RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBANGALORE , KARNATAKA

ANNEXURE – I I

PROFORMA FOR REGISTRATION OF SUBJECT FORDISSERTATION

1Name of candidate and Address( In block letters )

MR. BESSYMON BABYI YEAR MSc NURSINGSHREE DEVI COLLEGE OF NURSINGMAINA TOWER , BALLALBAGHMANGALORE - 575003

2 Name of the InstitutionSHREE DEVI COLLEGE OF NURSINGMAINA TOWER , BALLALBAGHMANGALORE - 575003

3 Course of Study and Subject

MSc NURSING,(MEDICAL SURGICAL NURSING )

4 Date of Admission to the Course 02/05/2011

1

5

Title of the Topic

“A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL

MODULE ON BRAIN TUMORS & ITS MANAGEMENT AMONG STAFF

NURSES IN A SELECTED HOSPITAL, MANGALORE.”

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

BACKGROUND OF THE STUDY

Brain tumors the word itself strikes fear in the heart of anyone threatened by one. It once was

considered one of the most frightful events that could occur. Today, however, with improving

technology and the gradual unfolding of scientific understanding of the basic biology of brain

tumors, patients and families can look to the future with considerably more hope1.

Brain tumors can arise either from the brain itself (primary brain tumors: astrocytoma,

glioblastoma, oligodendroglioma, ependymoma), or its coverings (meningiomas, pituitary

tumors, pineal tumors), or the nerves at the base of the brain (acoustic neuromas, schwannomas),

or even from outside the brain (metastatic brain tumors)1.

Tumors of the brain produce dysfunction of body organs activated by the area of the brain

invaded by the tumor. Symptoms, therefore, may be many & varied. To establish a base line for

future planning, observations made at the time of admission are critical. The nurse must establish

rapport, help to quell fear, & assist the family, she also must use this time for determining the

patient’s level of consciousness; ability to comprehend & speak; difficulties in seeing, hearing,

tasting, & smelling; ability to use extremities normally; & levels of temperature, pulse &

respiration & blood pressure. It is at this time that the family can be a source of helpful

information, such as whether the patient needs special assistance or has had difficulty in

2

communicating at home2.

Tumors of the brain produce neurologic manifestations through a number of mechanisms.

Small, critically located tumors may damage specific neural pathways traversing the brain.

Tumors can invade, infiltrate, or supplant normal parenchymal tissue, disrupting normal function.

Nursing care of patients with brain tumors differ from that of general surgical patient in the kinds

of observations needed both pre- & post- operatively. Nurses taking care of these patients need an

understanding of the neurophysiologic basis for the symptoms & an awareness of the need for

rapid institution of nursing or medical measures to preserve life3.

6.2 NEED FOR THE STUDY

Primary brain cancers account for about 2% of all the cancers. In US it is the leading cause of

cancer related deaths in patients who are younger than 35 years. In case of secondary tumors the

incidence increases with age. This accounts for almost 20% of total cancer deaths each year.

Primary brain tumors account for about 20% of the cancers in children4.

Estimates of the annual incidence rate of primary brain tumors range from 7-19.1 cases per

100,000 population. Metastatic tumors to the brain are more common with more than 200,000

patients per year in the United States with a new diagnosis of intracranial metastases. An increase

in the prevalence of HIV infection corresponds to an increase in the occurrence of primary CNS

lymphoma. Pituitary adenomas are exceptionally common, and they are frequent incidental

findings on autopsy. Autopsy series of patients with systemic cancer show that intracranial

metastases are present in 18-24% of patients.The international incidence is not known, but it is

thought to parallel that of the United States3.

In India in 2009, primary cancers of the central nervous system were the cause of death in

approximately 13,100 people. Brain tumors are the second most common cancer in children,

comprising 15-25% of all pediatric malignancies. Perhaps no other cancer is as feared as brain

tumor since severe disability, including paralysis, seizures, gait disturbances, and impairment of

intellectual capacity may occur3.

3

A descriptive survey was conducted in Canada to determine the knowledge of physicians &

nurses regarding the importance of palliative radiotherapy in advanced stages of brain tumor.

