i
The Effect of a Self-Efficacy Enhancing Education Program on Family Caregivers’
Competencies in Caring for Patients with Mild Traumatic Brain Injury
in Yogyakarta, Indonesia
Erfin Firmawati
A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of
Master of Nursing Science (International Program)
Prince of Songkla University
2013
Copyright of Prince of Songkla University
ii
Thesis Title
The Effect of a Self-Efficacy Enhancing Education Program on
Family Caregivers’ Competencies in Caring for Patients with
Mild Traumatic Brain Injury in Yogyakarta, Indonesia
Author
Miss Erfin Firmawati
Major Program
Nursing Science (International Program)
Major Advisor :
Examining Committee :
…………………………………………… …...……………………….…Chairperson
(Assoc.Prof.Dr.Praneed Songwathana)
(Asst.Prof.Dr.Wongchan Petpichetchian)
……………………….…………………..
Co-advisor :
(Prof.Dr.Sanguansin Ratanalert, M. D)
…………………………………………… ……………………….…………………..
(Dr.Luppana Kitrungrote)
(Dr.Marisa Suwanraj)
……………………….…………………..
(Assoc.Prof.Dr.Praneed Songwathana)
……………………….…………………..
(DrLuppana Kitrungrote)
The Graduate School, Prince of Songkla University, has
approved this thesis as fulfillment of the requirements for the Master of Nursing
Science (International Program).
..………………………………….
(Assoc.Prof.Dr.Teerapol Srichana)
Dean of Graduate School
iii
This is to certify that the work here submitted is the result of the candidate’s own
investigations. Due acknowledgement has been made of any assistance received.
……………………………….Signature
(Assoc.Prof.Dr.Praneed Songwathana)
Major Advisor
……………………………….Signature
(Erfin Firmawati)
Candidate
iv
I hereby certify that this work has not been accepted in substance for any degree, and
is not being currently submitted in candidature for any degree.
……………………………….Signature
(Erfin Firmawati)
Candidate
v
Thesis Title
The Effect of a Self-Efficacy Enhancing Education Program on
Family Caregivers’ Competencies in Caring for Patients with
mild Traumatic Brain Injury in Yogyakarta, Indonesia
Author
Miss Erfin Firmawati
Major Program
Nursing Science (International Nursing)
Academic Year
2012
ABSTRACT
Family caregivers’ competencies in caring for patients with mild
traumatic brain injury (TBI) are essential in post-acute rehabilitation to prevent the
patients having persistent symptoms and complications after being discharged from
hospital. This quasi-experimental study aimed to examine the effect of a self-efficacy
enhancing education program on family caregivers’ competencies regarding perceived
confidence and performance in caring for patients with mild TBI in Yogyakarta,
Indonesia. Fifty family caregivers and patients with mild TBI who met the inclusion
criteria were recruited. The 25 subjects in the control group received the routine care,
while another 25 subjects in the experimental group received the routine care and a
self-efficacy enhancing education program. The program was constructed using
Bandura’s four sources of self-efficacy: enactive mastery experiences, vicarious
experiences, verbal persuasion, and physiological and affective status. The
components of the program included exploring feelings, teaching, sharing
information, showing pictures, demonstrating and re-demonstrating, and following-up
with telephone calls. The family caregivers’ perceived confidence and performance
were measured by using the Perceived Confidence Questionnaire (PCQ) and the
Performance Questionnaire (PQ). The statistics in this study used paired t-test,
independent t-test, Wilcoxon Signed Rank test, and Mann-Whitney U test.
The results of the study showed that the family caregivers’ perceived
confidence in caring for patients with mild TBI after receiving the intervention was
higher than before (t = -8.44, p < .05), while the family caregivers’ performance in the
experimental group in the second week was significantly lower than those in the first
vi
week after discharge (Z = -2.94, p < .05). After the completion of the program, the
findings showed significant difference of the family caregivers’ perceived confidence
between the control and the experimental groups (t = 8.30, p < .05). A significant
difference of the family caregivers’ performance between groups was also found (U =
.00, p < .05).
This study provides evidence that a self-efficacy enhancing education
program was effective in improving the family caregivers’ competencies regarding
perceived confidence and also influencing their performance in caring for patients
with mild TBI. Therefore, this program is recommended to extend this knowledge for
nursing practices and research.
Keywords:
self-efficacy, education program, family caregivers, mild traumatic
brain injury
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ACKNOWLEDGEMENTS
By the name of Allah SWT, the most compassionate and the most
merciful, praise and gratitude is to Allah, the Lord of the Universe and blessings to
the last Prophet Muhammad, his family and his companions.
I would like to express my sincere gratitude and deep appreciation to
my major advisor, Assoc. Prof. Dr. Praneed Songwathana, and co-advisor,
Dr.Luppana Kitrungrote. I would like to extend my sincere gratitude to the
chairperson of the International Nursing Program, Asst. Prof. Dr. Wongchan
Petpichetchian for her guidance, motivation, and inspiration during my study.
My gratefulness is extended to the Directorate General of Higher
Education, Ministry of National Education of Indonesia for providing the scholarship
for my study and Muhammadiyah University for the support. It also goes to all my
colleagues at the School of Nursing, Faculty of Medicine and Health Science,
Muhammadiyah University of Yogyakarta, Indonesia for providing support for my
study. I also would like to thank the Graduate School, Prince of Songkla University,
all my friends from the International Program and the external committee.
Special thanks goes to the Director of the PKU Muhammadiyah
Yogyakarta and PKU Muhammadiyah Bantul Hospital and also all the nurses for their
help. I also would like to thank all the participants in my study and my research
assistants.
Finally, I would like to extend the greatest respect to my beloved
parents, Mrs. Siti Darul Ilmiyati and Mr. Sujud Hadi Purwato, my sisters (Tutiek Umi
Yudaryanti and Dwi Wahyuningsih), my brothers (Budi Susanto and Ahkob
Krisnanto), my nephews (Rozan, Alfi, Faiz, and Ihsan), and my niece (Azizah) for
their prayer and support.
Erfin Firmawati
viii
CONTENTS
Page
ABSTRACT.............................................................................................................
v
ACKNOWLEDGEMENTS ....................................................................................
vii
CONTENTS ............................................................................................................ viii
LIST OF TABLES ................................................................................................... xii
LIST OF FIGURES ...............................................................................................
xiv
CHAPTER ...............................................................................................................
1
1. INTRODUCTION ...............................................................................................
1
Background and Significance of the Problem .....................................................
1
Objectives ............................................................................................................
6
Research Questions .............................................................................................
6
Conceptual Framework .......................................................................................
7
Hypotheses ..........................................................................................................
12
Definitions of Terms ...........................................................................................
12
Scope of the study ...............................................................................................
14
Significance of the Study ....................................................................................
14
2. LITERATURE REVIEW ....................................................................................
15
Overview of Mild Traumatic Brain Injury (Mild TBI) .......................................
16
Definition of TBI .........................................................................................
16
Definition of Mild TBI.................................................................................
17
Pathophysiology of Mild TBI ......................................................................
18
Symptoms of Mild TBI ................................................................................
20
ix
CONTENTS (continued)
Page
Warning Signs and Symptoms .....................................................................
24
Complications of Mild TBI..........................................................................
24
Impacts of Mild TBI ....................................................................................
25
Mild TBI Management in Indonesia ............................................................
27
Family Caregivers’ Competencies in Caring for Patient with Mild TBI ............
27
Definition of Family Caregivers ..................................................................
27
Family Caregivers’ Competencies in Caring for Mild TBI Patients ...........
29
Factors Contributing to Family Caregivers’ Competencies.........................
34
Education Program for Family Caregivers ..........................................................
38
Education Program.......................................................................................
38
Self-Efficacy in Education Program ............................................................
39
The Existing Education Program for Family Caregivers with TBI .............
43
Summary .............................................................................................................
48
3. RESEARCH METHODOLOGY.........................................................................
50
Research Design ..................................................................................................
50
Variables ..............................................................................................................
51
Setting..................................................................................................................
51
Population and Sample ........................................................................................
52
Sampling Procedure ............................................................................................
53
Instrumentation ....................................................................................................
53
Translation of the Instruments .............................................................................
57
Validity and Reliability of the Instruments .........................................................
58
x
CONTENTS (continued)
Page
Data Collection Procedures .................................................................................
60
Ethical Considerations .........................................................................................
63
Data Analysis ......................................................................................................
65
4. RESUTS AND DISCUSSION ............................................................................
66
Results .................................................................................................................
66
Demographic Characteristics’ of Family Caregivers ...................................
66
Demographic Characteristics’ of Patients and Patients’ Clinical
Characteristics ..............................................................................................
68
The Effect of a Self-Efficacy Enhancing Education Program on Family
Caregivers’ Competencies in Caring for Patients with Mild TBI................
71
Discussion ...........................................................................................................
76
Demographic Characteristics of Family Caregivers ....................................
76
Demographic and Clinical Characteristics of Patients................................
77
The Effect of a Self-Efficacy Enhancing Education Program on Family
Caregivers’ Competencies in Caring for Patients with Mild TBI................
79
5. CONCLUSION AND RECOMMENDATIONS ................................................
88
Conclusion ...........................................................................................................
88
Strengths and Limitations of the Study ...............................................................
90
Implications and Recommendations ...................................................................
91
Nursing Practice ...........................................................................................
91
Nursing Education .......................................................................................
91
Nursing Research .........................................................................................
91
xi
CONTENTS (continued)
Page
REFERENCES ........................................................................................................
93
APPENDICES ......................................................................................................... 106
A. Effect Size Calculation............................................................................ 107
B. Informed Consent .................................................................................... 108
C. Family Demographic Data Questionnaire ............................................... 113
D. Patient Demographic Data Questionnaire ............................................... 114
E. Injury Characteristics............................................................................... 115
F. Rivermead Post-concussion Symptoms Questionnaire ........................... 116
G. Perceived Confidence Questionnaire ...................................................... 117
H. Performance Questionnaire ..................................................................... 119
I. Self-Efficacy enhancing Education Program Guideline .......................... 121
J. Teaching Plan for Self-Efficacy enhancing Education Program............. 125
K. Booklet ................................................................................................... 132
L. List of Experts ........................................................................................ 139
M. Permission of the Instrument .................................................................. 140
VITAE ................................................................................................................. 141
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LIST OF TABLES
TABLE
1.
Page
Frequencies and Percentages of Family Caregivers’ Characteristics of
the Control Group and the Experimental Group (N = 50) ...............................
2.
Frequencies and Percentages of Patients’ Characteristics of
the Control Group and the Experimental Group (N = 50) ................................
3.
70
Comparison of the Perceived Confidence Scores in Caring for Patients
with Mild TBI between Two Groups before Intervention (N = 50) .................
5.
69
Frequencies and Percentages of Patients’ Clinical Characteristic of
the Control Group and the Experimental Group (N = 50) ................................
4.
67
71
Comparison of the Perceived Confidence Pre-test and Post-test Scores
in Caring for Patients with Mild TBI within the Experimental Group
(N= 25) .............................................................................................................
6.
72
Comparison of the Performance Scores in caring for Patients with
Mild TBI in the First Week and Second Week within the Experimental
Group (N= 25) ..................................................................................................
7.
73
Comparison of the Performance Scores in the First Week and Second
Week based on Each Domain of Caring for Patients with Mild TBI
Within the Experimental Group (N = 25) .........................................................
8.
73
Comparison of the Perceived Confidence Scores in Caring for
patients with Mild TBI between Two Groups (N = 50) ...................................
74
xiii
LIST OF TABLES (continued)
TABLE
9.
Page
Comparison of the Performance Scores in Caring for Patients
with Mild TBI in the Second Week between Two Groups (N = 50)................
74
10. Frequencies and Percentages of Patients’ Symptoms at Different Time Point
(before Discharge, in the First week and the Second Week after Discharge)
in the Control and the Experimental Group (N = 50) .....................................
75
xiv
LIST OF FIGURES
FIGURE
Page
1. Conceptual Framework of a Self-Efficacy Enhancing Education Program on
Family Caregivers’ Competencies in Caring for Patients with Mild TBI ........... 11
2. The Implementation Protocol of Data Collection Procedures ............................. 64
1
CHAPTER 1
INTRODUCTION
Background and Significance of the Problem
Traumatic brain injury (TBI) is one of the leading causes of death and
disability in the United States of America (USA) (Faul, Xu, Wald, & Coronado,
2010). The number of cases with mild to severe brain injury in the USA is
approximately 1.7 million every year, with 1,350,000 visits to an emergency
department and 52,000 deaths annually (Faul et al., 2010). According to the Health
Department of Indonesia as cited in Ayu (2010), TBI was the seventh leading cause of
death in Indonesia in 2007. Similarly in Yogyakarta, Indonesia, TBI was the second
cause of death with an annual mortality rate of 12% (Daerah Istimewa Yogyakarta
[DIY], 2010). Mild TBI had the highest incidence, as reported by Cassidy, et al.
(2004), 70%-90%, of all treated brain injuries. Meanwhile, the cases of mild TBI in
Yogyakarta, Indonesia in 2007 accounted for 60% of all treated brain injuries
(Kurniawan, 2009). The most common cause of mild TBI is motor vehicle accidents
(DIY, 2010; Faul et al., 2010).
Many people who sustain a mild TBI have symptoms that include
cognitive, physical, and emotional symptoms. The symptoms occur in 38% to 80% of
the patients (Rao & Lyketsos as cited in Hall, Hall, & Chapman, 2005). The common
symptoms experienced after a mild TBI are headache, dizziness, fatigue, and memory
difficulties (Lannsjo, Geijerstam, Johansson, Bring, & Borg, 2009; Yang, Tu, Hua, &
2
Huang, 2007). Symptoms may occur alone or in combination and may emerge
immediately or within days to up to three months after the injury. The symptoms
occur in approximately 59% to 91% of patients in one month after the injury (Paniak
et al., 2002), 45% within two months (Yang, et al., 2007), 41.8% to 58% within three
months (Dischinger, Ryb, Kufera, & Auman, 2009; Kashluba et al., 2004; Lundin, De
Boussard, Edman, & Borg, 2006), and more than three months at around 21% to 62%
(Hou et al., 2011; Roe, Sveen, Alvsaker, & Bautz-Holter, 2009). Symptoms are
usually resolved within days, weeks (Emanuelson, Andersson, Bjorklund, &
Stalhammar, 2003), or within three months (Lannsjo et al., 2009), but several patients
continue exhibiting symptoms for more than three months (Emanuelson et al., 2003).
Mild TBI is usually not life threatening, consequently a patient with a
mild TBI is treated and released from an emergency department, with no hospital
admission and receives medication only (Faul et al., 2010). However, the admission
criteria for mild TBI may differ as shown in Indonesia. According to the guideline of
treatment for patients with mild TBI in Indonesia, patients need to be hospitalized for
observation within three days of their injury (Siswanto & Wahyu, 2012). Therefore in
short periods of hospitalization, and consequently after discharge, mild TBI patients
need to be monitored. Fabbri et al. (2004) reported that patients with mild TBI and a
negative computed tomography scan developed intracranial injuries in 1.4% of
patients after being discharged and 0.8% patients had died at home six months after
their discharge. Moreover, mild TBI patients have difficulties in activities of daily
living, returning to pre-injury work status and heightened emotional distress (Bay &
Bergman, 2006). Bay and Bergman reported that these difficulties are associated with
3
persistent post-concussion symptoms after a mild TBI. Therefore, family caregivers
are the key persons who are needed in providing care for patients with mild TBI after
discharge.
Family caregivers carry the primary responsibility for post acute
rehabilitation. A previous study found that family caregivers contributed significantly
to the patients’ psychological adjustment of their disability and emotional
dysfunction; a family’s distress correlated strongly with increased rates of patients’
neurobehavioral symptoms (Testa, Malec, Moessner, & Brown, 2006). The family
caregivers can help prevent the development of mild TBI symptoms and/or reduce
their duration, number and severity (Department of Veterans Affairs & Department of
Defense [DVA/DoD], 2009) by symptoms assessment, symptoms management, and
symptoms evaluation after provided management symptoms. As a result, persistent
symptoms and complications of mild TBI can be prevented (DVA/DoD, 2009).
In reality, family caregivers with mild TBI patients often felt
incompetent due to lack of confidence about their caregiving, because they do not
have the adequate knowledge and skills (Utami, 2012). Additionally, several studies
found that the family caregivers had anxiety and stress before the patient’s discharge
often due to the patient’s neurobehavioral disturbance (Testa et al., 2006) and the
difficulty in managing the symptoms (Falk, von Wendt, & Klang, 2008). Moreover,
before their patients discharge from hospital, most family caregivers reported that
they received limited and inconsistent information (Lefebvre, Pelchat, Swaine,
Gelinas, & Levert, 2005), and they met with little guidance (Utami, 2012). Therefore,
4
improving the family caregivers’ competencies in caring for patients with mild TBI is
important.
Several factors may influence the family caregivers’ competencies in
caring for patients, and one of these factors is self-efficacy (Kouri, Ducharme, &
Giroux, 2011; Utami, 2012). Self-efficacy is one of the important factors that
influence the family caregivers’ competencies in caring for patients with mild TBI
(Utami, 2012). Self-efficacy is one’s self judgments of her or his personal capabilities
to initiate and successfully perform a specified task (Bandura, 1997). Based on
Bandura’s theory self-efficacy operates as a key factor in individual competency
which is constructed from four sources including enactive mastery experiences,
vicarious experiences, verbal persuasion, and physiological and affective status.
People who have high self-efficacy will positively affect performance and would be
more successful in completing those tasks (Bandura, 1997). High self-efficacy
positively correlates with the performance of family caregivers (Kouri et al., 2011).
Several interventions to improve family caregivers’ competencies in
terms of perceived confidence and performance in caring for patients with mild TBI
were reviewed. One of the most common interventions is an education program.
Providing an education program that is focused on the family caregiver is needed
because in the early stages of post injury, the patient still has difficulties in receiving
some information, concentrating, remembering discharge instructions (Bazarian et al.,
2005), and making decisions or finding solutions to manage their symptoms (Bell
et al., 2008; Sayegh, Stanford, & Carson, 2010). Moreover, it was found that
providing only education to the patients in the early phase showed no significant
5
difference in the patient’s outcome including an improvement of symptoms after a
mild TBI (Elgmark, Emanuelson, Bjorklund, & Stalhammar, 2007; Heskestad et al.,
2010).
Educational programs could increase the family caregivers’ knowledge
(Shocker, 2008) and skill (Kouri et al., 2011), and reduce the family caregivers’ stress
and anxiety (Backhaus, Ibarra, Klyce, Trexler, & Malec, 2010; Kreutzer et al., 2010).
Moreover, an education program may increase family caregivers’ competencies in
terms of self-efficacy (Backhaus et al., 2010; Srijumnong, 2010; Utami, 2012).
One quasi experimental study in Indonesia was conducted by Utami
(2012) who provided an education program for family caregivers to improve their
self-efficacy in caring for patients with mild TBI. The family caregivers’ self-efficacy
in term of perceived confidence was measured before and after the intervention given
in the emergency department. The contents being given were information of mild TBI
that included warning signs, postconcussion symptom, diet, activity, and medication.
The result showed that this education program improved family caregivers’ selfefficacy in terms of perceived confidence. However, this study was not constructed
based on Bandura’s self-efficacy theory and did not measure the family caregivers’
performance while they were caring for patients with mild TBI at home; whereas the
family caregivers’ must have some particular skills in the early detection, the
monitoring of warning signs and the management of the symptoms of these patients.
Therefore, it is necessary to examine a self-efficacy enhancing education program on
the family caregivers’ competencies including perceived confidence and performance
in caring for patients with mild TBI beyond the emergency department and including
follow-up after discharge.
6
Objectives
The objectives of this study were as follows:
1. To compare family caregivers’ perceived confidence in caring for
patients with mild TBI before and after receiving a self-efficacy enhancing education
program.
2. To compare family caregivers’ performance in caring for patients
with mild TBI in the first week and in the second week after discharge in those who
receive a self-efficacy enhancing education program
3. To compare family caregivers’ perceived confidence in caring for
patients with mild TBI who receive a self-efficacy enhancing education program and
those who receive the routine care
4. To compare family caregivers’ performance in caring for patients
with mild TBI who receive a self-efficacy enhancing education program and those
who receive the routine care
Research Questions
The research questions of this study are stated as follows:
1. Is the family caregivers’ perceived confidence in caring for patients
with mild TBI after receiving a self-efficacy enhancing education program higher
than before receiving the program?
7
2. Is the family caregivers’ performance in caring for patients with
mild TBI in the second week after discharge similar to that in the first week after
discharge in those who receive a self-efficacy enhance education program?
3. Is the family caregivers’ perceived confidence in caring for patients
with mild TBI who receive a self-efficacy enhancing education program higher than
those who receive the routine care?
4. Is the family caregivers’ performance in caring for patients with
mild TBI who receive a self-efficacy enhancing education program higher than those
who receive the routine care?
Conceptual Framework
The conceptual framework of this study was constructed based on the
self-efficacy theory from Bandura (1997), the content of the education program and
literature review about family caregivers’ competencies in caring for patients with
mild TBI. According to Bandura (1997), self-efficacy is one’s self-judgment of one’s
personal capabilities to initiate and successfully perform a specified task at designated
levels, one expends greater effort, and perseveres in the face of adversity. Banduras’
theory explains how people acquire and maintain certain behavioral patterns and
provide the basis for intervention strategies. This theory states that self-efficacy relies
on one’s self judgments of personal capabilities on how to initiate and completely
perform specific skills at designated levels, expends greater effort, and perseveres in
the face of adversity. Self-efficacy is a person’s belief in his or her capability to do
8
activities to avoid disease. People can undertake decision making in self-monitoring
and adhere the recommendations relating to their health. Good self-efficacy may
enable family caregivers to be competent in providing care for patients with mild TBI
after discharge from hospital. Self-efficacy is constructed from four sources of
information: physiological and affective states, enactive mastery experiences,
vicarious experiences, and verbal persuasion (Bandura, 1997).
The first is physiological and affective states. Physiological and
affective states influence people’s capabilities to make judgments of their personal
efficacy. Physiological indicators of efficacy play an especially influential role in
health functioning and in activities requiring physical strength and stamina. People
who have fatigue, pain, and aches may influence their performance. In addition,
affective states can widely affect beliefs of personal efficacy. People who have
positive mood enhance perceived self-efficacy, however people who have stress can
decrease people’s judgments of their personal efficacy (Bandura, 1997). In this
program, the researcher provides an opportunity for the family caregivers to express
their feelings and concern related to caring for patients with mild TBI.
