“The Nurses’ Caring Factors and Coping Mechanisms of Patients with

pulmonary Tuberculosis undergoing directly observed treatment

short-course (DOTS) PROGRAM”

BSN406-GROUP21

Aguirre, Kevin Sam

Alarcon, Mikko Anthony

Aliga, Keith

Alupani, Queenie Ann

Andalecio, Micah Grace

Arboleda, Jungie Grace

Bartido, Ma. Mennet

Baylon, Anne Nickol

Binauhan, Pauline Rubie

Castro, Kathleen Cris

RESEARCH ADVISER:

Esther O. Salvador-Dela Cruz, R.N, M.A.N.

March 14, 2013

TABLE OF CONTENTS

Title page…………………………………………………………….…………………………..1

1

Table of Contents……………………………………………………………………………….2

CHAPTER I

Background of the Study……………………………………………………………………….4

Statement of the Problem……………………………………………………………………...6

Significance of the Study…………………………………………………………………….…7

Scope and Limitation……………………………………………………………………………9

CHAPTER II

Review of Related Literature and Studies…………………………………………………..10

Theoretical Framework……………………………………………………………..…………18

Research Hypothesis………………………………………………………………………….22

The Main Variables of the Study……………………………………………………………..22

Definition of Terms…………………………………………………………………………….23

CHAPTER III

Research Design………………………………………………………………………………25

Population and Sample……………………………………………………………………….25

Research Locale……………………………………………………………………………….25

Research Instruments…………………………………………………………………………27

Data Collection Procedure……………………………………………………………………27

Statistical Treatment of Data…………………………………………………………………29

Ethical Principles………………………………………………………………………..….….31

Reference………………………………………………………………………………………32

CHAPTER I

INTRODUCTION

2

BACKGROUND OF THE STUDY

Tuberculosis is a disease caused by a bacterium called Mycobacterium

tuberculosis that is mainly acquired by inhalation of infectious droplets containing viable

tubercle bacilli. The organism may attack other tissues in the body, but in Europe and

North America, the lungs are most frequently the primary site of invasion-although most

organs in the body can be attacked (Walsh, 2002) and this kind of tuberculosis is called

Pulmonary Tuberculosis.

Pulmonary Tuberculosis (PTB) is a contagious bacterial infection that involves

the lungs, but may spread to other organs. Only about 10% of people infected with M.

tuberculosis ever develop tuberculosis disease. Many of those who suffer TB do so in

the first few years following infection, but the bacillus may lie dormant in the body for

decades. Pulmonary tuberculosis frequently goes away by itself, but in 50%-60% of

cases, the disease can return.

People infected with TB bacteria have a lifetime risk of falling ill with TB of 10%.

When a person develops active TB, the symptoms (cough, fever, night sweats, weight

loss etc.) may be mild for many months. This can lead to delays in seeking care, and

results in transmission of the bacteria to others. People ill with TB can infect up to 10-15

other people through close contact over the course of a year. Without proper treatment

up to two thirds of people ill with TB will die (World Health Organization, 2012).

Philippines has the ninth highest number of Pulmonary Tuberculosis (PTB) cases

in the world and the highest in Southeast Asia (World Health Organization, 2012).

Globally, there were more than nine million new cases and about 1.7 million deaths

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from the disease in 2006; the WHO estimates there are more than 14 million people

living with PTB, which kills 75 Filipinos each day (Department of Health, 2012).

Over the years, the government, with the private sector and humanitarian

community, has steadily made gains against tuberculosis. The Directly Observed

Treatment Short-course (DOTS) program, recommended in the mid-1990s by the WHO,

played an important role in this success (Humanitarian News and Analysis, 2012).

DOTS required patients to take their medicine in front of a health worker to ensure

proper compliance with the entire treatment program. It is considered as one of the

most effective methods of ensuring patient compliance. With DOTS, health care

providers can achieve a higher cure rate and expand services to detect more TB cases.

The program is open for all suspected TB patients regardless of one’s status life

(Humanitarian News and Analysis, 2012).

Patients who are diagnosed with TB are distressed and face challenges that they

need to cope up with it. As healthcare providers, listening to these patients is important

because it will help them cope up with their disease. According to Lazarus, copingis

defined as “constantly changing cognitive and behavioral efforts to manage specific

external and/or internal demands that are appraised as taxing or exceeding the

resources of the person” (Lazarus &Folkman, 1984, pp. 141). This definition is

intimately related to the concept of cognitive appraisal and hence to the stress-relevant

person-environment transactions. Most approaches in coping research follow Folkman

and Lazarus (1980, pp. 223) efforts made to master; tolerate or reduce external and

internal demands and conflicts among them (Folkman and Lazarus, 1980). Lazarus and

Folkman’s concept of coping defines how a person reacts to a stressful event. An

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individual’s way of coping to stressful encounters can be assessed based on the

cognitive-phenomenological theory of stress and coping by Lazarus and Folkman. For

instance, young people uses proportionately more active, interpersonal problem-

focused forms of coping than do the other people, while the older people uses

proportionately more passive, intrapersonal emotion-focused forms of coping than do

the younger people. Coping, when considered as a process, is characterized by the

dynamics and changes that are a function of continuous appraisals and reappraisals of

the shifting person-environment relationship (Folkman, et.al, 1986).