They surveyed 250 family physicians, family medicine residents, and nurses attending oncology

educational symposia to determine their knowledge of propotion of response (PR). The survey

response rate was 59%, and most respondents (77%) were involved with the care of cancer

patients. Many (58%) thought that their knowledge of PR was insufficient for their needs.

Although bone metastasis and spinal cord compression were frequently recognized indications for

PR, only 50% of other assessed indications for PR were correctly identified. Almost all

respondents stated that they wanted to learn more about PR5.

Patients with brain tumors require extensive, skilled, professional care from nurses with

patience, a deliberate & unhurried pace, & a great deal of consideration. It is the nurse who must

provide comprehensive care for the patients & a sense of security for the family. In addition, she

must accurately observe & record all physical signs & symptoms as well as any changes in the

behavior if the physician, who sees the patient for such a short time, is to be helped to make a

diagnosis & plan a treatment regimen. The nurse thus plays two roles: that of assistance to the

physician or surgeon that of determining, planning, & carrying out the nursing care needed. These

roles are not separate & distinct in all instances: when she is caring for the patient, she observes

for the physician as well as the nursing staff2.

To determine nursing needs, the nurse must understand the functions of the brain & cranial

nerves & the effect tumors have upon these structures, the physician’s plan of care, & the special

needs of the particular patient. Once needs have been determined, a plan for care can be devised.

However, any plan must be flexible; it will undergo changes as the patient’s needs change.

Information obtained from the physician & from related disciplines, such as medical social

service, as well as daily observation by the nursing staff, will affect the plan. Conferences of

several kinds- multidisciplinary, ward, team- and reports between nurses on various shifts will

enable all those concerned to discuss the patient’s need & the plan for meeting them. The

professional nurse should be responsible for planning care from the care of the patient’s

admission until his return to the community. She will also determine the care which must be

4

given by the professional nurse & that which can be entrusted to vocational nurses & auxillary

personnel2.

In the light of the above facts have urged the researcher to asses & educate these staff

nurse’s knowledge about care of patients with brain tumors for patient well being by using

intervention based measures.

6.3 THE REVIEW OF LITERATURE

The review of literature of brain tumor & its management is divided into:

Literature related to incidence & prevalence of brain tumors

Literature related to the management of brain tumors

Literature related to the knowledge of staff nurse on the management of brain tumors

Literature related to SIM as an effective teaching module

Literature related to the incidence & prevalence of brain tumors

A descriptive study was conducted in USA with the aim to assess the Survival outcomes and

patterns of care for brain tumor patients in the USA Veterans population and the extent of

variation in outcomes between Veterans and the rest of the USA. This was a retrospective review

of microscopically-confirmed, supratentorial glioblastoma multiforme in male Veterans actively

followed by the VACCR; survival was analyzed and compared to a national cohort from the

surveillance, epidemiology and end results program. In this study they analyzed 1,219 Veterans

with glioblastomas diagnosed between 1997 and 2006. Median survival was 6.5 months and 1, 2,

and 5 years survival rates were 26.8, 5.4, and 0.5%, respectively. The result shows that more

aggressive therapy was associated with better survival, even among elderly Veterans and whether

compared overall or by age group, VA patients showed decreased survival relative to a national

cohort6.

A descriptive study was conducted in Minnesota with a purpose to assess the increasing

5

incidence of primary brain tumors, especially malignant astrocytomas, in the elderly population.

In this study they analyzed the incidence and temporal trends of 123476 cases of primary

intracranial neoplasms diagnosed in the population of Rochester, Minnesota, over the 40 years

between 2000 and 2010. The result indicates that the reported increase in the incidence of primary

brain tumors is an artifact of improvement in diagnostic technology and practice7.

Literature related to the management of brain tumors

An experimental study was conducted in Switzerland with an objective to assess whether

antiepileptic drugs (AEDs) modulate the effectiveness of temozolomide radiochemotherapy in

patients with newly diagnosed glioblastoma. The method used for this study is the clinical trial

data base of radiotherapy (RT) with or without temozolomide (TMZ) for newly diagnosed

glioblastoma was examined to assess the impact of the interaction between AED use and

chemoradiotherapy on survival. When treatment began, 175 patients (30.5%) were AED-free, 277

(48.3%) were taking any enzyme-inducing AED (EIAED) and 135 (23.4%) were taking any non-

EIAED. The result reveals that the patients receiving valproic acid (VPA) only had more grade

3/4 thrombopenia and leukopenia than patients without an AED or patients taking an EIAED

only. The overall survival (OS) of patients who were receiving an AED at baseline vs not

receiving any AED was similar8.

