A STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING
MANAGEMENT OF STRESS AND ANXIETY
AMONG WOMEN WITH INFERTILITY PROBLEM AT SELECTED INFERTILITY CLINIC, COIMBATORE
By
Reg.No:301731001
A dissertation submitted to
THE TAMIL NADU Dr. M.G.R. MEDICAL UNIVERSITY, CHENNAI-600 032
In partial fulfillment of requirement for the degree of
MASTER OF SCIENCE IN NURSING
OCTOBER 2019
A STUDY TO ASSESS THE EFFECTIVENESS OF
STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING MANAGEMENT OF STRESS AND ANXIETY
AMONG WOMEN WITH INFERTILITY PROBLEM AT SELECTED INFERTILITY CLINIC , COIMBATORE
By
Reg.No:301731001
EXTERNAL INTERNAL
A dissertation submitted to
THE TAMIL NADU Dr. M.G.R. MEDICAL UNIVERSITY, CHENNAI-600 032
In partial fulfillment of requirement for the degree of
MASTER OF SCIENCE IN NURSING
OCTOBER 2019
A STUDY TO ASSESS THE EFFECTIVENESS OF
STRUCTURED TEACHING PROGRAMME ON KNOWLEGDE REGARDING MANAGEMENT OF STRESS AND ANXIETY
AMONG WOMEN WITH INFERTILITY PROBLEM AT SELECTED INFERTILITY CLINIC , COIMBATORE
CERTIFIED THAT THIS IS THE BONAFIDE WORK OF Reg. No: 301731001
PPG College of Nursing Coimbatore
SIGNATURE: COLLEGE SEAL
Dr. P. MUTHULAKSHMI, M.Sc(N)., M.Phil., Ph.D., Principal,
PPG College of Nursing, Coimbatore – 35.
A dissertation submitted to
THE TAMIL NADU Dr. M.G.R. MEDICAL UNIVERSITY, CHENNAI-600 032
In partial fulfillment of requirement for the degree of
MASTER OF SCIENCE IN NURSING
OCTOBER 2019
A STUDY TO ASSESS THE EFFECTIVENESS OF
STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING MANAGEMENT OF STRESS AND ANXIETY
AMONG WOMEN WITH INFERTILITY PROBLEM AT SELECTED INFERTILITY CLINIC, COIMBATORE
APPROVED BYTHE DISSERTATION COMMITTEE ON OCTOBER 2018 RESEARCH GUIDE : ______________________
Dr. P. MUTHULAKSHMI, M.Sc (N)., M.Phil, Ph.D., Principal
PPG College of Nursing Coimbatore – 35.
SUBJECT GUIDE
:
__________________________DR.M.ABIRAMI M.Sc (N)., Ph.D., Professor
Department Of Psychiatric Nursing, PPG College Of Nursing,
Coimbatore – 35.
MEDICAL GUIDE
:
__________________________
DR.RAJENDIRAN M.B.B.S., D.P.M., Consultant Psychiatrist,
Naveen Mental Hospital, Coimbatore.
A dissertation submitted to
THE TAMIL NADU Dr. M.G.R. MEDICAL UNIVERSITY, CHENNAI-600 032
In partial fulfillment of requirement for the degree of
MASTER OF SCIENCE IN NURSING
OCTOBER 2019
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SUBJECT GUIDE SIGNATURE PRINCIPAL SIGN WITH SEAL
ACKNOWLEDGEMENT
Whole heartedly convey the gratitude to Lord Almighty for his abiding grace, love, compassionate and immense showers and blessings on me, which gave me the strength and courage to overcome all the difficulties and whose salutary benison enabled me to achieve this target.
I am highly obliged to my beloved Parents, my sister and Friends for their constant support, love, prayer, motivation and evergreen memorable help and care throughout my life.
I express my deep sense of gratitude to Dr. L. P. Thangavelu, MS., F.R.C.S., Chairman and Mrs. Shanthi Thangavelu, M.A., Correspondent, PPG group of institutions and our trustees for encouragement and providing the source of the success of the study.
It is my long felt desire to express my profound gratitude and exclusive thanks to Dr. P. Muthulakshmi, M.Sc(N)., M.Phil., Ph.D., Principal and our research guide with professional competence. It is obvious that without her esteemed suggestion, highly scholarly touch and perching insight at every stage of the study, this work could not have been presented in the manner it has been made. I also express my gratitude for her valuable guidance and help in the statistical analysis of data which is the core of the study.
The present study has been completed under the expert guidance and support of Dr.M.Abirami M.Sc(N)., Ph.D., If not the present study would have missed much of its presence and substance. Her keen support, guidance, encouragement, sustained patience, valuable suggestions and constrictive evaluation have enabled me to shape up this research as a worthy contribution to the field also my sincere thanks to Mr.Venugopal M.Phil., professor of research methodology.
My sincere thanks to Prof. Kalaivani., M.Sc(N)., M.Phil., Dr. Prof. Jeyabharathi M.Sc(N)., Ph.D, Prof. Kaladevi, M.Sc(N)., and other Faculty Members of other departments in PPG college of nursing for their valuable suggestion in research.
I extent my gratitude to the class coordinator Prof.V.Andria M.Sc.,(N) for their valuable guidance and support.
I express my sincere thanks to sudha fertility center, for granting permission to conduct the study in the hospital , and I extend my grateful thanks to all staffs for their co-operation and help for completing my work successfully.
I profusely thank to Dr.Rajendiran, Consultant Psychiatrist, Naveen Hospitals , Coimbatore for his support and valuable suggestions in completing this study.
I take this opportunity to thank the Experts who have done the content validity and valuable suggestions in modification of tool.
I express my thanks to the Dissertation Committee Members for their healthy criticism, supportive suggestions which moulded the research.
I extend thanks to Librarian and Assistant Librarian PPG institute of health science for leading their help for my literature review.
I express my heartiest thanks to the womens of the samples who have supported and co-operated with me throughout the study. Last but not the least, my sincere thanks to my Colleagues for their kind cooperation and effort in making my study great success also my friend who supported my system updates for my completion of the research.
ABSTRACT
Statement of the problem
“A study to assess the effectiveness of structured teaching programme on knowledge regarding management of stress and anxiety among women with infertility problem at selected hospital, Coimbatore.‖
Objectives :
To identify the socio demographic variables of women with infertility problem.
To assess the level of knowledge regarding management of stress and anxiety among women with infertility problem.
