Professional Documents
Culture Documents
Medical Surgical Nursing Assignment
Medical Surgical Nursing Assignment
(SJMCH), Bangalore”.
By
2005
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
REG.NO: 03NM052
Signature of the candidate
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CERTIFICATE BY THE GUIDE
in Nursing.
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ENDORSEMENT BY THE HOD, PRINCIPAL / HEAD OF THE
INSTITUTION
bonafide research work done by Lillykutty M.J (Sr. Lilly Joseph) under
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COPY RIGHT
Karnataka shall have the rights to preserve, use and disseminate this
purpose.
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ACKNOWLEDGEMENT
My profound gratitude
To
I place on record my deep sense of appreciation and obligation for the untiring
efforts and constant vigilance put in by my guide who is the moving spirit behind
this academic work and whose dedication and personal interest to this cause is
unmatched.
To
GASTROENTROLOGY DEPARTMENT
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My special thanks
To
To
Sr. Suma Kuttickal, Addl. VICE PRINCIPAL for her sisterly support and prayers
Before
For her commitment, professionalism and tireless efforts in keeping track of the
number of activities involved in the production of this work.
I remain indebted
To
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My special thanks are due to the team of dedicated faculty at SJCON for their
generous contribution of time, effort, knowledge and discussions in refining this
study.
I am thankful to all the experts for critical evaluations of the Research tools and their
valuable comments and suggestions.
To
Sr. Onerine, my SUPERIOR and all the sisters of my dear congregation for they
prepared me for the Mission of Charity.
.
This blanket of acknowledgement is for the following persons for they made this
work possible:
• Dr. Mohammad, Associate professor, SJMC.
• Sr. Annie Sheela, CTC. MD, DM for her helps in the analysis of the data.
• Mr.Kurian John & Team, Browsing Centre, SJMC- for printing the text.
• Mr.Jinu James Kurian MCA, The computer graphic expert.
• My beloved parents, brothers and sisters for their prayers, sacrifices and
concerns.
• Dr.Sandeep, The editor
• Endoscopists, supervisors and staff members of endoscopy unit and inpatient
departments of SJMCH.
• All the study participants and their care givers
• My companions.
Lastly, it is the work of the Lord; Let His Name be glorified for ever.
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LIST OF ABBREVIATIONS
ABBREVIATIONS EXPANSIONS
Addl Additional
ANOVA Analysis of Covariance
CI Confidence Interval
CL Confidence Limit
CON Control
ERCP Endoscopic Retrograde Cholangio-
Pancreatography
EXP Experimental
f Frequency
G.I Gastrointestinal
HOD Head Of the Department
IEC Information, Education and Communication
IP Inpatients
KS Kolmogorov and Smirnov
MD Mean Difference
N(n) Sample
OP Outpatients
OPD Out Patient Department
RGUHS Rajiv Gandhi University of Health Sciences
SD Standard Deviation
SEM Standard Error of the Mean
SJCON St.John’s College of Nursing
SJMC St.John’s Medical College
SJMCH St.John’s Medical College Hospital
UGIE Upper gastrointestinal endoscopy
2
X Chi-Square test
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ABSTRACT
Background:
reinforcing the verbal message, especially for those health services where patients are
in the hospital for short times. Though there are information leaflets and booklets
published research studies are available on the quality and effectiveness of this
information.
Objectives:
2. To compare the satisfaction with the actual experience at the endoscopy unit in
variables.
Methods:
experimental design with two data collection points after the leaflet intervention. The
endoscopy. The sample size consisted of 200 patients, 100 each in group. Two self
report quantitative questionnaires were used for data collection. The content validity
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and reliability of the instruments were established and piloted in 20 patients before the
main study. Ethical approval to undertake this study was granted prior to pilot study.
Results:
The mean awareness score of experimental group was 17.55 +2.9 (M + SD)
satisfaction score of experimental group was 13.44 + 3.9 (M + SD) compared to the
Interpretation:
high satisfaction in the area of information provided when compared to control group.
Conclusion:
information.
KEY WORDS:
endoscopy.
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TABLE OF CONTENTS
1. INTRODUCTION 1 -3
2. OBJECTIVES
• hypothesis 12
• Assumptions 14-15
• Delimitations 15
• Projected outcome 15
• Introduction 21
• Diagnostic upper gastrointestinal
endoscopy 22 – 27
• Dimensions of satisfaction 38 – 39
39 – 42
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• Psychological aspects of care
• Conclusion 44
4.METHODOLOGY
• Research approach 45
• Research Design 47
• Population 48
• Sample size 49
• Sampling technique 50 – 51
• Instruments 54 – 59
• Content validity 59
• Reliability 60
• Pilot study 60 – 61
• Ethical considerations 65
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5. RESULTS
6. DISCUSSION
1. Findings related to demographic 94 – 96
variables of subjects
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• Limitations of the study 120
9. BIBLIOGRAPHY
10. ANNEXURES
F • Certificate of validation
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O • Patient Instrument -1 in English
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LIST OF TABLES
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information by experimental group.
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LIST OF FIGURES
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17 The percentage distribution of inpatients & outpatients 75
in experimental groups
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1. INTRODUCTION
acceptance of the concept, benefits and processes of that programme1. The efforts
mass education and media activities have resulted in creating 100% awareness among
the people about various issues related to healthy living, medical, surgical, nursing
methods and media, it has become possible to remove the deep-rooted attitudes,
efforts undertaken towards increasing awareness regarding health and illness related
subjects. Strategies of different types have been evolved and implemented with a view
to achieving behavioral and attitudinal changes and to convert the existing and
knowledge can make that knowledge understandable and usable for the receiver.
According to Healthy People 2010, the health literacy is “the degree to which
individuals have the capacity to obtain process and understand basic health
information and services for appropriate health decision.” Health awareness arises
from a convergence of education, health services, social and cultural factors, and
bring together research and practice from diverse fields4. In the opinion of past
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researchers, generating awareness is absolutely essential for creating an anxiety free
have featured that education, coping skills, relaxation techniques and a combination
of these including music, have decreased anxiety in patients across many settings.
Above all, the era of change is upon healthcare, and whatever the final
outcome may be, patient care, perception, expectation and satisfaction must be at the
procedures has two goals: to provide a mechanism by which patients can participate
in treatment decisions with full understanding of the factors relevant to their proposed
care, and to improve post-operative or post procedure recovery and reduce situational
anxiety10. As a result, informed signed consent is now a legal necessity for all medical
and surgical procedures. To obtain a legally safe informed consent requires that the
patient has a ‘substantial understanding’ of the proposed procedure and that the
person obtaining the informed consent has sufficient knowledge to explain the nature
physicians not only to perform to the best of their abilities, but also to do no harm (the
oath of Hippocrates) and nurses to do all in their power to maintain and elevate the
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standard of their profession (the pledge of Nightingale)12. This approach to medicine
and nursing is seemingly intuitive and although physicians and nurses embrace this
measure and verify our performance objectively to our patients, payees, accrediting
episode of care lets providers know what is important to the public about their
Surprisingly, changes have taken place in the arena of nursing profession too,
keep pace with the latest. The recent profusion of new nursing roles such as Clinical
Practitioner and Nurse Consultant extended the scope of professional practice. One of
medical procedures and care organization is recognized as one of the most important
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Need for the study
“The gem cannot be polished without friction, nor man perfected without trials.”
(Chinese proverb)
The need for efficient, evidence-based patient education has been growing
steadily concomitant with the recent changes in health management systems, the
Over the past 30 years, many medical and nursing researches have shown that giving
information to patients prior to surgery and investigations reduces stress and anxiety
associated with them17. There are empirical evidences that patient education is
important in ensuring quality of care, safety, and cost effectiveness. However, some
researches have consistently proved that patients are frequently dissatisfied with the
quality and quantity of information provided by nurses and other health professionals.
needs, enabling them to make informed decision regarding treatment options and in
fronts, including standard endoscopes and new instruments. The growing use and
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of Israel using a prospective, randomized, controlled design on 142 patients aged 18-
indicate that in practice there are many deficiencies in this process. The European
response rate was 59% (26/44). The endoscopist is responsible for giving the required
procedure is given to patients in 96% of the responding countries, in only 77% is there
sufficient time for the patients to ask questions about the nature of the procedure. In a
Israel, 66% of the patients were satisfied with the written consent process. Only 10%
considered that the written consent process altered their trust in their doctor. 98% of
the patients were satisfied with the consent form, 97% felt it was clear and
comprehensive and 80% of the patients felt it was reassuring. A prospective study24 in
detailed information, 84% indicated a high level satisfaction with the presented
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information, while the levels of knowledge concerning indications for surgery and
been shown to have limitations because patients frequently forget much of the
information they are told. The provision of written information is one way that the
information needs of patients can be improved. Studies25, 26 have showed that written
information given has several advantages. Firstly, the provision of written information
provides a back-up system in cases where patients are not provided with information
the information they want at the time they want it. Thirdly, written information may
be useful in clarifying verbal information and if presented clearly may be open to less
evaluating client’s satisfaction with the information provided was distributed to 100
clients undergoing a colonoscopy over a two-month period in 1998. The results of the
survey suggest that the leaflet has been instrumental in client learning about the
only if it is done well. This means it must be given to all patients and that it must be
detailed, and personalized according to the client culture and learning capacity. At
present, all the patients booked for colonoscopy receive the booklet in their homes28.
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A postal survey29 was conducted in London to investigate the practicability
and patient acceptability of postal information and consent booklet for patients
undergoing outpatient gastroscopy. An audit of 168 patients was used to test reaction
to the booklet and the idea of filling in a form before coming to the hospital; 155
patients (92.2%) reported the information given in the booklet to be “very useful” and
Previous researches have shown that information giving relieves anxiety and is
considered an act reassurance. Endoscopy nurses can help to relieve such anxieties,
using their skills to deep the patient safe and comfortable and explaining the coming
procedure in terms the patient can understand. Clement and Melby30 determined the
amount and type of information given to patients before, during and after undergoing
the information acquired by younger and older patients prior to the procedure and
nurses appeared to be the most important source of information for older patients
while the information leaflet was perceived as the most important source of
received most of the procedural information from nurses, and they recognized the
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Another area of growing interest in healthcare is patient satisfaction. There is
an abundance of literature regarding patient satisfaction and the factors that increase
researchers, policy makers, clinicians and patient groups in many countries and
considerable differences between satisfied and not satisfied clients in the service
received and their perception. Patient satisfaction relate clearly to the use of
The majority of scores related to satisfaction with nursing care ranged from ‘very
satisfied’ to ‘satisfied’ with their overall nursing care. Highest satisfaction scores were
indicated for overall caring and compassion (75%), skill with medications and
procedure in 2002, it was found that patient satisfaction is generally quite high, with
ratings of nurses and physicians topping the list. Another study evaluated36 the effect
Forty-five patients with a mean age of 58 years participated in the study. Effective
patient cooperation was achieved and all subjects were satisfied with the educational
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process and the ERCP team. These findings suggest that pre-procedure education is a
during their health and illness, the investigator was interested, above all, in two
in the Journal of Clinical Nursing, 199830 and 200331. The investigator searched for
the studies of same nature done in India. From the available published literature it is
evident that vast quantities of written patient information are produced and are freely
available in most of the major hospitals of India. Although there are information
leaflets and booklets provided for the patients, no published research studies are
to patients undergoing upper gastrointestinal endoscopy. To find out more about this
interesting development, the investigator visited the endoscopy unit of St. John’s
performed on the gastrointestinal tract in the year 2003-2004. The investigator made a
detailed study of information given in the endoscopy unit of St. John’s Medical
showed that on an average 350 patients per month have undergone upper
endoscopies, the information sheet provided is ‘the request for endoscopy form’
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The gastrointestinal endoscopy unit of SJMCH caters to patients from all
walks of life, who speak different languages like Kannada, Tamil, Telugu and
English. The unit is staffed apart from endoscopists with a senior nurse, a junior staff
on rotation for every 15 days, two nursing assistants and a typist. Those working in
endoscopic procedures have a major influence on their tolerance for the examination.