An restrospective study was conducted in Korea with an objective to evaluate the outcome

of gamma knife radiosurgery (GKRS) and/or whole brain radiation therapy (WBRT) for the

treatment of small cell lung carcinoma (SCLC) metastasis to the brain. They selected 50 patients

who underwent GKRS for metastatic brain lesions originating from SCLC from 2000 to 2010.

Among these patients, 11 received prophylactic cranial irradiation (PCI) before the development

of metastatic lesions (PCI group), and GKRS was performed as an initial treatment for newly

diagnosed lesions in 12 patients who had not received PCI (primary GKRS group). The result

obtained is the overall survival of the 50 patients was 20.8 months (range 1-53) after the

diagnosis of primary tumor and 12.0 months (range 1-47) after the development of cerebral

6

metastasis. Median survival after GKRS was 4.8 months (range 1-15) in the PCI group, 4.6

months (range 0-18) in the primary GKRS group, and 7.6 months (range 0-33) in the salvage

GKRS group. Further treatment for progressive lesions after GKRS was necessary in 15 patients,

after a mean interval of 3.8 months. Causes of death were systemic organ failure in 15 patients,

deterioration of neurological state in 13 patients, and unknown or combined causes in 16 patients.

The local control rate of the lesions treated with GKRS was 76.4% (decreased in 13 patients and

stable in 16 patients at the final imaging follow-up (mean 5.60 months)9.

Literature related to the knowledge of staff nurse on the management of brain tumors

A survey was conducted in France with an objective to describe knowledge, attitudes and

reported practice of blood transfusion of nurses in Aquitaine’s hospitals & to measure the

potential threat for patients safety of poor transfusion related knowledge and practice & to

identify factors associated with poor knowledge and practice. The survey was conducted in 14

hospitals in Aquitaine in a random sample of nurses. The data were collected anonymously by

investigators through structured individual interviews. The questionnaire contained mainly

knowledge & practice questions about blood transfusion reaction. The survey result shows poor

knowledge & practice of nurses concerned mainly 1) the bed side blood compatibility test

(propotion of responses (PR) with potential life threat between 12.7 & 35.5%); 2) pre-transfusion

compatibility check when receiving blood units (PR=34.5%); 3) delay between screening of red

cell antibodies & transfusion (PR=20.5%); 4) delay in preservation of blood unit in the ward

(PR=33.4%); & 5) recognitions of abnormal reactions after transfusion (PR=47.1%)10.

Literature related to SIM as an effective teaching module

An experimental study conducted to evaluate a self instructional education module with

audit and feed back, designed to increase the skills of General Practitioner in diagnosing

melanocyte lesion and in skin cancer. The sample size was sixteen General Practitioner. The

overall diagnostic accuracy of malignant lesions was 63.2%during baseline and 64.5%

posteducation. Significant improvements were seen posteducation in the proportion of

7

melanocytic lesions confirmed as malignant 6.1% baseline and 13.5% posteducation, The study

concluded with the findings that General Practitioners with less experience benifited most from

the programme, indicating that tailoring of programmes to individual skills and years of practice

might bebenificial11.

An experimental study was conducted in USA with the purpose to to examine the

effects of self-instruction on learning, satisfaction with the teaching approach, and health status of

persons with brain tumor. The method used was the control-group pretest-posttest design. Thirty

subjects receiving care at a oncology clinic who met study criteria were randomly assigned to two

groups: (a) self-instruction and (b) control. The result shows a significant difference between the

groups (P = 0.01). Participants who completed the self-instructional program had improved

scores on the posttest as compared to the control. Subjects rated self-instruction as an effective

teaching trategy in terms of promoting learning about brain tumor and patient acceptability. t-

Test demonstrated no significant difference between the groups in health status. Significant

correlations were found between subjects' test scores and selected variables12.

6.4 STATEMENT OF PROBLEM

“A study to assess the effectiveness of self instruction module on brain tumors & its

management among staff nurses in a selected hospital, Mangalore.”