To deliver the structured teaching programme regarding management of stress and anxiety among women with infertility problem.
To reassess the level of knowledge regarding management of stress and anxiety among women with infertility problem. .
To determine the association between the post test score level of knowledge and with demographic variables.
Hypothesis
H1: Their will be statistically significant different between pretest and posttest level of knowledge regrading management of stress and anxiety among women with infertility problem.
Methodology
The modified conceptual frame work for the present study was based on upon J.W.Kenny‘s open system model. Pre experimental-one group pretest posttest design was adopted for the present study. The Structured Knowledge Questionnaire was developed to collect the data. Pilot study was conducted among 5 women with infertility problem and samples were selected by purposive sampling to find the feasibility of the study. The main study was conducted at selected hospital, Coimbatore among 60 women with infertility problem and the data collected was analyzed and interpreted based on descriptive and inferential
Results
The pretest mean was 12.9 and posttest mean was 25.63 there was significant difference between the level of knowledge among the subjects in pretest and posttest after implementation of STP (t=13.17 and p<= 0.05).STP was effective in improving knowledge. It is evident that there is significant association exist between the posttest score of education (X2=14.32 ) were as the table value=12.59 are more than the table value at p >0.05 level. This shows that the significant association exists among the education of the women with infertility problems with their knowledge score.
Conclusion
The present study attempted to assess the effectiveness of STP on knowledge regarding management of stress and anxiety among women with infertility problem and found that the STP was effective in improving the knowledge of women with infertility problem.
TABLE OF CONTENTS
CHAPTERS CONTENT PAGE NO
I INTRODUCTION
Need for the study Statement of the problem Objectives
Operational definition Hypothesis
Assumption
1 5 8 8 8 9 10 II REVIEW OF THE LITERATURE
Part I Part II
11 11 20 III METHODOLOGY
Research design Research setting Population
Sampling techniques Sample size
Sample criteria
Development and description of the tool Data collection procedure
Plan for data analysis
23 23 24 24 24 24 25 25 26 27 IV DATA ANALYSIS AND INTERPRETATION 29
V DISCUSSION 42
VI SUMMARY & CONCLUSION 47
REFERENCES 51
APPENDICS 55
LIST OF TABLES
SL. NO. TABLES PAGE
NO.
1. Distribution Of Demographic Variables Women With Infertility Problem
30 2. Pre-test level of knowledge regarding management of stress and
anxiety among women with infertility problem.
35
3. Pre-test and post test level of knowledge regarding management of stress and anxiety among women with infertility problem.
36
4. Comparison of pre-test and post-test score of knowledge regarding management of stress and anxiety among women with infertility problem.
38
5. Association between post test scores of knowledge management of stress and anxiety among women with infertility problem..with selected demographic variables
40
LIST OF FIGURES
SL.
NO. FIGURES
PAGE NO.
1. Conceptual Frame Work Based on J.W.Kenny‘s Open System Model.
22
2. Schematic representation of Research Design of the study 28 3. Distribution of Age Women with infertility Problem 32 4. Distribution of Education Women with infertility Problem 32 5. Distribution of Occupation Women with infertility Problem 33 6. Distribution of Family monthly income Women with infertility
Problem
33
7. Distribution of duration of infertility 34
8. Pre-test level of knowledge regarding management of stress and anxiety among women with infertility problem.
35
9. Pre-test and Post-test level of knowledge regarding management of stress and anxiety among women with infertility problem
37
10. Mean and Standard Deviation of Pre-test and Post-test scores of knowledge among women with infertility problem.
39
2
LIST OF APPENDICES
S. No Content
1 Permission letter to conduct the study 2 List of experts for content validity 3 Content validity format
4 Informed consent form 5 Tamil editing certificate 6 English editing certificate 7 Plagiarism Report
8 Research tool-English 9 Research tool – Tamil
10 Intervention – Structure Teaching Programme
11 PPT
12 Photographs
1
CHAPTER – I INTRODUCTION
As birth and death followed and depends on parenthood as much for granted . We are born; we get an education, then a job, followed by marriage, parenthood and finally death. This is happened by some sorts of following unwritten cosmic schedule by humans without thinking about the effects for lives this living culture flow in a seamless fashion from one to another phase of life.This creates couples as a rude shock that they cannot have children for their life,the loss of parenthood, a basic ingredient of life, comes as a rude shock.
Infertility is a challenging experience, affecting individual and couples‘
adjustment. However, the way the members of the couple support each other may affect the experience of infertility and their adjustment.
Fertility is highly valued in most cultures and the wish for a child is one of the most basic of all human motivations. For women, pregnancy and motherhood are developmental milestones that are highly emphasized by our culture. When attempts fail to have a child, it can be an emotionally devastating experience But in the past two decades, advances in reproductive medicine have made the treatment of infertility a highly successful prospect that has given hope and success to thousands of couples. The high-tech reproductive technologies have associated psychological and ethical issues that must be addressed by the infertile couple. Therefore, it is important for the health care professional to understand the psychological issues surrounding infertility. Infertility involves suffering and being childlessness is a psychological trauma and it is this perceived undesirability that prompts patients & couples to seek professional help. Not everyone has the goal of becoming a parent, but for those who do, being unable to conceive a child is an exquisitely painful reality. Most of the people spend a portion of their lives attempting to avoid unplanned pregnancies, and assume that once we are ready to conceive, it will happen with little difficulty.
The belief that psychological factors play a role in infertility is long-standing, and there is evidence that stress levels influence the outcome of infertility treatment, as well as contribute to patients' decisions to continue treatment.
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Women are god‘s unique creations in fact they are even considered as god because only a woman has the ability to give birth to a new soul to this world. But by some unfortunate means, some women loose this ability. These unfortunate people are reported to as infertile. This inconceive effect may cause women to experience psychosocial problems. In most of the cases the couple must undergo extensive and invasive investigation and treatment procedures. The repeated failure of treatment may create emotional distress and depression . Human beings have two basic desires
―to get and to be got‖. Our universal dream is having own family. This dream cannot become true for the infertile couple, this issue can cause depression ,very stress and difficult emotions.
WHO., (2001) reported that 1/3rd of the people affected by infertility around the world and even in developing countries. In India infertility affects 10-15% of couples in reproductive age group.