However, the atmosphere of this busy unit is not the best environment in which to
give orally new and complex information about an unknown procedure. As a result
patients receive fractions of information from the busy staff. The endoscopy team
expressed that their patients often view this procedure with anxiety and fear and a
and alarming.
In St. John’s Medical College Hospital (SJMCH) no study has been done to
investigator felt that the timing of when information is provided, the form in which it
information givers and satisfaction with the information provided are all important
that they understand. Patients should be provided with information about their
procedure prior to their arrival at the unit. A written information leaflet would allow
the patients to assimilate the information in familiar surroundings and give them the
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opportunity to think of any questions they may want to ask before undergoing the
procedure. It is the responsibility of the nurse who is either giving or being asked for
for each individual patient. Nurses, in particular, are viewed as appropriate health
professionals to provide information to patients, both because they are accessible and
To address the above points the investigator felt that it is vital to develop a
Telugu and English. The effectiveness of newly designed leaflet information in terms
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2. OBJECTIVES
patient questionnaire.
2. To compare the satisfaction with the actual experience at the endoscopy unit in
HYPOTHESIS
The mean post test awareness score obtained from patients who receive a
significantly higher than the mean post test awareness score obtained form the
patients who did not receive a leaflet on upper gastrointestinal endoscopy as measured
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OPERATIONAL DEFINITIONS
a) an increase in awareness
b) a positive correlation between the written information and satisfaction with the
experimental group.
then translated into Kannada, Tamil and Telugu. The selected areas included in the
Leaflet: In this study leaflet refers to a printed sheet of three folds with
concise, precise and standardized explanation and instructions about the procedure of
endoscopists, college of nursing faculties, endoscopy nurses, patients who had upper
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Awareness: In this study awareness refers to the patent’s knowledge of what,
why and how upper gastrointestinal endoscopy is carried out, the sensations that they
may expect during and after procedure and what is expected of them before, during
patients of experimental and control groups perceived the episode of care at the
medical and nursing care at St. John’s Medical College Hospital and is advised to
endoscopy refers to a diagnostic procedure where a thin, flexible tube with a bright
duodenum.
ASSUMPTIONS
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3) Patients are generally willing to receive relevant information so as to cope with
the procedure.
patient as before, during and after the procedure and thus enhances the
satisfaction level.
systematic way.
DELIMITATIONS
PROJECTED OUTCOME
Firstly, this study will support other researches, which have indicated that one
way of facilitating improved information giving is through the greater use of written
information. Secondly, this study will lead to a major change in the quality of
information giving at the endoscopy unit of St. John’s Medical College Hospital,
informative and attractive in four languages: Kannada, Tamil, Telugu and English and
which would prove more satisfactory to patients. Thirdly, nurses and the other
members of the health team would deliver information through well-designed patient
endoscopists and endoscopy nursing team would identify the most efficient and
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Figure-1: The conceptual framework for the present study based on King’s Theory of goal attainment
Informal decision
making Post Test – 1
Provide (Awareness)
information on Leaflet
upper GI Information Upper GI Endoscopy
Endoscopy
Post Test – 2
Nurses’ Concern Process the (Satisfaction)
information into
Generate Awareness a leaflet
Informed Consent
Control Group
Enhance satisfaction
Feed Back
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CONCEPTUAL FRAMEWORK
The conceptual framework for the present study was based on Imogen King’s
theory of goal attainment. King’s conceptual framework for nursing (1981) consists of
three interacting open systems: (1) individual as personal system. (2) two or more
individuals forming inter-personal system and (3) larger groups, with common interests
forming social system. King’s theory of goal attainment focuses on interpersonal system
and the interaction that take place between individuals, specifically in the nurse-client
The theory describes the nature of nurse’s interaction with client to establish goals
mutually and to explore and agree on means to achieve goals. Mutual goal setting is
based on nurse’s assessment of client’s various problems and disturbances in health, their
perception of problems, and their sharing information to nurse towards goal attainment.
utilize communication and interaction to provide patients with information and education
the procedure and satisfaction after undergoing the procedure. These concepts provide a
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framework to structure the development of a written communication for patients
the concept that influences all behaviors or to which all other concepts is related.
in which data obtained through the sense and from memory are organized, interpreted and
transformed.
In this study, the investigator interacted with patients who had upper
gastrointestinal endoscopy, with patients who were posted for upper gastrointestinal
endoscopy during need assessment period and with endoscopy medical and nursing team.
The nurse and the patients perceived the need for increased awareness to make an
procedure.
is given from one person to another either directly in face-to –face meetings or indirectly
component of the interaction. Perception is action oriented in the present and based on
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In this study, the information component of interaction and the mutual goal setting
endoscopy. The key areas of information are (1) concepts regarding upper gastrointestinal
endoscopy (2) care before the procedure (3) care during the procedure (4) care after the
procedure.
communication between persons and environment and between persons and persons
In this study the interaction takes place between experimental group patients and
the new set of information leaflet on upper gastrointestinal endoscopy. The leaflet brings
concise, precise and standard information and instructions to exchange with patients
In this study the result of interaction between leaflet and experimental group of
endoscopy. If the goals are attained, satisfaction will occur and that will be measured by
post test-2. The opinion regarding leaflet information will be solicited from the
experimental group of subjects before and after undergoing the procedure. The nurse will
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determine the correlation between the leaflet information and the actual procedure as
and patients undergoing upper gastrointestinal endoscopy through the medium of written
leaflet information and if “perceptual accuracy” exists in the patients, transaction is the
procedure and increase in satisfaction after the procedure as comparable with a control
group of patients who will not have an interaction with the newly designed leaflet on
upper gastrointestinal endoscopy. If leaflet and client make transactions goals will be
obtained. If goals are obtained satisfaction will occur. If goal are obtained there is a good
nursing care. The goal outcome of leaflet interaction may or may not be influenced by the
age, sex, education, occupation, and previous experience with endoscopy and inpatient or
outpatient status.
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4. REVIEW OF LITERATURE
Introduction
The term literature review refers to the activities involved in identifying and
searching for information on a topic and developing and understanding of the state of
knowledge on that topic. Literature reviews can serve a number of important functions in
the research process. A systematic review aims to discover research ideas, what is
unknown about the research topic, conceptual framework into which a research problem
The studies reviewed for the present study is organized under the following
headings:
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6) Growth of interest in patient satisfaction
7) Dimensions of satisfaction
11) Conclusion
gastrointestinal endoscopy has existed for about 120 years. Although the first gastroscope
dates to about 1968, our present, presumably modern, era of digestive endoscopy began
in 1957 with the advent of the fiberoptic endoscope42. In little more than 40 years
gastrointestinal endoscopy has profoundly altered and fundamentally improved the care
clinically helpful and rapidly developing forms of medical investigation. The purpose of
the Endoscopy centers is to care for patients who require an endoscopic procedure in an
environment that provides an appropriate level of nursing and medical care supervision.
Upper gastrointestinal endoscopy can be a very challenging procedure, even in the hands
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Definition
the upper intestinal tract including the esophagus, stomach and duodenum. The doctors
can also take tiny biopsies during the test, which a later be analyzed in the laboratory.
Endoscope
see inside certain internal organs. When the scope is inserted through the mouth, the
lining of the esophagus stomach and upper duodenum can be visually examined for any
abnormalities or growths a biopsy can be taken through the endoscope of any suspicious
transmit light and images back to the viewer. The doctor can therefore see the structures
of the upper gastrointestinal tract directly by looking through the endoscope and make a
diagnosis. By inserting instruments, the doctor can also take specimens or remove foreign
objects or polyps48.
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Indications
• Abdominal pain
• Anorexia
• Weight loss
• Hiatus hernia
• Trouble in swallowing
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Contraindications51, 52
• Patient ate food or antacids (or had enteral feeding) within 4 hours of procedure
• Gross coagulopathy
Problems53
• Agitation of patients
• Over sedation
• Encountering resistance
• Bleeding
• Perforation
• Death
Review: During the initial clinic visit, the endoscopists should review all aspects
of a patient’s case or endoscopy nurses. They include history and symptom analysis,
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Explanation: A full explanation of the procedure and what the patient can expect
will greatly aid the endoscopist, since many fears or misconceptions can be eliminated in
anxious patients. Many endoscopy centers will also give patients an information
examination. There are things that patient a can do before the test to help.
Preparation: The examiner will want the patient’s stomach empty during the
procedure so that the doctor’s vision is not blocked by particles of food. If the test is
scheduled in the morning the patient must not eat or drink any thing after 10 PM the night
before the test. The patient must gargle and brush your teeth in the morning.
Medications: The patient must not take the medications that his/her personal
physician has prescribed in the morning of the test. But he/she must bring along those
medications when coming for the test, so that he/she can have it after an hour of the
resting period. If the patient is a diabetic, he/she must inform the physician in advance.
representative prior to the procedure indicating that he/she has received the appropriate
and necessary information regarding the examination including its benefits and potential
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The test: Normally the patient will be asked to lie on his/her left side on an
examining table. The patient’s head will be on the pillow and should be comfortable and
looking straight ahead with chin tucked in. The examiner will sit or stand before the
patient; a mouthpiece with an aperture wide enough to permit passage of the endoscope is
placed in between the teeth. The endoscope is then passed through the mouthpiece and
gently passed through the mouth examining each and every part of upper digestive tract.
The procedure is complete within 10-15 minutes. The discomfort appears once the tube is
removed.
observed for a minimum of one hour. It is normal to have a sore throat for a while after
the test, but it is important to report any new chest or abdominal pain promptly to the
doctor. The patient should not drink or eat for one hour after the test. The patient may
take his/her normal solid diet and the medications once the numbness is completely off.
Early and recent research has established that giving information to patients in
hospital prior to surgery decreases pain and stress associated with surgery and reduces the
patients can improve the quality of care provided in a variety of clinical settings61. A
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emotional response to the event. Examination of the relationship between type of
information and anxiety suggests that procedural and sensation information differentially
prior to surgery and invasive procedures also indicated that the effectiveness of structured
and sensory information enhances cognitive control, while facilitating active participation
in the procedures increases behavioral control. The patients’ perceptions of what they
need to learn are important determinants of learning outcomes. The adult learner is a
person who is motivated by the immediate needs of the situation and the self-directed
need to learn.
Paper “Working for Patients” in the year 1989 emphasized the necessity to put the needs
of the patient first. With regard to information giving it proposed that patients should be
provided with clear information about what was to happen to them and rapid notification
been further accentuated by the introduction of ‘Patients’ Charter’. It states that a patient
has a right to be given clear information about any aspect of treatment or care received.
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Reinforcing the significance of informing patients, the government in 1996 prepared
‘Guidelines for professional practice document’. It notes that: If a patient or client feels
that the information they received was insufficient, they could make a complaint to take
legal action31. American Hospital Association’s Patient’s Bill of Rights emphasize that a
patient has the right to obtain from his physician complete, current information
concerning his diagnosis, treatment and prognosis in terms the patient can be reasonably
expected to understand. So there is a need to put needs of the patient first. Patients should
be provided with clear information about what was to happen to them. In order to comply
with the patient’s right; health professional should consider whether they get their
message across to patients. Patients are essential source of data and patients have a right
to have their view taken into account when planning and evaluating services65.
Definition of consent
adequate information and deliberation to accept or reject some proposed course of action
that will affect him or her.”65 Kendrick in 1994 linked autonomy with consent: There is a
close relationship between autonomy and informed consent: the former being concerned
with freedom and choice, the latter being the key which unlocks and enables their
autonomous person determines his or her course of action in accordance with a plan
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general, the main areas that seemed to keep coming up were the age of consent, consent
to treatment and parental consent and that words generally associated with consent are
Informed consent
Consent allied to the term informed means that patients should be given the
intervention67. According to English law, for a valid consent to be obtained, the doctor
must give the patient sufficient information to enable them to understand the nature and
consequences of the proposed treatment64. The court recognizes that a doctor may decide
what is in the patients best interest to known provided any decision to withhold
information was reasonably made. In terms of ‘filling in’ with current literature on
consent in practice, certainly indicate that informed consent is high on the agenda as an
The process of obtaining informed consent can be summarized with the acronym
EMBRACE.54
B enefits.
R isks
A lternatives.
C omplications
Side E ffects.