The coping of Pulmonary Tuberculosis patients undergoing DOTS in relation to

Folkman and Lazarus way of coping is to describe what type of coping has the client

have and these types are: confrontive coping, distancing, self-controlling, seeking social

support, accepting responsibility, escape-avoidance, planful problem solving and

positive reappraisal.

These coping mechanisms of TB patients may be affected by how the nurse’s

caring factors will be applied.The carative factors deal with those features of caring that

mainly involve appraising patient health preferences and requirements, planning to

address those preferences, sharing to meeting patient health targets and assessing the

usefulness of the caring processes in developing gradually patient health and healing

(Backer , 2003 )

The changes in the health care delivery systems around the world have

intensified nurses’ responsibilities and workloads. Nurses must now deal with patients’

increased acuity and complexity in regard to their health care situation. Despite such

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hardships, nurses must find ways to preserve their caring practice and Jean Watson’s

caring theory can be reviewed in this study (Cara, 2003).

The study aims to correlate caring abilities of nurses as perceived by patients

with Pulmonary Tuberculosis (PTB) undergoing DOTS program and the patient’s ability

to cope in the said disease. The results or solutions of this study will serve as an

indicator of the quality of care rendered by nurses in practice to pulmonary tuberculosis

patients. Furthermore, the results will identify the present type of coping of these

patients which will help the nurses adjust the care that they are currently giving to the

patients with PTB.

STATEMENT OF THE PROLEM

The purpose of the study is to determine the nurse’s caring factors and coping

mechanisms of patients diagnosed with pulmonary tuberculosis undergoing Directly

Observed Treatment Short-course (DOTS) program in a selected hospital.

Specifically, the study would like to answer the following questions:

1.) What are the caring factors of nurses as perceived by patients with pulmonary

tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program?

2.) What are the coping mechanisms of patients with pulmonary tuberculosis

undergoing Directly Observed Treatment Short-course (DOTS) program as perceived

by nurses?

3.)Is there a significant relationship between nurse’s caring factors and coping

mechanisms of patients with pulmonary tuberculosis undergoing Directly Observed

Treatment Short-course (DOTS) program?

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SIGNIFICANCE OF THE STUDY

This study will discuss the new information and evidences of the nurses’ caring

factors and coping mechanisms of patients with PTB. Provide information that

establishes the rationale for selecting the research problem as important for society in

general and for nursing in particular and it is expected to contribute to the following

beneficiaries:

Nursing Practice

The study will greatly aid the nursing practice as it will expand more thoughts to

nurses in caring patients with pulmonary tuberculosis. In using the carative factors of

Jean Watson’s theory in the nursing practice, it will help develop a good patient-nurse

interaction that could give systematic approach in decision making by developing a

more enhanced interventions in the nursing practice. The patient-nurse interaction will

highly contribute in the progress of the patient’s health condition and this will also

develop a multidisciplinary approach that would ensure successful outcome. The study

will provide the provision for the supportive, protective, mental, physical, sociocultural

and spiritual environment in the nursing practice.

Nursing Administration

This research study aims to help the nursing administration to have increase

knowledge to inform the members of the health care team, and to guide nursing staff to

the most appropriate nursing caring factors that will surely have an effect to their

patients coping and healing process. They can gather data about the research study

that will help increase their ability to improve nurses’ caring factors.

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Nursing Education

In relation to nursing education, this research study can help the nursing

educators in teaching their students with the proper nursing care management related

to the nurses’ caring factors and coping mechanisms. This will help them give more

knowledge and holistic care to patients with Pulmonary Tuberculosis. This will also help

the nursing educators andclinical instructors in teaching thestudents about the factors of

nursing care and its relation to coping mechanism of Pulmonary Tuberculosis patients

under Directly Observed Treatment Short-course (DOTS) program. Nursing educators

or clinical instructors will be informed based on the findings of the research study for an

improved quality care for the patients.

Nursing Research

This research study aims to help researchers to have general information about

pulmonary tuberculosis patients undergoing DOTS program in a selected hospital

regarding their coping mechanisms and nurses’ caring factors. The results can become

useful data to improve the future researchers’ knowledge and understanding about the

topic. The study can also be a guide to have a better research studies.

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SCOPE AND LIMITATION

The study will cover the topics about the nurse’s caring factors and coping

mechanisms of pulmonary tuberculosis patients undergoing Directly Observed

Treatment Short-course (DOTS) conducted from a selected hospital. The study will

focus on the nurses’ caring factors as perceived by the patients and also the coping

mechanisms of patients perceived by the nurses.