The second is verbal persuasion from others which is another source of
continued self-efficacy development. Verbal persuasion serves as a further means of
strengthening people’s beliefs that they possess the capabilities to achieve what they
seek. It is widely used because of its easy and ready availability (Bandura, 1997). In
this program, the participants received verbal reinforcement, motivation, suggestions
and advice both at hospital and at home. Moreover, the participants received teaching
9
about the definition of mild TBI, warning signs and symptoms following mild TBI,
and caring for patients with mild TBI.
The third is vicarious experience which is produced by observing the
actions of others, often called modeling. Modeling is an effective way to raise
efficacy (Bandura, 1997). Vicarious experiences build efficacy in those who are
uncertain about their own abilities or have limited prior experiences. Personal efficacy
can also be impacted by the verbal persuasion of others affirming or negating
capability. Humans have evolved an advanced capacity for observational learning that
enables them to acquire knowledge, attitudes, values, emotions, and competences
through the rich fund of information conveyed by actual and symbolic modeling
(Bandura as cited in Bandura, 2002). Therefore, this program will use modeling by
sharing information about the success of management for patients with mild TBI and
showing some pictures about symptoms management for patients with mild TBI such
as neck stretching, sleeping position, and vestibular exercises.
The fourth is enactive mastery experiences. This source is the most
influential source of efficacy information because it provides the authentic evidence
of whether one can master what it takes to succeed (Bandura, 1997). Mastery
experiences are developed by actually learning and practicing the appropriate
behavior. It is perceived as the greatest influence on a person’s perception on selfefficacy. Enactive mastery experience is integrated into the self-efficacy enhancing
education program by a demonstration about symptoms assessment using the
symptoms checklist and management symptoms such as neck stretching, sleeping
position, and vestibular exercises. In addition, the researcher encourages family
10
caregivers to re-demonstrate the symptoms assessment and management symptoms.
These will help family caregivers to master them, and gives them more confidence for
the next time when they use it.
The education program is defined as the program to provide
information for the family caregiver with a mild TBI patient. Based on the literature
review, the contents of the education program includes the definition of mild TBI, the
warning signs and symptoms following a mild TBI, symptoms assessment, symptoms
management and symptoms evaluation. The education program was provided using a
teaching method, demonstration, and follow-up telephone calls.
Family caregivers’ competencies in caring for mild TBI patient refers
to the capabilities of family caregivers in providing care for the patient with a mild
TBI. Based on the literature review, their capabilities include symptoms assessment,
symptoms management, and symptoms evaluation of the patient with a mild TBI. The
conceptual framework used to guide this study is presented in Figure 1.
Self-efficacy enhancing education program
Approach
Content and strategies
Self-efficacy sources;
Physiological and affective Allowing family caregivers to explore their feelings about caring for a
status
patient with mild TBI
Verbal persuasion
Teaching:
1. Definition of mild TBI,
2. Warning signs and symptoms following mild TBI, caring for
patients with mild TBI
Providing reinforcement, motivation, suggestions and advice both at
hospital and follow-ups at home
Vicarious experiences
Sharing information about the success of management for patients with
mild TBI, showing pictures about symptoms management for patients
with mild TBI (neck stretching, sleeping position, and vestibular
exercises)
Enactive mastery experience
Demonstrating and re-demonstrating:
1. Symptoms assessment using the symptom checklist
2. Management of symptoms: neck stretching, sleeping position, deep
breathing, and vestibular exercises
Family caregivers’ competencies
in caring for patients with mild
TBI: perceived confidence and
performance:
1. Symptoms assessment
2. Symptoms management
3. Symptoms evaluation
Figure 1. Conceptual framework of a self-efficacy enhancing education program on family caregivers’ competencies in caring for
patients with mild TBI
11
12
Hypotheses
The hypotheses of this study were:
1. The family caregivers’ perceived confidence in caring for patients
with mild TBI after receiving a self-efficacy enhancing education program is higher
than before receiving the program.
2. The family caregivers’ performance in caring for patients with mild
TBI in the second week after discharge is similar to that in the first week after
discharge in those who receive a self-efficacy enhancing education program
3. The family caregivers’ perceived confidence in caring for patients
with mild TBI who receive a self-efficacy enhancing education program is higher than
those who receive the routine care.
4. The family caregivers’ performance in caring for patients with mild
TBI who receive a self-efficacy enhancing education program is higher than those
who receive the routine care.
Definitions of Terms
A self-efficacy enhancing education program refers to the set of
activities over two weeks that has been developed by the researcher based on the four
sources of self-efficacy as strategies to enhance family caregivers competencies which
include; enactive mastery experience, vicarious experience, verbal persuasion, and
physiological and affective states (Bandura, 1997). This program was conducted with
the family caregiver who stands beside the patient through individual education over
13
approximately 60 minutes at the second day of hospitalization. The programs consist
of explore feelings, teaching and providing reinforcement and support, sharing
information about the successfully of mild TBI management and providing pictures
about mild TBI management, demonstrating and re-demonstrating. Moreover, this
program included follow-up telephone calls twice after patient discharge.
Routine care refers to the usual care by nurses for the family caregiver
following the regular treatment for the patient with a mild TBI on the ward including
assessment (vital signs, physical examination, and complaints assessment), providing
medication, physical examination from physicians and receiving information
regarding the patient’s condition from doctors and nurses.
Family caregiver’s competencies refer to the family caregiver’s
perceived confidence and performance regarding care for the patient with a mild TBI,
as follows;
Perceived confidence regarding care for patients with mild TBI is the
level of confidence of the family caregivers to perform the symptoms assessment,
symptoms management, and symptoms evaluation of patients with mild TBI. This
was measured by using the Perceived Confidence Questionnaire (PCQ) developed by
the researcher based on the literature review. A higher score indicates higher
perceived confidence of family caregivers.
Performance regarding care for patients with mild TBI refers to the
perceived ability of family caregivers to provide care in appropriate time and action
for patients with mild TBI that have been performed over the past week in order to
assess the warning signs and mild TBI symptoms, symptoms management, and
symptoms evaluation. This was measured by using the Performance Questionnaire
14
(PQ) developed by the researcher based on the literature review. A higher score
indicates higher performance on family caregivers.
Scope of the study
This study was conducted to test the effect of a self-efficacy enhancing
education program on family caregivers’ competencies in caring for patients with
mild traumatic brain injury in Yogyakarta, Indonesia. The subjects were recruited
from the surgical ward at PKU Muhammadiyah Yogyakarta and PKU
Muhammadiyah Bantul Hospital, Yogyakarta Indonesia from November 2012 to
February 2013.
Significance of the Study
The outcomes of this study provide evidence related to the utilization
of a self-efficacy enhancing education program in improving family competencies in
caring for patients with mild TBI. This study will be useful not only for the family
caregivers but also the mild TBI patients regarding the management of mild TBI after
discharge. Moreover, the results of this study provide relevant information for nurses
or other health care professionals and also for future researchers.
15
CHAPTER 2
LITERATURE REVIEW
This chapter presents the literature review which includes the
following topics.
1. Overview of mild traumatic brain injury (mild TBI)
1.1. Definition of TBI and mild TBI
1.2. Pathophysiology of mild TBI
1.3. Symptoms of mild TBI
1.4. Warning signs after mild TBI
1.5. Complications of mild TBI
1.6. Impacts of mild TBI
1.7. Mild TBI Management in Indonesia
2. Family caregivers’ competencies in caring for patients with mild TBI
2.1. Definition of family caregivers
2.2. Family caregivers’ competencies in caring for mild TBI patients
2.3. Factors contributing to family caregivers’ competencies
3. Education program for family caregivers in caring for patient with mild TBI
3.1. Education program
3.2. Self-efficacy in the education program
3.3. The existing educational program for family caregivers with TBI
4. Summary
16
Overview of Mild Traumatic Brain Injury (Mild TBI)
Definition of TBI
TBI is a traumatically induced structural injury and/or physiological
disruption of brain function as a result of an external force that is indicated by new
onset or worsening of at least one of specified set of clinical signs, immediately
following the event (1) any period of loss or a decreased level of consciousness, (2)
any loss of memory for events immediately before or after the injury, (3) any
alteration in mental state at the time of the injury for example confusion,
disorientation, and slowed thinking, (4) neurological deficits for instance weakness,
balance disturbance, praxis, paresis/plegia, change vision, aphasia, (5) intracranial
lesion (Department of Veterans Affairs, Department of Defense [DVA/DoD], 2009).
TBI is classified in two types; there are closed head injury, and open
head injury (Boss, 2010; Morris, 2010). Closed head injury is the injury to the brain
without the occurrence of the breaking of the skull or any of the meninges, and the
brain itself is not externally penetrated. Closed head injuries are often the result of
blunt force to the skull. Types of closed injuries are concussion, contusion, and
laceration (Boss, 2010). Shaking of the brain is the cause of transient neurological
deficit in concussion injury. Clinical manifestations include immediate loss of
consciousness lasting from minutes to hours, loss of reflexes at the moment, amnesia
for the period immediately prior to and following the event. Others symptoms are
headache, drowsiness, confusion, dizziness, irritability, and visual disturbances. Open
head injury is penetrated or broken at the time of impact. Open head injuries include
17
skull fractures, blunt force trauma, or gunshot. Open head injuries occur when the
skull and meninges is penetrated by an external object (Boss, 2010).
The diagnosis is based on the depth and length of the coma, durations
of posttraumatic amnesia, time to respond consistently, neuroimaging and
electrophysiological studies, and measurements of brainstem function (DVA/DoD,
2009). The severity of TBI divided into three general categories: mild, moderate, and
severe. A mild injury includes a Glasgow Coma Scale (GCS) ranging from 13to15,
moderate injury includes a GCS ranging from 9 to12, and severe injury is
characterized by a GCS range of 3-8 (Jennett & Teasdale as cited in Selladurai &
Reilly, 2007).
Definition of Mild TBI
Mild TBI is an acute brain injury resulted from mechanical energy to
the head from external physical forces. The criteria for clinical identification includes
one or more of the following: confusion or disorientation, loss of consciousness for 30
minutes or less, post traumatic amnesia for less than 24 hours, and/or other transient
neurologic abnormalities like seizure, focal signs, and intracranial lesion not requiring
surgery; and GCS score of 13 to 15 at 30 minutes post-injury or later upon
presentation for health care, these manifestations of mild TBI must not be due to
drugs, alcohol, medications, or be caused by other injuries or treatment for other
injuries (for instance systemic injuries, facial injuries), caused by other problems (e.g.,
psychological trauma, language barrier or coexisting medical conditions) caused by
penetrating cranio-cerebral injury (World Health Organization [WHO] as cited in
Ruff, Iverson, Barth, Bush, Broshek & the NAN Policy and Planning Committee,
18
2009). The causes of mild TBI are falls, motor vehicle trauma, being struck by
something, hitting head on something, assault or intentional head trauma (including
blast injury),and sports related injury (Faul, Xu, Wald, & Coronado, 2010).
The grading scale of concussion consists of three grades (Cantu, 2001).
Grade 1 is characterized by no loss of concussion, either PTA or post-concussion
signs, and symptoms that clear in less than 30 minutes. Grade 2 is characterized by
loss of concussion lasting less than 1 minute and PTA or post-concussion symptoms
lasting longer than 30 minutes but less than 24 hours. Grade 3 is signed by loss of
concussion lasting more than 1 minute or PTA lasting longer than 24 hours or postconcussion signs or symptoms lasting longer than 7 days.
In conclusion, mild TBI is an acute brain injury resulted from external
mechanical force to the head that had at least one characteristic as follows: Glasgow
coma score 13-15 at 30 minute after injury, duration of loss of consciousness for 30
minute or less, post traumatic amnesia less than 24 hours, no focal neurology deficit
and normal neuro-imaging
Pathophysiology of Mild TBI
Neuropathology of mild TBI is Diffuse Axonal Injury [DAI]
(Cushman, Agarwal, & Fabian, 2001; de Kruijk et al., 2002). DAI caused by shearing
forces generated within brain parenchyma by sudden acceleration-deceleration or
torsional (Chusman et al., 2001). These forces undermine fragile structures in long
axis of the brain or stretching of axons. It can affect the small blood vessels and
axons. These may result a cascade of neurochemical changes (Bazarian et al., 2005).
19
Axonal injury leads to localized transport failures within the axon and
that leads to axon’s swelling and lysis followed fatty degeneration of nerve fibers. The
extent of axonal injury can be correlated with GCS score, duration of LOC and
duration of PTA (Cushman et al., 2001). Moreover, small vessels damages can
produce pethechical hemorrhages or local/focal edema. These histopathological
changes involved microglial cell proliferation (Cushman et al., 2001). Then, it can
result on metabolic cascade that characterized by an initial depolarization of neuronal
membranes and the release of excitatory amino acids, particularly glutamate, which
produces fluxes of calcium and potassium ions across neural and vascular tissue
resulting in at first a hypermetabolic glycolytic state as the neurons attempt to restore
equilibrium. There follows a calcium ion–induced vasoconstriction that reduces
cerebral blood flow and glucose delivery to the brain (Giza & Hovda, 2001). As a
result, cerebral oxygenation is reduced (Cote, Neary, Goodman, Parkhouse, &
Bhambani as cited in Len & Neary, 2010). This reduction in cerebral oxygenation
may produce the development of oxygen consumption-demand imbalance. This
mismatch can lead to ischemic or hypoxic situations resulting in secondary brain
tissue damage. Then, profound hypoperfusion of brain tissue may occur (Buchner,
Meixensberger, Dings, & Roosen as cited in Len & Neary, 2010). The increased
oxygen demands of the TBI-injured brain stress the autoregulatory and
cerebrovascular reactivity responses to physiological disturbances. This condition
may potentially result in cell dysfunction and increase the vulnerability of the cell to a
second insult (Lang as cited in Len & Neary, 2010).
20
Symptoms of Mild TBI
Symptoms experienced after mild TBI can be categorized as physical,
affective/emotional, and cognitive symptoms (Defense Centers of Excellence [DCoE],
2012; DVA/DoD, 2009).
Physical symptoms. Physical symptom usually refers to somatic
symptoms (Simon, Vonkorff, Fullerton, & Ormel, 1999). The physical symptoms
included headache, dizziness, nausea, fatigue, sleep disturbance, blurred vision,
sensitivity to noise, sensitivity to light, hearing difficulties/loss, seizure and tinnitus
(DVA/DoD, 2009). Physical symptoms mostly emerged in the early after injury up to
one month after injury such as dizziness, headache, fatigue, and nausea (Dischinger,
Ryb, Kufera, & Auman, 2009; Mackenzie & McMillan, 2005; Yang, Tu, Hua, &
Huang, 2007). Physical symptoms may occur within three months after injury
(Kashluba, Hanks, Casey, & Millis, 2008; Lannsjo, Geijerstam, Johansson, Bring, &
Borg, 2009; Lundin, De Boussard, Edman, & Borg, 2006) and more than three
months (Fourtassi et al., 2011; Dean, O’nell, & Sterr, 2012; Hou et al., 2011; Roe,
Sveen, Alvsaker, & Bautz-Holter, 2009). Headache and dizziness are the common
prevalent physical symptoms of mild TBI (Bryan & Hernandez, 2011; Dikmen,
Machamer, Fann, & Temkin, 2010; Kashluba et al., 2008; Lannsjo et al., 2009;
Packard, 2008; Ponsford, Cameron, Fitzgerald, Grant, & Mikocka-Walus, 2011).
Headache was prominent in the early after injury stage up to two
weeks after injury (Dischinger et al., 2009; Yang et al., 2007). Patients with mild TBI
reported having headache soon after injury as high as 90% (Nicholson & Martelli,
2004). This symptom may occur until three months after injury (Bergman, 2011;
Fourtassi et al., 2011; Kashluba et al., 2004). Headache can emerge more than that
21
time; some researchers found 18%-22% of post traumatic headache lasting longer
than 1 year (Lew et al., 2006; Nicholson & Martelli, 2004). The type of headache has
been associated with mechanism of injury. Blunt force trauma is usually associated
with tension type headache while blast injury is associated with a higher rate of
migraine type (Lew et al., 2006; Terrio et al., 2009).
Headache in mild TBI can be categorized into two types, migraine and
tension-type headache types (Headache Classification Subcommittee [HCS], 2004). A
migraine headache may be described as a type of headache that causes a throbbing
and pulsating pain around the head. Migraine has two subcategories (HCS, 2004).
Firstly, migraine without aura (common migraine) it attacks last for 4–72 hours and
has at least 2 of the following characteristics: pulsating pain, unilateral, moderate to
severe intensity of pain, and worsened with or causing avoidance of usual physical
activity. In addition, at least one of the following symptoms must be present: nausea,
vomiting, photophobia, and phonophobia (HCS, 2004). Secondly, migraine with aura,
it attacks have the same criteria as common migraine; in addition, the aura presents
within 60 minutes of the onset of headache. Aura consists of one of the following
fully reversible features: visual changes, sensory changes, or dysphasic speech (HCS,
2004). Tension-type headache, also called stress, muscle contraction, or essential
headaches. This type is characterized by headache lasting for 30 minutes–7 days
without nausea or vomiting, bilateral pressing or tightening pain quality (nonthrobbing), mild or moderate in intensity, and not precipitated by usual physical
activity (HCS, 2004).
Dizziness is a sensation of faintness and whirling or an inability to
maintain normal balance in a standing or seated position or sensation of unsteadiness
22
accompanied by a feeling of movement within the head (DCoE, 2012). Dizziness is
categorized in three types, there are vertigo, disequilibrium, and lightheadedness
(DCoE, 2012). Vertigo is a false sense of motion (spinning, rocking, and movement
of environment). Disequilibrium is being 0ff-balance or unsteady while standing or
attempting to walk. Lightheadedness is feeling faint or other vague sensations such as
disconnect with environment. Dizziness was one of common symptom that occurred
in the early after injury stage up to two weeks after injury (Dischinger et al., 2009;
Yang et al, 2007) up to three months (Bergman, 2011; Fourtassi et al., 2011;
Kashluba et al., 2004).
Another physical symptom is fatigue. Fatigue is overwhelming
feelings of exhaustion or tiredness, diminished energy or increased need to rest
(Stulemeijer et al., 2006). According to Stulemeijer et al. (2006) fatigue has been
shown to be associated with limitations in daily functioning and quality of live.
Fatigue is common symptom following mild TBI as nearly one third of patients
suffering with mild TBI reported severe fatigue for six months after injury
(Stulemeijer et al., 2006). Norrie et al. (2010) found fatigue after mild TBI prevalence
was 68%, 38% and 34% at 1 week, 3 and 6 month. Moreover, Sundstrom et al. (2007)
found that persistent fatigue prevalence rates of 22–59%. Studies have shown that
post-injury fatigue can persist for years and has been documented up to 5 years
following injury (Bushnik, Englander, & Wright, 2008).
Cognitive symptoms. Cognitive symptoms refer to disturbance with
thought, attention, memory, concentration, and speed of processing (DVA/DoD,
2009). Cognitive symptoms occurred within one month after injury (Mackenzie &
McMillan, 2005; Yang et al., 2007) within three months after injury (Laansjo et al,
23
2009; Lundin et al., 2006; Ponsford et al., 2011; Yang et al., 2007) and more than
three months (Dean et al., 2012; Fourtassi et al., 2011; Hou et al., 2011; Roe et al.,
2009). The common cognitive symptoms are difficulty remembering (Fourtassi et al.,
2011; Kashluba et al., 2004) and difficulty thinking (Dean et al., 2012; Mackenzie &
McMillan, 2005).
Emotional symptoms. Emotional symptoms refer to a state of feeling
related to aspect of consciousness. The emotional symptoms consisted of irritability,
frustration, anger, anxiety (Lannsjo et al., 2009; Sheedy, Harvey, Faux, Geffen, &
Shores, 2009; Yang et al., 2007), mood swings, depression, hyperactivity, and
aggression (Sohlberg & Mateer, 2001). These symptoms mostly occurred within three
months after injury (Lannsjo et al., 2009; Sheedy et al., 2009; Yang et al., 2007) or
more than three months (Dean et al., 2012; Fourtassi et al., 2011; Hou et al., 2011;
Roe et al., 2009). Some studies found that emotional symptoms may occur within one
after injury such as anxiety and feeling depressed (Dischinger et al., 2009). The
common emotional symptoms are irritability (Laansjo et al., 2009; Sheedy et al.,
2009; Yang et al, 2007), and anxiety (Dischinger et al., 2009).
In conclusion, symptoms experienced after mild TBI can be
categorized as physical, cognitive, and emotional/affective symptoms. Physical
symptoms mostly occurred in the early stage after injury up to three months, followed
by cognitive symptoms. Emotional symptoms mostly occurred more than three
months after injury. The common physical symptoms are headache and dizziness,
while irritability and feeling depressed are the common emotional symptom. In
addition, the common cognitive symptoms are difficulty remembering and difficulty
thinking.
24
Warning Signs and Symptoms
Warning symptoms after mild TBI refer to the increased intracranial
pressure (IICP). The signs and symptoms of IICP are impaired consciousness,
decreased responsiveness, disorientation, restlessness, increased respiratory effort,
mental confusion, projectile vomiting, and a constant headache or a headache that gets
worse (increasing in intensity and aggravated by movement or straining). This occurs
as IICP causes pressure and stretching of venous and arterial vessels in the base of the
brain. Additionally, weakness in one extremity or on one side of the body, this occurs
as IICP compresses the pyramidal tracts. Causes of IICP are increased pressure in the
brain resulting from edema or hemorrhage or increased volume of cerebral spinal
fluid (CSF) (Smeltzer, Bare, Hinkle, & Cheever, 2010). Other signs and symptom that
should be considered are that patients can’t wake up, act strange, say things that do
not make sense (change in behavior), cannot remember new events, recognize people
or place (increased confusion), pass out or have a blackout or a seizure, cannot move
parts of patients’ body or clumsiness, have blurred vision or slurred speech, and
experience continual fluid or bleeding from the ear or nose (Selladurai & Reilly,
2007).
Complications of Mild TBI
The complications of mild TBI patient were 8% pathological finding,
dominated by hemorrhages like subarachnoid hemorrhage (1%) and subdural
hemorrhage (1%) (Geijerstam & Britton, 2010). Additionally, Fabbri et al. (2004)
found 1.4% of patients developed intracranial injuries after discharge and 0.8%
patients had died at home after six months.
25
Impacts of Mild TBI
There are two impacts of mild TBI which include impacts in patients
and impacts on family caregivers
Impacts of mild TBI in patient. Impact of mild TBI in patient
includes difficulties in activities of daily living, interpersonal relationships, return to
pre-injury work status, and heightened emotional distress (Bay & Bergman, 2006).
These difficulties are associated with persistent post-concussion symptom after mild
TBI that symptom occurred in patient more than three months (Bay & Bergman,
2006). Lundin et al. (2006) found 25% of mild TBI patients had dysfunction in at
least one domain of everyday life, such as work, relationships, social and leisure
activities at three months post injury.