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Implication of “informed consent” for nursing
Despite the familiarity of the term ‘informed consent’, from the available
literature there is an impression that the giving of consent for an intervention is generally
regarded as part of the role of the medical practitioner. However, the investigator found a
wealth of literature in the nursing journals66 about the issues of consent; patient has the
right to receive personal health information necessary to give informed consent prior to
the start of any procedure and/or treatment. There is a danger in nursing to sideline the
members of the healthcare profession on gaining consent from patients for treatment67.
informed consent30, 31
read a simple information sheet on gastroscopy and flexible sigmoidoscopy, the majority
of patients (98%) felt that patients should be formally tested as to whether they
understood what they are told in the consent process. The conclusion of the study was:
information as well as any uncommon risks of the procedure. In order to ensure that the
educationalist69.
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3. Benefits of increasing awareness in patients
and diagnostic tests is well documented.5, 6, 7. Patient’s stress and anxiety have an impact
on their tolerance for endoscopic procedures. Researchers suggest that fear is a normal
enable nurses to care for them in an effective manner7. Some studies63, 66 of psychological
studies35’70 suggested that the effect of information varies according to the individual’s
coping mechanisms and that most adults respond to stress through information seeking
coping mechanisms. Studies have showed that preparing the patient psychologically can
significantly reduce the stress of surgery and diagnostic tests and hospitalization. Some
examining situations and deciding their implication for well being71. Seeking information
minimize the impact of a situation, thereby reducing the degree to which it is appraised as
stressful. This proposition has been tested in a large number of studies with regard
supplying information prior to medical and surgical procedures72. Some studies have
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examined cognitive coping strategies and information about sensory and procedural
information lessens anxiety and is associated with shorter recovery72. Some other studies
emotionally prepare the child for admission and surgery help reduce the severity of
central to their care. Studies30, 31 have investigated patient’s attitude to seeking sensory
and procedural information and identified wide spread dissatisfaction by patients with
regard to transmission of information from patient to doctor and from doctor to patients.
The patient’s preferences for type of information, its timing and format of preparation
were examined and over 90% patients approved this type of preparation. Most preferred
patient education needs as reported by congestive heart patients and their nurses. Patients
rated information as more important than nurses rated the same information areas.
Written information
Patients need and want written information. There is evidence that giving
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of sources they sought even more and felt that information in written form was useful and
appropriate27. Indeed, most health professionals recognize the need for written
information and literature exists giving guidelines on how to produce this resource. Some
of the studies31, 32
, which have evaluated written information, have looked at recall
result of survey suggests that the leaflet has been instrumental in client learning about the
aspects of ICU. All respondents rated the booklet ‘very worthwhile.’Chumbley, Hall and
Salmon conducted a study69 in 2002 to formulate and evaluate an information leaflet for
which was clearer, more attractive, and more informative and which proved more
information leaflets.
Although medical and nursing journals provide some guidance, many healthcare
professionals are unaware of the magnitude of the illiteracy problem in this country. An
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indeed conservative estimate of America suggests that one in five adults lack the reading
and writing ability to handle the minimum demands of daily living74This problem is
especially critical among the poor, women and elderly31. Therefore, the information must
be complete, detailed and personalized according to the culture and learning capacity.
communication tools for teaching and reinforcing the verbal message, especially in the
present climate of today’s health services where patients are in hospital for such short
times. They are only useful if the patient is able to read and understand them, otherwise
wide variations exist between the states. Although the literacy rate has improved since
1991 census but there is a clear differences between literacy rates4among males and
females. It was decided in 1991 census to use the term literacy rate for the population
relating to seven years age and above. A person is deemed as literate if he or she can
read and write with understanding in any one language. A person who can merely read
but cannot write is not considered literate. The national percentage of literates in the
population above 7 years of age is about 54%. The literacy rates of Karnataka according
to the census of 2001: male- 76%, female- 56%, and total- 67%; Tamil Nadu: male-
82%, female-65% and total- 73%; Andhra Pradesh: male- 71%, female- 51% and total-
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61%; Kerala: male- 94%, female- 88% and total- 91%. On the other hand Bihar and
Jharkhand had a literacy rate of only 49%. The states which have literacy rates below
the national average are Arunachal Pradesh- 58%, Andhra Pradesh- 61%, Rajasthan-
61%, Bihar- 49%, Jammu and Kashmir and Uttar Pradesh- 58%, Madhya Pradesh- 64%
Long sentences, medical terms and small print make hospital information
brochures and consent forms difficult for many patients to understand74, 75.
There are,
however, things nurses can do to make written information for patients more accessible.
8) Use large, bold-face print to accommodate patients with special needs such as
diabetic or cataract patients.
Providing the patient with information is an important part of the preparation for
an endoscopic procedure30. In most setting, the information includes written material that
is given to the patient before the procedure. This typically includes a description of the
actual procedure, its usefulness and risks, and the relevant preparation on the patient’s
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part31. Nursing literature supports the suggestion that endoscopy nurses use a
the patient’s ability to cope. Some previous researches have shown that information
giving relieves anxiety and is considered an act of reassurance76. Endoscopy nurses can
help to relieve such anxieties, using their skills to deep the patient safe and comfortable
and explaining the coming procedure in terms the patient can understand. Most
endoscopy nurses are practiced in teaching, reassuring and establishing a rapport with
to stress may enable endoscopy nurses to empower their patient, thereby reducing fear
and anxiety, and providing holistic care during endoscopic procedures68. Clement and
Melby30 determined the amount and type of information given to patients before, during
differences between the information acquired by younger and older patients prior to the
procedure. Nurses appear to be the most important source of information for older
patients while the information leaflet was perceived as the most important source of
most of the procedural information from nurses, and they recognized the importance of
providing sensory information. Patients were generally satisfied with the information
provided32,77.
At present, there is an increased emphasis on integrated care delivery and the need
to access information across the care continuum77. The delivery of medical care is
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changing dramatically. Patients are becoming customers, whereas physicians and nurses
are being viewed merely as providers78. To address these concerns, healthcare providers
must measure patient’s outcomes. The field of outcomes research has emerged to provide
tools to identify the most effective and efficient service. According to the Institute of
Medicine, quality represents “degree to which heath services for individuals and
populations increase the likelihood of desired health outcomes and are consistent with
appropriateness of service provided and the skills with which the appropriate care is
performed. In more simplistic terms quality can be defined as “doing the right things
right”. Patient satisfaction is a reflection of how the patient perceives an episode of care.
Satisfaction may affect whether a person seeks medical help and /or complies with the
prescribed treatment79.
8. Dimensions of satisfaction
The first issue concerns the healthcare attributes, representing patient expectations,
satisfaction literatures, it was found that the attributes commonly used to measure patient
satisfaction were ranked in the order of importance: overall quality, humanness, technical
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relationships between individual patient and nurse characteristics and patient satisfaction
with triage nursing care, patient satisfaction with triage nurse and patient’s intention to
¾ Knowledge of illness/problems
¾ Explanation of procedures
¾ Demonstrated interest
services and information received. The components of nursing care in patient satisfaction
questionnaire are:-
- 59 -
Some studies84, 85 identified three factors that influence the consumer’s satisfaction with
satisfaction in the emergency department was examined and the study concluded that
there was a tendency for staff to concentrate on technical competence rather than on
care were found to be the highest satisfying aspects of patients in a study conducted. The
psychosocial aspects included the way the care providers showed concern and
compassion, the patience of the nurse who cared of the patient, and the encouragement by
the nurses about how the family could help the patient. Along with psychosocial aspects,
the patient’s perception about the nurse’s affective behaviors was reflected in satisfaction
medical surgical unit. The important behaviors were: interpersonal skills, friendliness,
and helpfulness.
psychosocial aspects, one study found that technical quality of care was more important
- 60 -
Communication: Studies showed that patients wanted simple, easily understood
information presented in a timely fashion. Patient satisfaction is closely related with the
patient’s intentions to return to a department. Perceptions about waiting times, both actual
defining and measuring healthcare quality, less attention has been given to consumer’s
perceptions of quality healthcare. Most studies examined the type of information valuable
in choosing among varied health plans. The provider’s perceptions of quality are different
as having access to care, competent and skilled providers, proper treatment, freedom to
choose physician and hospitals, providers who communicate effectively, providing who
teach about conditions and treatments, providers who are caring and concerned, being
Quality nursing care means nurses who are competent and skilled, nurses who
mediations and self care, nurses who treat patients with respect, getting the proper
treatment and care84. Also important to consumers in their definitions of quality care are
providers and staff who communicate with them, listen and talk to them in
understandable terms, are responsive to their needs, and treat patients with respect and
the interpersonal relationship of physicians, nurses and other providers with patients.
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10. Satisfaction as an outcome measure
care because it ices importance as a measure of the quality of care78. The measurement of
satisfaction is, therefore, an important tool for research, administration and planning.
During the last decade measuring patient satisfaction has come to be regarded as the
method of choice for obtaining patient’s views about their care72. The patients are an
essential source of data about how the service functions; and those patients have a right to
have their views taken into account when planning and evaluating an episode of care. The
delivers information in a form, which can be used for comparison and monitoring. The
emphasis on patient satisfaction is consistent with the trend toward holding health
of Health and Social Security identified for health service providers to elicit patient’s
Another reason for the interest in patient satisfaction has arisen from the need to
evaluate health practices using outcomes, which are sensitive to user’s values. Previously,
trials of new forms of care have used clinical outcomes determined by knowledge rather
tan patient acceptability. Satisfaction, on the other hand, is a patient-focused outcome that
can be used to evaluate the effectiveness of nursing care. Patient satisfaction has been
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leaflet designed by nurses, community mental health programme, nurse-patient
nursing care behaviors. A further reason for the interest in measuring satisfaction draws
from the belief that patient satisfaction is an integral part of high quality care and any
system of delivering nursing care must pass this test. Patient satisfaction is a necessary
nursing and healthcare fields. Outcome research can be defined as the systematic study of
effectiveness rather than efficacy. Efficacy represents the benefits a medial or nursing
answers the question of whether an intervention can work in routine practice. Deficiency
determines whether it is worth doing. Outcome research is now being called effectiveness
trials82. Effectiveness trials strive to include a wide variety of practice settings to increase
the generalizability of their results. Effectiveness trials also collect data regarding quality
management by objectives, the key result areas of an effectiveness trial can be expressed
in quantitative as well as qualitative terms. Quantitative means the number and cost of
trial and qualitative terms related to the effectiveness of treatment and patient’s
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satisfaction. Outcome research approach contributes to the objectives of the whole rather
than a part87.
12. Conclusion
From the above literature review the investigator is convinced that client teaching
and information on medical procedures is recognized as one of the important task for the
nurse. All the above studies point out that patients information needs to any invasive
procedure is essential for better compliance. Above all the information must be complete,
concise, standardized and presented according to the client culture and learning capacity.
Several studies have suggested that patients do not recognize what they expected from
health services until an episode of care is completed. The key result areas of leaflet
- 64 -
4. METHODOLOGY
The research methodology is the framework for conducting study. This chapter
deals with the description of the methods and different steps used for getting and
information, pilot study, data collection, plan for data analysis and ethical considerations.
RESEARCH APPROACH
In view of the problem and to accomplish the objectives of the study an outcome
research approach was considered to be most appropriate for this study. Outcome
research helps define best practice, in a real-time setting. Outcome research develops a
intervention.
In this study, the investigator systematically studied the cognitive and perceptual
attention to patient centered data. A key emphasis was the effectiveness of leaflet
intervention (leaflet information) in the real world (endoscopy unit) that is, behavior of
patients and healthcare providers regardless of their training and area of practice.