Infertility may causes stress denfinitely when comparing to infertility men ,infertility women report high level of stress and anxiety. Stress lowers sexual and marital adjustment and isolation compared to men .While stress does not cause infertility, infertility most definitely causes stress. Infertile women report higher levels of stress and anxiety than infertile men and there is some indications that infertile women are more likely to become depressed. This infertility effect can interfere with work, family, money and sex of the women s life .by reducing stress and anxiety of women .their life become comfortable .
There have been dozens of studies on the efficacy of psychological interventions on women with infertility, with outcomes including pregnancy rates/live birth rates as well as multiple measures of psychological distress. Unfortunately, the various meta-analyses performed in the past 14 years fail to agree on the results.
The conclusions on efficacy were: Stress reliever interventions were more impactful on reducing negative affect than interpersonal functioning, there were no significant differences in pregnancy rates, group interventions which included actual skills acquisition were more effective than counseling ones, Men and women benefitted equally.
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Both pregnancy rates and psychological symptoms. They concluded that there were statistically significant and robust overall effects of psychosocial interventions...
―on both pregnancy rates and a variety of different psychological symptoms.‖ The conclusions also were that effect sizes were greater for women than for men and higher pregnancy rates were associated with greater decreases in anxiety.
The mind/body program for infertility is evident that infertility patients experience distress, depression, anxiety, and decreased quality of life. It is important for infertility providers and counselors to offer assistance to these patients by way of psychological interventions and emotional support.
The Mind/Body Program for Infertility was created and launched in September 1987. Because psychological interventions for infertile patients can improve psychological outcomes and marital relationships as well as increase patient retention and improve pregnancy rates, it was hypothesized that a research-based clinical program had the potential to accomplish all of these goals. The program has ten sessions, is a group model, and the partners of participants attend three of these sessions. It has been proven a successful way to reduce stress and increase pregnancy rates and provides patients with skills in cognitive behavior therapy, relaxation training, lifestyle changes, journaling, self-awareness, and social support components.
Relaxation techniques have been widely shown to reduce negative emotions in a range of medical patients, more specifically, they have been shown to significantly reduce anxiety scores in women undergoing infertility treatment. Patients learn a different technique each week, including progressive muscle relaxation, hatha yoga, meditation, imagery, etc, and are encouraged to try each one and then practice the one(s) which are most effective for them.
Both male and female infertility patients explored the benefit of expressive writing. The authors found that both partners exhibited decreased depressive symptoms. Participants in the mind/body program do a journaling exercise during the seventh session of the program and are encouraged to continue if they found it helpful. They also are encouraged to maintain a daily gratitude diary.
Mindfulness is commonly used as a coping strategy for infertility patients and is introduced early in the program. First time IVF patients randomized to a
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mindfulness-based intervention versus control found that women who attended the intervention revealed a significant increase in mindfulness, self-compassion, meaning- based coping strategies, and most importantly had higher pregnancy rates.
There have been a number of womens on the efficacy of the mind/body program. Participants experience significantly lower levels of distress as well as a higher pregnancy rate than the control subjects
The fact that various studies have demonstrated the importance of the mind body connection and fertility, the psychosocial aspect of infertility has not been adequately addressed .For women, the physical,emotional and fancial burden is infertility treatment. This causes heart rate to be changed inducedly and predictive cortisol are achieving a viable pregnancy.
Recent improvements in medications, micro-surgery and assisted reproductive technology possibly increases pregnancy of the couples precising treatment. The couples facing infertility deal for long time due to stress. This also creates guiltiness and tension with their the relationship. The cost of infertility treatment may also cause economic burdens and influence the utilization of treatment option and continuing the treatments. The cost of treatment and the level of family support may cause stress and alteration in the sexual behaviour of infertile couple. For infertile women ,their healths are in curcial and psychological manner and also particularly nurses should recognize the negative consequences of infertility and design healthy adaptation measures that could assist in infertile women to remain active and focus on the treatment process.
Counselling about meditation and daily habits is a great tool for relaxation and peace of mind, it may help us to reticfy ego, tension and it causes of human sufferings, at larger levels.
Meditation is the integral part of the divine of real nature that our real nature.
Positive thinking will get induced by meditation and mind get controlness. Meditation can give you back control over your mind and hence the researcher was interested to identify women‘s stress and anxiety level by assessing pre and post meditation effects through Perceived Stress Scale and Modified Hamilton Anxiety Scale. This would
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provide with valuable information for the health care providers to offer the best atmosphere to help the women in their ongoing acceptance of the fertility dilemma.
Keywords: anxiety, distress, infertility, IVF, psychosocial support, quality of life NEED FOR THE STUDY
Child bearing often is seen as one of the most basic of life‘s achievement. For those who can not achieve a pregnancy, feelings of failure, depression, isolation, guilt and anger accompany their desire for a child. Acknowledgement of these intense feelings aids the couple in their search for solution and acceptance of the testing and treatment procedures.
Rooney KL, Domar AD (Dialogues Clinic Neuroscienece 2018) the relationship between stress and infertility has been debated for years. Women with infertility report elevated levels of anxiety and depression, so it is clear that infertility causes stress. What is less clear, however, is whether or not stress causes infertility.
The impact of distress on treatment outcome is difficult to investigate for a number of factors, including inaccurate self-report measures and feelings of increased optimism at treatment onset. However, the most recent research has documented the efficacy of psychological interventions in lowering psychological distress as well as being associated with significant increases in pregnancy rates. A cognitive-behavioral group approach may be the most efficient way to achieve both goals. Given the distress levels reported by many infertile women, it is vital to expand the availability of these programs.
NVISAGE., stated that NIAC in UK (National Infertility Awareness Campaign) Fertility Fairness has created an infographic which briefly summarises the current provision of IVF in England(2018) For more than 20 years Fertility Fairness has campaigned for people to have comprehensive and equal access to a full range of appropriate NHS investigations and treatments for infertility;
this includes the right to access up to three full cycles of IVF treatment free on the NHS. Evidence suggests the effects of failing to provide NHS funding for infertility can be both financially and emotionally, devastating. Since its establishment, Fertility Fairness has pushed for recognition of the psychological effects of infertility, which if left untreated, can cause unnecessary and long-lasting harm to an individual‘s
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mental and general wellbeing.Fertility Fairness and its members are working hard to raise awareness of infertility and what is expected of the NHS among policymakers at a local and national level.
BMC Womens Health., ( 2017 ) infertility is often associated with a chronic state of stress which may manifest itself in anxiety-related and depressive symptoms.
