knowledge regarding self management of diabetes mellitus was assessed with a knowledge questionnaire. Results showed that Majority of the clients, (57%) scored between the ranges of 9-17 (average knowledge), and least (37%) were scored between18-26 (good knowledge) and 6 of them scored between1to 8. Highest percentage(64%) of the diabetic patients had good practice and least( 36%) had poor practice on self management of diabetes mellitus15
A quasi experimental study (one group pre-test &post-test design) was conducted on effectiveness of planned teaching programme on self-administration of insulin among the patients with diabetes mellitus in Bhubaneswar, Odisha. A sample size of 50 diabetes mellitus patients between the age group of (20-50) years were selected by purposive sampling method. The mean post test knowledge score 75.25% was higher than the pre-test knowledge score 58.25% and the mean post test practice score 94.5% was higher than the pre-test practice score 64.6%. The computed value of pre and post test knowledge and pre and post –test practice showed that the post test score was significantly increased and the planned teaching programme regarding self-administration of insulin was very effective among diabetes mellitus patients. The computed value (r=0.64, p<0.05) score showed that there was a positive correlation between post test knowledge &post test practice score16
A pre- experimental study was conducted on effectiveness of structured teaching programme on knowledge and practice regarding self- administration of insulin among insulin requiring diabetic patients in Salem. Sample sizes of 30 insulin- requiring diabetic patients were selected by purposive sampling technique. The study showed that there was a significant difference in knowledge regarding self-administration of insulin before and after administration of structured teaching programme[‘t’ = 12.3, p<0.05]. There was significant difference in the practice regarding self-administration of insulin before and after administering structured teaching programme [‘t’=25.2, p<0.05]. So the structured teaching programme was found to be effective.17
6.3Problem Statement
A study to assess the effectiveness of individual teaching programme (ITP) on knowledge and skill in self-administration of insulin among patients with diabetes mellitus receiving insulin in a selected hospital at Mangalore.
6.4Objectives of the Study
  • To determine the level of knowledge of diabetes patients regarding self-administration of insulin before and after ITP as measured by a structured knowledge questionnaire
  • To evaluate the effectiveness of ITP on knowledge in self-administration of insulin in terms of gain in post test knowledge scores.
  • To evaluate the effectiveness of ITP on skill in self-administration of insulin using an observation checklist.
  • To find out the association between pre-test knowledge score and selected demographic variables (education, occupation, and duration of diabetes mellitus).

6.5Operational Definitions
  1. Effectiveness: In this study effectiveness refers to the extent, to which the ITP will achieve the desired effect, i.e., increase in the post test knowledge score.
  2. Knowledge: In this study, knowledge refers to the correct response obtained from patient with diabetes mellitus regarding self-administration of insulin as measured by a structured knowledge questionnaire.
  3. Skill: In this study, skill refers to the correct technique in self-administration of insulin by patient with diabetes mellitus as measured by observation checklist.

  1. Individual teaching programme: It is an organised teaching programme that includes identifying the insulin, identifying the markings in the syringe, loading technique of insulin, sites for insulin administration, techniques of insulin administration, side effects of insulin and storage of insulin, which will be prepared and conducted by lecture-cum-demonstration.
  2. Patients with diabetes mellitus: In this study patients with diabetes mellitus refers to all adults patients diagnosed to have diabetes mellitus by the physician and who are on insulin therapy but not aware of self-administration techniques of insulin.
  3. Self-administration of insulin: In this study it is the ability of patients with diabetes mellitus to administer insulin correctly by himself or herself.

Variables under study

  1. Independent variable: In this study it is the ITPon self-administration of insulin.
  2. Dependent variable: In this study it is the skill and knowledge level of patient with diabetes mellitus regarding self-administration of insulin.
  3. Extraneous variable: In this study it refers to the selected variables such as education, occupation, and duration of diabetes mellitus.

6.6Assumptions
  1. Patients with diabetes mellitus will have some knowledge regarding self-administration of insulin.
  2. ITP is an accepted teaching strategy for improving the knowledge and skill of patients with diabetes mellitus on self-administration of insulin.

6.7Delimitations
The study will be delimited to:
  1. Patients with diabetes mellitus who are on insulin therapy but not aware of self-administration of insulin in a selected hospital at Mangalore at the time of data collection
  2. Generalization is not possible due to small sample size.

6.8Projectedoutcome(Hypotheses)
All hypotheses will be tested at 0.05 levels of significance.
H1:The mean post-test knowledge score of the patients with diabetes mellitus regarding knowledge and skill on self-administration of insulin will be significantly higher than their mean pre-test knowledge score.
H2:There will be significant correlation between knowledge level and skill regarding self-administration of insulin.
H3:There will be significant association between the mean pre-test knowledge score of self-administration of insulin and selected demographic variables.
7 / MATERIALANDMETHODS
7.1SOURCEOFDATA
The data will be collected from patients with diabetes mellitus on insulin therapy but not aware of self-administration techniques of insulin.