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FIGURE -2 SCHEMATIC REPRESENTATION OF RESEARCH DESIGN
DATA
POPULATION SAMPLE TOOLS VARIABLES COLLECTION OUTCOME
Independent
All All variable EXPERIMENTAL EXP
consecutive patients Information Leaflet
patients who met Leaflet information * Leaflet 2nd posttest-1 Leaflet
scheduled for inclusion 1st information day Endoscopy information
UGIE at & PostTest-1 day * Verbal PostTest-2 enhanced
SJMCH from exclusion Dependant information awareness
21/02/05 criteria. PostTest-2 variables CON on upper
to Awareness 2nd GI
31/03/05 Satisfaction CONTROL day PostTest-1 Endoscopy &
1st Endoscopy patient
day * Verbal PostTest-1 satisfaction
information
- 66 -
RESEARCH DESIGN (FIGURE-2)
patients measured by a structured patient instrument. The study was conducted also to
find out the correlation between the written information and the satisfaction with the
The research design used for this study was a randomized, controlled, post test
only experimental design. It was selected since it aided in attaining the study
objectives. The post test only design was preferred to exclude the effect of pretest on
Independent variable
Dependent variables
The settings of this study were the endoscopy unit (OP Room No.28) where
the appointment and endoscopy procedure takes place and the inpatient departments
of SJMCH from where the patients were referred for diagnostic upper gastrointestinal
endoscopy procedure.
- 67 -
STORE WORK AREA CONFERENCE TOILET NURSES’
ROOM ENDOSCOPY ROOM LOUNGE
ROOM - 2
TOILET
DOCTOR’S
ENDOSCOPY ROOM
TOILET RECOVERY
ROOM
ENDOSCOPY ENDOSCOPY DOCTOR’S
WAITING ROOM
- 68 -
The study site was under the Gastroenterology department of SJMCH. As per
the annual statistics of patients of this department in the years 2003-2004, the
41, and average hospital stay of 5.5 days and inpatient consultation of 1400 patients.
POPULATION
The population for this study was all OP and IP consecutive patients scheduled
SAMPLE SIZE
To estimate the sample size for a study using categorical data it is necessary to
know the effect size or odds ratio and the proportion of subjects expected for the
- 69 -
2) Mentally alert and able to communicate freely.
3) Patients who will have the upper gastrointestinal endoscopy on the same day
of appointment.
4) Patients who had upper gastrointestinal endoscopy within the past 6 months.
scheduled for diagnostic upper gastrointestinal endoscopy and who fell within the
inclusion criteria. All potential patient subjects meeting the inclusion criteria were
invited to participate until the sample size of 200 was obtained. Each patient who met
the inclusion criteria was given an information package explaining the identification
of the investigator, the nature and purpose, benefits of the study and what is expected
of him/her during the study. Each patient who volunteered signed a consent form that
involved in the research study. The investigator opened the sealed, sequentially
numbered cover in which there was a folded printed paper written either as
- 70 -
‘CONTROL’ or ‘EXPERIMENTAL’. The investigator was blinded until opening the
cover and this method was selected to reduce bias to the minimum. If the cover
indicated ‘control’ the outpatient subject obtained appointment form and verbal
explanation by the endoscopy counter clerical staff and if the cover indicated
information by the endoscopy counter clerical staff and the newly designed leaflet
indicated ‘control’ inpatient subject received verbal explanation by the night duty
nursing staff and if the cover indicated ‘experimental’ the inpatient subject was
addition to the verbal explanation given by the night duty nursing staff.
- 71 -
Experimental (100)
SAMPLES (200) Control (100)
INCLUSION
EXCLUSION CRITERIA
CRITERIA
OUTPATIENTS INPATIENTS
ENDOSCOPY ENDOSCOPY
- 72 -
*Review of Discussion with: * Personal
literature *Endoscopists experience
* Online *Endoscopy nursing team
PubMed & *Endoscopy office staff *Observations
Google search *Patients who had GI Endoscopy
FIRST DRAFT
DISCUSSIONS
SECOND DRAFT
THIRD DRAFT
ESTABLISHMENT OF RELIABILITY
EXPERTS’ OPINION
FOURTH DRAFT
PILOTED IN 20 PATIENTS
DEVELOPMENT
- 73 -
LEAFLET AND PATIENT INSTRUMENT-1 DEVELOPMENT (FIGURE-5)
added from a review of literature, online PubMed and Google search, and discussions
with endoscopy team, personal observations and suggestions from endoscopists. The
subsequent content was submitted for review. The revised content was tried with few
patients and sent to experts for content validity. Items that the panel decided
unnecessary were deleted and additional items were included. Comments and
were also used to revise the wording of the items. The leaflet was piloted with 10
patients undergoing upper gastrointestinal endoscopy. The subjects were also asked to
add any additional items they believed were important to learn. There was no revision
Leaflet design: (FIGURE-6). The leaflet dealt with four issues: the concept
of upper gastrointestinal endoscopy, the preparation before the procedure, the care
during the procedure and the care after the procedure. The leaflet is written in easy-to-
read English, comprising 560 words of which 70% were two syllables or fewer in
length. The sentences were 8-9 words long. The level of difficult words present in the
English version was made more understandable and simple while translated and
edited in Kannada, Tamil and Telugu. The final copy of the leaflet was designed with
improved illustrations on the cover page, easier language and a more legible lay out.
- 74 -
FIGURE – 6: UPPER GASTROINTESTINAL ENDOSCOPY
CONTINUUM OF CARE
- 76 -
The spring model outlined in figure shows the phases of upper
a continuum of care. The spring model stretched information to meet the needs of
patients from concept of upper gastrointestinal endoscopy, care before, during and
gastrointestinal endoscopy.
which explained the identity of the investigator, the nature and purpose of the study,
the method of data collection, what is expected of before and during the study, the
benefits of the study, the number and sequence of data collection and an informed
- 77 -
Section B: Opinion of leaflet information
undergoing upper gastrointestinal endoscopy. Item No.8 was a 5 point rating scale to
identify other sources of information from both subjects in experimental and control
groups
awareness level of patients in both experimental and control groups. The items and
the right response option are based on the content of leaflet information. The
respondent had to tick against the box corresponding to the single best option .The
right answer has a value of ‘1’ and ‘0’ for the wrong answer. The total score is
As a methodology to address the second objective of the study a post test-2 was
measuring patient satisfaction after an endoscopy procedure was executed using the
online PubMed and Goggle and published journals related to Gastroenterology from
Endoscopy Clinics North America.1999; 9(4) were adapted for this study. The
- 78 -
GHAA-9 questionnaire has been in existence for nearly 20 years and has been
Response options are in the form of a 4 point scale namely, excellent, very good,
good, and fair. There were two items added by the investigator and responded only by
provided and the actual performance during and after the procedure as perceived by
the patient. The last two open-ended questions are included for the patients to write
down their own comments and suggestions. The post test-2 was translated and edited
in Kannada, Tamil and Telugu and piloted in 20 patients before the main study.
CONTENT VALIDITY
patient instrument -1 was established by 10 experts: from the field of nursing (6),
Comments and suggestions were invited (Annexure -E). Modifications were made on
the basis of suggestions and comments given by experts (Annexure -E). The leaflet
and tool were translated and edited in Kannada, Tamil and Telugu by language
experts (Annexure-G-V).
RELIABILITY
Reliability for the questionnaire was established using Test Retest method.
The questionnaire was admitted to 10 staff nurses once and then after 5 days again it
- 79 -
was administered to same group. The scores obtained were utilized to check reliability
using deviation method. The value of r = 0.875. There is a positive high correlation.
The obtained value is greater than table value at 0.05 levels of significance.
on 20 patients from 17.1.05 to 25.1.05.The setting of the study were the endoscopy
they came to take appointment for upper gastrointestinal endoscopy procedure about
one day or at least 12 hours before the procedure. Inpatients were recruited from all
departments over a period of one week. Patients were approached in the afternoon of
the previous day of procedure and sought consent to take part in the study. Before,
randomization the eligible patients were given a written information sheet in their
own language, explaining the purpose and requirement of the study. Informed consent
for the research study was taken in writing. Patients were randomly assigned to
control and experimental groups. The allocation sequence was generated by the
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random placement of thoroughly shuffled and sequentially numbered envelops by a
person not involved in the research study. The control group received verbal
information and an appointment form, which carries the time of procedure. The
• Patients of control group requested for leaflet information after the post test-1.
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Stage Stage Stage Stage Stage
1 2 3 4 5
* Outpatients came to the
endoscopy unit to take
appointment * Study * Out patient E * Out patients
participants participants came for N completed post-
* Inpatients were identified had prescribed procedure D test 2 at the end of
from IP appointment register. minimum 12 O their resting time.
hours to * During their waiting S
* Identified study subjects read & time for the procedure C * Inpatients
were recruited based on the assimilate completed post test-1. O completed post –
exclusion and inclusion the leaflet P test 2 in the
criteria. information. * Inpatients completed Y afternoon of the
post- test 1 in their own procedure.
*Obtained informal Consent setting prior to coming P
for endoscopy. R
*Allocated subjects to exp & O
control groups with C
randomized cover. E
D
*Experimentals received: U
* Appointment form R
* Verbal explanation E
* New leaflet
* Controls received :
* Appointment form
* Verbal explanation
- 82 -
Details of main study (FIGURE-7).
provided. A quantitative method of data collection and analysis were employed in this
study. Two self-completed patient instruments were employed and data was collected
The subjects were adult outpatients and inpatients having referred for
controlled in this study were the inclusion and exclusion criteria set at the beginning.
Two hundred patients signed consent form on a daily basis. The subjects were
purposively selected and allocated to control and experimental groups by the random
In order to have control over all the staged of this study the investigator
positioned herself in front of the endoscopy counter. Outpatients were recruited on the
day they came to take appointment for upper gastrointestinal endoscopy. The eligible
subjects were identified and the investigator offered information package to them.
After signing the informed consent by the subjects the investigator opened the sealed
- 83 -
cover to allocate the subjects to the control or experimental groups. The subjects came
for endoscopy procedure on the day of appointment. The investigator offered them the
patient instrument-1 and completed the post test- 1 as they were waiting for the
procedure. The post test- 1 was picked up shortly before they were called for the
Then they went for the endoscopy procedure. At the end of resting period they were
offered patient instrument-2. Post tesst-2 was completed in about 10 minutes. The
investigator received back the instrument-2 as they were called to give the report of
their investigation.
endoscopy the following morning were identified from the patient appointment
identified by cross checking the patient record at nurse’s station to determine the age,
diagnosis, and purpose of the request for an upper gastrointestinal endoscopy. Then
each potential patient was met at his/her room/unit to ensure that the subject fall
within the inclusion criteria. After identifying the patient, the ward sister was notified
by the investigator that the patient was enrolled in the research study, but did not
reveal the method of study. Then the study continued as mentioned in the section of
instrument-1 prior to coming to the endoscopy unit. Then they came for endoscope
procedure. The post test-2 was completed in the afternoon of the same day at their
room/unit.
- 84 -
ETHICAL CONSIDERATIONS
research ethical committee and from the research committee of college of nursing.
The study site approval was obtained from the Director, Administrator, Nursing
inpatient departments, floor supervisors, the sister-in charges and other staff members
of the endoscopy unit and inpatient departments. An informed consent was sought
from patients to participate in the study after explaining the purpose, the method and
number of times the data will be collected from them. Ethical issues were considered
verbal information at the end of the completion of patient instrument-1 and the newly
designed leaflet on upper gastrointestinal endoscopy at the end of study if they desired
for it.
- 85 -
Figure – 8: DATA ANALYSIS PROCESS
GRAPH PREPARATION
- 86 -
TABLE- 1: DATA ANALYSIS PLAN
Objectives Statistics
- 87 -
5. RESULTS
This chapter deals with the analysis and interpretation of data collected to
the endoscopy unit of SJMCH from 21.2.05 to 31.3.05. The quantitative and
qualitative information collected by a prospective case control trial using 200 samples
this chapter.
Section 1
Description of selected baseline variables of the study subjects.
Section 2
To compare of two groups’ variables for the homogeneity.
Section 3
Objective-1: To compare the awareness of patients in the control and
experimental groups before undergoing upper gastrointestinal endoscopy.
Section 4
Section 5
Objective-3: To determine the association between awareness and selected
baseline variables of both control and experimental groups.
- 89 -
Section -1: DESCRIBTION BASELINE VARIABLES
26% 25%
18-30years
31-40years
41-50years
51-60years
24% 25%
Experimental Group
FIGURE -9:
The experimental subjects were composed of more or less equal proportion in their
age distribution as shown in figure-9.