The aim of our study is to assess the psychological state of women with and without fertility problems, and to investigate the background factors of anxiety-related and depressive symptoms in women struggling with infertility. Depressive and anxiety- related symptoms of infertile women are more prominent than those of fertile females. The measurement of these indicators and the mitigation of underlying distress by adequate psychosocial interventions should be encouraged.
Swarna, S.(2016) stated that recent year‘s infertility is becoming a world wide issue. Approximately 8 – 10% of couples experience infertility during their reproductive life. It affects all human beings present in all the societies.
Vaidhyanadan, R et.al. (2015), stated that WHO estimated approximately 8- 10% of couples experience some form of infertility on a world wide, this means that 50-80 million people suffer from infertility. The incidence of infertilies for all the peoples or more identical. Infertility is exclusively a female problem in 30-40% of cases and male in 10-30% of cases.
Marchiano, D.(2015),estimated that 10% to 20% of couples will be unable to become pregnant after a year. The chances for pregnancy occurring in healthy couples who are both under the age of 30 and having intercourse regularly are only 25% to 30% per month. A women‘s peak fertility occurs only in her early 20s. As a woman ages beyond 35 the likelihood of conceiving will be diminished to less than 10% per month.
Boivin,J et.al.,(2014) reported that the prevalence of infertility ranged from 3.5% to 16.7% in more developed nations and from 6.9% to 9.3% in less developed nations. The proportion of couples seeking medical care was on average of 56.1%
(range 42-76.3%) in more developed countries and 51.2% (range 27 – 74%) in less developed countries. Based on the current population rate, 72.4 million women are currently infertile and in this rate ,40.5 million are under infertility medical care.
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Alma Douglas.,(2014) stated that in India infertility affects 1015% of couples in reproductive age group.the stated that the problems of infertility have assumed an increased importance in health care system in recent years. In India ,under the age group of 18 – 40 years are infertile among 10 million couples and 70 – 80% following routine treatment.
Chander, P. P.,(2013), stated that all community people faces infertility problem. Approximately 8-10% of couples within the limit age presented for medical assessment, generally following two years of failed efforts to reproduce.it is estimated from 60 and 80 million couples, 15 and 20 million peoples are suffering from india.
Currently, infertility management, offered through the private sector. Identified that the cost per cycle,with a take home baby rate of just 20-30%, is between Rs.50,000 to Rs.75,000 which is in addition to the subsequent obstetric costs.
Karthik, M.(2013), published an article as infertility cases in Erode. The problem is the rise in infertility cases, particularly among men, which the doctors here attribute more to pollution than anything else. Dr. Nirmala Sadasivam, says that the situation at present is worser than it was about 15 years ago. In 1990, approximately 30 infertility cases a day were treated in Maruthi Medical Centre, Erode which is increased between 100 and 120 at present. Dr. S. Dhanabagyam of Sudha Women and Fertility and IVF Centre shares a similar perception. At present about 2,000 patients for fertility-related problems are treated, in that 60 percent are men. The number of infertility cases from four to five new cases day in 1998 is increased to around 20 at present in Erode District, Tamilnadu.
American society of reproductive medicine., stated that about 10-20%of couples cannot have a baby when they desire. In 1995 the most recent US data about 9 million women has used infertility services because they could not have a baby when desired. Slightly more women or 9.3million were currently in infertility therapy in nation survey, US associated is called RESOLVE. This infertility for women and men supports many informations for their family life journey. RESOLVE is celebraties a week for awarening infertility. RESOLVE is helping the 7.3 million people in the U.S build a family through increased public education, advocacy and support.
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During the clinical experience the investigator observed that the infertile couple attending the infertility clinic looked very anxious and depressed. Also the investigator on reviewing the literature found that the very few studies have been done regarding the analysis of psychological and social problems experienced by the infertile women and mind-body intervention for decreasing stress and anxiety among infertile women. The investigator felt that this study would help the nursing practitioner to understand the stress rate experienced by infertile women to adapt suitable situation for reducing stress and anxiety.
STATEMENT OF THE PROBLEM:
A study to assess the effectiveness of structured teaching programme on knowledge regarding management of stress and anxiety among women with infertility problem at selected infertility clinic , Coimbatore.
OBJECTIVES:-
1. To identify the socio demographic variables of women with infertility problem.
2. To assess the level of knowledge regarding management of stress and anxiety among women with infertility problem.
3. To deliver the structured teaching programme regarding management of stress and anxiety among women with infertility problem.
4. To reassess the level of knowledge regarding management of stress and anxiety among women with infertility problem. .
5. To determine the association between the post test score level of knowledge and with demographic variables.
OPERATIONAL DEFINITIONS:- ASSESS:
It refers to the measurement and improvement of scheduled teaching programme on knowledge regarding management of stress and anxiety among women with infertility problem from the score based.
9 EFFECTIVENESS:
It refers to the quality of being or able to bring an efficient of arranged teaching program in adequate knowledge gaining of management of stress and anxiety among women with infertility problem.
STRUCTURED TEACHING PROGRAMME:
It is a structural program which is well planned and prepared, those women with infertility problem to learn and gain more information by themselves to decrease stress and anxiety.
KNOWLEDGE:
It refers to the level of understanding women with infertility problem.
regarding management of stress and anxiety as measured by using questionnaries in pretest and posttest.
STRESS:
Stress is a feeling of emotional or physical tension. It can come from any event or thought that makes you feel frustrated, angry, or nervous.
ANXIETY:
It is an emotional subjective feelings of apprehension, tension, a person regularly feels disproportionate level of anxiety due to infertility problem.
WOMEN
Women who are married and attending the infertility clinic during the period.
INFERTILITY:
Infertility is defined as trying to get pregnant (with frequent intercourse) for at least a year with no success.
HYPOTHESES:-
H1: Their will be statistically significant different between pretest and posttest level of knowledge regrading management of stress and anxiety among women with infertility problem.
10 ASSUMPTIONS:-
1. Women with infertility problem will have stress and anxiety, it may be vary from one to another.
2. Women with infertility problem will have some techniques to manage the stress and anxiety.
3. Planned teaching Programme will enhance more information to manage the stress and anxiety among women with infertility problem. .