Impact of mild TBI on family caregivers. The impact of mild TBI on
family caregivers include in four aspects. The first one is psychological impact. The
most impact of TBI is stress/distress of family caregivers (Ganesalingam et al., 2007;
Prigatano, 2005; Testa et al., 2006). Distress among family caregivers and family
members of patient with TBI may affect the entire family caregivers’ system.
Neurobehavioral disturbance in patient with TBI was the strongest predictor of family
caregivers distress (Testa et al., 2006). The most common predictive factors are
changes in behavioral control and cognitive difficulties (Ergh, Rapport, Coleman, &
Hanks, 2002). Other factors included the injured individual’s emotional state (Testa et
al., 2006). Ganesalingam et al. (2007) found that post-concussion symptoms in after
injury was related to higher ratings of family distress at 3 months. Emotional problem
like distress in the family caregivers can influence patient’s rehabilitation (Sander,
Carosellis, Becker, Neeses, & Scheibel, 2002; Sady et al., 2010). Family caregivers
26
who are experiencing distress may not be effective partners in the rehabilitation
process (Sander et al., 2002). A person with less family caregiver distress was
predictive to have a better social integration (Sady et al., 2010).
The second aspect is physical impact. Marsh, Kersel, Havill, and
Sleigh (2002) found that TBI patients may influence of family caregivers’ physical
health such as physical illness (6%) and a change in the sleeping pattern (60%).
Moreover, TBI patients with persistent and high levels of disability require constant
assistance. Consequently, family caregivers may experience physical fatigue and
exhaustion (McPherson, Pentland, McNaughton as cited in Samartkit,
Kasemkitvattana, Thosingha, & Vorapngsathorn, 2010).
The third one is impacts in family caregivers’ functioning. Many
researchers have documented disruptions or deprivations in family functioning as
manifested by less of problem solving, communication, role functioning, affective
involvement, affective responsiveness, behavioral control and effective coping
(Curtis, Klemz, & Vanderploeg, 2000; Ergh et al., 2002; Gan & Schuler, 2002; Testa
et al., 2006).
The last one is family burden (Aitken et al., 2009; Ganesalingam et al.,
2007; Lethan, Arango-Lasprilla, de los Reyes, & Quijano, 2012; Nabors, Seacat, &
Rosenthal, 2002). Ganesalingsam et al. (2007) found that post family caregivers have
burden at three months post injury. Additionally, some family caregivers reported that
their burden was caused loss of free time (Marsh et al., 2002).
27
Mild TBI Management in Indonesia
In Indonesia, the hospitals have guideline for mild TBI management.
Mostly, the patients with mild TBI need hospitalization at least three days (Siswanto
& Wahyu, 2012). The management of mild TBI patients during hospitalization are
categorized in two parts, there non pharmacologic and pharmacologic. Non
pharmacologic treatment included observation of GCS score, CT scan examination,
monitor of increased intracranial pressure signs, vital signs, and neurologic signs
every two hours, and laboratory examination. Pharmacologic treatment of mild TBI
included providing medication such as analgesic, antipyretic, manitol and natrium
chloride fluid therapy, diuretic, and dexamethason. Before discharge, mild TBI
patients receive medication such as analgetic, antipyretic, and neuro vitamin, and they
should come to hospital one week after discharge (Siswanto & Wahyu, 2012).
Family Caregivers’ Competencies in Caring for Patient with Mild TBI
Definition of Family Caregivers
Family caregivers refer to anyone who provides assistance and support
to family members or acquaintances that have physical, psychological, or
developmental needs (Family Caregiver Alliance, 2006). Family caregivers with TBI
are defined as those people who are related to a head-injured individual and perform a
major unpaid caregiving function (Sinnakaruppan, Downey, & Morrison, 2005).
Family caregivers are defined as the individuals who would provide the majority of
care (e.g., parent, guardian, significant other) for the patient with mild TBI after
discharge.
28
Family caregivers play a central role in patient’s rehabilitation with TBI
after hospital discharge (Morris, 2001; Stejskal, 2008; Thorn, 2000) and reentry into
the community (Stejskal, 2008). Family has responsibility in rehabilitation process
such as providing care for patient and giving emotional support (Arango-Lasprilla et
al., 2010).
Research indicates that family members carry the primary
responsibility for post-acute caregiving, with as many as 80% of survivors returning
home after their hospital and/or rehabilitation discharges (Brooks as cited in Stejskal,
2008). Families have responsibility to provide support, socialization and assistance to
the injured person. Additionally, they help patients to facilitate the carryover of
rehabilitation strategies to compensate for cognitive difficulties (Fleming, Shum,
Strong, & Lightbody, 2005).
Family functioning is associated with progress in post-acute
rehabilitation program Sander, Maestas, Shere, Malec, and Nakase-Richardson
(2012). Sander et al. (2012) found that family caregivers with better emotional
functioning were associated with greater social integration outcomes and occupation
for mild to severe TBI persons who entered the post-acute rehabilitation program
within 6 months of injury, but not for those more than 6 months post-injury. Healthy
family functioning was predictive of greater home integration (Sady et al., 2010).
Additionally, patients performed better in rehabilitation with support from the family
caregivers than those who do not receive support from their family caregivers (Sady
et al., 2010; Sander et al., 2012). A person who received greater social support from
caregiver was associated with better outcomes in productivity and social integration
(Sady et al., 2010).
29
Family Caregivers’ Competencies in Caring for Mild TBI Patients
Definition of family caregivers’ competency. Competency is defined
as the ability to do something successfully or efficiently or the capability of applying
or using knowledge, skills, abilities, behaviors, and personal characteristics to
successfully perform critical work tasks, specific functions, or operate in a given role
or position (Lucia & Lespinger as cited in Ennis, 2008). The elements of competency
include knowledge, skills and abilities, as well as soft skills or behaviors (Rodriguez,
Patel, Gregory, & Gowing, 2002).
Family caregiver’s competencies are the family caregiver’s ability to
perform the necessary tasks of organizing and managing itself as it accomplishes
family tasks (Beavers & Hampson, 2003) or the effective performance of caregiving
actions that are associated with the care recipient’s safety and related knowledge and
skills (Horvath et al., 2005). Family caregivers’ competencies measure the family’s
ability, to communicate, coordinate, negotiate, establish clear roles and goals,
problem solve, adapt to new situations, accept responsibility, be autonomous, and
believe in itself (Beavers & Hampson, 20003). The family caregivers’ competencies
relate to the structure, function and flexibility of a family system, i.e. how a family
negotiates and functions in everyday and stressful situations, the communication
patterns of the family, parent/child roles, goal-direction of the family, autonomy of
each individual, and family affect.
Family caregivers’ competencies in caring for mild TBI patients.
Family caregivers have responsibility to help the patients with mild TBI by providing
care earlier after discharge from hospital until thirty days (DVA/DoD, 2009). The
aims of caring for patient following mild TBI are to prevent the persistent symptoms
30
and complications of mild TBI like increased intracranial pressure (IICP) (DVA/DoD,
2009). Family caregivers’ competencies to provide care for patients include patients’
symptoms, patients’ symptoms management, and patients’ symptom evaluation
(DVA/DoD, 2009).
1. Patients’ Symptom Assessment. Family caregivers’ competencies in
patient’s symptom assessment refer to family caregivers’ ability to assess the warning
signs and symptoms related to IICP and the patients’ symptom after being discharged.
Monitoring of intracranial pressure (ICP) is important to recognize impending
complications or worsening of intracranial pathology (Imhof & Lenzlinger, 2011).
Regarding to clinical practice guideline for management of mild TBI/concussion, the
assessment of patients’ symptoms can be grouped into three categories: physical,
cognitive, and emotional or affective symptom (DVA/DoD, 2009). Documenting
frequency and severity of patient’s symptoms is important to set a baseline for
monitoring subsequent symptom management. Additionally, family caregivers can
assess about the kind of patient’s symptoms, duration of patient’s symptom, onset and
triggers, location, intensity and impacts, and warning signs and symptoms (Heng et
al., 2007). In symptom assessment, family caregivers can use the patient’s symptom
checklists (DVA/DoD, 2009).
2. Patient’s symptom management. After the screening and
assessment of mild TBI symptoms, family caregivers can provide cares to the patient
by the using symptom management (DVA/DoD, 2009). For managing the warning
signs, family caregivers should bring the patient directly to the hospital. Another one
is symptom management following mild TBI patient. Symptom managements focus
on initial management of the physical, cognitive, and emotional symptoms. Symptom
31
managements consist of two managements: non pharmacological and
pharmacological (American Association of Neuroscience Nurses/AANN &
Association of Rehabilitation Nurses/ARN, 2011; DVA/DoD, 2009). In symptoms
management include management of physical symptoms, cognitive symptoms, and
emotional symptoms.
2.1. Physical symptoms management. In management of physical
symptoms include (1) headache symptom management, (2) dizziness symptom
management, and (3) fatigue symptom management.
1). Headache management. Non pharmacological managements for
headache are relaxation technique like a deep breathing, a review of postures and an
adjustment to ensure neck and spine be in a neutral position, series of neck exercises
and appropriate ranges of motions, massage therapy to help with headache from neck
tension (DVA/DoD, 2009), and regular exercise (American Association of
Neuroscience Nurses [AANN & ARN], 2011; DVA/DoD, 2009). Neck exercise was
effective to reduce or prevent a headache following a mild TBI (Ylinen, Nikander,
Nykanen, Kautiainen, & Hakkinen, 2009) that consisted three exercises, there are
flexion, lateral flexion, and rotation (DVA/DoD, 2009). Additionally, the
management of headache includes maintaining regular meal schedule; maintaining
adequate hydration; minimizing stress, and sleep hygiene (DVA/DoD, 2009). Sleep
hygiene significant decrease of headache pain (Ruff, Ruff, & Wang, 2009). While
pharmacological treatment for headache consists of treatment for migraine and
tension type. Family caregivers have responsibility to remind the patients in taking
medications to relieve or reduce headache (AANN & ARN, 2011). Pharmacological
treatment for migraine used Triptans (rizatripatan, eletriptan and
32
almotriptan)antiemetics; ergotamines; and dihydroergotamines (HCS, 2004).
Medication of tension-type headache used non-narcotic medications for acute
headaches used periodically to prevent rebound headaches, Tricyclic antidepressants,
muscle relaxants, indomethacin trial; limit non-steroidal anti-inflammatory drugs
[NSAIDs] for chronic headaches (HCS, 2004).
2). Dizziness management. Non pharmacological managements for
dizziness are neck stretching, changing position slowly, and performing vestibular
rehabilitation exercise (DCoE, 2012). The vestibular rehabilitation could decrease
dizziness and improve gait and balance function after concussion (Alsalaheen et al.,
2011; Gottshall, 2011). The vestibular rehabilitation included turning the head from
side to side, standing balance, walking with balance challenge (Alsalaheen et al.,
2011). The steps of turning the head from side to side are sitting upright on the bed,
turning head to the left, lying back, turning head to the right, rolling over to the right
side, and sitting up straight (DVA/DoD, 2009). Pharmacological therapy for dizziness
includes Meclizine, Dimenhydramin, Lorazepam (DCoE, 2012).
3). Fatigue management. Non pharmacological management for reduce
fatigue includes regular exercises (AANN & ARN, 2011; DVA/DoD, 2009), sleep
hygiene, and well balanced meal (DVA/DoD, 2009). Family caregivers should
encourage restructuring the timing of daily activities to minimize its deleterious
effects. Activities and rest required the most effort should be scheduled at a time.
Sleep hygiene includes maintaining regular bedtime and awakening schedules,
establishing usual bedtime routine; sleep in quiet, dark, cool room; avoiding the
consumptions of caffeine, stimulants, smoking, and alcohol prior to bed; if unable to
sleep after 15 minutes in bed, rise and go to another room until sleepiness returns
33
(Siebern & Manber, 2010). According to De Groot , Phillips, and Eskes (2003) some
patients have found that the scheduling of regular naps or rest periods can reduce
fatigue. In addition, family can teach patients like distraction, this technique is
beneficial to reduce fatigue by reducing stress (Portenoy & Itri as cited in De Groot et
al., 2003). Pharmacological treatment includes psycho stimulants such as
Methylphenidate and Modafinil, dopaminergic like Levodopa and Bromocriptine,
cholinesterase inhibitors such as Donepezil (Anderson, Heitger, & Macleod, 2006).
2.2. Cognitive symptom management. In cognitive symptom
management in term management of memory difficulties include practicing memory
skills about place, time, and person by asking directly or using memory aids such as
memory books or calendars, electronic memory aids (e.g., personal digital assistants);
and making daily planners (Tsaousides & Gordon, 2009). Pharmacologic
management includes the use of cholinesterase inhibitors (donepezil) for memory,
attention, and monitoring the effects of stimulant medications as may exacerbate postconcussion symptom (PCS). Other medications for cognitive impairments are
catecholaminergic augmentation and cholinergic augmentation (Arciniegas & Silver,
2006). Methylphenidate augments cerebral catecholaminergic function and is the firstline treatment for impaired speed of processing; it may also improve arousal and, to a
lesser extent, attention and memory (Warden et al., 2006).
2.3. Emotional symptom management. In management of emotional
symptoms including keeping safe, reducing noise, leaving the person for short period
when warning signs of anger develop in safety condition, using relaxation technique
(sitting, closing eyes, deep controlled breathing) are important. Warning signs include
verbal (high voice, cursing, threats), behavioral (making fists, increase movement,
34
angry face, breaking or throwing things, hitting, kicking or other forms of violence),
physiological (sweating, fast breathing, bulging eyes) (Tsaousides & Gordon, 2009).
3. Patient’s Symptoms Evaluation. Competency of family caregivers
on symptom evaluation is family ability to evaluate or follow-up or re-assessment of
symptom after they provided care to the patient with mild TBI. The patients should be
followed up in four weeks to confirm resolution of symptoms and to address any
concerns of providing care (DVA/DoD, 2009). Evaluation after the providing care is
important to determine patient status. Family caregivers can evaluate about patient’s
recovery from acute symptoms, either improving or not or status getting worsens
(DVA/DoD, 2009). If patient’s symptoms are getting worse or significantly impact in
daily activities, family caregivers should bring the patient to the hospital or health
care providers (DVA/DoD, 2009).
In summary, family caregivers’ competencies in caring for patients
with mild TBI include ability to assessing warning signs and symptoms following-up
mild TBI, managing of mild TBI symptoms, and evaluating of mild TBI symptom
after providing management symptoms.
Factors Contributing to Family Caregivers’ Competencies
There are some factors contributing to family caregivers’ competencies
in caring for patients hat are divided in two factors: internal and external factors.
Internal factors. The internal factors include psychological status,
physical health, experience, education level, self-efficacy, employment, and
knowledge and skills.
35
Psychological status. Psychological status such as stress and anxiety
could influence family caregivers’ competencies in caring for their patients. Ostberg
& Hagekull (2000) reported that stress and depression are significantly related to the
parent’s competencies. Similarity, distress can influence family function to take care
of the patients with traumatic brain injury (Testa et al., 2006). In addition, Backhaus,
Ibarra, Klyce, and Trexler (2010) found that family caregivers’ distress may influence
their self-efficacy.
Physical health. The family caregivers’ health had a relationship on
their caregiving. Samartkit et al. (2010) found that family caregivers who had a good
physical health would provide a good care for their patients. However, one study
mentioned that caregivers’ physical health was not associated with family functioning
in their caring for patients (Clark et al., 2004).
Experience. Prior experience of providing care for patients can
influence current family competencies (Horvath et al., 2005). Moreover, family
caregivers who never had experience in caring for their patients, they had lower skill
levels (Farran et al., 2011)).
Education level. The family education level influences their
competencies in providing care to the patients. Farran et al (2011) found that
education level can influence family’s skill in caring for patient with Alzheimer,
family caregivers with high school or less of education had lower skill level than the
family caregivers that were college graduates or beyond.
Self-efficacy. Self-efficacy influenced family caregivers’ performance
(Kouri et al., 2011). Self-efficacy is individuals’ belief or confidence in performing a
specific task or activity (Bandura, 1997). The family caregivers who have high self-
36
efficacy or confidence are better in their performance in caring for patients (Kouri et
al., 2011). Family caregivers who have a positive perception of their abilities to
implement caregiving successfully have more positive performance regarding their
role (Narayan, Lewts, Tornatore, Hepburn, Corcora-Perry as cited in Samartkit et al.,
2010).
Employment. Family caregivers who had working may influence in
their competencies in term caregiving roles for patients (Wang, Shyu, Chen, & Yang,
2010). Family caregivers with full time jobs significantly more role strain than family
caregivers working in part time or unemployed (Wang et al., 2010). Employed family
caregivers had been limited to the care responsibility, they were more likely to stop
caregiving than to give up work (Dautzenberg, Philipsen, Stevens, & Vernooij-Dassen
as cited in Wang et al., 2010). In contrast, Bullock, Crawford, and Tennstedt (2003)
found that employed family caregivers did not provide significantly less care than
unemployed family caregivers.
Knowledge and skills. Knowledge and skills are also important factors
that have contribution in family caregivers’ competencies in caring for patients. The
basic knowledge provides the foundation for improving skills (Given, Given, &
Sherwood, 2008). According to Utami (2012), the family caregivers who have
sufficient knowledge and skills may influence their competencies in term of
confidence (Utami, 2012) and abilities to provide care in caring for patients (Kouri et
al., 2011).
External factors. The external factors include professionals’ support,
education program, and patients’ symptoms.
37
Professionals’ support. Support from health care professionals such as
nurses and physicians may contribute on family caregivers’ competencies in caring
for patients. Providing information from health care professionals improved family
caregivers’ knowledge and competencies (Lefebvre, Pelchat, Swaine, Gelinas, &
Levert, 2005). Lack of psychological support and information from health care
providers may influence family caregivers’ knowledge, skills, and sense of ability in
their caregiving for patients with TBI (Lefebvre et al., 2005).
Education program. Education program means providing knowledge
and skills to the family caregivers. Education program can increase family caregivers’
knowledge and skills. Shocker (2008) provided education program for family
caregivers with moderate and severe TBI, the findings showed that their knowledge
was significantly improved. Moreover, education program may increase family
caregivers’ skills in caring for their relatives. Kouri et al. (2011) found that education
program could improve family caregivers’ skills. In addition, education program may
enhance family caregivers’ self-efficacy in caring for patients with TBI (Backhaus et
al., 2010; Sinnakaruppan et al., 2005; Utami, 2012).
Patients’ symptoms. Patients’ symptoms could influence the family
caregivers’ performance in their caring for patients with traumatic brain injury.
Anderson, Parmenter, and Mok (2002) showed that the greater of patients’ symptoms
was related to the amount of care. In addition, neurobehavioral symptoms may
influence on family caregivers’ functioning (Anderson, Simpson, & Morey, 2012).
38
Education Program for Family Caregivers
Education Program
Education program in this study uses term of health educational term.
Health education is any combination planned learning experiences based on sound
theories that provide individuals, group, and communities the opportunity to acquire
information and the skills needed to make quality health decisions (Joint Committee,
as cited in Cottrell, Girvan, & McKenzie, 2009). Health education consists of three
components. There is the using of teaching-learning strategies, learners maintain
voluntary control over the decision to make changes in their actions, and behavior
changes that have been found to improve health status (Edelman & Mandle, 2010).
Edelman and Mandle (2010) explained that health education facilitates
the development of health knowledge, skills and attitudes through the application of
theories or models. Generally, health education programs help families are satisfied
and have received the health care that is most relevant to their problems. Health
education is a tool or mechanism for health-related learning resulting in increased
knowledge, skill development, and change in behavior. Knowledge gained to
empower individuals and to promote change in the environment and society for better
health (Maville & Huerta, 2002).
The aim of education is to help family achieve optimal states of health
through their own actions and initiative (Anderson, Ward, and Hatton as cited in
Edelman & Mandle, 2010). Health education encourage positive or empowerment to
the family, thus family who believe that they can make different in health and make
changes (Anderson et al as cited in Edelman & Mandle, 2010). Family health
39
education can improve family’s self-concept, increased self-esteem, achieving
developmental task, better family functioning, and adaptation to change in family
situation or life state (Edelman & Mandle, 2010).
According to Edelman and Mandle (2010) three domains in education
program include cognitive, psychomotor, and affective were explained. Cognitive
domain refers to the development of new facts or concept, and building on or
applying knowledge to new situation (Edelman & Mandle, 2010). Shocker (2008)
measured the level of knowledge. Psychomotor domain involves developing skill
(Edelman & Mandle, 2010). Affective learning related to the recognition values,
family interaction patterns and relationships, and personal attitudes that affect
decisions and problem solving progress (Edelman & Mandle, 2010).
Self-Efficacy in Education Program
Self-efficacy is a psychological construct based on social cognitive
theory which describes the interaction between personal, behavioral, and
environmental aspects in health and chronic disease. Self-efficacy is one’s selfjudgmental of personal capabilities to initiate and successfully perform a specified
task at designated levels, one expends greater effort, and perseveres in the face of
adversity (Bandura, 1997). According to Bandura (1989), self-efficacy beliefs affect
thought patterns in which it can be self-aiding or self-hindering. The strength of
person’s conviction in her or his own capabilities is likely to affect whether they will
attempt to cope with a given situation (Bandura, 1997).
Based on the Bandura’s theory, self-efficacy makes a difference in
how people feel, think, and act. In terms of feeling, a low sense of self-efficacy is
40
related to depression, helplessness and anxiety. Persons with low self-efficacy have
low self-esteem and they have pessimistic thoughts about their personal development
and accomplishment. In terms of thinking, a strong sense of competence facilitates
cognitive process and performance in a variety of settings including quality of
academic achievement and decision-making. Self-efficacy has an influence on
preparing action because self-efficacy self-related cognitions are a major ingredient in
the motivation process. Self-efficacy levels can increase or inhibit motivation. People
with high self-efficacy choose to perform more challenging task (Bandura, 1997).
Self-efficacy beliefs are constructed from four sources of information.
There are enactive mastery experiences that serve as indicators of capability, vicarious
experiences that alter efficacy beliefs through transmission of competencies with
attainment of others, verbal persuasion, and physiological and affective states
(Bandura, 1997).
Enactive mastery experiences. This is the most influential sources of
efficacy information because they provide the most authentic evidence of whether one
can muster whatever it takes to succeed (Bandura, 1997). Successes make a strength
belief in personal efficacy. Enactive mastery produces stronger and more generalized
efficacy beliefs than do modes of influence relying solely on vicarious experiences,
cognitive simulation, or verbal instruction. Building a sense of personal efficacy
through mastery experiences is not matter of programming ready-made behavior. It
involves acquiring the cognitive, behavioral, and self-regulatory tools for creating and
executing effective courses of action to manage ever-changing life circumstances.