30% 24%
18-30years
31-40years
41-50years
51-60years
28% 18%
Control Group
FIGURE-10:
- 90 -
35%
Male
Female
65%
Experimental Group
FIGURE - 11:
Percentage distributions of experimental subjects according to their sex.
Figure 11 shows that among the experimental subjects 65% were males and 35%
were females.
27%
Male
Female
73%
Control group
FIGURE -12:
Percentage distributions of control subjects according to their sex.
Figure 12 shows that among the Control subjects 73% were males and 27% were
females.
- 91 -
P
28% 26%
30% 24% 24%
25%
18% 18%
20% 16% 14%
12% Experimental
15%
8% Control
10% 7%
5%
5%
0% 0%
0%
PR MS HS UG PG PRO OT
- 92 -
25%
19% 21%
20% 19% 19%
17%
15% 15%
15% 14% Experimental
12%
10% Control
10% 8% 10% 8%
7%
4%
5%
2%
0%
NIL LA HW RT PRO TECH BU OT
The figure 14 shows that 53% of experimental subjects were unemployed compared to 48% of control subjects.
- 93 -
26%
YES
NO
74%
Experimental Group
FIGURE-15:
Figure 15 show that only 26% of the Experimental subjects had a previous
endoscopy experience.
33%
YES
NO
67%
Control Group
FIGURE -16:
Percentage distribution of control subjects according to their previous endoscopy
experience.
Figure 16 show that only 33% of the Control subjects had a previous endoscopy
experience.
- 94 -
50% 50% IP
OP
Experimental Group
FIGURE-17:
Figure 17 shows that among the experimental group of study subjects 50% were
inpatients and 50% were outpatients.
40%
OP
IP
60%
Control Group
FIGURE-18:
Figure 18 shows that among the control group of study subjects 40% were inpatients and
60% were outpatients.
- 95 -
Section -2
Education Primary 18 24
Middle Secondary 28 24 X2 = 507df(5) NS
Higher Secondary 26 18
Undergraduates 16 14
Post Graduates 5 12
Professional 7 8
Any other 0 0
OP 50 60 X2 = 4df(1) NS
Admission IP 50 40
Kannada 38 43 X2 = 1.1df(1) NS
Language Tamil 25 25
Telugu 10 11
English 27 21
- 96 -
Section -3
Objective-1:
To compare the awareness of the patients in the control and experimental groups before
undergoing upper gastro intestinal endoscopy
TABLE -3:
- 97 -
TABLE -4:
Experimental Control
Parameters n=100 n=100 Mann-Whitney Test
Since data of experimental group failed the normality test with P<0.05,
considered using a non parametric test also to prove hypothesis. The obtained P value
using Mann-Whitney test (<0.0001) suggests that the experimental group has a higher
Hypothesis:
The research hypothesis was converted to null hypothesis for the purpose of testing.
There will be no significant difference in the mean post test awareness score
obtained from patients who received a newly designed information leaflet on upper
gastrointestinal endoscopy from the mean post test awareness score obtained form the
patients who did not receive a leaflet on upper gastrointestinal endoscopy as measured by
Since the P value of parametric and non parametric test is extremely significant
(P<0.0001), the high awareness of experimental subjects could be the effect of leaflet
interaction Therefore, the null hypothesis is rejected and research hypothesis is accepted.
- 98 -
TABLE -5:
The overall mean awareness scores of experimental subjects in all the content
areas of upper gastrointestinal endoscopy is higher than the awareness scores of control
subjects as depicted in tabele-5. Therefore the leaflet information could have been
- 99 -
Section-4
To compare the satisfaction with the actual experience at the endoscopy unit in the
control and experimental groups after undergoing upper gastrointestinal endoscopy
measured by a structured patient questionnaire.
TABLE-6:
Comparison of subjects with the actual experience at the endoscopy unit measured
after undergoing the upper gastrointestinal endoscopy.
Medium 13 9
the control group (10.5 +3.9). The obtained P value figured in the above table is
satisfied of the actual experience at the endocopy unit than the control group.
- 100 -
TABLE -7:
n=100 n=100
Since data of control group failed the normality test with P<0.05, considered
using a non parametric test. The obtained P value (<0.0001) suggests that the
experimental group has a higher satisfaction than the control group. Since both
parametric and non parametric P value (P<0.0001) is extremely significant the high
- 101 -
TABLE–8:
Association between awareness and satisfaction in experimental and control groups
(within group comparisons)
Maximum score: 20 19 18 19
Minimum score: 12 6 1 4
Median
18 13 7 9
From the above values it is apparent that the awareness gained by the leaflet
interaction and the satisfaction expressed by the experimental group did not co vary
effectively. The association awareness and satisfaction of control group is statistically
significant. The awareness and satisfaction did co vary effectively.
From the above table values it is assumed that although the awareness and
satisfaction of experimental group did not co vary as that of control group, the
experimental group has a high satisfaction mean score. It could be probably attributed to
the interaction of experimental group with leaflet information.
- 102 -
TABLE-9:
Agreement and disagreement among subjects on time spent waiting for the
procedure and actual endoscopy procedure measured after undergoing upper
gastrointestinal endoscopy.
Waiting for the procedure: Among the experimental group 21% of subjects
spent < 30 minutes as compared to 25% of control subjects (Excellent), 44% spent 30
minutes to one hour (Very Good)as compared 40% in control subjects 28% of subjects
spent one hour to one and half hours, as compared to 23% control subjects 7% of subjects
spent more than one and half hours as compared to 12% control subjects waiting for the
procedure. The experimental and control groups did not differ significantly in their
satisfaction regarding the time spent waiting for the procedure(X 2 P = 0.5).
Satisfaction with endoscopy procedure: The experimental and control groups did not
- 103 -
TABLE-10:
Agreement and disagreement among subjects on care during, after the procedure
and information provided measured after undergoing upper gastrointestinal
endoscopy.
Care during procedure: The experimental group has higher satisfaction about
the care during the procedure than the control group (P<0.0001).
Satisfaction with the information provided: The experimental group has higher
satisfaction about the information provided to them than the control group (P<0.0001).
Care after the procedure: The experimental group and control group did not
differ in their satisfaction regarding the care after the procedure (P>0.05).
- 104 -
TABLE-11:
Agreement and disagreement among subjects on overall care and their satisfaction
to refer friends and relatives to the same facility measured after undergoing upper
gastrointestinal endoscopy.
Eon 5% 26% 7% 2%
Con 93% 7%
*Significant at P<0.0001 percent level NS: Not significant at 0.05 percent level
Overall rating for the care in the endoscopy unit: The experimental group has
a higher satisfaction about over all care of the unit than the control group (P<0.0001) as
presented in the above table.
Satisfaction to refer friends and relatives to the unit The experimental group
and control group did not differ in their satisfaction to refer their friends and relatives to
our facility as presented in table 9C(P>0.05). Both groups were apparently satisfied.
- 105 -
TABLE – 12:
Responses
Satisfaction areas n=100
Yes No
1. Received the leaflet 100%
100%
2. Read the leaflet
100%
3. Was understandable
The above table depicts that there was 100% satisfaction among the experimental
subjects about the readability, usefulness, understandability and the content of the leaflet
information. All of them expressed that the leaflet should be provided to patients in the
future.
- 106 -
50%
50%
44%
41% 40%
40%
30%
Before
20% 15% After
8%
10%
1% 1%
0%
Excellent V.Good Good Fair
FIGURE -19:
Before undergoing the procedure 44% of subjects opinioned that the leaflet
information was “Excellent” as compared to 41% after the procedure, and as “Very
Good” 40% as compared to 50% after the procedure. On the whole 91% of subjects
opinioned that the leaflet information was “Excellent to Very Good” in relation to the
actual procedure compared to the 84% of subjects who opinioned that the leaflet
information was “Excellent to Very Good” before undergoing the procedure
TABLE- 13:
Linear correlation between before and after opinion of experimental subjects on
leaflet information.
n=100
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2%
0%
10%
PAA
AAA
SAA
NAA
88%
The above diagram presents that 88% percentages of experimental subjects are in
agreement with the leaflet information as perfectly appropriate and adequate, 10% as
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Section – 5
Objective 3: To determine the association between the awareness and selected baseline
TABLE -14:
SD 13 12.5 r = -0.038NS
The above table depicts a non-significant association between age and awareness
score of experimental group. The age of the subjects had no impact on the awareness of
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TABLE -15:
The P values in the table suggest that there is no association between the sex and the
awareness scores of both experimental and control group. So the gender of the subjects did not
influence the awareness of the study subjects.
TABLE-16:
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TABLE – 17:
Experimental group
Sample 50 50 t = 0.954 NS
Mean awareness score 17.68 17.42 (98)df
SD 2.08 2.25
Control group
Sample 40 60
Mean awareness score 6.3 7.3 t = 2.027(98)df
SD 2.96 3.8
NS: Not significant at 0.05 percent level *Significant at P = 0.045 percent level.
The above table indicates the association between the awareness and the inpatient
suggests that there exists a significant difference in the awareness of outpatients and
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TABLE -18:
Experimental Control
n=100 n=100
Mean Mean
awareness awareness
Education f SD f SD
Score Score
NS: Not significant at 0.05 percent level *Significant at P<0.01 percent level.
The above table indicates that there is significant association between the
education and the awareness scores of control groups. The association is statistically
significant. But there exists a non-significant association between the education and
awareness of experimental group. From the above values it could be assumed that the
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TABLE-19:
Experimental Control
Mean Mean
Occupation awareness awareness
f SD f SD
Score Score
NS
ANOVA P = 0.28 ANOVA P < 0.0043*
The above table indicates that there is significant association between the
occupation and the awareness scores of control groups. The association is statistically
significant.
But the there exists a non-significant association between the occupation and
awareness of experimental group. From the above values it could be assumed that the
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6. DISCUSSION
The perspectives of the findings have been discussed with reference to research
problem, conceptual framework, objectives, hypothesis, and assumptions of the study and
address the research problem and the objectives of the study the conceptual frame work
used was Imogene King’s theory of goal attainment. Concepts integral to King’s
conceptual frame work and most applicable to present study are perception,
Section-1
To compare subjects from experimental and control groups, in relation to the baseline
variables.
Section-2
To compare the awareness of experimental and control groups before undergoing the
Section-3
To compare the satisfaction of patients with actual experience at the endoscopy unit
Section - 4
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Section-1
baseline variables
The subjects in the present study constituted 200 patients undergoing upper
gastrointestinal endoscopy 100 each in experimental and control group. From the view
point of the conceptual framework the baseline perceptions of clients were assumed to be
the factors likely to influence the dependant variable namely the awareness of patients on
King also added that if perceptual accuracy exists the goal will be met. Referring to this
assumption in the King’ conceptual framework the controlling factors for the recruitment
of the subjects were the inclusion and exclusion criteria set at the beginning of this study.
The table shows various categories of data covering the proportions of subjects that fall
into baseline variables like age, sex, education, occupation, previous endoscopy
experience and inpatient Vs outpatient status. Therefore the Chi-square statistics was
computed to compare two sets of categories in experiential and control group. It was also
so essential to determine the homogeneity of two group variables since the hypothesis
being tested was that the mean awareness obtained from patients who received newly
higher than the mean post awareness score obtained from the patients who did not receive
leaflet. Also the awareness score of control group was considered as the baseline
measurement to compare the awareness scores of experimental group after the leaflet
intervention.
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The computed probability levels (P>0.05) indicated that selected baseline
parameters of the experimental and control groups were comparable, It means that the
difference between the two groups were not statistically significant at 0.05 percent level.
Thus the Chi-Square test enabled the investigator to decide whether a difference in
proportions of magnitude is likely to reflect a real experiential effect, that is, leaflet
information on the awareness and satisfaction or only a chance fluctuation. Further more
the demographic data of experimental and control groups indicated that the mean age of
experimental group was 42 + 12.5 and of the control group was 40 +13 indicating more
middle aged subjects in the studied population. One study30 considered only ages
between 18-90. Among the sex distribution males were 65% in experimental group and
73% in control group reflecting greater proportion of males in the study subjects. Among
the subjects of experimental group 26% and of control group 33% had previous
referred for the procedure. While considering the education of the subjects, majority of
groups. All occupational categories were referred for this procedure. All the accessed
studies related to this topic considered only ages between 18-90, gender and previous
endoscopy experiences. Among the present study subjects 40.5% used Kannada, 25%
Tamil, 10.5% Telugu, and 24% used English as their common language for reading and
writing. Above findings are consistent with the previous researches61, 63, 66 that patient’s
instruction material should be designed according to literacy rate and education and
socio- economic background of the patient population to whom it will be addressed in the
future.