6.5 OBJECTIVES

1. To assess the prior knowledge of staff nurses regarding the care of patients with brain

tumors & its management.

2. To develop SIM regarding the care of patients with brain tumor.

3. To find out the effectiveness of SIM in terms of gain in post test knowledge score.

4. To associate the pre test knowledge score with selected demographic variables.

6.6 OPERATIONAL DEFINITION

Assess: In the present study, asses means judging the status of pretest and post test

knowledge of staff nurses on brain tumors & its management.

Effectiveness: In the present study, effectiveness refers to the extent to which the SIM has

8

achieved the desired objective, that means improvement of knowledge scores among staff

nurses on brain tumors & its management.

Self Instructional Module: In the present study, SIM is a learning package planned and

prepared from the brain tumors & its management provided to staff nurses with an aim to

facilitate self learning.

Brain Tumors: Brain tumors are defined as the malignant or benign mass or growth of

abnormal cells in the brain.

Staff Nurses: In the present study, staff nurse is a person who is having a diploma or basic

degree in nursing from a recognized university or board, registered under a state nursing

council and is working in selected hospital, Mangalore.

Selected Hospital: In the present study selected hospital refers to the place where the

researcher obtain permission & intents to conduct the study.

6.7 VARIABLES

Independent Variable: The SIM on brain tumors & its management.

Dependent Variables: Staff nurses knowledge on brain tumors & its management.

6.8 ASSUMPTION

The study assumes that,

Staff nurses will have some knowledge regarding brain tumors & its management.

Knowledge may vary from person to person

6.9 DELIMITATION

The study would be delimited to the staff nurses.

6.10 HYPOTHESES

All hypothesis will be tested at 0.05 level of significance.

H1: The mean post test score of the staff nurses will be significantly higher than mean pre test

score.

H2: There will be significant association between post test knowledge score of the staff nurses

on brain tumors & its management with their selected demographic variables.

9

7.

MATERIALS AND METHODS

7.1.1 SOURCE OF DATA:

Data will be collected from the staff nurses in a selected hospital, Mangalore.

7.1.2 RESEARCH DESIGN:

The research design selected for this study is pre experimental design one group pre and

post test.

O1 --- X --- O2

E = O2 - O1

O1= Pre test knowledge of staff nurses on brain tumor & its management

X = Intervention with Self Instruction Module on brain tumor & its management

O2= Post test knowledge of staff nurses on brain tumor & its management

E = Effectiveness of SIM

7.1.3 SETTING :

The study will be conducted in selected hospitals, Mangalore

7.1.4 POPULATION:

The population of this study will be staff nurses in selected hospitals, Mangalore.

7.2 METHOD OF DATA COLLECTION

7.2.1 SAMPLING PROCEDURE:

Purposive sampling technique will be adopted for this study.

7.2.2 SAMPLE SIZE:

The sample size will be approximately 50 staff nurses in a selected hospital, Mangalore.

10

7.2.3 INCLUSION CRITERIA:

Staff nurses who are

Admitted to staff nurses in selected hospital at Mangalore

willing to participate in the study

available at the time of data collection

7.2.4 EXCLUSION CRITERIA

Staff nurses who are not

available during the period of data collection

willing to participate in the study

7.2.5 DEVELOPMENT OF TOOL

Instrument Used

1. Closed ended questionnaire related to the brain tumors & its management.

2. SIM on brain tumors & its management.

Description Of The Tools

Closed ended questionnaire will be prepared to assess the knowledge of brain tumors & its

management among staff nurses.

The closed ended questionnaire will have two parts

Part A- demographic characteristics.

Part B- item on brain tumors & its management.

SIM will be prepared based on objectives, literature reviews and based on expert’s opinion.

7.2.6 DATA COLLECTION METHOD

Prior to the data collection permission will be obtained from the concerned authority for

conducting the study.

The data will be collected from approximately 50 staff nurses, after obtaining their consent.

Pretest will be conducted using structured knowledge questionnaire and a SIM will be

11

provided to the staff nurses on the same day and post test will be conducted by using the

same questionnaire on seventh day.