The development of efficacy beliefs through enactive experience creates the cognitive
41
and self-regulative facility for effective performance. Development of the cognitive
basis of human competencies is facilitated by easily mastered skills (Bandura, 1997).
Vicarious experiences. Bandura (1997) explain that vicarious
experiences refer to the symbolic modeling of the successful performance against the
challenging activities or frightening. Modeling serves as another effective tool for
promoting a sense of personal efficacy. The modeling situation is construed as an
opportunity to develop one’s knowledge and skills through the aid of proficient
models. Additionally, modeling by seeing or visualizing people similar to oneself
perform successfully typically raises efficacy beliefs in observers that themselves
possess the capabilities to master comparable activities. Moreover, by seeing oneself
perform successfully can enhance proficiency. It provides clear information on how
best to perform skills and it strengthens beliefs in one’s capability. Another prevalent
source of vicarious influence is the varied symbolic modeling provided by television
and other visual media. The accelerated growth of video technologies has vastly
expanded the range of models to which people are exposed day in and day out
(Bandura, 1997).
Verbal persuasion. Verbal persuasion serves as a further means of
strengthening people’s beliefs that they possess the capabilities to get what they seek
(Bandura, 1997). It uses suggestion, self-instruction, exhortation, and interpretive
treatment to encourage people. Verbal persuasion is most likely to be effective when
used in conjunction with mastery and modeling experiences than when used alone.
People who are persuaded verbally that they possess the capabilities to master given
tasks are likely to mobilize greater effort and sustain it than they have self-doubts and
dwell on personal deficiencies when troubles arise (Bandura, 1997). To the extent that
42
persuasive boots in perceived efficacy lead people to try for success, they promote the
development of a sense of personal efficacy and skills. Positive persuasion enhances
self-efficacy and negative persuasion decreases self-efficacy.
Physiological and affective states. The last source of efficacy beliefs
is somatic information generated by a person’s behavior, situation, or affect (Bandura,
1997). Bandura has recorded high physiological and affective states that can influence
individual performance to achieve success. People are more likely to expect failure
when they are very tense and nervous. For example, if an activity requires physical
exertion but the person quickly feels fatigue, aches, and pains, then he or she will
likely feel inefficacious about that activity. Somatic indicators of personal efficacy are
especially relevant to involve physical accomplishment, coping with stress or, and
health functioning. A person’s affect or mood can also impact self-efficacy by biasing
a person’s attention to an event, how the person interprets the event and how the
person organizes and then retrieves the event from memory. Mood gives and
additional source of affective information for judging personal efficacy because they
often accompany changes in the quality of functioning (Bandura, 1997). Enhancing
perceived self-efficacy can induce positive mood (Forgas, Bower, & Moylan as cited
in Bandura, 1997). Moreover, another way of modifying self-beliefs of efficacy is to
increase physical status, reduce level of stress and negative emotional, and correct
misinterpretation.
In conclusion, self-efficacy is fundamental to competent performance.
Self-efficacy can be enhanced by using four sources of information; enactive mastery
experiences, vicarious experiences, verbal persuasion, and psychological and affective
43
states. As a result, if people have a high level of self-efficacy they are more likely to
perform caring for patients with mild TBI.
The Existing Education Program for Family Caregivers with TBI
Several published experimental studies were reviewed to determine the
existing study about education program on family caregivers with TBI. It varied in
terms of target population, settings, teaching strategies, educations’ materials,
contents of education program, duration of intervention, follow-up, and outcomes.
Target population. The target population for education program was
family caregivers include parent, spouse, adult child, sibling, partner, friend, and other
relatives. For criteria of patients, five studies conducted in patient with mild to severe
TBI (Albert, Im, Brenner, Smith, & Waxman, 2002; Kreutzer et al., 2009; Morris,
2001; Sinnakaruppan et al., 2005), moderate to severe TBI (Backhaus et al., 2010;
Carnevale, Anselmi, Busichio, & Millis, 2002; Rivera, Elliot, Berry, & Grant, 2008;
Rodgers et al., 2007; Shocker, 2008;), and only one study was conducted in patient
with mild TBI (Utami, 2012).
Settings. Rehabilitation setting is the most places that used to provide
intervention. Two studies were conducted in the community (Albert et al., 2002;
Rivera et al., 2008). Mostly interventions were conducted in family caregiver with
patient who already discharged from hospital ranged from two months until one year.
Two studies were conducted in the hospital before discharged (Shocker, 2008; Utami,
2012).
Teaching strategies. The teaching strategies of interventions were
classified into deductive (researcher provide learning material through educational
44
sessions and might be followed by discussion); practice required skills; problem
solving, psychological support, and written information. Most of the studies combined
several methods in their education program. Two studies used deductive strategies
(Shocker, 2008; Utami, 2012) and study used deductive strategies with practice
(Sinnakaruppan et al., 2005). One study used written information (Morris, 2001). Four
studies employed a combination education, problem solving, and stress management
(Albert, 2002; Backhaus et al., 2010; Carnevale et al., 2002; Kreutzer et al., 2009;
Rivera et al., 2008; Rodgers et al., 2007). Mostly, education program was conducted
face-to-face with family caregiver. One study used telephone to provide education
(Albert et al., 2002). Moreover, educational program was provided in group
(Backhaus et al, 2010; Carnevale et al., 2002; Kreutzer et al., 2009; Sinnakaruppan et
al., 2005; Rodgers et al., 2007) or individual (Albert et al., 2002; Morris,2001; Rivera
et al., 2008; Shocker, 2008; Utami, 2012).
Education materials. During education program, family caregivers
received booklet/pamphlet (Morris, 2001, Rivera et al., 2008; Utami, 2012), handout
(Backhaus et al., 2010; Kreutzer et al., 2008; Rodgers et al., 2007; Sinnakaruppan et
al., 2005; Carnevale et al, 2002). Two studies did not provide materials for family
caregivers (Albert et al., 2002; Shocker, 2008).
Content of education program. The content of the educational
session focused on brain injury (Albert et al., 2002; Backhaus et al., 2010; Carnevale
et al, 2002; Morris, 2001; Rodgers et al., 2007; Shocker, 2008; Sinnakaruppan et al.,
2005; Utami, 2012), neurobehavioral consequences of traumatic brain injury, physical
and psychological symptoms of TBI (Albert et al., 2002; Kreutzer et al., 2008; Morris,
2001; Shocker, 2008; Sinnakaruppan et al., 2005; Utami, 2012), medical complication
45
(Rodgers et al., 2007; Utami, 2012), medication (Utami, 2012), and rehabilitation or
recovery (Albert et al., 2002; Kreutzer et al., 2008; Morris, 2001; Rodgers et al.,
2007).
Duration of intervention. The duration of the intervention is
measured using the length of intervention period, from the baseline assessment until
the completion of the program. The duration of intervention can be divided in three
categories: short-term (less than six months or 24 weeks) and long-term (six months
and more than six months). Three studies were conducted in short-term; one day
(Shocker, 2008; Utami, 2012), 4 weeks (Morris, 2001), 10 weeks (Kreutzer et al.,
2009), 12 weeks (Backhaus et al., 2010; Sinnakaruppan et al., 2005), 14 weeks
(Carnevale et al., 2002). Three studies were conducted in long-term; 6 months (Albert
et al., 2002); 1 year (Rivera, 2008), and 12-18 months (Rodgers et al., 2007).
Follow-up. The follow-up consists of two items: method and timing.
Commonly, the methods of follow-up used telephone call (Albert et al., 2002; Morris,
2001; Rivera et al., 2008) and face-to-face (Kreutzer et al., 2009; Rivera et al., 2008;
Rodgers et al., 2007; Sinnakaruppan et al., 2005). The time of follow up performed
after intervention approximately 1 month (Morris, 2001), 3 months (Backhaus et al.,
2010; Kreutzer et al.,2009; Sinnakaruppan et al., 2005), 6 months (Albert et al.,
2002), and more than 6 months (Rivera et al., 2008; Rodgers et al., 2007). Two
studies did not provide follow-up (Shocker, 2008; Utami, 2012).
Outcomes. The major results after following education programs are
reducing distress, depression, and anxiety (Albert et al., 2002; Backhaus et al., 2010;
Carnevale et al., 2002; Kreutzer et al., 2009; Morris, 2001; Rodgers et al., 2006;
Rivera et al., 2008; Shocker, 2008; Sinnakaruppan et al., 2005). Other outcomes were
46
reducing family’s burden (Albert et al., 2002; Rodgers et al., 2006), increasing level
of knowledge (Shocker, 2008), improving caregivers’ satisfaction (Albert et al.,
2002), and increasing of self-efficacy (Backhaus et al., 2010; Sinnakaruppan et al.,
2005; Utami, 2012). Additionally, education for family caregivers may help family
caregivers to increase in met family needs, perceived access to services (Kreutzer
et al., 2009) and support from health care professionals (Albert et al., 2002). Only one
study concerned to improve family competence (Albert et al., 2002). The outcomes of
these studies were measured at different periods of time, such as immediately after
program (Shocker, 2008; Utami, 2012), 1 week after the program (Morris, 2001), 5
weeks (Carnevale et al., 2002), 3 months (Backhaus et al., 2010; Kreutzer et al., 2009;
Sinnakaruppan et al., 2005), 6 months (Albert et al., 2002), and 1 year (Rodgers et al.,
2006; Rivera et al., 2008).
There is one study that is concerned with an education program on
family caregivers’ competencies in caring for patients with mild TBI. Utami (2012)
conducted a quasi-experiment study that aimed to examine the effect of health
education on family caregivers’ self-efficacy and desires in caring for mild TBI
patients. The researcher provided an education program for forty nine family
caregivers (23 family caregivers of the control group and 26 family caregivers of the
experimental group) with mild TBI in the emergency department. The contents of the
program included signs and symptoms of warning signs, diet, activity and rest,
medication, and post-concussion symptoms. The family caregivers’ self-efficacy and
desires were directly measured twice at pre and post intervention. This study did not
mention about the underlying theory of the program, the duration of the program, and
did not apply a follow-up. The findings showed the mean score of self-efficacy was
47
significantly higher than before receiving the program. However, the family
caregivers’ desires for caring for their patients with mild TBI were significantly
increased in both groups. The mean of the self-efficacy of the experimental group was
significantly higher than of the control group. In addition, the results of the family
caregivers’ desires of the experimental group were significantly different between the
groups (p < .05).
Apart from the studies listed above, there are two studies that concern
about education program on family competency in different population. The first one
is a study by Srijumnong (2010). The quasi-experimental study aimed to know the
effect of self-efficacy promotion program for thirty family caregivers of people with
stroke at home on their perceived self-efficacy, outcome expectation of care, and
satisfaction with the program. This study was conducted based on Bandura’s SelfEfficacy Theory included training the family caregivers before the patients were
discharge until eighth week after discharge. The researcher applied the home visit,
counseling, and giving advice in person and by telephone. The contents of program
were expressing about family caregiver’s opinion regarding caring benefits known or
encountered in caring experiences, lecturing, watching VCD on caring for persons
with stroke, teaching and demonstration. Then, the researcher conducted followed-up
in the first, second, fourth, and sixth week after discharge. The measurement of selfefficacy used tools that consisted of 19 items and the measurement of outcome
expectation used fourteen items. The result of this study showed significantly higher
perceived self-efficacy and outcome expectation of family caregiver’s care at the sixth
and eight week than before the program began.
48
The second one is a study by Kouri, Ducharme, and Giroux (2011)
who conducted the educational intervention to support family caregivers with
Alzheimer’s disease based on Bandura’s Self-efficacy Theory. The researchers used
four sources from Bandura (1997) in their program such as demonstration and redemonstration about communication skills, sharing with the subjects, explore feeling
to reduce fears and anxieties. The duration of education was two hours. The
researchers used the Caregiver Self-efficacy Scale from Bandura to measure family
caregivers’ self-efficacy and the Communication Skills Questionnaire to measure
family caregivers’ performance in communication with the patients. The findings
showed statistically significant on family caregivers’ self-efficacy and skills.
Summary
To sum up, the literature review of this study provides fundamental of
knowledge for the development of self-efficacy enhancing education program to
improve family caregivers’ competencies in term perceived confidence and
performance in caring for patients with mild TBI in Indonesia. Mild TBI is an acute
brain injury resulted from external mechanical force to the head that had at least one
characteristic such as GCS score 13-15 at 30 minute after injury, post traumatic
amnesia less than 24 hours, duration of loss of consciousness for 30 minute or less, no
focal neurology deficit and normal neuro imaging. Patients’ symptoms experienced
after mild TBI can be categorized as physical, cognitive, and emotional/affective
symptoms. There are three family caregivers’ competencies in caring for patients with
mild TBI, namely assessing warning signs and patients’ symptoms after mild TBI,
49
managing patients’ symptoms, and evaluating patients’ symptoms after providing
care. There are several factors can influence the family caregivers’ competencies in
caring for patients with mild TBI, either personal or external factors.
Several studies were reviewed to determine the existing study about
education program on family caregivers with TBI. The program used combination
methods to provide information for family caregivers and mostly education program
was given after the patients were discharge from hospital, only two studies were
conducted during the hospitalization. Mostly, the outcomes of previous studies
showed reduce emotional problem. Three studies had outcome to increase family
caregiver’s self-efficacy. But all of these studies did not measure the family
caregivers’ competencies in term family caregivers’ performance or skill. There were
two studies in different population that conducted education program based on selfefficacy from Bandura. These studies measured family caregivers’ self-efficacy and
one of these studies measured about family caregivers’ skill or performance.
Therefore, in this present study, researcher would like to conduct a self-efficacy
enhancing education program on family caregivers’ competencies in caring for
patients with mild TBI in Indonesia.
50
CHAPTER 3
RESEARCH METHODOLOGY
This chapter presents the design, variables, setting, population and
sample, sampling procedure, research instruments, validity and reliability of the
instruments, translation of instruments, ethical consideration, data collection methods,
and data analysis.
Research Design
This study was a quasi-experimental study, two groups pre-test and
post-test design with a non equivalent control group. It was conducted to examine the
effect of a self-efficacy enhancing education program on family caregivers’
competencies in caring for patients with mild TBI. The control group received routine
care and the experimental group received both the self-efficacy enhancing education
program and routine care. The research design was as follows:
Pre-test
Post-test
Hospital
Home
Control group
N
O1c
Experimental group
N
O1c
X
1 week
2 week
O1p
O2c, O2p
O1p
O2c, O2p
O1c : refers to the baseline data (pre-test score) of family caregivers’ competencies
(perceived confidence)
51
X
: refers to a self-efficacy enhancing education program
N
: non equivalent/ non randomization
O2c : refers to post-test score of family caregivers’ competencies (perceived
confidence)
O1p : refers to the first post-test score of family caregivers’ competencies
(performance) after receiving a self-efficacy enhancing education program at
the first week after discharge
O2p : refers to the second post-test score of family caregivers’ competencies
(performance) after receiving a self-efficacy enhancing education program at
the second week after discharge
Variables
The independent variable in this study was the self-efficacy enhancing
education program. The dependent variables were family caregivers’ competencies
(perceived confidence and performance) in caring for patients with mild TBI.
Setting
This study was conducted in a surgical ward of PKU Muhammadiyah
Yogyakarta and PKU Muhammadiyah Bantul Hospital, Yogyakarta, Indonesia. Both
hospitals are referral hospitals in which received all patients from various regions in
Yogyakarta Province. These hospitals have been standardized by the Ministry of
Health Republic Indonesia as a level B of accreditation. In addition, these hospitals
52
are located in the centre of the city and have comprehensive facilities like a Computed
Tomography (CT) scan, so patients and their family caregivers have easy access.
Population and Sample
Population
The population of this study was the family caregivers of patients with
mild TBI who were admitted to the target hospitals during the study period.
Sample Size
The sample size estimation of the study was based on a power analysis
by using the effect size (d), as calculated from a previous study by Srijumnong
(2010). It was conducted on the effect of a self-efficacy promotion program for family
caregivers of persons with a stroke. The researcher identified the sample size using
power analysis (Appendix A). The calculation of the effect size was 1.03. Since this
study is conducted in a different population the effect size of 0.8 was used as a large
effect size to calculate the sample size. According to Polit and Beck (2008) to achieve
alpha (α = .05), power (p = .80), and effect size (d = 0.80), at least 25 subjects were
required per group (experimental and control group) or a total of 50 subjects.
Inclusion Criteria
The sample of this study was selected using the inclusion criteria for
the family caregiver as follows: (1) age > 17 years - 70 years, (2) had the first time
experience in caring for patients with mild TBI, (3) who were identified by patients
53
that they had the primary responsibility in providing care for them, (4) lived with the
mild TBI patient, (5) did not have any history of psychiatric disorders, physical
problems, and hearing problems, (6) were able to communicate in the Indonesian
language both verbally and in writing, (7) had access to telephone contact, and (8)
consent to participate in the study either verbally or with written consent. Moreover,
the inclusions criteria for patients were (1) persons with a mild TBI who have been
diagnosed by a doctor, and (2) age > 17 years old.
Sampling Procedure
The sample of the present study was taken from the surgical ward of
two hospitals. The subjects who met the inclusion criteria were approached by a
nurse. They were approached to ascertain his/her willingness to participate in the
study. Then, the researcher assigned first the 25 family caregivers in the control
group. After the control group was filled with the correct number of subjects, the
researcher placed the 25 family caregivers in the experimental group.
Instrumentation
There are two parts of instruments that were used in this study, part
one was a self-efficacy enhancing education program and part two were the data
collection instruments, including the demographic data form, and the family
competencies questionnaire (Perceived Confidence Questionnaire and Performance
Questionnaire). Each part of the instrument was described as follows:
54
Part I: Self-Efficacy Enhancing Education Program
The self-efficacy enhancing education program was developed by the
researcher based on self-efficacy by Bandura (1997), the content of the education
program and literature review about family caregivers’ competencies in caring for a
patient with mild TBI. This program covered the four domains of self-efficacy
sources; verbal persuasion, vicarious experience, mastery experiences, and
physiological, affective states, and conducted weekly telephone follow-up (Appendix
I). This program was conducted over two weeks. The description of the program was
as follows:
During hospitalization, the researcher conducted individual a selfefficacy enhancing education programs and family caregivers received intervention
sessions as follows: (1) exploring feelings before the education program; (2) a
teaching session which included definition of mild TBI, symptoms assessment,
symptoms management, and symptoms evaluation, and providing reinforcement and
support; (3) demonstration and re-demonstration of the assessment of symptoms
using a symptom checklist; 4) sharing information about successfully of mild TBI
management and showing the pictures about management of symptoms: neck
stretching, sleeping position, and vestibular exercise (Appendix J). During this
session, family caregivers received the management of mild TBI booklet (Appendix
K). The content of the booklet included a definition of mild TBI, the symptoms
following mild TBI, warning signs, symptoms checklist, and the management of
symptoms. These sessions take about 60 minutes.
The first week after discharge, (5) the researcher then conducted a
telephone follow-up in order to evaluate the competencies during implementation of
55
the programs. In this session, the researcher asked the family caregiver; a progress
report related to performance in caring for the patient with mild TBI at home, the
concerns or worries were providing care for the patient with mild TBI and provided
information related to family caregivers’ concerns, reinforcement for any success of
the family caregiver to assess symptoms, manage symptoms, and evaluate symptom
of mild TBI, evaluated the family caregivers’ performance related to symptoms
assessment, symptoms management, and symptoms evaluation using the PQ, provided
support to the family caregivers related to their performance in caring for patients
with mild TBI. The second week after discharge, and (6) the researcher conducted
activities that similar to the first week.
Part II: Data Collection Instruments
Demographic Data Questionnaire (DDQ). The DDQ consists of
Family Caregivers Demographic Data Questionnaire (FDDQ), Patient Demographic
Data Questionnaire (PDDQ), and Injury Characteristics (IC). The FDDQ (Appendix
C) and PDDQ (appendix D) were used to collect the patient’s and family caregiver’s
data. Data about the family caregivers included age, gender, marital status, religion,
educational level, and occupation. The FDDQ and PDDQ form were completed by the
family caregivers before the education program began. The IC (Appendix E) was used
to collect the patient’s injury characteristics. This information was obtained from
medical records as well as in an interview format with the patient and his or her
family members; the date of the injury, etiology, GCS score admission, CT scan,
other injuries, and duration of hospitalization.
56
The Rivermead Post-concussion Symptom Questionnaire (RPSQ).
The RPQ was developed by King, Crawford, Wenden, Moss, and Wade (1995). This
RPQ (Appendix F) was used to assess the number of symptoms of patients who
sustain a concussion/mild TBI. It includes physical, cognitive, and emotional
symptoms and is composed of 15 items list of symptoms, using yes/no answers. The
total score ranges from 0 to 15. A higher score implies the number of patient’s
symptoms.
The Perceived Confidence Questionnaire (PCQ). This instrument
was developed by the researcher. It was used to measure the family caregivers’
confidence regarding care for the patient with a mild TBI and consists of three
domains; the confidence of the family caregiver to assess warning signs and four
common symptoms of mild TBI, the confidence of family caregiver to manage the
warning signs and four common symptoms, and the confidence of the family
caregiver to evaluate the four symptoms (Appendix G). This questionnaire consists of
23 items and uses a 4-point Likert scale that was scored from 1 to 4; no confidence =
1, low confidence = 2, moderate confidence = 3, and high confidence = 4. The total
perceived confidence score ranges from 23 to 92. A higher score implies a higher
level of perceived confidence of family caregiver.
The Performance Questionnaire (PQ).This instrument was
developed by the researcher. It is used to measure the family caregivers’ performance
regarding care for a patient with mild TBI and consists of three domains; the
performance of the family caregiver to assess the four symptoms of a mild TBI, the
performance of family caregiver to manage symptoms, and the performance of the
family caregiver to evaluate symptoms (Appendix H). This questionnaire consists of
57
three parts. Part I, family caregivers were asked about warning signs and symptom
following the mild TBI that occurred in the patients. Part II measured family
caregivers’ performance related to symptoms assessment, symptoms management and
symptoms evaluation. Part III is an addition statement that asked family caregivers
action if patients have warning signs and symptom following mild TBI. This
questionnaire consists of nineteen statements using a 5-point Likert scale that is
scored from 1 to 5; never = 1, rarely= 2, sometimes = 3, often = 4, and regularly= 5.
The performance of the symptoms assessment consists of four statements about the
family caregivers’ performance to assess the four common symptoms. The total
performance score ranges from 19 to 95. A higher score of performance regarding
care for patients with mild TBI indicates a high level of family caregiver’s
performance.