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Section -2
The first objective of the study was to compare the awareness of patients in the
According to the conceptual frame work of present study the concerns of client and nurse
were converged into a mutual goal setting – to communicate with patient’s information
Prior to the dissemination of leaflets the investigator evaluated the effectiveness of leaflet
interaction using a prospective case control design. Post test only experimental design
was composed of two randomly assigned groups but neither of which was pre- tested in
the before period of time. The independent variable- leaflet information was introduced
to experimental group and withheld from the control group. This design was particularly
useful in the present study setting because the population studied would not be available
to pretest as 50-60 % patients were outpatients and also the investigator wanted to recruit
both inpatients and outpatients for better accuracy and generalization of the findings from
the population studied. In this design the score of control group was referred to as the
baseline measures. The scores of experimental group was the outcome measure of the
dependent variables- awareness and satisfaction that captured the outcome of interaction
interaction took place between the experimental group of patient and newly processed
was to bring concise, precise and standard information and instruction to exchange with
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patients undergoing upper gastrointestinal endoscopy. If perceptual accuracy existed in
the experimental group transaction is the outcome, which also is the evaluative
component of interaction.
awareness scores of experimental and control groups. The mean awareness score of
experimental group was 17.55 +2.9 and mean awareness score of the control group was
7.16 + 3.5. The two – tailed P value was <0.0001which is considered extremely
significant. Importantly, that’s’ test assumes that data are sampled from population that
(Gaussian) distribution. Since this play a predominant part in medical and biological
research and a particular use of this normal distribution is made whenever we have a
large sample. That’s’ test assumption was tested using the method Kolmogrov &
Smirnov (KS). The computed P value suggested that the experimental group failed the
normality test and the control group passed. Since the experimental group did not have
frequency distribution plotted a symmetric bell shaped curve it indicated the curve is
skewed or distorted. Since the testing of hypothesis constituted the heart of this empirical
investigation that were quantitative and also to place greater confidence in hypothesis
testing it was also suggested doing a non parametric test. Although, the statisticians
disagree about the utility and virtues of non paramedic test over parametric test which is
more powerful, the more moderate position in this debate, and one that the investigator
thought reasonable was that non parametric tests are also useful when the distribution of
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data is skewed. The Mann Whitney non parametric test (P<0.0001) suggested that the
difference in the experimental and control groups regarding the awareness in the areas of
concept of upper gastrointestinal endoscopy, care before, care during, care after the
procedure which were dealt in the leaflet information. All the computed P values
(<0.0001) are extremely significant. So the null hypothesis was rejected, the research
hypothesis, then, came to be accepted with evidences from the P values of parametric
and non parametric test, that is, the awareness of experimental group is significantly
higher than the control group regarding upper gastrointestinal endoscopy, which was
measured before undergoing the procedure. This could be probably due to an effective
interaction between leaflet information and the experimental group. It means that
increasing the awareness of experimental group. The awareness score of control group
(7.16 + 3.5) also supported the assumption of the study that patient may have some basic
The above evidences from the present study amplify the findings of the previous
researches in the areas of information giving and awareness before medical and nursing
procedures. Early and recent researches also support the findings of the present study that
A previous study75 support the findings of the present study that patients desire
and want written information. Another study26 reported that written information is a cost-
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effective intervention that complements verbal advice given by health care professionals
as reflected in the present study. Although not all studies show consistent results some
measures of stress which was not the main focus of consideration in this study. The
present study identified the same findings of a study32 conducted which evaluated the
effect of giving both sensory and procedural information, to patients prior to gastroscopy
is central to their care as was seen by the high awareness score in the experimental group
of the present study. In particular, they appear to rate the receiving of information high
which was also true in the present as well as many other studies10, 11. The present study
format will, maximize knowledge and keep anxiety to a minimum as indicated by the
Mean difference of 10.39 from control group to experimental group. Almost all patients
of present study and other studies found such information were to be of help. It is
minor gynecological surgery, special preparatory information was given and its timing
and format of presentation were examined. Over 90% of patients approved of this type of
preparation for surgery which was also similar in the present study too. Like in the
present study on the effectiveness of leaflet information in an another study the most
and reassuring information. Some studies17, 21 suggest that the effect of information varies
according to the individual’s coping mechanisms which were not evident in the present
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studies63,66 argue that most adults respond to stress through information seeking coping
mechanisms which was evident in the control group of subjects of the present study.
Beneficial effects of information giving were experienced by those who receive sensory
and procedural information. The findings of some studies30,31 indicate that fewer distress
behaviors are displayed by patients provided with sensory information in a written format
as compared with patients provided with less information which was also the findings of
the present study. There is some evidence in the present study when compared to similar
studies to suggest that patients who received sensory information prior to a procedure
significantly were more realistic with actual experiences than subjects who received few
procedural information from the counter staff. An experimental study7 looked at the
outcome of giving structured written information and reported that less pain and
discomfort was expressed during the procedure by patients who received information
of information from patient to doctor and doctor to patient which was carefully addressed
by the present study. One of the benefits of the present study is that it supports the
findings and investigations of the previous researches that written information materials
the present study findings also added its major contribution to the body of knowledge
which argues that information giving and generating awareness in patients before taking
consent is one of the major responsibilities of doctors and nurses. The present study
findings together with previous research findings73, 74, 75 suggest that providing patients
with professional and targeted information content in a written form can significantly
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Section -3
To compare the satisfaction with the actual experience at the endoscopy unit in the
The second measurement point in this study was after the subjects undergoing
data of experimental group and compared with control group to determine the perceptual
success of leaflet information as it was the most unique feature of this study. This study
considered effectiveness as the utility of leaflet information in the real world, that is,
endoscopy unit. Although it is a noble concept available in the literatures only two
studies were available to support the present study79,86 because most of the past studies
examined either the type of information required by the patients or the cognitive success
From the view point of conceptual framework of the study, if leaflet and
experimental group made transaction goals must have been obtained, that is, generating
would occur. This assumption would lead one to consider the second objective of the
study as the dual effect of leaflet interaction that is increased awareness leading to
enhanced satisfaction towards the actual procedure at the endoscopy unit. Unpaired’ test
was computed to compare the satisfaction of experimental and control groups and the
obtained mean satisfaction score of experimental group (13.44 + 3.9) was higher than the
mean satisfaction score of control group (10.54 + 3.9) which was significant at P <0.0001
level. Here too, the data of experimental group failed the normality test, considered also
using a non parametric test. The Mann Whitney test P value (<0.0001) suggests that
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experimental group has a higher satisfaction with actual experience than the control
group. So it could be argued that the higher satisfaction in the experimental group which
satisfaction among the experimental and control groups rather to compare control and
experimental groups in their sub areas of satisfaction. For this purpose the Chi-square test
was used to determine which were the sub-domains of actual experience where the
experimental and control groups agreed and disagreed. The experimental group had a
higher satisfaction in the areas of care during the procedure, information provided in
relation to the actual procedure and overall care at the endoscopy unit compared to
control group which was significant at P<0.0001 level. In fact these findings were similar
and found that patient satisfaction is generally quite high, with rating of care given during
the procedure topping the list. There were few similar findings in another study75
showing that simple easily understood information presented in timely passion would
lead to satisfaction.
The two groups of the present study did not differ in their opinion regarding the
time spent waiting for the procedure, endoscopy procedure, care after the procedure, and
satisfaction to refer friends and relatives to the same facility as proved by non significant
P values, meaning to say, control group even without leaflet information was satisfied
with some of the aspects of actual care. So one of the highlights of this study was that
both groups were more or less preferred to come to the same facility as observed in a
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survey study79 which concluded that patient’s opinion reflected in their intentions to
Another aspect that was inherent to the first and second objectives of the study
was to find out the effect of awareness on the satisfaction of experimental and control
group separately. Although the satisfaction of experimental group was higher than the
control group the awareness gained from the leaflet information and the satisfaction with
actual experience did not co vary (r = 0.06; P=0.24). One could not conclusively say that
written information was effective in increasing awareness and satisfaction with equal
magnitude. Here the investigator did not succeed in accessing empirical studies which
evaluated the effect of awareness on the satisfaction with actual procedure. One could
also assume from the present study that leaflet has succeeded to get a high satisfaction in
the areas of information provided and the care during the procedure (<0.0001) when
ascertain the correlation between the scores given before and after the procedure by the
were the leaflet information to the actual experience at the endoscopy unit as perceived
by the experimental group and found significant with ‘ t’ value 27.45(99df) at P<0.0001
level. Therefore, it could be assumed that the leaflet information was true to its content
in relation to actual procedures at the endoscopy unit. These findings were supported by
procedures and assessed the degree of correlation between the written information and
the actual procedure as perceived by the patient. The post-endoscopy response of the
same study indicated that the patients had received a realistic description of the procedure
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and rated as “excellent” or “very good” by 87% of the respondents where as the post-
endoscopy response of the present study were rated as “Excellent” or , “Very Good” by
91% of subjects. In addition the post endoscopy rating as “Excellent” or “Very Good”
was given by 91% experimental subjects when compared to their pre- endoscopy
rating(84%).
together with a multiple choice questionnaire also evaluated client’s satisfaction with the
in 1988. The results of survey27 like the result of the present study findings suggest that
the leaflet has been instrumental in client learning about the procedure. At present, all the
Another interesting opinion of the experimental group of the present study was
procedure the experimental group experienced. Among them 88% experimental subjects
agreed that the leaflet is perfectly appropriate and adequate when compared to the
Israel, 66% of the patients were satisfied with the written consent process. The above
expressed before undergoing the procedure that the content in the leaflet was readable,
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endoscopy, care before, care during and care after the procedure and it is preferable to
disseminate to all patients before undergoing the procedure. The present study findings
match with the findings of a survey conducted in Israel, where 98% of the patients were
satisfied with consent form and 97% felt it was clear and comprehensive and 80% of the
patients felt it was reassuring. A prospective study24 in Austria also investigated the
200 patients, 97% indicated to wish detailed information, 84% indicated a high level
satisfaction with presented information where as in the present study all the experimental
subjects were satisfied with the leaflet information. Also there are evidences from the
that patient information leaflets are poor and are in language that is difficult for the public
to understand. The findings of the present study was still more satisfying reflecting a
100% agreement on the readability and the usability of the newly designed information
considerable time, effort and user involvement are required to produce acceptable and
appropriate information leaflets for the patients. These suggestions were considered very
much from the beginning of this study, indeed, the present study was built on the findings
satisfied and not satisfied clients in the service received and their perception. Patient
communication, empathy, listening, openness and genuiness. This is an area where the
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The strength of this study is that the investigator evaluated the effectiveness of a
angles exclusively based on patient reported data. No published studies had done as
leaflet . No attempt was made from the part of the investigator to be with the study
participants, indeed, they were allowed to report their opinion in a free environment.
While the investigator was actively engaged in recruiting the subjects during the first
stage of the data collection, the participants were actively engaged in completing the
second, third and fourth stages of the data collection. The investigator picked up the data
collection instruments only when the participants handed over. Therefore, one could
conclusively say that the above findings are drawn from the free response of the patients
Section -4
Association between the awareness and the baseline variables of experimental and
control groups
The third objective of the study was to determine the association between the
awareness and the selected baseline variables of experimental and control groups. Since it
was assumed that the baseline variable would probably influence the awareness levels of
patients attempts were made to determine the impact of these variables on the awareness
of control and experimental groups. The‘t’ test and ANOVA revealed that there existed a
endoscopy experience and the inpatient Vs outpatient status of the experimental subjects.