Through the process, the respondents of the study will be chosen randomly. The

study will cover approximately 20-30 patients with pulmonary tuberculosis undergoing

DOTS program from a selected hospital and about 5-10 nurses who provide care to

these patients.

The study will be conducted in a selected hospital in Quezon City. The hospital

was selected by the researchers because it has numbers of tuberculosis patients

undergoing DOTS.

The study will be accomplished through a step-by-step process. Starting with

data gathering procedure by means of structured interviews and surveys to the selected

respondents namelythe PTB patients and the staff nurses assigned to these specified

patients.

The exclusion criteria includephysically, mentally and emotionally disabled

patients. Only patients willing to cooperate with the researchers’ study are allowed to

answer the survey. The study will be conducted with a span of 2-3 months starting June

2013.

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CHAPTER II

REVIEW OF RELATED LITERATURE AND STUDIES

In this chapter, related studies and literature about Pulmonary Tuberculosis and

coping mechanism and carative factors will be discussed in relation to the research

study.

Tuberculosis in the Philippines

The Department of Health (DOH) reported lower Tuberculosis (TB) prevalence.

The Philippines has itself made great strides in fighting TB. From a high mortality rate of

38.2 deaths per 100,000 population in 1990, the Philippine Health Statistics reported a

lower rate of 31/100,000.

According to the WHO, more than two billion people – one third of the world’s

total population – are infected with TB bacilli. One in every 10 of those people will

become sick with active TB in their lifetime. People living with HIV are at a much greater

risk. A total of 1.77 million people died from TB in 2007 (including 456,000 people with

HIV), equal to about 4,800 deaths a day. TB is a disease of poverty, affecting mostly

young adults in their most productive years. The Philippines is among the 22 high

burden countries for tuberculosis, according to the WHO. According to the 2nd National

Prevalence Survey done in 1997, most TB patients belong to the economically

productive age-group (15-54 years old).

Overcoming Tuberculosis

Thorn (2007) stated that Isolation is the hardest part of having TB, wherein

patients must stay away from other people who are vulnerable in developing and active

TB disease. Isolation of the patients contributes a unique set of coping problems. The

10

study has considered a long period of isolation to patients and was found out that they

have developed depression, anxiety and disorientation. Some patients also experienced

odd sleeping patterns and mood swings. Patients were advised to temporarily isolate

themselves from a great number of people to avoid spreading their disease. Isolation

does greatly affect patients in a very subtle way. He also stated the benefits of DOTS

program that would greatly help in coping with regards to the problems of those patients

with TB having a difficulty in adjusting.

According to Lewis and Newell (2009), health workers should be aware of all

aspects regarding the caring and treatment they will render to patients with tuberculosis.

Effective medical treatment is just one of the procedures that will help patients recover

from tuberculosis. Healthcare workers should also interact with these patients so that

they will be engaged in the curing process of their disease. With this, patients will have

the advantage of gaining knowledge about the disease and its treatment for healthcare

workers will also complement the medical treatment with health teachings about the

disease. Thus, another study supports the same principle in taking care patients with

tuberculosis.

National Tuberculosis Controllers Association (2011) said that healthcare

workers provide consistent and concise documentation throughout the case

management and treatment process. Expected documentation provides an ongoing

clinical picture of the patient and the patient’s progress to cure, while ensuring continuity

of care. Case management, with appropriate documentation, provides the framework

that enables the public health nurse to ensure that the TB patient completes treatment

and is able to be discharged from the TB program.

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Coping Strategies

Coping is the way people act to lessen the burden they are carrying or the stress

they feel. They do certain things to fit or somehow manage their current situation

(Kiel,2004).

Being healthy or sick is related to the knowledge the person has regarding the

disease or illness and it also depend on the available coping resources. Their body feels

what it feels according to their interactions to others and to their environment. It is in

their will and capacity on how to deal with it for it is part of being human and permeates

their whole life if they find it hard to solve thus other researchers have the same idea for

it happens to each historical period of humanity (Burtson and Stichler, 2010).

In the study of Lyon (2010), she paid attention with regards to reconciling the

diverse views of stress, coping, and health for nursing. She used different theoretical

approaches for her to be able to interrelate stress, coping, and health. And it was seen

in her study that those three concepts are interrelated. Meaning, each concept indicated

directly affects the other. It stated that coping involves managing the stressful situation

that will lead to persons coping with his/her environment.

However, another study of Naughton stated that there are effects of stress that

are directly related to coping mechanisms. All of fields of psychology such as health

psychology, environmental psychology, neuropsychology and developmental

psychology are the start of encompassing a huge variety of disciplines to the fields of

medicine including the area of anthropology and sociology. The three broad

components of coping strategies will provide a better understanding of what the

seemingly immense is about.