Translation of the Instruments
The original instruments of this study were developed in the English
version. The instruments were examined for content validity by three experts. After
validation, the instruments were translated into Indonesian language. For developing
the Indonesian version of all tools, the researchers used the back-translation technique
for equivalence across the languages of these questionnaires. In this study, backtranslation was employed in which the preferred back-translation approach requires at
least two independent translators (Hilton & Skrutkowski, 2002). The first bilingual
expert translator translated the original English version of the questionnaires into the
Indonesian language. Then, the second bilingual translator translated the Indonesian
58
version back into English (second version). Both of translators were consulted to
identify discrepancies, and adjustments were made for inconsistencies. Some
discrepancies were found between the two English versions, which were “dizziness”
and assess”. Revision of the Indonesian version was based on the results of these
discussions.
Validity and Reliability of the Instruments
Validity of the Instruments
The intervention program, performance questionnaire, perceived
confidence questionnaire, teaching plan, and booklet were validated by three experts
in neurosurgical care. One of them was a doctor (neurosurgeon) from Songkla
Hospital, Thailand, one was an APN of neurosurgical intensive care from Hatyai
Hospital, Thailand, and one was a lecturer who was expert in TBI from the Faculty of
Nursing, Prince of Songkla University, Thailand. The recommendations from all
experts were performed to modify the instruments. The recommendations for the
Injury Characteristics Questionnaire included the additional cause of injury such as
car accident, body assault, blast injury, and sport injury. In addition, the
recommendations of the Rivermead Post-concussion Symptom Questionnaire (RPSQ)
included the additional explanation of fatigue symptoms using feeling more tired and
lacking energy.
59
Reliability of the Instruments
The researcher examined the internal consistency reliability of the
instruments. The Cronbach’s alpha coefficient was used to determine the internal
consistency reliability of the Perceived Confidence Questionnaire (PCQ) and the
Performance Questionnaire (PQ). The instruments were tested on 20 family
caregivers who met the same inclusion criteria. The results showed that the reliability
coefficient of the PCQ and PQ were .96 and .68 which was considered as reliable for
a newly developed instrument (Polit & Beck, 2008). The test-retest reliability of the
Rivermead Post Concussion Symptom Questionnaire (RPQ) was assessed with Kappa
coefficient. According to Landis and Koch as cited in Wynd, Schmidt, and Schaefer
(2003), there are six levels of strength of agreement; poor (<.00), slight (.00 - .20),
fair (.21 - .40), moderate (.41 - .60), substantial (.61 - .80), and almost perfect (.81 –
1.00). The result of test-retest of RPQ showed that five symptoms were considered as
very good (noisy, restless, frustrated, and difficulty in thinking), six symptoms were
considered as good (poor concentration, difficulty in remembering, sleep disturbance,
fatigue, and light sensitivity), two symptoms were considered as moderate (blurred
vision and double vision), two symptoms were considered as slight (headache and
nausea), and one symptom (anger) could not be tested because of no value ability.
Pilot Study
The purpose of the pilot study was to test the feasibility of the methods
and procedures for later use on a large scale (Everitt as cited in Thabane et al., 2010).
The pilot study was conducted with 3 family caregivers who met the inclusion criteria
at PKU Muhammadiyah Yogyakarta Hospital, Yogyakarta, Indonesia. They received
60
a self-efficacy enhancing education program with two follow-up telephone calls for
four weeks. The result of the pilot study showed that the self-efficacy enhancing
education program was feasible to be implemented in the target setting but the time of
follow-up must be shorten from four weeks to two weeks. Then the researcher revised
the time of follow-up plan. This pilot study was one kind of face validity.
Data Collection Procedures
The data collection procedures were divided into two phases:
preparation and implementation phase.
Preparation Phase
In the preparation phase, the researcher carried out the following steps:
(1) obtained official approval from the Faculty of Nursing Prince of Songkla
University; (2) obtained official permission for data collection from PKU
Muhammadiyah Yogyakarta Hospital and PKU Muhammadiyah Bantul Hospital,
Yogyakarta, Indonesia; (3) prepared the materials and the questionnaire package
including informed consent; (4) tested the validity and reliability of the instruments;
(5) recruited two research assistants (RAs) who have at least a bachelor degree of
nursing; (6) conducted training for the RAs; and (7) conducted the pilot study.
The RAs had the responsibility to carry out the pre-test and post-test
data collection. There were three steps of training for the RAs. First, the researcher
explained the objectives, protocol and the instruments used in this study. Secondly,
the researcher provided an explanation about the RA’s role and responsibility. Lastly,
61
the researcher and RAs reviewed each questionnaire. The RAs asked about any
confusion and the researcher clarified them during this process to ensure that the RAs
were able to answer any questions from the family caregivers during data collection.
Implementation Phase
In the implementation phase, the researcher carried out the following
steps: (1) asked the nurse in the surgical ward to select the family caregivers based on
the inclusion criteria; (2) asked the family caregivers regarding their willingness to
join in the study, the researcher conducted the study in the control group first; (3)
explained the objectives of the study and asked the family caregivers to sign the
informed consent form (Appendix B); (4) the RA collected the data, family caregivers
were asked to complete the Demographic Data Questionnaire for the family
caregivers and patient (DDQ), information from medical records regarding injury
characteristics was collected and an assessment of the patient’s symptom using the
Rivermead Post-concussion Symptom Questionnaire (RPSQ) was also undertaken and
the family caregivers’ perceived confidence was measured using the Perceived
Confidence Questionnaire (PCQ); (5) family caregivers received routine care; (6)
after the first week of the patient’s discharge, the RA conducted telephone calls to
measure the performance using the Performance Questionnaire (PQ). In the second
week, the researcher measured both the family caregivers’ performance and perceived
confidence.
After the number of family caregivers were fulfilled (n =25), the
researcher continued to conduct the intervention in the experimental group. Under the
same conditions, (7) the RA collected the data using DDQ, injury characteristics of
62
patients, RPSQ, PCQ and PQ. After completing the questionnaires, (8) the family
caregivers received a self-efficacy enhancing education program. The program was
conducted in one session of around 60 minutes during hospitalization. In this
program, the researcher asked the family caregivers to explore their feelings about
caring for patients with mild TBI, taught about the definition, warning signs and
symptoms after mild TBI, and caring for the patients with mild TBI, demonstrated
some skills about the assessment and management of symptoms, and asked the family
caregivers to re-demonstrate these skills. The researcher also shared information
about the success of management for patients with mild TBI and showed some
pictures related to symptoms management. A booklet was also provided by the
researcher. After the first week of the patient’s discharge; (9) the researcher
conducted the first follow-up telephone calls. In this program, the researcher asked the
family caregivers for a progress report related to caring for patients with mild TBI,
asked about their concerns and worries while providing care, provided information
related their concerns, provided reinforcement for any success and support for their
performance in caring for patients with mild TBI; (10) the RA conducted telephone
calls to measure the family caregivers’ performance using PQ; (11) the researcher
conducted the second follow-up telephone calls in which the activities were similar to
the previous follow-up; and (12) the RA measured the family caregivers’ performance
and perceived confidence using telephone calls. Figure 2 on the next page shows the
details of the implementation protocols of data collection procedures.
63
Ethical Considerations
This study was conducted after obtaining approval from the Research
Ethics Committee of the Faculty of Nursing, Prince of Songkla University and
permission from PKU Muhammadiyah Yogyakarta Hospital and PKU
Muhammadiyah Bantul Hospital, Yogyakarta, Indonesia. The nurses in the ward
introduced the researcher and RAs to the potential subjects. The researcher explained
the objectives of the study, the procedure, and the possible benefits and risks of the
study to the participants (Appendix B). The participants received information that
they have the right to choose whether to participate in the program or they may
withdraw at any time without any negative consequences. The participants conveyed
their agreement to participate in the program verbally and the written consent. The
researcher provided contact information including a telephone number and address for
future reference. All of the subjects’ information was kept confidential. Moreover, the
subjects in the control group received education or counseling after the program was
finished.
64
Surgical Ward PKU Muhammadiyah Yogyakarta & PKU Muhammadiyah Bantul Hospital
Family caregivers and patient with mild TBI who met the inclusion criteria
Hospital
Discharge
from
hospital
Home
Experimental group (n = 25)
Control group (n = 25)
Pre-test: DDQ, RPSQ, PCQ
Pre-test: DDQ, RPSQ, PCQ
Routine care and a self-efficacy enhancing education program
- Exploring the family caregivers’ feelings about caring for patient
with mild TBI
- Teaching: definition and impact of mild TBI, symptoms following
mild TBI and warning signs, caring for patients with mild TBI.
- Providing reinforcement and support
- Demonstrating and re-demonstrating: assessment of symptoms using
the symptom checklist
- Sharing information about success of management for patients with
mild TBI, show pictures about symptoms management for patients
with mild TBI (neck stretching, sleep position, and vestibular
exercises
- Providing mild TBI booklet which contained all the topics
Routine
care
The first week after discharge: Follow-up telephone calls
- Asking the family caregivers about progress report related to perceived
confidence and performance in caring for patient with mild TBI
- Asking the family about concerns or worries while providing care
- Provide information related to family caregivers’ concern
- Providing reinforcement for any success of the family caregiver to
assess the symptom, manage and evaluate the symptoms of mild TBI
- Providing support to family caregivers for family caregivers’
performance in caring for the patient with mild TBI
Post-test: PQ
Post-test: PQ
The second week after discharge: Follow-up telephone calls
- Asking the family caregivers about progress report related to
performance in caring for the patient with mild TBI
- Providing reinforcement for any success
- Providing support to family caregivers for family caregivers’
performance in caring for the patient with mild TBI
Post-test: PQ, PCQ
Pos-test: PQ, PCQ
DDQ = Demographic Data Questionnaire); RPSQ = Rivermead Post-concussion Symptoms Questionnaire;
PCQ = Perceived Confidence Questionnaire); PQ = Performance questionnaire.
Figure 2. The implementation protocol of data collection procedures
65
Data Analysis
Data were analyzed using descriptive and inferential statistics.
Descriptive statistics were used to analyze and describe the family caregivers’ and
patients’ demographic data, and patients’ clinical characteristics by using frequency,
percentage, mean, and standard deviation. The Chi-square test, Fisher exact test, and
Likelihood Ratio were used to test the equivalence of the proportion of demographic
data and clinical characteristics between the control group and experimental group.
The researcher tested the assumption of the normality and
homogeneity of variance of data sets of family caregivers’ perceived confidence and
family caregivers’ performance. The normal distributions were determined by
skewness and kurtosis, while, the homogeneities were determined by the non
significance of the Levene’s test (Munro, 2001). The perceived confidence in caring
for patients with mild TBI of both the control group and the experimental group met
the assumptions. The dependent t-test was used to test the mean score differences of
perceived confidence within the experimental group before and after receiving a selfefficacy enhancing education program, while the independent t-test was used to test
the mean differences of perceived confidence between groups. The performance in
caring for patients with mild TBI of both the control group and the experimental
group did not meet the assumptions. Wilcoxon Signed Rank test was used to test the
difference in the mean rank scores of performance within the experimental group,
while Mann-Whitney U test was used to test the difference in the mean rank scores of
performance between groups. The level of significance was set at p < .05.
66
CHAPTER 4
RESUTS AND DISCUSSION
This chapter presents the results and discussion of the study’s findings.
It is presented in three parts, namely: Part I: The demographic characteristics of the
family caregivers, Part II: The demographic characteristics of patients, and patients’
clinical characteristics; Part III: The effect of a self-efficacy enhancing education
program on family caregivers’ competencies in caring for patients with mild TBI
within and between groups.
Results
Part I: Demographic Characteristics’ of Family Caregivers
Demographic characteristics of family caregivers. Table 1 shows
that the mean age of the subjects in the control group was 38.76 years old (SD =
10.30) and the experimental group was 43.96 years old (SD = 14.27). More than half
of the subjects in both groups were female. The majority of the subjects in both
groups were married and Moslem. Half of the subjects in the control group (53%)
had secondary school education while half of the subjects in the experimental group
(48%) had primary school education. More than half of the subjects in both groups
were employed. The subjects in both groups had a relationship with the patients as a
spousal, 36% of the control group and 44% of the experimental group. There were no
statistical differences in the demographic characteristics between the two groups.
67
Table 1
Frequencies and Percentages of Family Caregivers’ Characteristics of the Control
and the Experimental Group (N =50)
Control Group
(n = 25)
n
%
MD (SD)
38.76 (10.30)
15
60
9
36
1
4
Experimental Group
(n = 25)
n
%
MD (SD)
43.96 (14.27)
9
36
14
56
2
8
Total
Characteristics
n
%
Age
(Min-Max = 20-69)
20-40
24 48
41-60
23 46
>60
3
6
Gender
Female
16
64
14
56
30 60
Male
9
36
11
44
20 40
Marital Status
Married
22
88
19
76
41 82
Single
3
12
5
20
8 16
Widowed
1
4
1
2
Religion
Moslem
25
100
24
96
49 98
Christian
1
4
1
2
Education Level
Primary School
9
36
12
48
21 42
Secondary School
13
52
8
32
21 42
College/university
3
12
5
20
8 16
Occupation
No occupation
7
28
9
36
16 32
Had occupation
18
72
16
64
34 68
- Government
officer
1
4
3
12
4
8
- Laborer
1
40
8
32
18 36
- Farmer
7
28
5
20
12 24
Relationship
Spouse
9
36
11
44
20 40
Parent
3
12
7
28
10 20
Child
7
28
4
16
11 22
Other relative
6
24
3
12
9 18
Note. a = Likelihood ratio test, b = Chi-square test, c = Fisher’s exact test.
Statistics
2.95a
p
.23
0.33b
.56
2.11a
.35
1.02c
1.00
9.26a
.10
3.62a
.46
8.64a
.20
68
Part II: Demographic Characteristics’ of Patients and Patients’ Clinical
Characteristics
Demographic characteristics of patients with mild TBI. The mean
age of the patients in the control group was 41.12 years old (SD = 16.20) and the
experimental group was 41.08 (SD = 18.58). Half of the patients in both groups were
female. More than half of the subjects in the control group were married (64%), while
a half of the subjects in the experimental group were married (48%). The majority of
subjects in both groups were Moslem. Half of the subjects both in groups had
secondary school education, 56% of the control group and 60% of the experimental
group. More than half of the subjects in the control group were employed (76%) and
the majority of subjects in the experimental group were employed (92%). There were
no statistical differences in the demographic characteristics between both groups
(Table 2).
Table 2
Frequencies and Percentages of Patients Characteristics of the Control and the
Experimental Group (N =50)
Control
Group
(n = 25)
n
%
MD (SD)
41.12 (16.20)
13
52
10
40
2
8
Experimental
Group
(n = 25)
n
%
MD (SD)
41.08 (18.58)
13
52
8
32
4
16
Total
Characteristics
n
%
Statistics
Age
MD (SD)
.90a
(Min-Max = 17-85)
41.10 (17.25)
17-40
26
52
41-60
18
36
>60
6
12
Gender
.08b
Female
14
56
13
52
27
54
Male
11
44
12
48
23
46
Marital Status
1.39a
Married
16
64
12
48
28
56
a
b
c
Note. = Likelihood ratio test, = Chi-square test, = Fisher’s exact test.
p
.64
1.00
.50
69
Table 2 (continued)
Control
Group
(n = 25)
n
%
Experimental
Group
(n = 25)
n
%
Total
Characteristics
n
%
Statistics
Marital Status
1.39a
Single
8
32
11
44
19
38
Widowed
1
4
2
8
3
6
Religion
1.02c
Moslem
25
100
24
96
49
98
Christian
1
4
1
2
Education Level
1.87a
Primary School
8
32
7
28
15
30
Secondary School
14
56
15
60
29
58
College/university
3
12
3
12
6
12
Occupation
3.93a
No occupation
6
24
2
8
8
16
Had occupation
19
76
23
92
42
84
- Government
officer
2
8
3
12
5
10
- Laborer
10
40
14
56
24
48
- Farmer
4
16
3
12
7
14
- Student
3
12
3
12
6
12
Note. a = Likelihood ratio test, b = Chi-square test, c = Fisher’s exact test.
p
.50
1.00
.87
.56
Patients’ clinical characteristics. Table 3 shows that the majority of
causes of injury in both groups were mainly from motorcycle accidents. Almost all
subjects had a GCS on admission at 15. With regards to the CT scan, 48% subjects of
the control group had cerebral edema, while, the experimental group had 40% with
normal findings and 40% with cerebral edema. More than half of the subjects in both
groups were hospitalized from 4 days up to 6 days. Regarding the patients’ symptoms
at discharge, the majority of the subjects in both groups had symptoms (92%) and the
majority of symptom was headache. There were no statistical differences in the
clinical characteristics between the two groups.
70
Table 3
Frequencies and Percentages of Patients’ Clinical Characteristics of the Control
Group and the Experimental Group (N = 50)
Control
Group
(n = 25)
n
%
Experimental
Group
(n = 25)
n
%
Total
Characteristics
n
%
Statistics
p
a
Cause of injury
4.86
.18
Bicycle accident
1
4
2
8
3
6
Motorcycle accident
24
96
20
80
44
88
2
Falling injury
2
8
4
1
1
2
Other
4
.24
GCS Score
2.87a
4
1
1
2
13
4
1
1
2
14
92
48
25
96
23
15
100
.66
CT Scan
1.62a
44
21
10
42
11
Normal
40
48
22
10
44
12
Cerebral edema
40
4
4
8
1
3
SDH/EDH
12
Extracranial
4
3
6
1
2
hematoma
8
1.00
Other injuries
.00b
16
8
16
4
4
Yes
16
84
42
84
21
21
No
84
.59
Hospitalization
1.06a
(min-max 3 – 14 days)
16
6
12
4
2
1-3 days
8
52
29
58
13
16
4-6 days
64
32
15
30
8
7
28
>7 days
Symptoms
.31
4
4
8
1
3
12
No symptom
.61b
96
46
92
24
22
88
Had symptom
92
23
16
64
- Headache
80
20
16
64
- Dizziness
32
8
6
24
- Fatigue
- Difficulty in
8
2
3
12
remembering
52
13
15
60
- Nausea
12
3
3
12
- Noise
28
7
5
20
- Sleep disturbance
20
5
1
4
- Restlessness
- Light sensitivity
4
16
Note. a= Likelihood ratio test, b= Fisher’s exact test; SDH = subdural hematoma, EDH
= epidural hematoma.
71
Table 3 (continued)
Control
Group
(n = 25)
n
%
4
16
2
8
2
8
Experimental
Group
Total
(n = 25)
Characteristics
n
%
n
%
Statistics
p
- Blurred vision
3
12
- Double vision
1
4
- Feeling frustration
1
4
- Irritability
1
4
- Poor concentration
2
8
3
12
- Longer to think
8
8
2
8
Note. a= Likelihood ratio test, b= Fisher’s exact test; SDH = subdural hematoma, EDH
= epidural hematoma.
Part III: The Effect of a Self-Efficacy Enhancing Education Program on Family
Caregivers’ Competencies in Caring for Patients with Mild TBI
Before testing the effect of a self-efficacy enhancing education
program on family caregivers’ perceived confidence and performance in caring for
patients with mild TBI, the family caregivers’ perceived confidence in caring for
patients with mild TBI at the baseline was assessed. Table 4 showed that there were
no significant differences of perceived confidence between the control group and the
experimental group (Table 4). The mean score of perceived confidence in the control
group and the experimental group were 51.24 (10.76) and 57.60 (16.62), respectively.
Table 4
Comparison of the Perceived Confidence Scores in Caring for Patients with Mild TBI
between Two Groups before Intervention (N = 50)
Variable
Perceived confidence
Control Group
(n = 25)
M
SD
51.24
10.76
Experimental Group
(n = 25)
M
SD
57.60
16.62
t
1.61
p
.12
72
Family caregivers’ perceived confidence in caring for patients with
mild TBI within the experimental group. The mean scores of the perceived
confidence at pre-test and post-test score in the experimental group were 57.60
(16.62) and 80.68 (9.67), respectively. The dependent t-test showed that the mean
score of the perceived confidence of subjects in the experimental group after received
a self-efficacy enhancing education program was significantly higher than before
(t = -8.44, p < .05) (Table 5). This result supported the first hypothesis.
Table 5
Comparison of the Perceived Confidence Pre-test and Post-test Scores in Caring for
Patients with Mild TBI within the Experimental Group (N=25)
Perceived Confidence
Pre-test
Post-test
Experimental Group
M
SD
57.60
16.62
80.68
9.67
t
-8.44
p
.00
Family caregivers’ performance in caring for patients with mild
TBI within the experimental group. Table 6 shows the performance in the
experimental group at the first week and the second week. The mean rank of the
performance in the first week and the second week in the experimental group were
6.00 and .00. Using a Wilcoxon Signed Rank test, the result of performance score in
the experimental group after received a self-efficacy enhancing education program at
the second week was significantly lower than those in the first week (Z = -2.94,
p < .05). This result did not support the second hypothesis (Table 6).
73
Table 6
Comparison of the Performance Scores in Caring for Patients with Mild TBI in the
First Week and Second Week within the Experimental Group (N=25)
First week
Performance
MR (SR)
Experimental Group
6.00 (66.00)
Note. MR = mean rank, SR = sum of rank.
Second week
MR (SR)
.00 (.00)
Z
-2.94
p
.00
However, when comparing the family caregivers’ performance in
caring for patients with mild TBI in the first week and the second week based on each
domain of caring for patients with mild TBI, it was shown that the majority of
performances in the second week were decreased except two domains which were
assessing warning signs and managing headache (Table 7).
Table 7
Comparison of the Performance Scores in the First Week and Second Week Based on
Each Domain of Caring for Patients with Mild TBI within the Experimental Group
(N=25)
Performance
First week
MR
SR
0.00
0 .00
6.00
66.00
0.00
0 .00
5.50
55.00
6.00
66.00
Assessing warning signs
Assessing symptoms
Managing headache
Managing dizziness
Managing fatigue
Managing difficulty in
remembering
5.00
45.00
Evaluating symptoms
5.00
45.00
Note. MR = mean rank, SR = sum of rank.
Second week
MR
SR
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Z
p
0.00
-2.95
0.00
-2.83
-2.96
1.00
.00
1.00
.00
.03
0.00
0.00
-2.70
-2.75
.00
.01
0.00
0.00
Family caregivers’ perceived confidence in caring for patients with
mild TBI between groups. Regarding the family caregiver’s perceived confidence
score, an independent t-test was used to examine the differences between the groups
74
(Table 8). After receiving a self-efficacy enhancing education program, the mean
score of perceived confidence in the experimental group was significantly higher than
that of the control group (t = 8.30, p < .05). The findings supported the third
hypothesis.
