Journal presentation

Effectiveness of nursing intervention on anxiety and depression in individuals suffering from stroke

Submitted to : Ms. Sucheta Yangad Asso. Professor

Submitted by : Swapnil Mahapure M.Sc. Nursing 1st year

Statement of the problem

Effectiveness of nursing intervention on anxiety and depression in individuals suffering from stroke.

Aim of the study

To evaluate the effectiveness of nursing intervention on anxiety and depression in individuals suffering from stroke.

Objectives

To understand the socio-demographic profile of stroke subjects. To assess the knowledge of stroke subjects about stroke and its management. To assess the level of anxiety and depression experienced following stroke event. To provide individually tailored nursing intervention to stroke survivors. To find out the effect of nursing intervention on anxiety, depression and knowledge scores in stroke subjects.

Hypothesis
1. There will be statistically significant increase in the knowledge scores obtained by the subjects after the nursing intervention. 2. There will be a statistically significant decrease in the level of anxiety and depression in response to nursing intervention.

Methodology
The study was based on Betty Newmans systems model of nursing (1989). The model focused on the client systems reaction to stress and the factors of re-constitution or adaptation. The research design was a quasi-experimental one group pre-test, post-test design without control group was applied to test the relationship among the study variables was carried out in the DPNR, NIMHANS. The investigator first selected a single test group and level of anxiety and depression and knowledge on stroke and its management was measured before the introduction of the nursing intervention (pre-test). Then the nursing intervention was introduced. Level of anxiety and depression and knowledge on stroke and its management was measured again after a minimum period of 15 days from the day of pre-test (post- test). The effect of the intervention would be equal to the level of anxiety and depression and knowledge on stroke and its management after the treatment minus the level of the anxiety and depression and knowledge on stroke and its management before the treatment

SOURCES OF DATA : Using non-probability purposive sampling approach, 30 subjects suffering from stroke for a period of 6 months to 18 months and undergoing physiotherapy were selected for this study. Subjects were assessed for their level of anxiety and depression and knowledge scores on stroke and its management using hospital anxiety and depression scale (Indian Version adapted by Chaturvedi, et. al., 1994) and knowledge assessment scale (Lakshmi, 2000) respectively before and after nursing intervention.

METHOD OF COLLECTION OF DATA 1. RESEARCH DESIGN: A quasi experimental one group pretest-posttest design 2. POPULATION: Patients were attending Physiotherapy Unit at Department of Psychiatric & Neuro Rehabilitation (DPNR), National Institute of Mental Health and Neuro-Sciences (NIMHANS). 3. SAMPLE SIZE: 30 subjects suffering from stroke for a period of 6 months to 18 months and undergoing physiotherapy were selected for this study. 4. SAMPLING TECHNIQUE: Non-probability purposive sampling approach 5. TOOL FOR THE DATA COLLECTION

Performa for socio-demographic data - It was a semi structured interview schedule focusing on the background information of the subject. Knowledge assessment checklist - Knowledge assessment checklist which consists of seven domains has 35 items about stroke and its management. The seven domains are knowledge about stroke, causes of stroke, problems they experience due to stroke, the importance of exercise, the importance of nutrition, the medication and the psychosocial aspects. It has been modified by the investigator according to need for the present study (modified version Lakshmi, 2000) Hospital anxiety and depression scaleIndian version adapted by Chaturvedi, et al., (1994), was used in this study to screen subjects for anxiety and depression. This is a brief selfadministered rating scale, specially designed for subjects with medical illnesses. It consists of 14 items to measure anxiety and depression.

6. DURATION OF DATA COLLECTION: 15 days after pre-test 7. VARIABLES: a. Dependent variable:- stroke. b. Independent variable: - anxiety and depression

Nursing intervention
The nursing intervention tested in the study to decrease the anxiety and depression in stroke subjects and to increase the knowledge on stroke and its management was individually tailored and the details of the sessions were as follows: I Session - Basic facts about anxiety and depression management of anxiety and depression II Session - Education on stroke, meaning, causes, risk factors, clinical features, prevention of recurrence

III Session - Individual session with subjects to understand the changes that they experience in their body and mind IV Session - Group sessions on measures to decrease the physical and emotional problems V Session - To work with families as family members had lot of doubt in taking care of the subjects. The researcher found significant feelings of burden and burnout in lot of family members. The intervention package was prepared by the investigator with the help of experts like nurse educationalists, neurologists, physiotherapist, social worker and psychiatrists. By incorporating their opinion the package was prepared. Suitable audio-visual aids like charts, posters were used to explain the causes of stroke, prevention of stroke and measures to overcome anxiety and depression. A pilot study was undertaken to find out the feasibility and practicability of the study. The nature of the study was explained to each study subject and one of his/her first degree relative and an informed consent was taken from both of them. A formal permission to conduct the study was obtained from the Head of the Department, Department of Psychiatric and Neuro Rehabilitation (DPNR), NIMHANS. Systematically collected data was processed and analyzed by using percentage, mean and standard deviation for socio-demographic data. Pairedt test was used to find out the comparison of pre and post assessment of level of anxiety and depression and pre and post assessment of knowledge of subjects about stroke and ANOVA for comparison of attributes of anxiety, depression and knowledge scores with selected demographic variables.