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In all the above associations the probability values were not significant at 0.05 levels. The
baseline awareness scores obtained from the control group suggested that there is
significant association between the age and sex of control group. But there was a
statistically significant association between the awareness and the education (ANOVA
outpatient status (P= 0.045) of control group. Tukey kramer multiple comparison test
was computed to identify the specific difference among the subgroups. The association is
also is significant (P<0.01) and the total group ANOVA P value is (0.0043) considered
previous endoscopy experience and the outpatient status of the subjects as found in a
patients’ age and education did not affect video education; however the sex and previous
In a study by Clement and Melby30 which determined the amount and type of
acquired by younger and older patients prior to the procedure and nurses appeared to be
the most important source of information for older patients while information leaflet was
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perceived as the most important source of information for younger patients. In another
study31 found that younger patients read the information leaflet than the older patients
where as in the present study there were no such differences. However, Ley30 argued that
age is not the determination factor in terms of how much information they remember, if it
information from nurses and they recognized the importance of providing sensory
information, patients were generally satisfied with the information provided where as the
patients received most of the information from leaflet information topping in the list.
Other study findings in South Australia24 suggested that written information is successful
in this aim only in a proportion of education in the population, because it requires at least
basic literacy as well as the motivation to read the material provided. Surprisingly the
written leaflet information studied in the present study proved truly beyond such findings.
provided for routine procedures do not adequately inform patients , perhaps to due to the
fact that readability information leaflets was too difficult for the ordinary lay person. The
major strength present study is that all the experimental subjects expressed satisfaction
regarding the leaflet information and the awareness gained was irrespective of age, sex,
From the above discussions it is very clear that this study ascertained the
the awareness level of control group through an unbiased sample drawn from that
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random sampling method, each member of patient population undergoing diagnostic
upper gastrointestinal endoscopy from 21.2.05 to 31.3.05 had an equal chance of being
selected into the sample. The allocation sequence into experimental and control group
numbered envelope by a person who is not involved in this study. Strength of this study
is that generalization is possible since a large sample study was conducted. The size of
the sample reproduced the characteristics of population studied with greatest possible
questionnaire in order to qualify for analysis. Since some of the questionnaire has to be
recruited some more samples by placing randomized covers. This design safeguarded
also to an extent the extraneous variables that could have interfered with research in
human subjects like history, maturity, bias, and reaction or interaction effect of pre- test.
To the question paused by the investigator, whether other patients waiting for the
procedure were the source of information, none reported “yes” rather all reported “no”
also safeguarded the internal validity . Indeed it could be argued that this study was less
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7. CONCLUSION
During the study, it was observed that all patients undergoing upper
Patients from control group had lack of awareness as was evident from their awareness
mean % scores (35.8%) when compared to the mean % awareness score of experimental
group 87.75%. The mean % difference between the awareness scores of two groups was
51.75%. The similarity of two groups’ variables makes one possibly conclude that the
two groups came form the same population. Therefore the high awareness scores of
experimental group could be the work of leaflet information on the already existing
contribution in increasing the awareness of experimental group regarding the care after
There was a high satisfaction for experimental group compared with control
group which was statistically significant. The Chi-Square test computed for test of
differences indicated that the control and experimental group agreed on the sub domains
of satisfaction, which were waiting for the procedure, endoscopy procedure, care after the
procedure, and satisfaction to refer friends and relatives to the same facility. But there
was a disagreement on sub domains of satisfaction like care during the procedure,
information provided prior to the procedure in relation to the actual experience at the
endoscopy unit and overall satisfaction with the endoscopy unit performance, meaning to
say that the experimental group had a high satisfaction in these areas (P <0.0001).
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Even though one could assume that leaflet has succeeded to get a high
satisfaction in the areas of information provided, from the statistical point of view the
satisfaction scores and the awareness scores of experimental group did not co vary
effectively. These findings of the study revealed that leaflet information and the
subsequent awareness gained could not be claimed to be the single most variable that
would enhance the satisfaction with actual experience rather multiple factors are to be
considered in the course of time. Hence, one cannot conclusively say that increase in
It also was noticed that the experimental group perceived the content of
the leaflet information as closely related to the actual experience at the unit. Indeed, it
could be argued that the leaflet information was true to its content as and what was
required for the specific procedure. all the experimental subjects before undergoing the
procedure recognized the content of leaflet information as readable, useful, and expressed
that it should be disseminated to all patients in the future. Among them 88% agreed that it
is adequate and appropriate and 8% agreed that it was almost adequate and appropriate in
From the above findings the investigator would like to conclude that the newly
awareness about the pending procedure had a high recognition, acceptability and utility in
the experimental group of subjects. It also could be presumed that leaflet was acceptable
and comprehensible to the particular sample studied which was a true representation of
multi-lingual and multi-cultural population that come to our facility daily. Indeed it was
a useful study and that it was beneficial to make the information leaflet available to the
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8. SUMMARY
The primary aim of the study was to assess the effectiveness of an information
endoscopy.
patient questionnaire.
2. To compare the satisfaction with the actual experience at the endoscopy unit in
There will be no significant difference in the mean post test awareness score
obtained from patients who received a newly designed information leaflet on upper
gastrointestinal endoscopy from the mean post test awareness score obtained form the
patients who did not receive a leaflet on upper gastrointestinal endoscopy as measured by
The conceptual framework used for the study was the Imogene King’s theory of
goal attainment. Concepts integral to King’s conceptual framework and most applicable
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Review of literature on studies related to information giving, patient
In view of the problem and the objectives of the study an outcome research
approach was considered to most appropriate. The research design used for this study
was a prospective, randomized, controlled, post test only experimental design with
two data collection points. The independent variable in this study was a newly
designed information leaflet and the dependent variables were the awareness before
the procedure and satisfaction after the procedure. The setting of the study was the
endoscopy unit of SJMCH and the population studied was patients undergoing
diagnostic upper gastrointestinal endoscopy in the same facility. The sample size
consisted of 200 patients 100 each in control and experimental groups. The only
controlling factors of this study were the inclusion and exclusion criteria set at the initial
phase of the study. Subjects were recruited and randomized into both groups by drawing
dealt with four major issues: concept, care before, care during and care after the
by Group health Association of America was used. The content validity and reliability
of the patient instruments were established prior to the pilot study. The instruments and
the leaflet were piloted in 20 patients before the main study. Ethical approval to
undertake this study was granted from the intuitional research ethical committee and the
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MAJOR FINDINGS OF THE STUDY:
Demographic data of experimental ad control groups indicated that the mean age of
experimental group was 42 + 13.5 and of the control group was 40 +13. This finding is
consistent with previous researches that although the upper gastrointestinal can affect any
age from young children to the very elderly the onset of problem is more common in the
middle aged population. Among the sex distribution in the groups males were 65% in
experimental group and 73% in control group. The females were 35% in experimental
group and 27% in control group. The greater proportion of males in both groups reflects
the findings of the past researches that men are more susceptible to upper gastrointestinal
The mean awareness score of experimental group was 17.55 +2.9 and mean
awareness score of the control group was 7.16 + 3.5. The two – tailed P value was
experimental group in all the content areas of leaflet information was significantly higher
(P<0.0001) than mean awareness scores of control group. Hence hypothesis could be
rejected. This also implies that the information leaflet could have been instrumental in
The mean satisfaction score of experimental group (13.44 + 3.9) was higher
than the mean satisfaction score of control group (10.54 + 3.9). The computed P value
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experimental group is higher than the control group the awareness gained from the leaflet
information and the satisfaction with actual experience did not co vary. These findings of
the study revealed that leaflet information and the subsequent awareness gained could not
be claimed to be the single most variable that would enhance the satisfaction with actual
experience rather multiple factors are to be considered in the course of time. Hence, one
cannot conclusively say that increase in awareness would result in equal increase in
closely related to the actual experience at the unit. Indeed, it could be argued that the
leaflet information was true to its content as and what is required for the specific
procedure. It could be assumed that the leaflet information was true to its content in
relation to actual procedures at the endoscopy unit. Among them 88% agreed that the
leaflet is perfectly appropriate and adequate and 10% agreed that the leaflet information
is almost appropriate and adequate 2% agreed that the leaflet information is somewhat
appropriated and adequate. Moreover, all the experimental group of subjects (100%)
expressed before undergoing the procedure that the content in the leaflet was readable,
endoscopy, care before, care during and care after the procedure and it is preferable to
occupation, previous endoscopy experience and the inpatient Vs outpatient status of the
experimental subjects. The baseline awareness scores obtained from the control group
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suggested that there is no significant association between the age and sex of control
group. But there was a statistically significant association between the awareness and the
The implications made in this study are vital to patients, nursing practice,
Patients:
are not provided with information or cannot recall information. Written information
enables patients to access the information they want at the time when they want it. The
information before-hand regarding the procedure helps the patients undergoing upper
Nursing practice:
all patients undergoing diagnostic upper gastrointestinal endoscopy. This study will lead
to a major change in the quality of information giving at the endoscopy unit of SJMCH,
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and attractive in four languages: Kannada, Tamil, Telugu and English and which would
prove more satisfactory to patients. Nurses and other members of the health team would
Endoscopists:
fulfills the medico-legal considerations and consumer’s right for the relevant information.
identified the effectiveness information leaflet in real world. Patient centered data may
Nursing administration:
The dissemination of written information would take place in a co-ordained manner that
patients receive the leaflet at the appropriate time and all know who is responsible for its
Hospital administration
care because it gives information on the provider’s success at meeting these client values
and expectations which are matters in which the client is the ultimate authority.
Satisfaction with endoscopy unit performance can be used to guide quality improvement
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Nursing education:
instructional tool for nurse educators in imparting knowledge to students with regard to
Nursing research:
The study supported other research, which has indicated that one way of
facilitating improved information giving is through the greater use of written information.
suggestions and recommendations can be utilized by other researchers for studies in the
same field. The outcome may serve as guidelines in preparing module in the other
RECOMMENDATIONS
leaflet information
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5. A descriptive study must obtain patient’s views about their care allowing free
6. The same type of study could be conducted in the future in view of helping
PERSONAL LEARNING
gain credibility. To take this role successfully, nurses need to develop a clear
information was an increased awareness about the procedure. One of the important
regarding the care in the facility and the information provided. The study suggests
that providing patients with a professional, personal and targeted educational system
can significantly increase their satisfaction to return to the same health care facility.
Nurses should design information materials in an easy- to- read language considering
the literacy rate and education of all clients to whom it is addressed. Consent needs to
their expectations and satisfaction must be at the forefront of any piece of service
provided by nurses.
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9. BIBLIOGRAPHY
4. Park K. Text Book of Preventive and Social Medicine. 17th ed, M/S Banarsidas
113.
(4): 202-205.
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11. Byrne, Napier, Euschieri. How informed is signed consent? British Medical Journal.
1998; 296 (19): 839-341.
12. Brennan. A concept analysis of consent. Journal of Advanced Nursing.1997; 26:477-
484
13. Larnabe & Bolden. Defining patient-perceived quality of nursing care. Journal of
Nursing Care Quality. 2001; 16(1): 34-60.
14. Mary Carol. The nurse-patient relationship: theme and variations. Journal of
Advanced Nursing.1992; 17,496-506.
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INFORMED CONSENT
Introduction
I am Sr. Lilly Joseph, a second year MSc Nursing student of St.John’s College of
Nursing. I have developed an information leaflet for patients undergoing upper gastrointestinal
endoscopy. The leaflet would provide information about various aspects of procedure that you
are undergoing.
I want to study how effective this information leaflet would be in enhancing your
awareness related to upper gastrointestinal endoscopy. I want to find out also the correlation
between the information received and the actual procedure as perceive by you when you
underwent the upper gastrointestinal endoscopy. Hence some of you will receive a newly
developed information leaflet on upper gastrointestinal endoscopy and an appointment form and
some of you will receive only on this day. A thoroughly shuffled envelope will indicate whether
you will receive the information leaflet or not. This is the way the study will be done.
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truthfully as you can you need not write your name. The time required to complete this
questionnaire will e 10 minutes. A pen or pencil will be provided to you. You have to
place a tick in a box corresponding to the appropriate option,
¾ Then, you will go for the upper gastrointestinal endoscopy.
¾ At the end of your resting period and as you waits for the typed copy of the result of your
test; you have to fill the questionnaire – 2. This is to assess how related are the written
information in the newly developed leaflet and the actual procedure as perceived or
experienced by you. The time required to fill this questionnaire within 5 minutes.