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CHAPTER - II
REVIEW OF LITERATURE
PART-I
This chapter explains in detail about the review of literature and conceptual frame work and for the used for the study. A literature review is a body of text that aims to review the critical points of current knowledge including substantive findings as well as theoretical and methodological contribution to a particular topic. Literature review as secondary sources, and as such do not report any new or original experimental work. Also, literature review can be interpreted as a review of an abstract accomplishment.
Literature review servers a number of important functions in research process.
It helps the researcher to generate ideas or to focus on a research approach, methodology meaning tools and even type of statistical analysis that might be productive in pursuing the research problem. Review of literature in the study is organized under the following headings.
The Related Review Of Literature Has Been Organized Under Following Headings.
Section A:
Literature related to level of knowledge regarding management of stress and anxiety among women with infertility problem.
Section B:
Literature related to structured teaching programme regarding management of stress and anxiety among women with infertility problem.
Section C:
Literature related to effects of STP on knowledge regarding management of stress and anxiety among women with infertility problem.
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2.1 LITERATURE RELATED TO LEVEL OF KNOWLEDGE MANAGEMENT OF STRESS AND ANXIETY AMONG WOMEN WITH INFERTILITY PROBLEM.
Boivin, J and Schmidt, L., (2016) conducted study on Infertility related stress all people treatment outcome a year later. A fertility problem stress inventory was integrated at the start of treatment, and the treatment outcome was calculated 12 months later. Repeated cycles in 12-month study period and treatment outcome (i.e., success, no success). Fertility problem stress was combined with a poorer treatment outcome in women (pooled within groups [WGr] correlation, (WGr = .517) and men (WGr = .392) with the effect significantly more pronounced for women (z = 3.19, P<.001). Fertility problem stress increasing in the personal and marital domain express high associations with treatment outcome than did fertility problem stress from the social domain. Logistic regression identified that women need who reported more marital distress required more treatment cycles to conceive (median 3) than women reporting less marital distress (median 2) (odds ratio [OR] = 1.20: chi2(3) = 77.21, P<.001). The results provide evidence that infertility-related stress has direct and indirect effects on treatment outcome.
Redshaw, M et.al., (2015) conducted study on a qualitative study that make women successfully pregnant .The result shows that a total of 230 women responded (50%). Some of the emergent themes which are related to various aspects are taken and care .Women praised and treated to be with respect and dignity and also given appropriate information and support. Even they are uncertain ,they wanted their distress recognized, and also confidence in professional situation.
Kalavathi, S., (2014) conducted a descriptive study to measure the stress rate of infertile women undergoing IUI treatment. In this study most of the infertile women were in the age group of 21-30 years (68%) and (73.3%) of them were Hindus. About (44%) of them had consanguineous marriage and they were living equally in nuclear (45.3%) and joint families (44%). Most of them (65.4%) had 3-6 periods of infertility and about (40%) of them had family income of Rs.2000-4000 per month. Majority of them were housewives (73.3%) and about (54.7%) had higher secondary level of education. Majority of women had increased stress level (60%) and
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less number of women had moderate stress (1.4%). Thus infertile women under the IUI treatment was experiencing high level of stress.
Vashumathi, S.P., (2014) conducted a study on level of stress and coping among the women undergoes infertility treatment in GG hospital, Chennai. The over all score on stress was among 60 women undergoing infertility treatment, the majority of them (55%) had moderate stress, 30% had mild level of stress and (13%) had severe level of stress. Coping of the mother was found that majority (80%) of them had adequate coping and (20%) had moderate coping. It is found that there was a positive correlation between level of stress and level of coping. So majority of women undergoing infertility treatment had a moderate level of stress and adequate coping.
Ramezanzadeh, F et.al., (2014) conducted study on a survey of communication between anxiety, depression and periods of infertility. This was studied in relation to patient‘s age, educational level, socioeconomic status and job (patients and their husbands). A survey undergone among 370 female patients participated in and data gathered by beck depression inventory questionnaires for assessing anxiety and depression due to duration of infertility. This survey showed that 151 women (40.8%) had depression and 321 women (86.8%) had anxiety.
Depression had a specific relation with cause of infertility, duration of infertility, educational level and job of women. Anxiety had an important relationship with duration of infertility and educational level, but no cause of infertility or job. Result showed that anxiety and depression were most common after 4-6 years of lack of fertility and especially severe depression could be found infertility for 7-9 years.
Sreshthaputra, O., (2013) conducted study on gender differences in infertility-related stress and the relationship between stress and general support in Thai infertile couples. The Fertility Problem Inventory (FPI) and the Personal Resource Questionnaire (PRQ) were used to measure the level of infertility-related stress and perceived social support, respectively, in 238 infertile subjects. The global Fertility Problem Inventory scores for all people were 154.2 +/- 18.3 and 154.7 +/- 22.6, respectively (p > 0.05). There was no specific various in their perceived social support (PRQ scores = 137.8 + 14.0 and 134.0 +/- 16. 7 respectively). A specific negative correlation (r = -0.1894; p < 0.001) existed between global stress and social support for women only. Thai infertile couples express a high rate of stress. Existence
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studies from Western countries, there was no gender differences in infertility-related stress.
Ozkan,Met.al., (2013) Conducted study on emotional distress of lack of fertile women in Turkey. This study is to find out the prevalence, severity and predictability of psychiatric symptoms of lack of fertile women and the effects of infertility on marital and sexual relationships. Various martial questionary where utilized for various level of women as a controlled group. generally infertility group consisted of depression and psychological symptoms. Depression was reduced as the rate of employment level,economic value and knowledge increased. Due to infertility treatment failure ,sexual relationship where negatively affected for long. Special attention must be given to finding issues in lack of fertile women. For infertility ,relationship and sexual difficulties or appear central to infertility related stress.
Targeting problems in these domains will have maximal therapeutic benefit.
The HADS and the POMS scores of infertile women were significantly increased than those of pregnant women. Positive HADS indicating emotional disorders in Infertile women with (39/101, 38.6%) were significantly (P = 0.0008, chi square=2) more than those of pregnant women (13/81, 16.0%) when the threshold was set at 12/13 of total HADS scores. The HADS scores were not affected women's age, duration of infertility, experience of conception, routine tests, and work states. In this Japanese population, infertile women reported high rate of emotional distress than pregnant women consider that psychological support is needed for infertile women.