Results and discussion A total of 30 subjects were studied. There were 22 males (73.3%) and 8 females (26.7%). As for as the religion is concerned, 76.7% of subjects were Hindus, 10% were Christians and 13.3% were Muslims. 10% of the samples were illiterate, 23% had primary education. 40% had secondary education and 26.7% had collegiate education. Regarding family type, 46.7% were from nuclear families where the stress and strain may be greater because of the lack of support and guidance. 433% were from joint families. This shows joint families are still held with respect in India. The data presented in Table -1 showed that the total pre knowledge assessment mean score was 8.77 which were increased to 34.87 mean score after education programmed and thet value again was 0.000. This indicates that there is significant improvement in the knowledge related to the various domains like meaning, causes, and clinical feature, important of exercise, role of nutrition, medication and psychosocial aspects of stroke compared to their pre assessment before intervention.

The hypothesis of the present study which stated that There will be statistically significant difference between the knowledge scores obtained by the subjects prior to and after the education programme about stroke and its management was accepted. The level of anxiety and depression prior to and after nursing intervention was tested by using pairedt test. Results revealed that there was a significant decrease in the level of anxiety and depression in subjects following the nursing intervention. The data presented in Table- 2 depicts the anxiety scores of subjects which were assessed after acute stage from 6 months to 18 months duration of illness. The total mean pre-test scores of all 7 domains of anxiety items were 17.37 and following the nursing intervention there was a significant reduction in anxiety level by 8.10.

The total pre-assessment depression mean score in the present study was 18.10. Following the nursing intervention there was a significant decrease in level of depression in post-assessment score to 9.00 as against the pre-assessment mean score of 18.10. In the present study the comparison of sociodemographic characteristics of the subjects with their anxiety and depression level showed no significant relationship between them. The results of the study supported the hypothesis that, level of anxiety and depression decreases in response to nursing intervention. Hence the hypothesis was accepted. Benett (1996) recommended that nurses have access to expert personnel both as a source of referral for subjects and as a resource for support and guidance to staff by conducting education programme combining theoretical and practical aspects of psychological care. Further, the subjects in the study identified the researcher during the interview as someone who gave them mental strength, subjects found this intervention programmes as encouraging which enhanced confidence. Subjects reported that many of their misconceptions regarding stroke, uncertainty of prognosis, the mobility and outcome of physiotherapy were cleared through this intervention programme as well. It also helped in dealing with various physical, psycho social problems in their lives which are highly demanding in nature. Caregivers also expressed that they identified the importance of maintaining their own emotional, social and physical health.

Limitations
The design selected for the study was quasi experimental, one group pre-test, post-test design. Hence the findings regarding the cause- effect relationship among the variables cannot be generalized. No followup, hence there is no information about long term maintenance of the changes seen.

Conclusion
The present study was conducted to evaluate the effectiveness of nursing intervention on anxiety and depression in individuals suffering from stroke. Despite this studys limitation, statistical analysis showed a significant decrease in the level of anxiety and depression. Thus, the present study reaffirms the valuable contribution to the recognition of emotional problems in stroke subjects by the nurses. The study emphasized the effect of nursing intervention in decreasing anxiety and depression and in helping them to adjust to disability and gaining mastery over resolving emotional problems.

References
1. Bennett B, How nurses in a stroke rehabilitation unit attempt to meet the psychological needs of subjects who become depressed following a stroke, Journal of Advanced Nursing 1996; Vol. 23, No. 2: 314-321. 2. Chaturvedi SK, Chandra PS, Channabasavanna SM and Pandian RD Detection of anxiety and depression in cancer subjects. NIMHANS Journal 1994; 12 (2): 141-144. 3. Dorsey MK and Vaca KJ, The stroke patient and assessment of caregiver needs, Journal of Vascular Nursing, 1998; 16: 62-67. 4. Gainotti 0, Aritonucci G, relation between depression after stroke, antidepressant therapy and functional recovery, J Neurology Neurosurgery Psychiatry, 2001; 71: 258-261. 5. Morris K et al, Emotional liability after stroke, and New Zealand Journai Psychiatry 1993; Vol. 27, No. 4: 601-605. 6. Parikh RM et al, The impact of post-stroke depression on recovery in activities of daily living over a 2 year follow-up, Arch Neurology, 1990; 47: 785-789.