7.2.7 DATA ANALYSIS PLAN

The data will be planned and analyzed using differential and inferential statistics

the differential statistics will be used are mean, median, standard deviation, and mean

percentage etc

inferential statistics will be used are paired ‘t’ test and chi- square.(P > 0.05)

7.3 DOES THE STUDY REQUERE ANY INVESTIGATION TO BE CONDUCTED ON

PATIENTS OF OTHER HUMANS OR ANIMALS?

Yes, a self instruction module on brain tumors & its management will be required to assess the

knowledge of staff nurses.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTE IN

CADE OF 7.3?

Yes, ethical clearance will be obtained from the concerned authority.

12

8.

REFERENCES

1. Brain cancer information centre. Overview of brain tumor. [Updated on 2010 March]. Available from http://td1lazdyx.net23.net/assignment/overview1.htm.

2. Hilkemeyer Renilda, Fleming Brooks Ethel, Kincaid Mildred. Nursing care of patients with brain tumors. USA: The American journal of nursing; [updated on Mar 1964, Vol.64,No. 3]. [about two screens]. Available from http://www.jstor.org/pss/3419010.

3. Huff Stephen J. Brain neoplasms. Brenner Barry E publications; [updated on 2001 Aug 2]. [about two screens]. Available from http://emedicine.medscape.com/article/779664-overview.

4. Oncologist-approved cancer information from the American society of clinical oncology. Brain tumor. USA: Conquer publications; [updated on 2011 Aug 03]. [about two screen]. Available from http://www.cancer.net/portal/site/patient.

5. Berrang T, Samant R. Palliative radiotherapy knowledge among community family physicians & nurses. J Cancer Educ.; 2008;23(3):156-60.

6. ArrigoRT, Boakye M, Skirboll SL. Ptterns of care & survival for glioblastoma patients in the Veterance population. J Neurooncol. 2011 Sep 1.

7. Radhakrishnan Kurupath, Mokri Bahram MD, Joseph E. Parisi, O'Fallon W. Michael, Sunku Jayasimha, Dr.Kurland Leonard T et al. The trends in incidence of primary brain tumors in the population of nochester, minnesota. J Neurooncol. 1995 January; Volume 37: Pages 67-73.

8. Weller M, Gorlia T, Cairncross JG, Mason W, Belanger K, Brandes AA. Prolonged survival with valporic acid use in the EORTC/NCIC temozolomide trial for glioblastoma. Neurology. 2011 Sep 20;77(12):1156-64.

9. Jo KW, Kong DS, Lim do H, Ahn YC, Nam DH, Lee JI. The role of radiosurgery in patients with brain metestasis from small cell lung carcinoma. J Korean Neurosurg Soc. 2011 Aug;50(2):99-102.

10. Saillour-Glenisson F.,Tricaud S., Mathoulin-Pelissier S., Bouchon B., Galperine I., Fialon P. Factors associated with nurses’ poor knowledge & practice of transfusion safety

13

procedures in Aquitaine, France. International Journal for Quality in Health Care. 2002, volume 14, number 1: 25-32.

11. Youl PH, Raasch BA, Janda M, Aitken JF. The effect of an educational programme lesions. Available from The effect of an educational programme to improve the skills of general practitioners in diagnosing melanocytic/pigmented lesions.

12. Oermann H.Marilyn, Doyle H. Teresa, Clark R. Lillian, Rivers L. Carolyn, Rose Y. Victoria. Effectiveness of self instruction for brain tumor patient education. Patient education & Counselling. 1986 September, Volume 8, Pages 245-54.

14

9. Signature of the candidate

10. Remarks of the guideTOPIC IS RELEVANT TO CONDUCT THE RESEARCH STUDY

11. Name and designation of (in block letters)

11.1 Guide MR. GIREESH G. R. HOD, MEDICALSURGICAL NURSINGSHREE DEVI COLLEGE OF NURSINGMANGALORE

11.2 Signature

11.3 Co-guide (if any)

11.4 Signature

12. 12.1 Head of the department

MR. GIREESH G. R. HOD, MEDICALSURGICAL NURSINGSHREE DEVI COLLEGE OF NURSINGMANGALORE

12.2 Signature

13. 13.1 Remarks of the Chairman and Principal RECOMMENDED FOR APPROVAL

13.2 Signature

15