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According to Plotnik and Kouyoumdjian (2008), there are two kinds of coping and

these are Problem-focused coping which means the patient try to decrease stress by

solving the problem through seeking information, changing own behavior, or taking

whatever the action is needed to resolve the difficulty and second, emotion-focused

coping which means that the patient do things primarily to deal with their emotional

distress, such as seeking support and sympathy or avoiding or denying the situation.

Reichman (2000) places the blame at the feet of the medical sector and

politicians. Perhaps their reluctance to change current practice is understandable,

although wrong. Changes in the design of treatment delivery do not always dramatically

reduce costs to the health department; and it is these costs that health professionals

and politicians care about most. But as has been shown in this study, the treatment of

tuberculosis, particularly with the DOTS regime, substantially reduces the costs of the

illness to patients and their families. Once these costs are taken into account, there is a

compelling case for treatment for tuberculosis to be given a high priority by decision-

makers and for DOTS to be adopted as the treatment regime.

Stressors, coping mechanisms and quality of life among TB patients

Somaya (2012) stated that patients with TB have many related illness such as

pain, financial problem and dependency, stigma and threat to self-esteem. It was stated

that a patients with illness related stressors may affect their emotional, physiological

and behavioral reactions. With this, according to the study, nurses could provide

optimum health by proving support, information, critical analysis and alternative

problem-solving strategies.

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Caring and the Professional Practice of Nursing 

Jean Watson stated that, “Caring is a science that encompasses a humanitarian,

human science orientation, human caring processes, phenomena, and experiences.

Caring science includes arts and humanities as well as science”. A caring science

perspective is grounded in a relational ontology of being-in-relation, and a world view of

unity and connectedness of all. As such, caring science is rapidly becoming an

Interdisciplinary Transdisciplinary field of study. It has relevance to all the health,

education human service fields and professions (Watson, 2003).

Caring takes place when nurse and patient meet. Nurses interact with patient

and that reveals the nature of care (Shoenhofer, 2002). Thus, caring from nurses

enhance patients health and this explains that caring exists even with caring otherwise

curing cannot be attain without caring (Watson, 2003).

There are ten carative factors and these are: Formation of a humanistic- altruistic

system of values; installation of faith-hope; cultivation of sensitivity to one’s self and to

others; development of a helping-trust relationship; promotion and acceptance of the

expression of positive and negative feelings; systematic use of the scientific problem-

solving method for decision making; promotion of interpersonal teaching-learning;

provision for a supportive, protective and /or corrective mental, physical, socio-cultural

and spiritual environment; Assistance with the gratification of human needs; allowance

for existential-phenomenological forces (J. George, 2008).

According to Watson, promotion of health, prevention of illness, caring for the

sick and restoration of health are prominent factors in nursing and practice of caring in

this field is based on holistic care that is essential for the well-being of patients and

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aside from the assistance given by nurses to promote quality care, nurses are also

active participants for patient to gain self-actualization.

Watson’s theory of Human Caring

Adeline (2000) states that a humanistic altruistic value system of a person begins

at birth and continuously developed through consciousness and introspection by

interacting with the society we live in which enhance the caring – healing where it

interacts with the carative factor she called as “faith - hope”. That allows the nurse to be

authentically present with patients. She also said that human caring is influenced by the

values of person such as loudness, concern, and love of self and others which enhance

therapeutic effects of faith – hope.

According to Watson as inspired by Carl Roger’s work in order for the nurse to be

able to do his responsibilities to his patients, the nurse must have a balanced sensitivity

to self which is the foundation to empathy. Sensitivity to self can be developed by

reflecting values, beliefs, thoughts, feelings and experiences in life as well as in the

clinical area and the evaluate transpersonal caring (Adeline, 2000).

The transpersonal caring relationship

According to Adeline (2000) Watson’s have four carative factors that focus on the

transpersonal caring relationship. Faith hope is one of the important carative factors on

nurse patient relationship. Faith Hope extends beyond the nurse’s understanding of the

integration of mind, body spirit it involves posturing faith hope based on the patient’s

belief system. Sensitivity to self is important for the preparation of nurse to care. Helping

trusting is also an important carative factors that involves in nurse patient relationship,

15

Watson states that the development of this factor helps in maintaining the integrity of

the patient (Adeline, 2000)

As noted she focus her thinking on the therapeutic relationships and

communication to the work of Carl Roger’s and found out that congruency, empathy and

warmth are the found action that helps in the expression of patient’s emotions.

Congruency refers to authenticity and genuiness while empathy means understanding

both the content and emotion of the patient and warmth is the degree of which the nurse

conveys caring to the patient.

Caring processes

According to Adeline (2000), the five remaining carative factors which are primarily

involved in assessing patient health, prioritizingthe patient health goals and evaluating

the effectiveness of caring processes in promoting client health and healing. These

carative factors are effective if nurses and patient are together in deciding caring

processes. These involve creative and reflective problem solving or nursing care

process that is helpful in guiding content and organizing assessment of patients in

which permits interaction of multiple factors that also includes the personal on intuitive,

aesthetic and ethical knowledge.