Items on the questionnaire

The items on the questionnaire that relate to anxiety are

I feel tense or wound up I get a sort of frightened feeling as if something bad is about to happen Worrying thoughts go through my mind I can sit at ease and feel relaxed I get a sort of frightened feeling like butterflies in the stomach I feel restless and have to be on the move I get sudden feelings of panic

The items that relate to depression are

I still enjoy the things I used to enjoy I can laugh and see the funny side of things I feel cheerful I feel as if I am slowed down I have lost interest in my appearance I look forward to enjoyment with things I can enjoy a good book or radio or TV programme

Scoring the questionnaire

Each item on the questionnaire is scored from 0-3 and this means that a person can score between 0 and 21 for either anxiety or depression. The scale used is a Likert scale and therefore the data returned from the HADS is ordinal.

Non-probability sampling represents a group of sampling techniques that help researchers to select units from a population that they are interested in studying. Collectively, these units form the sample that the researcher studies [see our article, Sampling: The basics, to learn more about terms such as unit, sample and population]. A core characteristic of non-probability sampling techniques is that samples are selected based on the subjective judgement of the researcher, rather than random selection (i.e. probabilistic methods), which is the cornerstone of probability sampling techniques.

Types of non-probability sampling technique There are five types of non-probability sampling technique that you may come across when doing a dissertation at the undergraduate and masters level:

Quota sampling Convenience sampling Purposive sampling Self-selection sampling Snowball sampling

To get a sense of what these five types of non-probability sampling technique are, imagine that a researcher wants to understand more about the career goals of students at a single university. Lets say that the university has roughly 10,000 students. These 10,000 students are our population. Each of the 10,000 students is known as a unit (although sometimes other terms are used to describe a unit; see Sampling: The basics). In order to select a sample of students from this population of 10,000 students, we could choose to use:

Quota sampling With proportional quota sampling, the aim is to end up with a sample where the strata (groups) being studied (e.g. males vs. females students) are proportional to the population being studied. If we were to examine the differences in male and female students, for example, the number of students from each group that we would include in the sample would be based on the proportion of male and female students amongst the 10,000 university students. To understand more about quota sampling, how to create a quota sample, and the advantages and disadvantages of this non-probability sampling technique, see the article: Quota sampling: An overview.

Convenience sampling A convenience sample is simply one where the units that are selected for inclusion in the sample are the easiest to access. In our example of the 10,000 university students, if we were only interested in achieving a sample size of say 100 students, we may simply stand at one of the main entrances to campus, where it would be easy to invite the many students that pass by to take part in the research. To understand more about convenience sampling, how to create a convenience sample, and the advantages and disadvantages of this non-probability sampling technique, see the article: Convenience sampling: An overview.

Purposive sampling Purposive sampling, also known as judgmental, selective or subjective sampling, reflects a group of sampling techniques that rely on the judgement of the researcher when it comes to selecting the units (e.g. people, cases/organisations, events, pieces of data) that are to be studied. These purposive sampling techniques include maximum variation sampling, homogeneous sampling, typical case sampling, extreme (or deviant) case sampling, total population sampling, and expert sampling. Each of these purposive sampling techniques has a specific goal, focusing on certain types of units, all for different reasons. The different purposive sampling techniques can either be used on their own or in combination with other purposive sampling techniques. To understand more about purposive sampling, the different types of purposive sampling, and the advantages and disadvantages of this non-probability sampling technique, see the article: Purposive sampling: An overview.

Self-selection sampling Self-selection sampling is appropriate when we want to allow units or cases, whether individuals or organisations, to choose to take part in research on their own accord. The key component is that research subjects (or organisations) volunteer to take part in the research rather than being approached by the researcher directly. To understand more about self-selection sampling, how to create a self-selection sample, and the advantages and disadvantages of this non-probability sampling technique, see the article: Selfselection sampling: An overview.

Snowball sampling Snowball sampling is particularly appropriate when the population you are interested in is hidden and/or hard-to-reach. These include populations such as drug addicts, homeless people, individuals with AIDS/HIV, prostitutes, and so forth. To understand more about snowball sampling, how to create a snowball

sample, and the advantages and disadvantages of this non-probability sampling technique, see the article: Snowball sampling: An overview.