Harlow, C.R et.al., (2013) conducted study on stress and stress related hormones during IVF treatment. The biochemical and questionnaire based stress of infertile women was measured during median baseline, follicular phase and preoperative period. The serum prolactin (229, 311 and 457 IU/I), cortisol (927, 369 and 496 mmol/l) and anxiety score (38, 40 and 49) respectively all high during stimulated IVF treatment. There was no such increase in a control group having same laproscopic surgery not related to infertility, suggesting that anxiety levels are higher in IVF treatment and adequately reflected by anxiety scores.
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2.2 LITERATURE RELATED TO STRUCTURED TEACHING PROGRAMME REGARDING MANAGEMENT OF STRESS AND ANXIETY AMONG WOMEN WITH INFERTILITY PROBLEM.
Jain, S et.al., (2017) conducted study on a randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination, and not able concentrate. Result shows that hierarchical linear modeling obvious that both meditation and relaxation groups experienced important reduction in distress as well as rise in positive mood states, compared with the control group (p < .05 in all cases). There were no significant differences between meditation and relaxation on distress and positive mood states. Effect sizes for distress were large for both meditation and relaxation (Cohen's d = 1.36 and .91, respectively), whereas the meditation group showed a larger effect size for positive states of mind than relaxation (Cohen's d =.71 and .25, respectively). The meditation group also demonstrated significant pre-post decrease in both not able to concentrate and ruminative thoughts/behaviors compared with the control group (p < .04) in all cases.
Krisanaprakornkit, T et.al., (2016) conducted study on meditation therapy for anxiety disorders. Outcome shows that two randomized controlled studies were eligible for inclued in the review. Both of the studies were of moderate quality and used active control comparisons. Anti-anxiety drugs were used as standard treatment.
The periods of trials arranged from 3 months (12 weeks) to 18 weeks. In one study transcendental meditation expressed a reduction in anxiety symptoms and electromyography score comparable with electromyographybiofeedback and relaxation therapy. Other studies compared Kundalini Yoga (KY), with Relaxation/Mindfulness Meditation. The Yale-Brown Obsessive Compulsive Scale showed no statistically significant difference between groups. Neither study reported on side effects of meditation.
Sivasankaran, S et.al., (2016) conducted study on the effect of a six-week program of yoga and meditation on brachial artery reactivity: do psychosocial interventions affect vascular tone? A session in yoga and meditation gave to the subjects for 1.5 hr three times weekly for 6 weeks and patients were instructed to continue their efforts at home. This prospective cohort study included 33 subjects (mean age 55 +/- 11 years) both with (30%) and without (70%) established coronary
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artery disease (CAD). In the group with CAD, endothelial-dependent vasodilatation improved 69% with yoga training and meditation (6.3810.78%; p = 0.09). Yoga and meditation appear to improve endothelial function in subjects with CAD.
Brown, R.P and Gerbarg, P.L., (2015) conducted study on Sudarshan Kriya Yogic breathing in therapy of stress, anxiety, and depression. Part I of this series a neurophysiologic theory of the effects of Sudarshan Kriya Yoga (SKY). Part II will review hospitals studies, our own observations, and guidelines for effective use of yoga breath techniques in a wide range. Although more hospital studies are needed to document the benefits of programs that combine pranayama (yogic breathing) asanas (yoga postures), and meditation, there is sufficient evidence to consider Sudarshan Kriya Yoga to be a beneficial, low-risk, low-cost adjunct to the treatment of stress, anxiety, post-traumatic stress disorder (PTSD), depression, stress-related medical illnesses, substance abuse, and reinforcement of criminal offenders. SKY has been used as a public health intervention to increased PTSD in survivors of mass disasters.
Yoga techniques improve well-being, mind, attention, mental focus, and stress tolerance. Proper training by a skilled trainner and a 30minute practice every day will maximize the benefits.
Coppola, F., (2015) conducted study on effects of stress relief meditation on anxiety: a pilot study. The meditation is planned in a self-administered program, required one hour of training duration of three days, followed by the 2 times daily practice. 15min once. Section consists in sitting quietly with closed eyes while applying a specific procedure. To test the effects of meditation in reducing anxiety, Spiel Berger‘s State-Trait Anxiety Inventory was delivered to 25 participants 4 times over a 3-wk. period: one week before starting to practice the meditation, a few hours before starting, 1 wk. after, and 2 wk. after. The difference in Anxiety score between pretest and before starting the practice was no important , while it was significant both after the first week of practice (Cohen d=.46) and after the first 2 wk. of practice (d=.67).
Gupta, N et.al., (2015) conducted study on effect of yoga based lifestyle treatment on anxiety. The patients had history of hypertension, coronary artery disease, diabetes mellitus, obesity, psychiatric disorders ,gastrointestinal problems and thyroid disorders. The treatment consisted of asana, pranayama, relaxation techniques,
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group support, individualized therapy , and lectures and videos on philosophy of yoga, the place of yoga in daily life, meditation, stress management therapy, nutrition, and knowledge related the illness. The outcome assess were anxiety scores, taken on the first and last day of the section. Anxiety scores were significantly reduced. Among the diseased subjects significant improvement in the anxiety levels of patients of hypertension, coronary artery disease, obesity, cervical spondylitis and psychiatric disorders. The observations suggest that a short educational programme for lifestyle modification and stress management leads to remarkable reduction in the anxiety scores within a period of 10 days.
Lane, J.D et.al., (2015) conducted study on brief meditation training can increase perceived stress and negative mood. Result shows that all four finds measures improved significantly after instruction, with reduct from baseline that ranged from 14% (State –trait anxiety inventory) to 36% (Brief symptom inventory).
More often practice was combination with better outcome. Higher baseline neuroticism scores were associated with high improvement. Preliminary prove suggests that even some instruction in a simple meditation technique can improve negative mood and perceived stress in healthy adults, which could yield long-period health benefits. Frequency of practice does affect results. Those most likely to express negative emotions may profit from the intervention.
Carlson, L.E and Bultz, B.D., (2014) conducted study on Mindbody interventions in oncology. Many of mind-body interventions have been studied for use with cancer patients, primarily assess outcomes relating to pain control, anxiety reduction, and enhancing quality of life. Current proof supports the efficacy of hypnosis and imagery/relaxation for control of pain and anxiety during cancer treatments. Meditation is helping for drecease in stress and improvements in mood, quality of life, and sleep problems.