Transpersonal teaching learning is one of the nursing activities where in both

nurse and patient will teach and learn from each other. It involves the entire significance

of the patient’s response to the health concerns and also explores patient’s perception

about his condition. So teaching – learning is based on gaining knowledge and skills

that are important in developing self-efficacy (Adeline, 2000).

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THEORETICAL FRAMEWORK

The study will be conducted to determine the nurse’s caring factors and coping

mechanisms of patients diagnosed with pulmonary tuberculosis undergoing Directly

Observed Treatment Short-course (DOTS) program in a selected hospital.

Jean Watson’s Lazarus’ Concept

Carative Factors of Coping

17

Formation of a humanistic- altruistic system of values

Installation of faith-hope

Assistance with the gratification of human needs

Promotion of interpersonal teaching-learning

Allowance for existential-phenomenological forces

Development of a helping-trust relationship

Cultivation of sensitivity to one’s self and to others

Systematic use of the scientific problem-solving

method

Provision for a supportive mental, physical…env’t

Promotion& acceptance of the expression of positive &

negative feelings

Pulmonary Tuberculosis

Patients undergo Directly Observed Treatment Short-course (DOTS)

Program

Positive reappraisal

Planful problem solving

Escape-avoidance

Accepting responsibility

Seeking social support

Self-controlling

Distancing

Confrontive

Watson’s Ten Carative Factors are based on a dynamic phenomenological

approach related to the nurse-patient relationship.

The first factor is the formation of humanistic and altruistic values. It is learned

early in life but continues to be influenced through interactions with parents, family,

friends, and others, including nurse educators (Neil, 2002).

The second factor is the instillation of faith and hope. It integrates humanistic and

altruistic values, aid the promotion of holistic nursing care and positive health within the

patient population. This factor also states that by helping patients adopt health-seeking

actions, the nurse can help develop an effective nurse-patient interrelationship (Neil,

2002).

The third factor is the cultivation of sensitivity to self and others. It means self-

acceptance and acknowledgement of feelings for both nurse and patient (Neil, 2002).

The fourth factor is the development of a helping-trust relationship. It is very

important for transpersonal caring. A helping-trust relationship encourages the

expression of both positive and negative feelings (Neil, 2002).

The fifth factor is the promotion and acceptance of the expression of positive and

negative feelings. It is a risk-taking experience for both nurse and patient. Nurses

should be ready for a positive or negative expression of feelings carried out by the

patient (Neil, 2002).

The sixth factor is the systematic use of the scientific problem-solving method for

decision making. It is the utilization of the nursing process in the provision of care to

patients. Thus, this factor eliminates the belief that nurses are handmaids of doctors

(Neil, 2002).

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The seventh factor is the promotion of interpersonal teaching and learning. It

separates nursing from curing. This factor allows the patient to have a sense of

responsibility over his/her own health. The nurse helps the patient in acquiring this

responsibility through teaching-learning techniques. These techniques are geared at

enabling patients to provide self-care, determine personal needs, and provide

opportunities for their personal growth (Neil, 2002).

The eighth factor is the provision for supportive, protective and corrective mental,

physical, sociocultural and spiritual environment. It implies that nurses must recognize

the influence internal and external environments have on the health and illness of

individuals (Neil, 2002).

The ninth factor is the assistance with the gratification of human needs. It

involves the nurse’s recognition of the biophysical, psychological, psychosocial and

intrapersonal needs of patients. Following Maslow’s hierarchy of needs, patients must

answer lower needs first before moving up to satisfy higher needs (Neil, 2002).

The last factor is the allowance for existential-phenomenological forces. It

describes the relevant information needed by an individual to understand the present

situation. This factor aims to a better understanding of self and others (Neil, 2002).

The caring factor survey tool will be used to assess the perception of care that

patients with pulmonary tuberculosis receive from the nurses.

Coping, when considered as a process, is characterized by dynamics and changes that

are a function of continuous appraisals and reappraisals of the shifting person-

environment relationship. Shifts may result from coping efforts that are directed outward

19

toward changing the environment or efforts that are directed toward changing the

meaning of the event (Lazarus and Folkman, 1988).

The patient’s perception of Watson’s caring factors is assessed using the caring

factor survey tool and it will describe the interrelationship to the ways of coping

questionnaire by Lazarus. The caring factor survey will determine whether or not the

nurses are providing the carative factors to the patients as based on the patients’

perception per se. the utilization of the carative factors on patient care will be correlated

with the extent of the patient’s coping mechanism in a healthcare environment.

RESEARCH HYPOTHESIS

20

Based on the specific questions raised in the statement of the problem, the

researchers hypothesized the following:

1.) There is no significant relationship between the nurse’s caring factors to the coping

mechanisms of patients with pulmonary tuberculosis undergoing Directly Observed

Treatment Short-course (DOTS) program.