Table 8
Comparison of the Perceived Confidence Scores in Caring for Patients with Mild TBI
between Two Groups (N =50)
Perceived confidence
Post-test
Control Group
(n = 25)
M
SD
52.96
13.60
Experimental Group
(n = 25)
M
SD
80.68
9.67
t
8.30
p
.00
Family caregivers’ performance in caring for patients with mild
TBI between groups. In order to examine the effect of a self-efficacy enhancing
education program, the performance at the second week of the experimental group
and the control group were examined by using Mann-Whitney U test. Table 9 shows
that the mean rank of performance in the control group and the experimental group
were 13.00 and 38.00, respectively. The significant difference was found (U = .00,
p < .05).
Table 9
Comparison of the Performance Scores in Caring for Patients with Mild TBI in the
Second Week between Two Groups (N =50)
Control Group
Experimental Group
(n = 25)
(n = 25)
Performance
MR (SR)
MR (SR)
Second week
13.00 (325.00)
38.00 (950.00)
Note. MR = mean rank, SR = sum of rank.
U
0.00
p
.00
75
Patients’ symptoms. In regards to the patient’s symptoms before
discharge that were reported by patients and the patients’ symptoms after discharge
that were reported by family caregivers, Table 10 shows that the majority of patients’
symptoms in both groups were headaches. Three of the patients’ symptoms remained
during the first week and the second week in the control group, which were headache,
dizziness, and fatigue. The occurrence of patients’ symptoms in the experimental
group was only reported in one case with headache symptoms (4%) in the first week
after discharge and no symptoms reported in the second week after discharge. In
addition, the warning signs did not occur in both groups in the first week and the
second week after discharge.
Table 10
Frequencies and Percentages of Patients’ Symptoms at Different Time Points (Before
Discharge, in the First Week and the Second Week after Discharge) in the Control
and the Experimental Group (N = 50)
Control Group
(n = 25)
n
%
Symptoms
Before discharge*
No symptom
5
Headache
18
Dizziness
17
Fatigue
8
First week after discharge
Warning signs
- Yes
- No
25
Mild TBI symptoms*
- No symptom
7
- Headache
14
- Dizziness
11
- Fatigue
8
Note. * = one patient had more than one symptom.
Experimental Group
(n = 25)
n
%
20
72
68
32
10
13
13
4
40
52
52
16
100
25
100
28
56
44
32
24
1
96
4
76
Table 10 (continued)
Control Group
(n = 25)
n
%
Symptoms
Second week after discharge*
Warning signs
- Yes
- No
25
Mild TBI symptoms*
- No symptom
8
- Headache
12
- Dizziness
9
- Fatigue
4
Note. * = one patient had more than one symptom.
Experimental Group
(n = 25)
n
%
100
25
100
32
48
36
16
25
100
Discussion
Discussion of the study consists of demographic characteristics of
family caregivers, demographic characteristics of patients, patients’ clinical
characteristics, and the effect of a self-efficacy enhancing education program on
family caregivers in caring for patients with mild TBI.
Demographic Characteristics of Family Caregivers
There were no significant differences between the control group and
experimental group at the baseline. The average age of subjects in both groups was
around 40 years which is similar to a previous study in Indonesia (Utami, 2012). The
majority of subjects in both groups were female which is similar to the previous
studies (Backhaus, Ibarra, Klyce, Trexler, & Malec, 2010; Shocker, 2008;
Sinnakarupapan et al., 2005; Utami, 2008). More than half of the subjects in both
groups had higher education level (secondary school and college/university) which
77
were different compared to the previous study in which Shocker (2008) and Utami
(2012) found that the majority of family caregivers had a lower education levels
(primary school). Family caregivers with high education level were expected to have
better competencies in terms of skills than those with low education levels
(Muhlenkamp & Syales as cited in Srijumnong, 2010). The majority of family
caregivers were married and half of the subjects had the relationship of spouse to the
patients, was the same with the previous study (Utami, 2012). The relationship
between the family caregivers and patients may influence in the care provision.
Family caregivers of spouses spent more time in providing care than family caregivers
of parents (Stoller as cited in Mathiowtz & Oliker, 2005). The majority of subjects in
both groups worked and mostly as laborers, which similar to a previous study
(Shocker, 2008).
Demographic and Clinical Characteristics of Patients
Demographic characteristics of patients. There were no significant
differences between the control group and experimental group at the baseline. The
mean age of subjects in both groups in this study was 41.10 years. This result was
similar to the previous studies (Jamaludin, 2008; Kurniawan, 2009) who found that
mostly mild TBI in Yogyakarta, Indonesia occurred at this average age. Half of the
mild TBI subjects in this study were female (54%). In contrast, a previous study found
that the majority of mild TBI patients were mostly male (Hou, Moss-Morris, Peveler,
Mogg, Bradle, & Belli, 2011). In general, male patients with mild TBI had a higher
incidence than female patients in Indonesia (Jamaludin, 2008; Kurniawan, 2009) and
also found in other countries (Lundin, Boussard, Edman, & Borg, 2006; Meares et al.,
78
2008; Tunvirachaisakul, Thavichachart, & Worakul, 2011). However, the ratio of
female to male may be equal in the future as the high numbers of Indonesian women
are working outside similar to men.
Patients’ clinical characteristics. There were no significant
differences between the control group and the experimental group at baseline.
Regarding the cause of mild TBI, it was found that the majority of mild TBI was
caused by motorcycle accident (96%). This result was consistent with the previous
study in Indonesia, in which Kurniawan (2009) and Utami (2012) found that the
majority of mild TBI were caused by motorcycle accidents. Regarding the patients’
hospitalization, the majority of patients with mild TBI in this study were hospitalized
more than three days. According to the guideline of treatment for patients with mild
TBI in Indonesia, patients needed hospitalization for observation and providing
medication in the hospital within three days (Siswanto & Wahyu, 2012). The majority
of the subjects were fully conscious (GCS = 15) which similar to previous studies
(Hou et al., 2011, Lundin et al., 2006; Meares et al., 2008). More than half of the
subjects had CT scan findings in both groups as an abnormal CT scan including
cerebral edema, subdural hematoma (SDH), and epidural hematoma (EDH). Those
abnormal CT scan results were also found in other studies (Hou et al, 2011; Lundin
et al., 2006; Sigurdardottir, Andelic, Roe, Jerstad, & Schanke, 2009). Some studies
found that the abnormality of the CT scan may influence patients’ symptoms (Iverson,
2006; Kashluba, Hanks, Casey, & Millis, 2008; Sadowski-Cron et al., 2006).
According to the findings of patients’ symptoms, the majority of subjects had post
traumatic headache (Table 3). Headache is the most common symptoms of mild TBI
patients in the early stage after injury (Lundin et al., 2006; Yang et al., 2007).
79
The Effect of a Self-Efficacy Enhancing Education Program on Family
Caregivers’ Competencies in Caring for Patients with Mild TBI
This experimental study showed in significant positive findings on
family caregivers’ competencies in caring for patients with mild TBI. The findings of
the present study confirmed all hypotheses except the second hypothesis. The first
hypothesis which was supported by the findings that after receiving the self-efficacy
enhancing education program, the perceived confidence in caring for patients with
mild TBI among family caregivers were higher than before (Table 5). The second
hypothesis was not supported by the results, which showed that family caregivers’
performance was significantly decreased in the second week after discharge compared
to the first week (Table 6). The third and fourth hypothesis was supported in terms of
the family caregivers’ perceived confidence (Table 8) and performance (Table 9) in
caring for patients with mild TBI who receiving a self-efficacy enhancing education
program were higher than those receive the routine care. There are several reasons
underpinning the positive findings of family caregivers’ competencies include
application of self-efficacy based on Bandura’s theory, education session, follow-up,
and family caregivers’ confidence.
Application of self-efficacy based on Bandura’s theory. The
application of a self-efficacy enhancing education program based on the four sources
of self-efficacy from Bandura (1997) which include enactive mastery experiences,
vicarious experience, verbal persuasion, and physiological states. The Bandura’s selfefficacy theory is a useful framework to guide an educational program. It can increase
one’s self-judgment of personal capabilities to initiate and successfully perform a
specified task at designated levels and one expends greater effort. A person who
80
believes in their self-efficacy will practice with perseverance, industry and persistence
until becoming successful eventually (Bandura, 1997).
With regard to the program of the physiological and affective status,
family caregivers had an opportunity to explore their feelings about caring for mild
TBI patients such as talking their problems, anxiety or worry. The researcher and the
family caregivers discussed together regarding about it. This could help family
caregivers to release their problems, anxiety and worry in the care provision of the
patient’s. Bandura (1997) has mentioned that a high physiological and affective state
can influence individual performance to achieve success. Family caregivers’ distress
can influence family functioning in taking care of the patients with traumatic brain
injury (Testa, Malec, Moessner, & Brown, 2006). Similar to Srijumnong (2010) who
provided an opportunity for family caregivers to explore their feelings as a part of the
self-efficacy promotion program, therefore, the stress of family caregivers could be
decreased.
In verbal persuasion, family caregivers received support, reinforcement,
and feedback. These activities may improve family caregivers’ and self-efficacy
(Srijumnong, 2010). In addition, they received health education including basic
information about mild TBI and the management of mild TBI. The education may
affect positive changes of family caregivers’ self-efficacy in caring for patients with
mild TBI (Utami, 2012). All these activities serves as a further mean of strengthening
people’s beliefs that they possess the capabilities to get what they seek (Bandura,
1997).
By vicarious experience, family caregivers received information about
the successful management of mild TBI patients and they looked at some pictures
81
related to management of mild TBI such as neck stretching which could decrease
headache symptoms, vestibular exercise which could overcome dizziness symptoms,
the arrangement of diet and exercise which could help fatigue symptoms, and
reminding patients anything such as name and place which help to prevent or manage
the difficulty in remembering. In addition, family caregivers looked at some pictures
related to these managements of mild TBI patients. These activities were effective
through symbolic modeling which is an effective way to raise efficacy (Bandura,
1997). By seeing oneself perform successfully, it can provide clear information on
how best to perform skills and it strengthens beliefs in one’s capability (Bandura,
1997).
Using enactive mastery experience as a part in this study, the
researcher demonstrated some skills of caring for patients with mild TBI such as neck
stretching, vestibular exercise, deep breathing, sleep position, and assessing
symptoms using the symptoms checklist. Subsequently, the researcher asked family
caregivers to re-demonstrate these skills and they were given an opportunity to ask
some questions. The researcher also provided feedback and reinforcement for their
success. These activities could improve family caregivers’ skill. As a result, they felt
more confident. This is similar to the previous study that performed demonstrations
may increase family caregivers’ skill (Kouri et al., 2011) and self-efficacy
(Srijumnong, 2010). According to Bandura (1997), enactive mastery experience in
term of performing skills is the most influential sources of efficacy information
because it was the most authentic evidence. Moreover, the development of efficacy
beliefs through enactive experience creates the cognitive and self-regulative facility
82
for effective performance. In addition, easily mastered skills can develop the
cognitive basis of human competencies.
Educational session. The educational session was given as individual
based rather than a group-based session. It can help family caregivers to be more
focused when the researcher provided the education and they felt to be more confident
to re-demonstrate some skills. Utami (2012) conducted an individualized education
program for family caregivers caring for mild TBI patients in the emergency
department who having no hospitalization and this strategy helped them to increase
their self-efficacy. Additionally, this program was provided earlier or the day before
discharged patients from hospital. It was a sufficient time to prepare family caregivers
to be ready before discharge. Similar with the previous study, Utami (2012)
conducted health education for family caregivers before discharge and this program
had beneficial outcomes to prepare family caregivers in caring for patients.
Furthermore, the content of this educational session focused on the
definition of mild TBI, following symptoms of mild TBI, symptoms assessment,
symptoms management, and symptoms evaluation which were also included in the
booklet. These contents provided the basic knowledge to the family caregivers related
to the mild TBI. Glanz, Rimer, and Vismanath (2008) mentioned that knowledge is
one factor that can strengthen of self-efficacy. The booklet used simple language and
pictures which could assist family caregivers to gain better understanding. Although
the researcher did not measure their satisfaction, the family caregivers who accepted
the booklet during the program reported that it was useful to them as guidance in
caring for patients with mild TBI. The family caregivers read the booklet several
times to make sure that they had followed the guidance given on how to take care of
83
the mild TBI patients. This study is similar to a previous study in that the booklet was
very helpful for caregivers to understand about caring for patients with traumatic
brain injury and it helped to alleviate some of the anxiety experienced in the early
stages of head injury (Morris, 2001). Therefore, family caregivers could learn more
about caring for patients with mild TBI as well by themselves.
Follow-up. The follow up telephone calls after discharge could help
family caregivers to feel more competent. Some issues that occurred while caring at
home were also consulted via phone. The researcher encouraged the family caregivers
to talk about their success in their practice of caring for their patients. Family
caregivers reported that the knowledge and skills that had been demonstrated by
researcher were very beneficial and easy to do it. They had been provided caring for
patients directly every day such as management of headache, fatigue, dizziness, and
difficulty in remembering. They also learned from their own direct experiences, as a
result their confidence in caring for mild TBI patients were increased. Kouri,
Ducharme, and Giroux (2011) who mentioned that modeling from family caregivers
themselves may increase self-efficacy by the success of the applying skills after an
education program. The researcher also provided reinforcement related their success
in caring the patients with mild TBI via phone.
In the follow-up activity, the researcher also asked the family
caregivers to report and repeat what they learned at hospital about caring for patients
with mild TBI. This activity aimed to encourage and remind the family caregivers
about caring for patients with mild TBI. The family caregivers could explain it as
well. In addition, the researcher provided an opportunity for them to express their
feelings and they reported that they felt more confident in caring for their patients.
84
Moreover, the family caregivers were provided time for consultation related to their
worries or concerns such as a diet for patients with headaches. They received
information related to their concerns. In the second follow-up, some family caregivers
had problems related to their caring for patients, they were busy with their work and
sometime forgot to care for the patients. The researcher encouraged them and
provided strategies such as providing information related to symptoms management
before they went to work and they could follow-up on the patients using telephone
calls. Under the Bandura’s concept, verbal persuasion may be another source of
continued self-efficacy development. Hence, a follow-up activity is one way to help
family caregivers to enhance their confidence in caring for their patients (Connell &
Janevic, 2009; Srijumnong, 2010) and it is one important way to monitor and help
family caregivers in their performance directly to the patients (Kouri et al., 2011). As
a result, they could be successful in their performance.
However, the family caregivers’ performance was measured using
telephone calls, which could make the response bias because the performance in
caring for patients with mild TBI was reported verbally by family caregivers and it
was not observed directly. This limitation could influence the findings. Therefore, the
researcher followed-up twice to monitor the family caregivers’ performance in caring
for patients with mild TBI at home and encouraged caring activities during the
follow-up as mentioned above.
Family caregivers’ confidence. Based on the results, the family
caregivers’ perceived confidence in the experimental group was increased after
receiving a self-efficacy enhancing education program and the scores of perceived
confidence were significantly higher than that of the control group. Subsequently, the
85
family caregivers’ performance scores in the experimental group were significantly
higher than the control group. Self-efficacy had a relationship with family caregivers’
performance in their caring for patients with mild TBI. Family caregivers who were
confident may be more success to perform caring for their patients. According to
Bandura (1997) self-efficacy is fundamental to competent performance. People with
high self-efficacy will positively affect performance (Bandura, 1982; Kouri et al.,
2011; Li & McLaughlin, 2011).
Although family caregivers’ performance in the experimental group
was increased after discharge at the first week, the result found that the performance
at the second week was decreased as compared to the first week except some domains
of caring were remained in terms of assessing warning signs and managing headaches
(Table 7). Moreover, family caregivers still performed activities in caring for patients
but performed less. This is partly due to most symptoms were disappeared and
unrecognized to detect or required further management. According to the previous
study reported that the greater of patients’ symptoms was related to the amount of
care (Anderson, Parmenter, & Mok, 2002). In addition, daily assessment and
monitoring would allow them to perform after phone calls. Based on the discussion
with the family caregivers during follow-up, they were busy with their work and
sometime forgot to provide care especially for those patients who were able to care
themselves. More than half of family caregivers in this study (64%) were employed.
In addition, family caregivers who had working may influence in their caregiving
roles for patients (Wang, Shyu, Chen, & Yang, 2010). Moreover, family caregivers
with mild and moderate brain injury were more likely to work outside because the
person with injury needed less supervision (Sady et al., 2010).
86
Regarding patients’ symptoms in the first week and the second week
after discharge, the most common symptoms after mild TBI were headache, dizziness
and fatigue similar to those in the previous study (Dischinger, Ryb, Kufera, &
Auman, 2009; Yang et al., 2007). Patients in the control group reported symptoms
both in the first week and second week after discharge. On the other hand, in the
experimental group, only one patient reported symptoms in the first week after
discharge from hospital and all patients reported no symptoms in the second week
after discharge. In this group, family caregivers performed caring for patients with
mild TBI including an assessment of warning signs and following symptoms,
symptoms management, and symptoms evaluation.
In symptoms management, family caregivers often managed four
symptoms such as headache, dizziness, fatigue, and difficulty to remember, by
guiding the patients to do some exercises including vestibular exercise, neck exercise,
helping in the management of fatigue and difficulty in remembering every day during
the first and second week after discharge. Regarding to post concussive symptoms,
vestibular rehabilitation could reduce dizziness and improve gait and balance function
after concussion (Alsalaheen et al., 2010; Gottshall, 2011). In addition, the family
caregivers provided neck exercise for the patients. This exercise was effective to
reduce or prevent a headache following a mild TBI (Ylinen, Nikander, Nykanen,
Kautiainen, & Hakkinen, 2009). Additionally, exercises could reduce symptoms in
patients with post-concussion syndrome (Kozlowski, 2008).
In conclusion, the self-efficacy enhancing education program in this
study significantly improved the family caregivers’ perceived confidence and
performance in caring for patients with mild TBI. Although, the family caregivers’
87
performance score within the experimental group was decrease in the second week,
these performance scores were significantly higher than those in the control group. In
addition, the occurrence of symptoms in the experimental group was lower than the
control group both in the first week and second week. The results of this study did not
only offer benefits to family caregivers, but also gave benefits to the mild TBI
patients through their active participation in caregiving. Therefore, a self-efficacy
enhancing education program was recommended for promoting family caregivers
with patients with mild TBI.
88
CHAPTER 5
CONCLUSION AND RECOMMENDATIONS
This chapter presents the conclusions of the study based on the
research findings. The strengths and limitations of the study are also presented.
Furthermore, implication and recommendations for nursing practice, nursing
education, and future studies will be offered.
Conclusion
The objective of the study was to examine the effect of a self-efficacy
enhancing education program on family caregivers’ competencies in caring for
patients with mild TBI in Yogyakarta, Indonesia. A quasi-experimental pre-test and
post-test design with non-equivalent control group was conducted at the medical and
surgical ward of PKU Muhammadiyah Yogyakarta and PKU Muhammadiyah Bantul
Hospital, Yogyakarta, Indonesia, from November 2012 to February 2013. Fifty
subjects who met the inclusion criteria were recruited. The twenty five subjects in the
experimental group received the routine care and a self-efficacy enhancing education
program and two follow-up phone calls, whereas another twenty five subjects in the
control group received the routine care.
The instruments consisted of the family caregivers’ demographic data,
patients’ demographic data, patients’ clinical characteristics, the Rivermead Postconcussion Symptom Questionnaire, the Perceived Confidence Questionnaire, and
Performance Questionnaire. The questionnaires was validated by three experts and
89
tested for reliability by using Cronbach’s alpha coefficient for Perceived Confidence
Questionnaire yielding of .96 and the Performance Questionnaire yielding .68,
whereas the Rivermead Post-concussion Symptom Questionnaire was tested by test
re-test reliability yielding of five symptoms in very good agreement, six symptoms in
good agreement, two symptoms in moderate agreement, two symptoms in slight
agreement, and one symptom could not be tested because of no value ability.
In regards to the demographic characteristics of both the family
caregivers and the patients, the patients’ clinical characteristics were presented using
frequency, percentage, mean, and standard deviation. The Chi-square, Fisher exact
test, and Likelihood ratio test were used to test the proportion of equivalence between
the experimental group and control group. A paired t-test was used to measure the
significant differences of perceived confidence within the group, whereas Wilcoxon
Signed Rank test was used to measure the significant differences of performance
within the group. An Independent t-test was used to measure the significant
differences of perceived confidence between the groups and Mann-Whitney U test
was used to examine the significant differences between groups.
The findings revealed four main results. Firstly, the mean score of
perceived confidence in the experimental group was significantly higher after
receiving the program (t = -8.44, p < .05). Secondly, the mean rank score of the
performance in the experimental group in the second week was significantly lower
than those in the first week (Z = -2.94, p < .05). Thirdly, there was a significant
difference of perceived confidence between the experimental group and the control
group (t = 8.30, p < .05). Fourthly, the performance between the experimental group
and the control group showed significant difference (U = 0.00, p < .05). According to
90
the findings, this self-efficacy enhancing education program improved the family
caregivers’ perceived confidence and also measured their performance in caring for
patients with mild TBI after discharge.
Strengths and Limitations of the Study
The study had several strengths. Firstly, the individualized education
program approach including follow ups after discharge with some specific content
could improve the family caregivers’ perceived confidence. Secondly, the theorydriven approach using self-efficacy from Bandura (1997) is considered as an
appropriate intervention. Thirdly, the self-efficacy enhancing education program used
multiple educationally strategies to improve family caregivers’ competencies in terms
of perceived confidence and performance in caring for patients with mild TBI.
Besides these strengths, this study had some limitations. Firstly, this
study did not apply the random assignment as it will threaten the internal validity.
Secondly, the perceived confidence was not measured in the first week after
discharge, therefore it could influence the performance in caring for patients with
mild TBI. Thirdly, follow-up using telephone calls were conducted to ensure
effectiveness and improvement, however it may not reflect the real action due to a
lack of observation and it could make the measurement bias. Fourthly, even the
individualized education program had strengths, however this method could take a lot
of time to administer.
91
Implications and Recommendations
This study provides evidence of the effectiveness of a self-efficacy
enhancing education program on family caregivers’ competencies. Some
recommendations for the nursing practice are proposed.
Nursing Practice
Nurses should provide a self-efficacy enhancing education program for
family caregivers who are caring for mild TBI before discharge and implement with
follow-up phone calls. Nurses should provide support for the family caregivers to take
care of their patients and provide written materials such as booklets or other teaching
media for family caregivers as guidance in caring for mild TBI patients.
Nursing Education
The findings of this study can be used as a guide for novice nurses to
educate family caregivers in caring for patients with mild TBI. In addition, the results
of the study can also be used as basic knowledge for further development of selfefficacy enhancing education program for monitoring family caregivers’ performance.