I assure you that the information provided by you, will be kept strictly confidential and will be
used only to assess the effectiveness of newly developed information leaflet on upper
gastrointestinal endoscopy though some of you will receive it after the procedure.
If you agree to the above conditions, kindly sign the paper,
then I will proceed with the research.
I understand that I will be part of a research that will focus on the effectiveness of information
leaflet for patients undergoing upper gastrointestinal endoscopy. I understand that this study
will help the researcher to draw conclusion on the benefit of an information leaflet for patients
under going upper gastrointestinal endoscopy and make it available for all those who undergo
this procedure in the future. So I am giving my consent to participate in this research which
will be conducted by Sr.Lilly Joseph, the second year MSc Nursing student of St.John’s
College of Nursing, knowing fully what is expected of me in this study.
SIGNATURE………………………………………
DATE……………………………………………
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INFORMATION ON
UPPERGASTROINTESTINAL
ENDOSCOPY
GASTROENTEROLOGY DEPARTMENT
ST.JOHN’S MEDICAL COLLEGE HOSPITAL
BANGALORE – 34
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Dear…………………………………………
Your doctor has recommended that you have an upper gastrointestinal endoscopy.
WHAT?
Upper G.I endoscopy refers to the examination of upper gastrointestinal tract: the
esophagus, stomach and duodenum using an endoscope.
ENDOSCOPE?
A tube-like, thin, flexible device with a light on one end attached to a color TV camera
WHY?
To discover the reasons for:
• Abdominal pain
• Anemia.
• Bleeding from the digestive tract
• Chronic heartburn
• Fullness of stomach
• Indigestion
• Nausea, vomiting
• Trouble in swallowing
• Unexplained chest pain
WHERE?
At the Endoscopy unit of SJMCH Outpatient Room No.28.
WHO DOES?
A GASTROENTEROLOGIST who has received special training in diagnosing the diseases of
the digestive system and in the safe and proper operation of an endoscope.
HOW LONG?
The test lasts for 5-15 minutes.
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VERY ESSENTIAL
Your cooperation & How?
Don’t:
¾ drink or eat anything for at least 10 – 11 hours .
¾ use tobacco, within 2 hours of the test.
¾ take antacids on the day of the test.
¾ If you are a diabetic, don’t take your medications including insulin in the morning of
the test.
It means:
¾ If your test is scheduled in the morning, not to eat or drink anything after 10 PM on
the night before the test.
¾ If your test is scheduled in the afternoon, you can have only liquids: juice, coffee, tea
for breakfast, then don’t take anything by mouth.
Do Take:
¾ All your regular medications with water in the night before the test.
Come With:
¾ A family member or a friend with whom doctor can freely discuss the results of tests.
¾ You can go home safe with.
Consent:
You will need to sign a “consent form” before the endoscopy begins, which will state that
you understand and agree to the test.
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¾ Insert a mouth piece.
¾ Help you to relax.
¾ Give intravenous sedation if needed.
Doctor will:
¾ Gently & painlessly pass an endoscope through your mouth down to your stomach.
¾ View clearly the esophagus, stomach & duodenum in the TV camera.
¾ Take painlessly tiny biopsies using the endoscope, if needed.
You must:
¾ A bitter taste, numbness & excessive saliva in the mouth after the gargle.
¾ Little discomfort while inserting & removing the endoscope.
¾ Putting air into the stomach.
¾ A humming noise from the equipment.
¾ May feel slightly bloated with air.
¾ Sore throat for the rest of the day.
Don’t
¾ Drive a vehicle.
¾ Drink alcohol beverages.
¾ Travel alone.
¾ Go to work.
THE RESULT
¾ Your doctor will discuss the test findings and any recommended treatment.
¾ A typed copy will usually be given to you about 15 minutes.
¾ Biopsy result will be given on the next appointment day.
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If you have any concerns or questions regarding this procedure,
please do not hesitate to consult your doctor or a nurse.
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Post test – 1
PATIENT INSTRUMENT –1
1. GENDER
ٱMale ٱFemale
2. AGE
ٱless than 18 years
ٱ18 – 30 years
ٱ31 – 40 years
ٱ41 – 50 years
ٱ51 – 60 years
ٱmore than 60 years
3. EDUCATION
ٱPrimary
ٱMiddle secondary
ٱHigher secondary
ٱ college – Undergraduate level
ٱCollege – Post graduate level
ٱProfessional level
ٱAny other (please write)
4. OCCUPATION
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ٱNil
ٱLaborer
ٱHousewife
ٱRetired
ٱProfessional
ٱTechnician
ٱBusiness
ٱAny other (please write)
5. Did you undergo an upper gastro intestinal endoscopy in the past?
ٱYES ٱNO
6. If your answer is YES, when did you undergo?.
ٱ6 months before
ٱOne year before
ٱTwo years before
ٱI do not remember
7. Are you admitted no, in St. John’s Medical College Hospital?
ٱYES ٱNO
SECTION – “B”
QUESTIONNAIRE TO IDENTIFY THE SOURCES OF INFORMATION
REGARDING UPPER G.I ENDOSCOPY
QUESTIONS
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1. Did you receive yesterday together with your appointment forms written
information regarding upper gastrointestinal endoscopy, which you
have to undergo today?
[INFORMATION ON UPPER GASTROINTESTINAL ENDOSCOPY with two
pictures on the cover page, written in your own language].
ٱYES [If your answer is YES, please answer questions 2-8]
ٱNO (If your answer NO, please do not answer questions 2- 7,
but answer question number: 8.)
2. If you have received, did you read those information?
ٱYES ٱNO
3. Were you able to understand the information given in the leaflet?
ٱYES ٱNO
4. Do you think the leaflet was useful to you?
ٱYES ٱNO
5. Do you think the leaflet information was adequate in the following areas
of care?
1. Concept of upper G.I endoscopy ٱYES ٱNO
2. Care before the procedure ٱYES ٱNO
3. Care during the procedure ٱYES ٱNO
4. Care after the procedure ٱYES ٱNO
6. Do you think the leaflet should be given to all patients who will have to
undergo upper G.I endoscopy?
ٱYES ٱNO
7. To express your over all opinion about the leaflet what rating will you
give?
ٱExcellent
ٱVery good
ٱGood
ٱFair
8. Did you receive any information regarding the procedure you have to
undergo today from the following persons? (Please tick in the box
corresponding to your option).
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If your answer is YES, what rating will you give to the information provided by
them?
Please circle | the single most appropriate score.
Very Poor Good Very Excellent
Poor Good
Doctors ٱNo ٱYes 1 2 3 4 5
Nurses ٱNo ٱYes 1 2 3 4 5
Office staff of ٱNo ٱYes 1 2 3 4 5
endoscopy
counter
Other patients ٱNo ٱYes 1 2 3 4 5
who are also
waiting for the
procedure
Any others ٱNo ٱYes 1 2 3 4 5
(please write)
SECTION “C”
AWARENESS QUESTIONNAIRE REGARDING
UPPER GASTROINTESTINAL ENDOSCOPY
INSTRUCTIONS TO PARTICIPANTS:
QUESTIONS
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Upper G.I endoscopy refers to the examination of:
1.1 ٱThe esophagus, stomach & duodenum
1.2 ٱThe ileum, jejunum & cecum
1.3 ٱPancreas, Liver, Spleen
1.4 ٱNose, windpipe, lungs
1.5 ٱDo not know
4. What is the role of your co-operation for the success of this test?
4.1 ٱVery essential
4.2 ٱMay be essential
4.3 ٱMay not be essential
4.4 ٱNot essential
4.5 ٱDo not know
5. Who is performing upper gastrointestinal endoscopy?
5.1 ٱGynecologist
5.2 ٱGastroenterologist
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5.3 ٱNeurologist
5.4 ٱUrologist
5.5 Do not know
6. Before the test, you should not drink or eat for at least
6.1 ٱ2 to 4 hours
6.2 ٱ5 to 6 hours
6.3 ٱ7 to 9 hours
6.4 ٱ10 to 11 hours
6.5 ٱDo not know
7. If your test is scheduled in the morning you can take all your regular
medications
7.1 ٱTwo hours before the test
7.2 ٱIn the morning of the test
7.3 ٱIn the might before the test
7.4 ٱAny time before the test
7.5 ٱDo not know
8. When you come for the test, you must bring with you
8.1 ٱAppointment form
8.2 ٱX-rays & scan if you have
8.3 ٱCurrent medications that you take regularly
8.4 ٱAll the above
8.5 ٱDo not know
9. You are expected to arrive at the endoscopy unit of St. John’s Medical
College Hospital, Outpatient Room No. 28 at least
9.1 ٱ30 minutes to one hour before your test
9.2 ٱTwo hours before the test
9.3 ٱThree hours before the test
9.4 ٱFour hours before the test
9.5 ٱDo not know
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10. You will need to sign a “consent form” before the endoscopy begins.
What is the reason?
10.1 ٱTo state that you understand and agree to the test.
10.2 ٱTo ensure that you arrived here
10.3 ٱTo calm your fear & anxiety
10.4 ٱTo permit you for endoscopy procedure
10.5 ٱDo not know
13. During the test, you are expected to help the passage of Endoscope by
13.1 ٱholding the tube
13.2 ٱlooking at the tube
13.3 ٱswallowing the tube
13.4 ٱbiting the tube
13.5 ٱDo not know
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14.3 ٱtake painlessly tiny biopsies using the endoscope if needed
14.4. ٱAll the above
14.5 ٱDo not above
15. What is your attitude towards the test
15.1 ٱI am safe & secure in the expert presence of doctors & nurses
15.2 ٱI am uncertain what will happen to me
15.3 ٱI am anxious and tensed.
15.4 ٱI am afraid of complications
15.5 ٱDo not know
16. After the anesthetic gargle & test you may feel
16.1 ٱbitter taste and numbness in the mouth
16.2 ٱexcessive saliva in the mouth
16.3 ٱslightly bloated with air
16.4 ٱAll the above
16.5 ٱDo not know
17. After the test, it is normal for the rest of the day to experience
17.1 ٱChest discomfort
17.2 ٱSore throat
17.3 ٱStomachache
17.4 ٱHeadache
17.5 ٱDo not know
18. After the test, you should not eat or drink for
19. You may resume your normal solid diet, when the numbness is
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19.3 ٱalmost off
19.4 ٱcompletely off
19.5 ٱDo not know
20. A typed copy of the result of your test will be given to you in about
- 162 -
option
1 1.1 1 0 1
2 2.5 1 0 1
3 3.5 1 0 1
4 4.1 1 0 1
5 5.2 1 0 1
6 6.4 1 0 1
7 7.3 1 0 1
8 8.4 1 0 1
9 9.1 1 0 1
10 10.1 1 0 1
11 11.5 1 0 1
12 12.1 1 0 1
13 13.3 1 0 1
14 14.4 1 0 1
15 15.1 1 0 1
16 16.4 1 0 1
17 17.2 1 0 1
18 18.1 1 0 1
19 19.4 1 0 1
20 20.2 1 0 1
20 20 20 20
POST TEST – 2
PATIENT INSTRUMENT – 2
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PATIENT SATISFACTION QUESTIONNAIRE TO PATIENTS AFTER UNDERGOING UPPER
GASTROINTESTINAL ENDOSCOPY
Dear Friend,
you.
QUESTIONS
1) The courtesy, respect and sensitivity of the office staff of the endoscopy unit at
2) The length of time spent waiting at the endoscopy unit to get an appointment.
- 164 -
less than 30 minutes
4) The thoroughness, carefulness, gentleness and the friendliness of the doctor who
5) The assistance, the care and the friendliness of nurses and supporting staff who
attended on you.
6) Adequacy of explanations of what was done for you and answers to all your
questions.
7) The adequacy of assistance, care and sensitivity of nurses after the procedure.
9) Would you consider referring your relatives and friends to this unit if their doctors
Yes No
Please Notice:
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[Question numbers 10 & 11 are applicable to you, only if you received an information
10) The appropriateness and adequacy of information in the leaflet about upper
you.
11) Overall rating of the information written in the information leaflet in relation to
12) What are the other information you would have liked but did not get?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………..
………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………………………
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