THE MAIN VARIABLES OF THE STUDY

The major variables under investigation are the nurse’s caring factors and the

coping mechanisms of pulmonary tuberculosis patients undergoing Directly Observed

Treatment Short-course (DOTS). The independent variable is the nurse’s caring factors

whereas the dependent variable is the coping mechanism of pulmonary tuberculosis

(PTB) patients.

The researchers will be using the Caring Factors Survey developed by Jean

Watson and her colleagues to measure the nurses caring factors to patients undergoing

Directly Observed Treatment Short-course (DOTS) Program in the selected tertiary

hospital in Quezon City. The patients would be asking to answer fifteen questions about

their perception regarding the care that they receive from the nursing staff.

After the study, the hospital administrator will be able to note if the caring factors

of the nurses help in improving the condition of their patients.

The coping mechanism will be measured using the Ways of Coping

Questionnaire. This questionnaire is used to identify the extent of coping of individuals

with stressful events they encounter in the institution. It comprises of thirty two item

cognitive and behavioral strategies under eight-coping scales.

DEFINITION OF TERMS

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For better understanding of the terms used in the study, the following

terminologies were conceptually and operationally defined.

1.) Coping

It consists of constantly changing cognitive and behavioral efforts to manage

specific external and/or internal demands that are appraised as taxing or exceeding the

resources of the person (Lazarus and Folkman, 1984).

Refers to the patient’s response on the coping strategies they utilize when given

a stressful situation. The extent of coping is measured in this study by using a

standardized questionnaire developed by Lazarus. For each question, they will be

asked to indicate, by circling 5 for “always”, 4 for “frequently”, 3 for “occasionally”, 2 for

“rarely”, and 1 for “never”, to what extent they used it in the situation.

2.) Directly Observed Treatment Short-Course Program

It is a comprehensive strategy endorsed by the World Health Organization

(WHO) and International Union against Tuberculosis and Lung Diseases (IUATLD) to

detect and cure TB patients. There are five elements of DOTS that need to be fulfilled.

These are: political commitment; quality sputum microscopy for diagnosis; regular

supply of anti-TB drugs; standardized recording and reporting of TB data; and

supervised treatment by a treatment partner (Department of Health, 2012).

Refers to a program by the Department of Health utilized by the patients

diagnosed with pulmonary tuberculosis. The respondents of the study are those TB

patients undergoing DOTS within 6-8 months.

3.) Nurse’s Caring Factors

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The act of providing Nursing care that attempts to honor the human dimensions

of nurse’s work and the inner life world and subjective experiences of the people we

serve (Cara, 2000).

Refers to the patient’s response about how they feel regarding the care they are

currently receiving from the nursing staff. The nurse’s caring factors are measured in

this study by using a standardized questionnaire developed by Jean Watson and her

colleagues. For each questions, they will be asked to indicate how much they agree or

disagree with the statement. They would be marking their response by filling in the

circle, 5 for “always”, 4 for “frequently”, 3 for “occasionally”, 2 for “rarely”, and 1 for

“never”, that best represents their opinion.

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CHAPTER III

RESEARCH METHODOLOGY

RESEARCH DESIGN

The study is a quantitative non-experimental correlation design, because it

describes the existing phenomena which are the nurse’s caring factors and the patient’s

coping mechanism without manipulating the conditions that affects the subject’s

responses. It also does not involve manipulation of the independent variable which is

the nurse’s caring factors. Thus, the research tends to correlate the existing variables

involve in the study.

POPULATION AND SAMPLE

The population of the study includes TB patients undergoing Directly Observed

Treatment Short-course (DOTS) program and nurses that are contributing caring

attributes to gain their optimal health on a selected hospital where the study will be

obtained. The population includes 20-30 patients undergoing Directly Observed

Treatment Short-course treatment (DOTS) program and 5-10 nurses who provide care

to these patients as the respondents of the study. Patients who are physically, mentally

and emotionally disabled are excluded in the population and sample.

Randomized sampling was used as the sampling technique, wherein the willing

and available participants were assigned to treatment conditions at random. Through

this the researchers can avoid systemic biaswhich could affect outcome variables.

RESEARCH LOCALE

The study will be conducted at the selected tertiary hospital located in Quezon

City, with the Pulmonary Tuberculosis patients undergoing Directly Observed Treatment

24

Short-course (DOTS) program and the staff nurses providing care to them as

respondents.

The researchers chose the tertiary hospital to get their study population for being

a well-known institution for lung diseases which provides quality health care through

excellent service, training and research as greatly emphasized to their mission and

vision. Moreover, the researchers have already started communicating to the research

and training department of the said institution.