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2.3 STUDIES RELATED TO EFFECTS OF STP (STRUCTURED TEACHING PROGRAMME) ON KNOWLEDGE REGARDING MANAGEMENT OF STRESS AND ANXIETY AMONG WOMEN WITH INFERTILITY PROBLEM
Mariana Moura-Ramos ,(2018) This study aimed to investigate the role of dyadic coping by oneself and by the partner in the association between the impact of infertility and dyadic and emotional adjustment (anxiety and depression) to infertility.
In this cross‐ sectional study, a total of 134 participants (67 couples with infertility) completed self‐ report questionnaires assessing infertility‐ related stress, dyadic coping, dyadic adjustment, and depression and anxiety symptoms. A path analysis examined the direct and indirect effects between the impact of infertility in one's life and dyadic and emotional adjustment. There is an indirect effect of the impact of infertility in one's life on dyadic adjustment through men's perceived dyadic coping efforts employed by the self (dyadic coping by oneself) and women's perceived dyadic coping efforts of the partner (dyadic coping by the partner). Regarding the emotional adjustment of infertile couples, infertility stress impact had an indirect effect only on depressive symptoms through men's dyadic coping by oneself. The results highlight the importance of men's dyadic coping strategies for the marital adjustment of couples as well as for men's emotional adjustment. Findings emphasize the importance of involving men in the fertility treatment process, reinforcing the dyadic nature of infertility processe
Maryam Mohammadi.,(2018) The purpose of the study was to determine whether infertility is associated with coping processes and is there a difference between infertile women and men in the use of coping strategies.In a cross-sectional study, the study sample consisted of 400 infertile couples, age at least 18 years and could read and write in Persian were enrolled at the Royan institute, Tehran, Iran, between July and September 2014. Participants provided demographic and Ways of coping questionnaire (WOCQ). Data was analyzed by paired t-test and multivariate analysis using SPSS software.There was a significantly higher score for self-control in husbands compared to wives (P=0.016). As well as wives have lower score of Confronted Coping and Distancing than their husbands however Accepting Responsibility, Positive Reappraisal were lower in wives than husbands but these
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differences are not significant (P>0.05). Mean score of Seeking Social Support and escape avoidance of wives was higher and significant (P=0.037, P=0.022 respectively).Our finding showed that husbands have more Problem focused coping style and wives have more Emotion focused coping style.
Domar, A.D., (2017) conducted study on mind/body interventions for infertility. Couples dealing with infertility may become depressed, anxious and angry. After structured teaching to help them cope he taught the relaxation response to one group of infertile couples. Compared with a similar group of infertile couples who did not learn deep relaxation, the mediators experienced less distress and were more likely to get pregnant.
Venkatesan, L., (2016) conducted study on the impact of positive therapy on stress in infertile women was studied through a randomized clinical trial. The infertile women were randomly alloted into the control (n=60) and experimental group (n=60) of women. Pre test stress was measured on day 2 of the menstrual cycle of control and experimental group of infertile women and the positive therapy was administered from day 2 to 7 of the menstrual cycle only for the experimental group .Post test stress was assessed on day 14 of the cycle in both groups. The outcome have shown that in experimental group the post test stress level (M=164.30, SD=19.03) was less than the pre test stress level (M=247.51, SD=23.14) , the difference was statistically significant at p<.001 level. In control group there was no statistical difference between the pretest (M=246.65, SD=22.18) and post test (M=247.06, SD=21.89) stress levels. The results can be attributed to the effectiveness of (STP) .
Khalsa, H.K., (2015) conducted study on Yoga: an adjunct to infertility intervention. Yoga and meditation can help couples to challenges of infertility. The practice of meditation and relaxation can supporting to increase the clarity of the mind, maintain healthy body and undergo the rigors of infertility treatments. When one understands and can attain relaxation, one tends to feel better about the body itself, and begins to treat the body with respect. This understanding can lead to healthier lifestyle habits as well as increased sensitivity .This is beneficial to both doctor and patient as the patient can results with sense cycles and physical issues more readily.
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Domar, A.D et.al., (2013) in their study conducted at Harvard medical school on 184 women going through infertility, of those who went through 10 week session of relaxation training, cognitive restructuring and stress reduction,55% had a pregnancy with in one year. This is compared to only 20% of the control group achieving a pregnancy in one year.
PART-II
CONCEPTUAL FRAMEWORK
Conceptual frameworks are interrelated concepts that arranged together in varies rational scheme by motive of their relevance to a general theme. Conceptual framework helps to induce research and the extension of knowledge by directing both facts. (Polit and Hungler, 1999).
Conceptual framework is the precursor of a theory and it suggest wide prospective concept for nursing practice, research and education. Conceptual framework plays several inter- related roles in the progress of science. Their overall purpose is to make scientific and meaningful findings and also to generalize the findings. (Polit and Hungler, 1999).
The present study is focused on the effectiveness of planned teaching programme according to the management of stress and anxiety among infertility couples. This research refers on J.W.Kenny‘s open system model. This system‘s theory refers to with changes due to interrelation between with in some factors. All living systems are continual exchange of matter, energy with information. Open system converts degrees of input to output in form of matter and energy with information.
Kenny‘s open system model concept consists of input, throughput, output and feedback. Input refers to matters and information, which are repeatedly processed through the system and released as outputs. After processing the input, the system returns output (matter and information) to the environment in as altered state, affecting the environment for information to guide its operation. This feedback information of environment responses to the systems output is used by the system in
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adjustment correlation with the environment. Feedback may be possible, negative or neutral. In this study the concepts have been modified as follows.
INPUT:-
According to J.W. Kenny‘s input includes matter and energy with information from the environment. In the present study the input refers to assessment of the level of knowledge regarding management of stress and anxiety among infertility couples through structured interview schedule questionnaire.
THROUGHPUT:-
Throughput was the implementation of planned teaching programme regarding management of stress and anxiety among infertility couples.
OUTPUT:-
The expected outcome was obtained by assessing the level of knowledge regarding management of stress and anxiety among infertility couples through self- structured questionnaire. The output was considered in terms of change in posttest level of knowledge regarding management of stress and anxiety among infertility couples obtained through structured interview schedule questionnaire.
FEEDBACK:-
Differences in pre and post-test scores were observed from the level of knowledge scores of the sample. In the present study, the feedback considered as a process of maintaining the effectiveness of planned teaching programme. Feedback was based on the analysis of post-test scores, the intervention strategy can be modified if necessary and the same pattern can be followed once again.