Nursing Research
Further research is needed to use random assignment to minimize the
selection bias. A study design using randomized controlled trials is strongly
recommended. Additionally, the researcher needs to conduct the education program in
a shorter time period (less than one hour), in group education instead individualized
92
education, and use other media in the education program. Subsequently, the
researcher could conduct follow-ups face to face. This program may be beneficial to
incorporate a longer time period for follow-ups. Moreover, perceived confidence must
be continuously measured with performance in the following week after discharge to
ensure the effectiveness of the program.
93
REFERENCES
Aitken, M. E., McCarthy, M. L., Slomine, B. S., Dring, R., Durbin, D. R., Jaffe,
K.M.,… MacKenzie, E. J. (2009). Family burden after traumatic brain injury
in children, Pediatrics, 123, 199-206. doi:10.1542/peds.2008-0607
Albert, S. M., Im, A., Brenner, L., Smith, M., & Waxman, R. (2002). Effect of a
social work liaison program on family caregivers to people with brain injury.
Journal Head Trauma Rehabilitation, 17, 175-189.
Alsalaheen, B. A., Mucha, A., Morris, L. O., Whitney, S. L., Furman, J. M., CamioloReddy, C. E., et al., (2011). Vestibular rehabilitation for dizziness and balance
disorder after concussion. Journal of Neurologic Physical Therapy, 34, 87-93.
doi:10.1097/NPT.0b013e3181dde568
American Association of Neuroscience Nurses & Association of Rehabilitation
Nurses [AANN & ARN]. (2011). Care the patient with mild traumatic brain
injury: AANN and ARN clinical practice guideline series. Retrieved from
http://www.rehabnurse.org/uploads/files/cpgmtbi.pdf
Anderson, M. I., Parmenter, T. R., & Mok, M.(2002). The relationship between
neuronehavioural problems of severe traumatic brain injury (TBI), family
functioning and the psychological well-being of the spouse/caregiver: Path
model analysis. Brain Injury, 16, 743-757.
Anderson, M. I., Simpson, G. K., & Morey. (2012).The impact of neurobehavioral
impairment on family functioning and the psychological well-being of male
versus female caregivers of relatives with severe traumatic brain injury, P. J.
Multigroup analysis, The Journal of Head Trauma Rehabilitation.
doi:10.1097/HTR.0b013e31825d6087
Anderson, T., Heitger, M., & Macleod, A. D. (2006). Concussion and mild head
injury. Practical Neurology, 6, 342-357. doi:10.1136/jnnp.2006.106583
Arango-Lasprilla, J. C., Quijano, M. C., Aponte, M., Curvo, M. T., Nicholls, E.,
Rogers, H. L.,… Kreutzer. J. (2010). Family needs in caregivers of individuals
with traumatic brain injury from Colombia, South America. Brain Injury, 24,
1017-1026. doi:10.3109/02699052.2010.490516
Arciniegas, D. B., & Silver, J. M. (2006). Pharmacotherapy of posttraumatic cognitive
impairments. Behavioral Neurology, 17, 25–42.
Ayu, I. M. (2010). Karakteristik penderita trauma kapitis rawat inap di Rumah Sakit
Haji Medan tahun 2009 [Characteristics of traumatic brain injury at Haji
Medan Hospital, 2009]. Retrieved from
http://www.repository.usu.ac.id/bitstream/123456789/Cover.pdf
94
Backhaus, S. L., Ibarra, S. L., Klyce, D., Trexler, L. E., & Malec, J. F., (2010). Brain
Injury coping skills group: A preventative intervention for patients with brain
injury and their caregivers. Archives Physiology Medical Rehabilitation, 91,
840-848. doi:10.1016/j.apmr.2010.03.015
Bandura, A. (1982). Self-efficacy mechanism in human agency. American
Psychologist, 37, 122-147.
Bandura, A. (1989). Social cognitive theory. Annals of Child Development, 6, 1-85.
Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: W. H.
Freeman.
Bandura, A. (2002). Social cognitive theory in cultural context. Applied Psychology:
An International Review, 51, 269-290.
Bay, E., & Bergman, K. (2006). Symptom experience and emotional distress after
traumatic brain injury. Care Management Journal, 7, 3-9.
Bazarian, J., McClung, J., Shah, M., Cheng, Y., Flesher, W., & Kraus, J. (2005).
Mild brain injury in the United States, 1998–2000. Brain Injury, 9, 85–91. doi:
10.1080/02699050410001720158
Beavers, W. R. & Hampson, R. B. (2003). Measuring family competence: The
Beavers systems model. (3rd ed.). New York, NY: Guilford Press.
Bell, K. R., Hoffman, J. M., Temkin, N. R., Powell, J. M., Fraser, R. T., Esselman, P.
C.,… Dikmen, S. (2008). The effect of telephone counseling on reducing
posttraumatic symptoms after mild traumatic brain injury: A randomized trial.
Journal of Neurology, Neurosurgery, and Psychiatry, 79, 1275-1281.
Bergman, S. K. (2011). Symptom self-management for mild traumatic brain injury
(Doctoral dissertation). Available from ProQuest Dissertations and Theses
database. (UMI No. 3489662).
Boss, B. J. (2010). Disorders of the central and peripheral nervous systems and the
neuromuscular junction. In K. L. McCance., S. E. Huether., V. L. Brashers.,
N. S. Rote (Eds.). Pathophysiology the basic for disease in adults and children
(6th ed., pp. 583-588). St. Louis, MO: Mosby Elsevier.
Bryan, C., & Hernandez, A. (2011). Predictors of posttraumatic headache severity
among deployed military personnel. Headache, 51, 945-953.
doi:10.1111/j.1526-4610.2011.01887
Bullock, K., Crawford, S. L., & Tennstedt, S. L. (2003). Employment and caregiving:
Exploration of African American caregivers. Social Work, 48, 150-162.
95
Bushnik, T., Englander, J., & Wright, J. (2008). Patterns of fatigue and its correlates
over the first 2 years after traumatic brain injury. Journal Head Trauma
Rehabilitation, 23, 25-32. doi:10.1097/01.HTR.0000308718.88214
Cantu, R. C. (2001). Posttraumatic retrograde and anterograde amnesia,
pathophysiology and implications in grading and safe return to play. Journal
of Athletic Training, 36, 244-248.
Carnevale, G. J., Anselmi, V., Busichio, K., & Millis, S. R. (2002). Changes in ratings
of caregiver burden following a community-based behavior management
program for persons with traumatic brain injury. Journal of Head Trauma
Rehabilitation, 17, 83-95.
Cassidy, J. D., Carroll, L. J., Peloso, P.M., Borg, J., von Holst. H., Holm, L.,… Kraus,
J. (2004). Incidence, risk factors and prevention of mild traumatic brain injury:
Results of the WHO Collaborating Centre Task Force on Mild Traumatic
Brain Injury. Journal of Rehabilitation Medicine, 43, 28–60.
Clark, P. C., Dunbar, S. B., Shields, C. G., Viswanathan, B., Aycock, D. M., & Wolf,
S. L. (2004). Influence of stroke survivor characteristics and family conflict
surrounding recovery on caregivers’ mental and physical health. Nursing
Research, 53, 406-413.
Connell, C. M., & Janevic, M. R. (2009). Effect of a telephone-based exercise
intervention for dementia caregiving wives: A randomized controlled trial.
Journal Application Gerontologist, 28, 171-194.
doi:10.1177/0733464808326951
Cottrell, R. R., Girvan, J. T., & McKenzie, J. F. (2009). Priciples and Foundations of
Health Promotion and Education. (4th ed.). New York, NY: Pearson
Benjamins Cummings.
Curtiss, G., Klemz, S., & Vanderploeg, R. D. (2000). Acute impact of severe
traumatic brain injury on family structure and coping responses. Journal of
Head Trauma Rehabilitation, 15, 1113-1122.
Cushman, J. G., Agarwal, N., & Fabian, T. C. (2001). Clinical Management Update.
Practice management guidelines for the management of mild traumatic brain
injury: The EAST Practice Management Guidelines Work Group. The Journal
of Trauma Injury, Infection and Critical Care, 51, 1016-1026.
Daerah Istimewa Yogyakarta. (2010). Sekilas kesehatan Provinsi DIY [Overview of
healthcare Province DIY] Retrieved from
http://www.mpu.dinkesjatengprov.go.id/index.php
Dean, J. P., O’Neill, D., & Sterr, A. (2012). Post-concussion syndrome: Prevalence
after mild traumatic brain injury in comparison with a sample without head
injury. Brain Injury, 26, 14-26. doi:10.3109/02699052.2011.635354
96
Defense Centers of Excellence. (2012). Assessment and management dizziness
associated with mild TBI. Retrieved from
http://www.dcoe.health.mil/ForHealthPros/TBIInformation.aspx
De Groot, M. H., Phillips, S. J., & Eskes, G. A. (2003). Fatigue associated with stroke
and other neurologic conditions: Implications for stroke rehabilitation.
Archives Physical Medical Rehabilitation, 84, 1714-1720.
De Kruijk, J. R., Leffers, P., Menheere, P. P. C. A., Meerhoff, S., Rutten, J., &
Twijnstra, A. (2002). Prediction of post-traumatic complaints after mild
traumatic brain injury: Early symptoms and biochemical markers. Journal
Neurology Neurosurgery Psychiatry, 73, 727–732. doi:10.1136/jnnp.73.6.727
Department of Veterans Affairs, Department of Defense [DVA/DoD]. (2009).
VA/DoD Clinical Practice Guideline for Management of Concussion/Mild
Traumatic Brain Injury/mTBI (Versions 1.0). Retrieved from
http://www.dcoe.health.mil/VA/DoDManagement/Concus.pdf
Dikmen, S., Machamer, J., Fann, J. R., & Temkin, N. (2010). Rates of symptom
reporting following traumatic brain injury. Journal of the International
Neuropsychological Society, 16, 401-411. doi: 10.1017/S1355617710000196
Dischinger, P. C., Ryb, G. E., Kufera, J. A., & Auman, K. M. (2009). Early predictors
of post injury syndrome in a population of trauma patients with mild traumatic
brain injury. Journal Trauma, 66, 286-96. doi:10.1097/TA.0b013e3181961da2
Edelman, C. L. & Mandle, C. L. (2010). Health Promotion throughout the Life Span,
(7th ed.). St. Louis, MO: Mosby Elsevier.
Elgmark E, E., Emanuelson, I., Bjorklund, R., & Stalhammar, D. A. (2007). Mild
traumatic brain injuries: The impact of early intervention on late sequelae: A
randomized controlled trial. Acta Neurochirurgia, 149, 152-160.
Emanuelson, I., Andersson, H. E., Bjorklund, R., & Stalhammar, D. (2003). Quality
of life and post-concussion symptoms in adults after mild traumatic brain
injury: a population-based study in western Sweden. Acta Neurologica
Scandinavica, 108, 332–338.
Ennis, M. R. (2008). Competency models: A review of the literature and the role of
the employment and training administration (ETA). Retrieved from
http://www.careeronestop.org/competencymodel/OPDRLiteratureReview.pdf
Ergh, T. C., Rapport, L. J., Coleman, R., & Hanks, R. (2002). Predictors of caregiver
and family functioning following traumatic brain injury: Social support
moderates caregiver distress. Journal of Head Trauma Rehabilitation, 17, 155174.
97
Fabbri, A., Servadei, F., Marchesini, G., Dente, M., Iervese, T., Spada, M.,…
Vandelli, A. (2004). Which type of observation for patients with high-risk
mild head injury and negative computed tomography?. Europe Journal
Emergency Medicine, 11, 65-69.
Falk, A., von Wendt., & Klang, B. (2008). Informational needs in families after their
child’s mild head injury. Patient Education and Counseling, 70, 251-255.
Family Caregiver Alliance. (2006). Caregiver assessment: Principles, guidelines and
strategies for change. Report from a national consensus development
conference (Vol. 1). Retrieved from
http://www.caregiver.org/caregiver/jsp/content/pdfs/v1_consensus
Farran, C. J., Fogg, L. G., McCann, J. J., Etkin, C., Dong, X., & Barners, L. L. (2011).
Assessing family caregiver skill in managing behavioral symptoms of
alzeimer’s disease. Aging and Mental Health, 15, 510-521.
Faul, M. Xu, L., Wald, M. M., & Coronado, V. G. (2010). Traumatic Brain Injury in
the United States: Emergency Department Visits, Hospitalization, and Deaths
2002-2006. Atlanta, GA, Centers for Disease Control and Prevention,
National Center for Injury Prevention and Control, Retrieved from
http://www.cdc.gov/traumaticbraininjury/pdf.
Fleming, J. M., Shum, D., Strong, J., & Lightbody, S. (2005). Prospective memory
rehabilitation for adults with traumatic brain injury: A compensatory training
programme. Brain Injury, 19, 1-10.
Fourtassi, M., Hajjioui, El Ouahabi, A., Benmassaoud, H., Hajjaj-Hassouni, N., & El
Khamlichi. A. (2011). Long term outcome following mild traumatic brain
injury in Moroccan patients. Clinical Neurology and Neurosurgery,113, 716720. doi: 10.1016/j.clineuro.2011.07.010
Gan, C., & Schuler, R. (2002). Family system outcome following acquired brain
injury: clinical and research perspective. Brain Injury, 16, 311-322.
Ganesalingam, K., Yeates, K. O., Ginn, M. S.,Taylor, H. G., Dietrich, A., Nuss, K., &
Wright, M. (2007). Family burden and parental distress following mild
traumatic brain injury in children and its relationship to post-concussive
symptoms. Journal of Pediatric Psychology, 33, 621-629.
doi:10.1093/jpepsy/jsm133
Geijerstam, J. L., & Britton, M. (2010). Mild head injury-mortality and complication
rate: Meta analysis of findings in a systemic literature review. Acta
Neurochirurga, 145, 843-850.
Given, B., Given, C. W., & Sherwood, P. (2008). What knowledge and skills do
caregivers need?. American Journal of Nursing, 108 (9), 28-34.
doi:10.1097/01.NAJ.0000336408.52872
98
Giza, C.C., & Hovda, D. A. (2001). The neurometabolic cascade of concussion.
Journal Athletic Training, 36, 228–235.
Glanz, K., Rimer, B. K.., & Viswanath. (2008). Health behavior and health
education: Theory, Research, and Practice (4th ed.). San Francisco, CA: John
Wiley and Sons.
Gottshall, K. (2011). Vestibular rehabilitation after mild traumatic brain injury with
vestibular pathology. Neuro Rehabilitation, 29, 167-171. doi:10.3233/NRE2011-0691
Hall, R. C. W., Hall, R. C. W., & Chapman, M. J. (2005). Definition, diagnosis, and
forensic implications of postconcussional syndrome. Psychosomatics, 46, 195202.
Headache Classification Subcommittee [HCS]. (2004). The international
classification of headache disorders: 2nd edition. Cephalalgia. 24, 9–160.
Heng, K. W., Tham, K. Y., How, K. Y., Foo, J. S., Lau, Y. H., & Li, A. Y. (2007).
Recall of discharge advice given to patients with minor head injury presenting
to a Singapore emergency department. Singapore Medical Journal, 48, 11071110.
Heskestad, B., Waterloo, K., Baardsen, R., Helseth, E., Romner, B., & Ingerbrigtsen,
T. (2010). No impact of early intervention on late outcome after minimal,
mild, and moderate head injury. Scandinavian Journal of Trauma
Resuscitation and Emergency Medicine, 18, 2-5.doi:10.1186/1757-7241-18-10
Hilton, A., & Skrutkowski, M. (2002). Translating instruments into other languages:
Development and testing processes. Cancer Nursing, 25(1), 1-7.
Horvath, K. J., Hurley, A. C., Duffy, M. E., Gauthier, M. A., Harvey, R. M., Trudeau,
S. A., et al. (2005). Caregiver competence to prevent home injury to the care
recipient with dementia. Rehabilitation Nursing, 30, 189-196.
Hou, R., Moss-Morris, R., Peveler, R., Mogg, K., Bradley, B. P., & & Belli, A.,
(2011). When a minor head injury results in enduring symptoms: A
prospective investigation or risk factors for postconcussional syndrome after
mild traumatic brain injury. Journal Neurology Neurosurgical Psychiatry, 83,
217-223. doi:10.1136/jnnp-2011-300767
Imhaf, H. G., & Lenzlinger, P. (2011). Traumatic brain injury. In H. Ostern., O.
Trents., & S. Urames. Head, thorasic, abdominal, and vascular injuries:
Trauma surgery I. New York, NY: Springer.
Iverson, G. L. (2006). Complicated vs. uncomplicated mild traumatic brain injury:
Acute neuropsychological outcome. Brain Injury, 20, 1335-1344.
99
Jamaludin (2008). Karakteristik kasus trauma kepala di Instalasi Rawat Darurat
RSUD Sleman periode Maret 2007 – Maret 2008 [Characteristics of traumatic
brain injury at emergency room in RSUD Sleman, March 2007-2008].
Retrieved from http://www. repository.uii.ac.id/uii-skripsikarakteristik/kasus.pdf
Kashluba, S., Hanks, R. A., Casey, J. E., & Millis, S. R. (2008). Neuropsychologic
and functional outcome after complicated mild traumatic brain injury.
Archives Physical Medical Rehabilitation, 89, 904-911.
doi:10.1016/j.apmr.2007.12.029
Kashluba, S., Paniak, C., Blake, T., Reynolds, S., Toller-Lobe, G., & Nagi, J., (2004).
A longitudinal, controlled study of patient complaints following treated mild
traumatic brain injury. Archives of Clinical Neuropsychology, 19, 805-816.
King, N. S., Crawford, S., Wenden, F. J., Moss, N. E. G., & Wade, D. T. (1995). The
rivermead post concussion symptoms questionnaire: A measure of symptoms
commonly experienced after head injury and its reliability. Journal of
Neurology, 9, 587-592.
Kouri, K. K., Ducharme, F. C., & Giroux, F. (2011). A psycho-educational
intervention focused on communication for caregivers of a family member in
the early stage of Alzheimer’s disease: Results of an experimental study.
Dementia, 10, 435-453. doi:10.1177/1471301211408124
Kozlowski, K.F. (2008). Progressive aerobic exercise treatment of post concussion
syndrome (Doctoral dissertation). Available from ProQuest Dissertations and
These database. (UMI No. 3342106)
Kreutzer, J. S., Stejskal, T. M., Ketchum, J. M., Marwitz, J. H., Taylor, L. A., &
Menzel, J. C. (2009). A preliminary investigation of the Brain Injury Family
Intervention: Impact on family members. Brain Injury, 23, 535-547.
doi:10.1080/02699050902926291
Kurniawan, A. (2009). Proporsi trauma kepala akibat kecelakaan lalu lintas di RS
PKU Muhammadiyah Yogyakarta periode 1 Januari 2007-31 Desember 2007
[Proportion of severe traumatic brain injury at PKU Muhammadiyah Hospital
Yogyakarta]. Retrieved from http://www.medicine.uii.ac.id/index.php
Lannsjo, M., Geijerstam, J., Johansson, U., Bring, J., & Borg, J. (2009). Prevalence
and structure of symptoms at 3 months after mild traumatic brain injury in a
national cohort. Brain Injury, 23, 213-219. doi:10.1080/02699050902748356
Lefebvre, H., Pelchat, D., Swaine, B., Gelinas, I., & Levert, M. J. (2005). The
experiences of individuals with a traumatic brain injury, families, physicians and
health professionals regarding care provided throughout the continuum. Brain
Injury, 19, 585-597.
100
Len, T. K., & Neary, J. P. (2010). Cerebrovascular pathophysiology following mild
traumatic brain injury. Clinical Physiology Functional Imaging, 31, 85-93.
doi:10.1111/j.1475-097X.2010.00990
Lethan T., Arango-Lasprilla,J. C., de los Reyes, C. J., & Quijano, M. C. (2012). The
ties that bind: the relationship between caregiver burden and the
neuropsychological functioning of TBI survivors. Neuro Rehabilitation. 30, 8795. doi:10.3233/NRE-2011-0730
Lew, H. L., Lin, P., Fuh, J., Wang, S., Clark, D. J., & Walker, W. C. (2006).
Characteristics and treatment of headache after traumatic brain injury: A
focused review. American Journal of Physical Medicine and Rehabilitation, 85,
619–627.
Li, L. W., & McLaughlin, S. J. (2011). Caregiver confidence: Does it predict changes
in disability among elderly home care recipients?. The Gerontologist, 52(1),
79-88. doi:10.1093/geront/gnr073
Lundin, A., De Boussard, C., Edman, G., & Borg, J. (2006). Symptoms and disability
until 3 months after mild TBI. Brain Injury, 20, 799-806.
Mackenzie, J. A., & McMillan, T. M. (2005). Knowledge of post concussional
syndrome in naïve lay-people, general practitioner and people with minor
traumatic brain. British Journal of Clinical Psychology, 44, 417-424.
Marsh, N. V., Kersel, D. A., Havill, J. H., & Sleigh, J. W. (2002). Caregiver burden
during the year following severe traumatic brain injury. Journal of Clinical
and Experimental Neuropsychology, 24, 434 – 447.
Mathiowetz, N. A., & Oliker, A. (2005). The gender gap in caregiving to adults.
Retrieved from http://www.atususers.umd.edu/wip2/papers/Oliker.pdf
Maville, J. A. & Huerta, C. G. (2002). Health promotion in nursing. St. Louis, MO:
Mosby.
Meares, S., Shores, E. A., Taylor, A.J., Batchelor, J., Bryant, R. A., Baguley, J.,…
Chapman, J. (2008). Mild traumatic brain injury does not predict acute
postconcussion syndrome. Journal Neurology Neurosurgeon Psychiatry, 79,
300-306. doi:10.1136/jnnp.2007.126565
Morris, K. C. (2001). Psychological distress in carers of head injured individuals: the
provision of written information. Brain Injury, 15, 239-254.
Morris, T. (2010). Traumatic brain injury. In C. L. Armstrong & L. Morrow (Eds.).
Handbook of medical neuropsychology: Application of cognitive neuroscience
(p. 18). New York, NY: Springer.
Munro, B. H. (2001). Statistical methods for health care research. Philadelphia:
Lippincott Williams Wilkins.
101
Nabors, N., Seacat, J., & Rosenthal, M. (2002). Predictors of caregiver burden
following traumatic brain injury. Brain Injury, 16, 1039-1050.
Nicholson, K., & Martelli, M. (2004). The problem of pain. Journal of Head Trauma
Rehabilitation, 19, 2-9.
Norrie, J., Heitger, M., Leathem, J., Anderson, T., Jones, R., & Flett, R. (2010). Mild
traumatic brain injury and fatigue: a prospective longitudinal study. Brain
Injury, 24, 1528-1538.doi:10.3109/02699052.2010.531687
Ostberg, M., & Hagekull, B. (2000). A structural modeling approach to the
understanding of parenting stress. Journal of Clinical Child Psychology, 29,
615-625.