The selected tertiary hospital is situated at the heart of Quezon City. At present

the center has 210 bed capacities along with numerous programs and services

specifically focused on lung diseases. One of the said services where it was established

in early 2000 and was a self – installed public – private mix DOTS clinic certified by the

Department of Health (DOH), and accredited by the PhilHealth Insurance Corporation. It

became a satellite DOTS Plus Clinic in the year 2004 through tripartite coordination

between the DOH, Tropical Disease Foundation Inc., and the selected tertiary hospital

in Quezon City. According to the institution data statistics, the treatment outcome of

patients treated for pulmonary tuberculosis at the center has seen remarkable success.

Eighty-eight percent of their cases were cured in 2004 and partial result for 2005

revealed a success break of one hundred percent among the smeared positive cases.

These results have surpassed the expected global outcome of curing at least 85% of TB

cases detected. Thus, the tertiary hospital in Quezon City being in the process of

acquiring state-of-the-art facilities and providing top quality care at affordable costs to

the thousands of Filipinos is indeed a place of choice for the study.

25

RESEARCH INSTRUMENTS

The researchers will be using three instruments for the study. The first instrument

is Demographic profile. The second instrument is a 15 item Caring Factors Survey tool

developed by Jean Watson and her colleagues to measure the nurses’ caring factors to

patients undergoing Directly Observed Treatment Short course (DOTS) Program in the

selected tertiary hospital in Quezon City. The researcher’s instrument is a standard tool

and was reconstructed by eliminating items from Watson’s Caring Assessment tool

reducing it from 100 to 15 questions.

The third instrument is the Ways of Coping Questionnaire by Lazarus that will

measure the coping mechanism. It is a standard tool which comprises of 32 item

cognitive and behavioral strategies under 8-coping scales. The instrument will measure

the caring factor of nurses that affects the coping mechanism of tuberculosis patient

undergoing Directly Observed Treatment Short Course.

Lazarus ways of coping mechanisms was restructuredfrom 66 to 32 questions

due to the fact that some questions have the same thought. The researchers also made

sure that the questions are applicable for Filipino respondents diagnosedwith

Pulmonary Tuberculosis who are currently undergoing DOTS. The questionnaires were

pre tested in a pilot study that was conducted last February 5, 2013.

DATA COLLECTION PROCEDURE

The focus of the study is on the coping mechanism of patients undergoing

Directly Observed Treatment Short course (DOTS) Program and the Caring Factors of

the patients and the nurses providing care in the selected tertiary hospital in Quezon

City. Before the data collection, the researchers made a letter of consent in the selected

26

tertiary hospital in Quezon City. The initial visit to the selected institution was to

seek their consent for the study. After getting their permission, the researchers’ second

visit was to collect data using questionnaires developed by Jean Watson which is the

Caring Factors Survey and the Ways of Coping Questionnaire by Lazarus. The design

was used by the researchers is experimental randomized design wherein the table of

random numbers in choosing the respondents. Due to the limited population of patients

undergoing DOTS Program the researchers ended up with twenty (20) respondents.

The respondents needed in the study should be undergoing DOTS Program and

included in the middle age range. The researchers will collect the data starting June 30,

2013.

The steps that the researchers did in data gathering procedures are as follows:

First, the researchers made a letter of consent to be given in the selected tertiary

hospital in Quezon City to ask for their permission for the researchers to instigate study.

After the researchers made the letter and had it signed by their adviser, the researchers

submitted the letter together with the questionnaire to the head of the institution and

waited for the confirmation for them to initiate and collect the data needed in the study.

Third, the researchers went to the selected tertiary hospital in Quezon City to collect

pertinent data in the study using caring factors Survey by Jean Watson and ways to

coping questionnaire by Lazarus. The day after the researchers have collected our data,

the researchers tallied and interpreted the results and compared it with the norms and

standard.

27

STATISTICAL TREATMENT OF DATA

For this study, the researchers used the weighted arithmetic mean in getting the

results for questions 1 and 2.

In answering question number 1and 2 which is asking for the caring factors of

nurses as perceived by patients with pulmonary tuberculosis undergoing Directly

Observed Treatment Short-course (DOTS) program and coping mechanisms of patients

with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course

(DOTS) program as perceived by nurses respectively, the weighted arithmetic mean

used is that:

x = w1x1+w2x2+...+wnxn

w1+w2+...+wn

Where

x = weighted arithmetic mean

∑wx= sum of all products of x and y is the frequency of each option and x is the

weight of each option

∑w= sum of all subjects

In answering question no. 3 which is asking for the significant relationship

between nurse’s caring factors and coping mechanisms of patients with pulmonary

tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program,

spearman’s rho will be used. Spearman’s rho is a statistical calculation that takes two

rankings and produces a numerical relation from 1 to -1. A score of 1 means that the

lists are identical (1,2,3,4 vs. 1,2,3,4). A score of -1 means that the lists are reversed

(1,2,3,4 vs. 4,3,2,1). A score of zero means that there is no relation whatsoever

28

between the two lists.It was developed by CharlesSpearman and will be used when

testing the significance of the relationship between two variables.