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FIGURE 1: CONCEPTUAL FRAME WORK BASED ON MODIFIED – J.W. KENNY’S OPEN SYSTEM
INPUT THROUGHPUT OUTPUT
Demography variable Age, Education, Occupation, Family, monthly
Income and duration in fertility
Pre – Test assessing the level
of knowledge regarding management of stress and anxiety
among women with infertility
problem
Post – Test assessing the level
of knowledge regarding management of stress and anxiety
among women with infertility problem after administration of
STP
Postitive outcome increase level of
knowledge regarding management of stress and anxiety Women with
infertility problem attending OPD
Administration of STP regarding
management of stress and anxiety among
women with infertility
problem
FEEDBACK
Women with infertility problem
attending OPD
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CHAPTER – III METHODOLOGY
This chapter deals with research approach, research design, setting, population, sample, criteria for sample collection, sample size, sample techniques, description of tool, scoring procedure, validity, reliability, pilot study, data collection procedure, plan for data analysis and ethical consideration.
RESEARCH APPROACH:-
The research approach used for this study was Quantitative approach.
RESEARCH DESIGN:
The investigator used pre experimental design (one group pre-test and post- test) for this study to assess the effectiveness of (STP) on knowledge regarding management of stress and anxiety among women with infertility problem.
PRE TEST INTERVENTION POST TEST
O1 X O2
O1 - Pretest the level of knowledge regarding management of stress and anxiety.
X - Structured Teaching Programme (STP).
O2 - Posttest the level of knowledge regarding management of stress and anxiety.
Research Variables:
Independent variable:
The independent variable was Structured teaching programme on knowledge regarding management of stress and anxiety among women with infertility problem
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Dependent variable:
Dependent variable was knowledge regarding management of stress and anxiety among women with infertility problem.
Attribute variables : age, Education, Occupation, Income duration of infertility.
RESEARCH SETTING:-
The study was conducted in selected infertility centre which is a Sudha Hospitas Fertility and Women Care centre, located in coimbatore . In this centre artificial reproductive techniques like invitro fertilization (IVF), intracytoplasmic sperm insemination (ICSI) and intra uterine insemination (IUI) are used to treat infertility. Approximately 800-900 patients visits to out patient department per month .this clinic is located in 15 km away from PPG College Of Nursing.
STUDY POPULATION:- TARGET POPULATION:
Women with infertility problem are the target population of the study.
ACCESSIBLE POPULATION:
Women with infertility problem who were attending in Sudha hosptials fertility and women care center are the accessible population.
SAMPLE:-
The sample selected for this study was women with infertility problem who are attending out patient department in selected infertility center at Coimbatore.
SAMPLING TECHNIQUE:-
Purposive sampling was used to select the sample.
SAMPLE SIZE:
The sample size was 60.
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SAMPLING CRITERIA:
INCLUSION CRITERIA: Couples who are
Attending infertility clinic.
Clients willing to participate.
Able to understand and speak in English and Tamil language.
Available during data collection procedure.
EXCLUSION CRITERIA: Couples who are,
Not willing to participate.
Not able to understand and speak in English and Tamil language.
Attended structured teaching programme previously regarding management of stress and anxiety.
DEVELOPMENT AND DESCRIPTION OF THE TOOL:- PART – I:-
It consists of demographic variables such as age, educational qualification, occupation, family income per month and duration of infertility.
PART – II:-
Based of structured teaching programme, prepared knowledge assessment questionnaries by use of steps involved in the development of the tool with 50 questions. Each questions has four options with one correct answer. Each correct answer carries one mark, wrong answer carries zero marks. The possible maximum score was 50 marks. The possible minimum score was zero.
Adequate knowledge- 31-50
Moderately adequate knowledge-16-30
Inadequate knowledge- less than 0-15
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Based on knowledge score was graded into three categories
Knowledge Scores Percentage
Inadequate Level Moderate Level Adequate Level
0-15 16-30 31-50
0-31%
32-61%
62-100%
RELIABILITY OF THE TOOL:-
“The reliability of an instrument is the dependability with which an instrument measures an attribute”.
– POLIT AND BECK (2008) To ensure reliability, of the tool was established using test retest method. The reliability value of the tool is 0.9 so the tool was found to be feasible and reliable.
VALIDITY OF THE TOOL:-
The validity of the tool was established in consultation with guide and five experts in the field of obstetrics and gynecology nursing, obstetrician and gynecologist, psychologist and psychiatric nursing and statistician. The tool was modified according to the suggestions and recommendations of experts.
PILOT STUDY:-
A pilot study was conducted at NOVA IVI Fertility Center in peelamedu at coimabtore ,among 5 women with infertility problem (who were not included in the main study ) who will fulfill the inclusion criteria with regarding to the setting with the cooperation of the people and availability of the sample ,in a manner in which a final study would be done it was carried over the period of 7 days from 21.01.2019 to 28.01.2019 the finding of the pilot study revealed that the study was feasible and practicable.
DATA COLLECTION PROCEDURE:-
The study was conducted at Sudha hosptial fertility and women‘s care center in Coimbatore. Written permission was obtained from the medical officer of fertility center. The data was collected for a period of 4 weeks from 30.1.2019 to 28.2.2019
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with selected of 60 samples. The investigator selected 60 women with infertility problem as per inclusion criteria. An introduction and then written informed consent were obtained to participate in the study. Each day 10 samples were selected ,first week days data collection and pretest was conducted for 60 women with infertility problem. The pretest questionnaire was given to them and to assess the level of knowledge regarding management of stress and anxiety by structured questionnaries.
Next 2 weeks, the investigator given structured teaching programme upto 40 minutes in the morning session for 5 women with infertility problem each day. Finally, posttest was conducted on fourth week for assessed the level of knowledge among women with infertility problem.
PLAN FOR DATA ANALYSIS Sl.
No.
Data
analysis Methods Remarks
1. Descriptive statistics
Frequency, percentage mean Standard deviation.
For the analysis of the demographic data For analyzing the pretest and post test score 2. Inferential
statistics
Paired ‗t‘ test To find out the differences between in pretest and posttest knowledge .
To find out the association between knowledge in the pretest and variables.
ETHICAL CONSIDERATION:
The study was conducted after obtaining approval from the institutional ethical committee PPG College of nursing Coimbatore. The respondents were explained about the purpose and need for the study. They assured that their details and answers will be used only for the research purpose. Further they were ensured that their details will be kept confidentially. Thus, the investigator followed ethical guidelines, which were issued by the ethics committee after getting a written permission.