The Spearman correlation coefficient is defined as the Pearson correlation

coefficient between the ranked variables. For a sample of size n, the n raw

scores   are converted to ranks , and ρ is computed from these:

Identical values (rank ties or value duplicates) are assigned a rank equal to the

average of their positions in the ascending order of the values.

In applications where duplicate values (ties) are known to be absent, a simpler

procedure can be used to calculate ρ. Differences   between the ranks of

each observation on the two variables are calculated, and ρ is given by:

Where

di= difference of rank of order between the two variables

n= number of scores in each group

29

ETHICAL PRINCIPLES

Within the study it encompasses the ethical principles such as the principle of

beneficence, respect for human dignity and justice. Firstly, the principle of beneficence

because the study’s main goal is to produce benefits and alleviate their sufferings rather

than to cause harm and discomfort to the patients with pulmonary tuberculosis

undergoing Directly Observed Treatment Short-course program. Also, the respondent’s

rights from exploitation were protected by having the time allotment for the respondents

to participate in the study clearly discussed and negotiated.

Second is the principle of respect for human dignity wherein it gives the

respondents the right to decide if they will participate in the study or not. The

respondents, whoever refused to be interviewed shall not be forced nor obligated to

answer the questionnaires for it is purely voluntary. The objectives and instructions of

the questionnaires during the interview were also clearly elaborated to the respondents

to promote full understanding of the respondents regarding the questions to be asked.

The researchers even translated it in the Filipino language.

Lastly, the principle of justice, for all the respondents should be treated equally

and fairly regardless of their social status and so on and so forth. Their answers and

other related information were also kept in confidentiality to promote and provide the

respondents with privacy. Informed consent was also secured and settled. Thus,

abiding all their rights into the overall ethical principles provided for each of our

respondents participated in our study.

30

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6.) Cara, C., (n.d.). A pragmatic View of Jean Watson’s Caring theory. Retrieved

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7.) Damazo, L. (2012). PHILIPPINES: Tuberculosis remains a major killer. Retrieved

from http://www.irinnews.org/Report/78539/PHILIPPINES-Tuberculosis-remains-a-

major-killer

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stories. Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?

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10.) Johnson, M., et.al (2000). Patients' Perceptions of Physicians' Recommendations

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21.) Republic of the Philippines Department of Health (2011). National Tuberculosis

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Caring. The Online Journal of Issues in Nursing (OJIN). Retrieved from

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pages 1-4. Retrieved from http://www.tbsurvivalproject.org/OVERCOMINGinside.pdf

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28.) Ver, J. (2010). Tuberculosis in the Philippines today. Retrieved from

http://thepoc.net/thepoc-features/health-and-wellness/health-and-fitness-features/5266-

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experiences: Carative factors/Caritas processes as a disciplinary guide to the

professional nursing practice, volume 16, pages 129-135. Retrieved from

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30.) Williams, G., et. al (2007). Best Practice for the care of patients with

tuberculosis. International Union against Tuberculosis and Lung Disease, page 23.

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Books:

1.) Carlson, N., et.al (2007). Psychology: The Science of behavior. Chapter 16:

Lifestyle, stress and health pages 536-539. Ref#: Cir BF121 P88 2007

35

2.) George, J.(2008). Nursing Theories: The Base for Professional Nursing Practice, 5th

ed., pages 410. Ref#: Cir RT 84.5 N8 2008

3.) Nelson, K., Williams, C. (2007). Infectious Disease Epidemiology Theory and

Practice, chapter 18, pages 653-689. Ref#: Cir RA 643 I5 2007

4.) Plotnik, R., Kouyoumdjian, H. (2008). Introduction to Psychology, module 21: Health,

stress, coping, 8th ed., pages 499. Ref#: Cir BF 121 P6 2008

5.) Tomey, A., Alligood, M. (n.d.). Nursing Theorists and their work, 5th ed., chapter 11,

pages 145-150

6.) Walsh, M. (2002). Watson’s Clinical Nursing and Related Sciences, 6th edition, page

352. Ref#: Cir RT 65 W3 2002

7.) Walsh, M., Crumbie, A. (2007). Watson’s Clinical Nursing and related Sciences, 7th

ed., chapter 14, pages 344-346. Ref#: Cir RT65 W3 2007

8.) Weiten, W. (2008). Briefer Version Psychology: Themes and Variation, 7th ed.,

chapter 13, page 381. Ref#: Cir BF121 W4 2008

Theses:

1.) Anchenar, I. (2010). Factors Affecting non-adherence to TB DOTS program

among patients: basis for a proposed health education guide. Ref#: Thesis RC 306 I5

2010

2.) Enriquez, K., et al (2009). The relationship between the Nurse's Caring Factors

and the extent of Coping of Lung Cancer patients in a selected special tertiary hospital

in Quezon City.

3.) Joel, M. (2011). Proposed Sanitarium Complex: Incorporating Green Architecture

to TB disease.Ref# Cir RC 309.5 P5M4 2011

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