Packard, R. (2008). Chronic post-traumatic headache: Association with mild
traumatic brain injury, concussion, and post-concussive disorder. Current Pain
and Headache Reports, 12, 67-73.
Paniak, C., Reynolds, S., Phillips, K., Toller-Lobe, G., Melnyk, A., & Nagy, J.
(2002), Patient complaints within 1 month of mild traumatic brain injury: A
controlled study. Archives of Clinical Neuropsychology, 17, 319-334.
Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing
evidence for nursing practice (8th ed.). New York, NY: Lippincott Williams
& Wilkins.
Ponsford, J., Cameron, P., Fitzgerald, M., Grant, M., & Mikocka-Walus, A. (2011).
Long-term outcomes after uncomplicated mild traumatic brain injury: A
comparison with trauma controls. Journal of Neurotrauma, 28, 937-946.
doi:10.1089/neu.2010.1516
Prigatano, G. P. (2005). Disturbances of self-awareness and rehabilitation of patients
with traumatic brain injury: A 20-year perspective. Journal of Head Trauma
Rehabilitation, 20(1), 19–29.
Rivera, P. A., Elliot, T. R., Berry, J. W., & Grant, J. S., (2008). Problem-solving
training for family caregivers of persons with traumatic brain injuries: A
randomized controlled trial. Archives of Physical Medicine and Rehabilitation,
89, 931-941. doi:10.1016/j.apmr.2007.12.032
Rodgers, M. L., Strode, A., Norell, D. M., Short, R. A., Dyck, D.G., & Becker, B.
(2007). Adapting multiple-family group treatment for brain and spinal cord
injury intervention development and preliminary outcomes. American Journal
of Physical Medicine & Rehabilitation, 86, 482-491.
Rodriguez, D., Patel, R., Bright, A., Gregory, D., & Gowing, M. K. (2002).
Developing competency models to promote integrated human resource
practices. Human Resource Management, 41, 309-324.
doi:10.1177/1534484312456690
102
Roe, C., Sveen, U., Alvsaker, K., & Bautz-Holter, E. (2009). Post concussion
symptoms after mild traumatic brain injury: Influence of demographic factors
and injury severity in a 1-year cohort study. Disability and Rehabilitation, 31,
1235-1243. doi:10.1080/09638280802532720
Ruff, M. R., Iverson, G. L., Barth, J. T., Bush, S. S., Broshek, D. K., & NAN Policy
& Planning Committee. (2009). Recommendation for diagnosing a mild
traumatic brain injury: A national academy of neuropsychology education
paper. Archives of Clinical Neuropsychology, 24, 3-10.
doi:10.1093/arclin/acp006
Ruff, R. L., Ruff, S., & Wang, X. F. (2009). Improving sleep: Initial headache
treatment in OIF/OEF veterans with blast-induced mild traumatic brain injury.
Journal of Rehabilitation Research & Development, 46, 1071-1084.
Sadowski-Cron, C., Schneider, J., Senn, P., Radanov, B. P., Ballinari, P., &
Zimmermann, H. (2006). Patients with mild traumatic brain injury: Immediate
and long-term outcome compared to intra-cranial injuries on CT scan. Brain
Injury, 20, 1131-1137.
Sady, M. D., Sander, A.M., Clark, A.N., Sherer, M., Nakase-Richardson, R., &
Malec, J. F. (2010). Relationship of preinjury caregiver and family functioning
to community integration in adults with traumatic brain injury. Archives of
Physical Medicine Rehabilitation, 91, 1542-1550.
doi:10.1016/j.apmr.2010.07.012
Samartkit, N., Kasemkitvattana, S., Thosingha, O., & Vorapngsathorn, T. (2010).
Caregiver role strain and rewards: Caring for Thais with a traumatic brain
injury. Pacific Rim International Journal Nursing Res, 14, 297-314.
Sander, A. M., Carosellis, J. S., Becker, C., Neeses, L., & Scheibel, R. (2002).
Relationship of family functioning to progress in post-acute rehabilitation
programme following traumatic brain injury. Brain Injury, 16, 649-657.
Sander, A. M., Maestas, K. L., Shere, M., Malec, J. F., & Nakase-Richardson, R.
(2012). Relationship of caregiver and family functioning to participation
outcomes after postacute rehabilitation for traumatic brain injury. A
multicenter investigation. Archives of Physical Medicine Rehabilitation, 93,
842-848. doi:10.1016/j.apmr.2011.11.031
Sayegh, A., Sandford, D., & Carson, A. (2010). Psychological approaches to
treatment of postconcussion syndrome: A systematic review. Journal of
Neurology, Neurosurgery, and Psychiatry, 81, 1128-1134.
Selladurai, B., & Reilly, P. (2007). Initial management of head injury: A
comprehensive guide. Sydney, NSW: McGraw-Hill.
103
Sheedy, J., Harvey, E., Faux, S., Geffen, G., & Shores, E. (2009). Emergency
department assessment of mild traumatic brain injury and the prediction of
postconcussive symptoms: A 3-month prospective study. Journal of Head
Trauma Rehabilitation, 24, 333-343. doi:10.1097/HTR.0b013e3181aea51f
Shocker, M. (2008). Pengaruh penyuluhan kesehatan terhadap penurunan tingkat
kecemasan keluarga pasien dengan cedera kepala (sedang-berat) di ruang 13
(akut) Rumah Sakit Dr. Saiful Anwar Malang [Effect of health education on
anxiety level of family caregivers with severe traumatic brain injury patients at
Dr. Saiful Anwar Malang Hospital]. Retrieved from
http://www.scribd.com/doc/70328400/Pengaruh-Penyuluhan-KesehatanTerhadap-Penurunan-Tingkat-Kecemasan-Keluarga-Pasien.html
Siebern, A. T., & Manber, R. (2010). Insomnia and its effective non-pharmacologic
treatment. Medical Clinics of North America, 94, 581-591.
doi:10.1016/j.mcna.2010.02.005
Sigurdardottir, S., Andelic, N., Roe, C., Jerstad, T., & Schanke, A. K. (2009). Postconcussion symptoms after traumatic brain injury at 3 and 12 months postinjury: A prospective study. Brain Injury, 23, 489-497.
doi:10.1080/02699050902926309
Simon, G. E., Vonkorff, M., Fullerton, C., & Ormel, J. (1999). An international study
of the relation between somatic and depression. The New England Journal of
Medicine, 341, 1329-1364.
Sinnakaruppan, I., Downey, B., & Morrison, S. (2005). Head injury and family carers:
A pilot study to investigate an innovative community-based educational
programme for family carers and patients. Brain Injury, 19, 283-308.
Siswanto., & Wahyu, S. (2012). Pedoman tatalaksana cedera kepala [Guideline for
management of head injury]. Retrieved from
http://sisclinic.wordpress.com/2012/04/09/pedoman-tatalaksana-cederakepala.html
Sohlberg, M. M. & Mateer, C. A. (2001). Cognitive Rehabilitation: An Integrative
Neuropsychological Approach. New York, NY: Guilford Publication.
Srijumnong, N. (2010). The effects of a self-efficacy promotion program for family
caregivers of persons with stroke at home. Retrieved from
http://
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, KK. H. (2010). Management of
patients with neurologic dysfunction. In P., Dubendorf (Ed.). Brunner &
Suddarts’s textbook of medical-surgical nursing (12th ed., pp. 1865-1873).
Philadelphia, PA: Lippincott Williams & Wilkins.
104
Stejskal, T. M. (2008). Evaluating an evidence-based intervention for families and
survivors after traumatic brain injury: The brain injury family intervention
(Doctoral dissertation). Retrieved from drum.lib.umd.edu/bitstream/
Stulemeijer, M., van der Werf, S., Bleijenberg, G., Biert, J., Brauer, J., & Vos, P.
(2006). Recovery from mild traumatic brain injury: A focus on fatigue.
Journal of Neurology, 253, 1041-1047.
Sundstrom, A., Nilsson, L., Cruts, M., Adolfsson, R., Van Broeckhoven, C., &
Nyberg, L. (2007). Fatigue before and after mild traumatic brain injury: Prepost-injury comparisons in relation to Apolipoprotein E. Brain Injury, 21,
1049–1054.
Terrio, H., Brenner, L. A., Ivins, B. J., Cho, J. M., Helmick, K., Schwab, K.,…
Warden, D. (2009). Traumatic brain injury screening: Preliminary findings in
a U.S. Army brigade combat team. The Journal of Head Trauma
Rehabilitation, 24(1), 14–23. doi:10.1097/HTR.0b013e31819581d8
Testa, J. A., Malec, J. F., Moessner, A. M., & Brown, A. W. (2006). Predicting family
functioning after TBI: Impact of neurobehavioral factors. Journal Head
Trauma Rehabilitation, 21, 326-47.
Thabane, L., Ma, J., Chu, R., Cheng, J., Ismaila., Rios, L. P.,… Charles, H. (2010). A
tutorial on pilot study: The what, why and how. BMC Medical Research
Methodology, 10, 1-10. doi:10.1186/1471-2288-10-1
Tsaousides, T., & Gordon, W. A. (2009). Cognitive rehabilitation following traumatic
brain injury: Assessment to treatment. The Mount Sinai Journal of Medicine,
76, 173-181. doi:10.1002/msj.20099
Tunvirachaisakul, C., Thavichachart, N., & Worakul. P. (2011). Executive
dysfunction among mild traumatic brain injured in Northeastern Thailand.
Asian Biomedicine, 5, 407-411. doi:10.5372/1905-7415.0503.053
Utami, G. T. (2012). Pengaruh pendidikan kesehatan terhadap kepercayaan diri dan
keinginan keluarga dalam merawat pasien cedera kepala ringan di RSUP Dr.
Hasan Sadikin Bandung, [The effect of health education on family caregivers’
self-efficacy and desires in caring for mild TBI patients in Dr.Hasan Sadikin
Bandung Hospital]. Unpublised master thesis, Fakultas Keperawatan,
Universitas Padjajaran, Bandung, Indonesia.
Wang, Y., Shyu, Y. L., Chen, M., & Yang, P. (2010). Reconciling work and family
caregiving among adult-child family caregivers of older people with dementia:
Effects on role starin and depressive symptoms. Journal of Advanced Nursing,
67, 829-840. doi:10.1111/j.1365-2648.2010.05505
Warden, D. L., Gordon, B., McAllister T. W., Silver, J. M., Barth, J. T., Bruns, J.,…
Zitnay, G. (2006). Guidelines for pharmacologic treatment of neurobehavioral
sequelae of traumatic brain injury. Journal of Neurotrauma, 23, 1468-1501.
105
Wynd, C. A., Schmidt, B., & Schaefer, M. A. (2003). Two quantitative approaches for
estimating content validity. Western Journal of Nursing Research, 25, 508518.
Yang, C., Tu, Y., Hua, M., & Huang, S. (2007). The association between the
postconcussion symptoms and clinical outcomes for patients with mild
traumatic brain injury. The Journal of Trauma, Injury, Infection, and Critical
Care, 62, 657-663.
Ylinen, J., Nikander, R., Nykanen, M., Kautiainen, H., & Hakkinen, A. (2009). Effect
of neck exercises on cervicogenic headache: A randomized controlled trial.
Journal Rehabilitation Medicine, 42, 344-349. doi:10.2340/16501977-0527
106
APPENDICES
107
APPENDIX A
Effect Size Calculation
1. Effect size of the previous study
The calculation effect size (d) of this study is as below:
M1 − M 2
SD12 + SD22
d=
and where pooled SD=
SD
pooled
2
Where M1 : Mean of experimental group (pre-test)
M2 : Mean of experimental group (post-test)
pooled SD : Standard deviation of the experimental group (pre-test and
post-test)
Where M1 = 69.87; M2 = 79.93
SD1 = 11.05; SD2 = 8.14
pooled SD = √ (11.05)2 + (8.14) 2 /2
= √ (122.1025+66.2596)/2
= √ 188.3621/2
= √ 94.18105
= 9.7046922
d = 69.87– 79.93/9.7046922
= -10.06/9.7046922
= -1.036612
108
APPENDIX B
Informed Consent
My name is Erfin Firmawati. I am a master nursing student at Prince of
Songkla University, Thailand. I am also a lecturer of Faculty of Nursing,
Muhammadiyah University of Yogyakarta, Indonesia. I am conducting a research
entitle “Effect of a Self-Efficacy Enhancing Education Program on Family
Caregivers’ Competency in Caring for Patients with Mild Traumatic Brain Injury in
Yogyakarta, Indonesia”. This study will be held for four weeks and the findings of
this study are expected to improve the family competencies with mild TBI. This study
has been approved by the Research Ethics Committee of Prince of Songkla
University, Thailand and also has been granted permission from PKU
Muhammadiyah Yogyakarta Hospital and PKU Muhammadiyah Bantul Hospital.
You are asked to participate in this study. If you are interested, I will explain the
procedures as follows:
Explanation Procedures
1.
You will be assigned to either the experimental or the control group
2.
If you are in the experimental group, you will receive a self-efficacy enhancing
education program during the period of study. In addition, a routine care will be
provided by our nurses.
3.
If you are in the control group, you will not receive the program. You will
receive a routine care in the surgical ward. However, if you want to receive the
similar program, you will receive it after the end of the study.
109
Evaluation and Forms
1.
You will be asked to fill the forms about your personal data and health
information. This activity will spend time around 15 minutes.
2.
You will be asked to fill the perceived confidence questionnaire and the
performance to measure your competencies in caring for patients with mild TBI
before the program (in the hospital) and after the program in the first week and
the second week after discharge (at home) via phone calls. This activity will
spend time around 15 minutes.
Risk and Comfort
There is no known risk or harm related to participating in this study.
However, this program may make you spend your time with us. Moreover, there is
neither cost nor payment to your participation in this study.
Benefits
The finding of this study will provide benefits to the nurses and other
health care providers in order to provide the self-efficacy enhancing education
program to enhance family caregiver’s competencies in caring for patients with mild
traumatic brain injury. The data from this study will be used to write research paper. It
also will provide useful information for further research in this area.
Confidentiality
All information and your personal identity will be kept confidential
and anonymous. I will use a code number so that your identity will not be discovered
110
and all information will be used just for the report of the study. Finally, the
questionnaires will be destroyed after completion of the study.
Participation and withdrawal from participation
Participation in this study is voluntary. Signing the informed consent
or agreeing verbally to participate indicates that you understand what is involved and
you consent to participate in this study. You have the right to withdraw from
participation anytime without any problems prior to completion of data collection.
Finally, if you have any questions or suggestions, you can contact
directly to me by phone +6281328737805 or send email to
fifinku_jogja@yahoo.co.id. If you agree to participate in this study, please sign your
name on the consent form.
Thank you very much for your consideration to participate in this
research study.
Erfin Firmawati
Researcher
111
Informed Consent Form
Title
Self-Efficacy enhancing Education Program on Family Caregivers’
Competency in Caring for Patients with Mild Traumatic Brain Injury in
Yogyakarta, Indonesia
Researcher Erfin Firmawati (Master Student of Faculty of Nursing, Prince of
Songkla University, Hatyai, Thailand)
Family’s name:………………………………………………..Age:……………
Family’s consent
I ………………………………, was informed of the detail of the
research entitled “Self-Efficacy enhancing Education Program on Family Caregivers’
Competencies in Caring for Patients with Mild Traumatic Brain Injury in Yogyakarta,
Indonesia” and was assured that no part of my personal information and research
result may be individually revealed to the public. If any problem or issues occur, I
will discuss with the researcher. I have right to withdraw from this program at any
time without any effects on any nursing/medical service and treatment I must receive.
I am willing to participate in this research project voluntarily and hereby endorse my
signature.
Given by :……………………………………. Date :……………………….
Researcher note:
I provided the detailed information of the research entitled “SelfEfficacy enhancing Education Program on Family Caregivers’ Competencies in
Caring for Patients with Mild Traumatic Brain Injury in Yogyakarta, Indonesia” to the
family caregiver. I give the opportunity to the family caregiver to ask any question
and give the required answer.
Signature: …………………………………………... (Researcher)
Date
: ………………………………………….
112
Research Information Sheet
Self-Efficacy enhancing Education Program
If you are in the program, I will initiate the following procedures:
1. During hospitalization
a. You will be asked to fill some forms including the demographic data and
Perceived Confidence Questionnaire that will …………………………….
b. You will receive a self-efficacy enhancing education program to help you to
increase your competencies in caring for patients with mild TBI.
2. The first week after discharge
In this period, the researcher will conduct the phone calls follow-up to evaluate
your progress report related to ………………………………………………….
3. The second weeks after discharge
In the last week of the study, you will receive the same activities with the first
week after discharge. The research assistance will
……………………………………………………………………………………
113
APPENDIX C
Family Demographic Data Questionnaire (FDDQ)
Participant ID :
Date and time :
Phone number :
Instruction
The following items are some information about yours self. Please answer by
marking (√) in the available space or filling in the blank that is appropriate for you.
Participant information
1. Age
:
years
2. Gender:
(1) Female
(2) Male
3. Marital status:
(1) Married
(2) Single
(3) Widowed
(4) Divorced
(1) Moslem
(2) Catholic
(3) Christian
(4) Buddhist
4. Religion:
(5) Hindu
5. Level of education:
(1) No schooling
6. Occupation:
(1) None
(2) Retired
(3) Government employee
(4) Farmer
(5) …………………..
(6) Other……
(1) Husband
(2) Wife
(3) Mother
(4) Father
(5) Child
(6) Other……
7. Family relationship:
114
APPENDIX D
Patient Demographic Data Questionnaire (PDDQ)
Participant ID :
Date and time :
Phone number :
Instruction
The following items are some information about yours self. Please answer by
marking (√) in the available space or filling in the blank that is appropriate for you.
Participant information
Participant information
1. Age
:
years
2. Gender:
(1) Female
(2) Male
3. Marital status:
(1) Married
(2) Single
(3) Widowed
(4) Divorced
4. Level of education:
(1) No schooling
(2) Elementary school
(3) Junior high school
(4) Senior high school
(5) College/ University
5. Occupation:
(1) None
(2) Retired
(3) Government employee
……………..
115
APPENDIX E
Injury Characteristics (IC)
Cause of mild TBI:
(1) Body assault
(2) …………………….
(3) Bicycle accident
(4) Falling injury
(5) Car accident
(6) …………………….
(7) Other………………….
Admission GCS score:
(1) 13
(2) 14
(3) 15
(2) 14
(3) 15
Discharge GCS score
(1) 13
Confusion or disorientation:
(1) No
(2) Yes
Duration of hospitalization:
(1) 1 day
(2) ………………….
(3) 3 days
(4) Other……………
Other injuries sustained at the time of this injury:
(1) No
(2) Yes
116
APPENDIX F
Rivermead Post-concussion Symptoms Questionnaire (RPSQ)
Name :
Date:
We would like to know if you now suffer any symptoms given below. We would like
you to compare yourself now with before the accident (i.e., over the last 24 hours).
For each symptom listed below please circle the number that most closely represents
your answer.
Symptom
Physical
Emotion
Cognitive
Headache
Feeling or dizziness
……………………………………………
Noise sensitivity (easily upset by loud noise)
Sleep disturbance
……………………………………………
Blurred vision
Double vision
Restlessness
……………………………………………
Feeling frustrated or impatient
Irritability/ easy to anger
Difficulty remembering
Poor concentration
Taking longer to think
Other………
Not
present
0
0
0
0
0
0
0
0
0
0
0
Yes
present
1
1
1
1
1
1
1
1
1
1
1
1
0
0
0
0
1
1
1
…….
117
APPENDIX G
Perceived Confidence Questionnaire (PCQ)
Code :
Date :
Instruction: The following statements represent how much you are confident to
provide
care
for
your
patient
(loved
one/relative,
e.g.
your
daughter/son/father/mother). Please indicate the level of your confidence by marking
(√) in the appropriate column that best represent if you agree or disagree to that
statement.
Note:
1: High confidence
2: Moderate confidence
3: Low confidence
4: No confidence
No
Statements
Confidence level
1
2
3
4
Confidence to assess of warning signs or symptoms of increased intracranial pressure
(the following signs and symptoms are significant to send patient back to hospital)
1. I am confident to assess the level of consciousness
2.
I am confident to assess the constant headache
and/or severe headache
…. ………………………………………………………
6.
I am confident to assess the continual fluid or
bleeding from the ears or nose
Confidence to assess the other persistent symptoms to be managed after mild TBI
7. I am confident to assess the symptom of headache
8. I am confident to assess the symptom of dizziness
9. I am confident to ………………………………….
118
10. I am confident to assess the symptom of difficulty
remembering
Confidence to manage/prevent of complication
11. I am confident to transfer patient back to hospital
when I detect any warning signs of increased
intracranial pressure.
…. ……………………………………………………..
.
15. I am confident to cover the ear or nose with clean
gauze when he or she has continual fluid/discharge or
bleeding
Confidence to manage the symptoms after mild TBI
… ……………………………………………………..
19. I am confident to manage of difficulty remembering
Symptom evaluation
20 I am confidence to evaluate headache symptom
following mild TBI after I provide care
… ………………………………………………………
119
APPENDIX H
Performance Questionnaire (PQ)
Code :
Date :
Instruction: This questionnaire is to ask you about care you gave to your patient
(loved one/relative, e.g. your daughter/son/father/mother) during the past week.
Part I: Please mark (√) if your patient had experienced the following symptoms.
Please mark all that apply.
No
1.
2.
Symptoms had been experienced by your patient
Warning signs and symptoms during three days after
discharge:
a. Decrease level of consciousness
b. Constant of headache and/or severe headache
c. Vomiting projectile
d. Seizure
e. Continual fluid or bleeding from the ears or nose
Symptoms following mild TBI
a. Headache
b. Dizziness
c. Fatigue
d. Difficulty remembering
e. Other symptom (specify)……………….
Yes
No
120
Part II: Please respond to the questions asking things you have done for your patient
over the past week by marking (√) in the appropriate column that best represent how
often you performed each action.
Note
1: Never
2: Rarely (1-2 times/ week)
3: Sometime (3-4 times/ week)
4: Often (5-6 times/ week)
5: Regular (every day)
No
Performance
Statements
1
2
3
4
5
1.
2.
3.
I assess the warning signs
I assess the symptom of headache
I remind the patient to take medication (analgesic) or
giving medication to the patient when patient get
headache
…. ……………………………………………………….
…. ……………………………………………………….
19. Did you assess the patient’s progress (was better or
worse after you provided care)
Part III
Please respond to the questions asking things you have done for your patient over the
past week by marking (√) in the appropriate column.
No
Statements
1. Did you transfer the patient to the hospital when any of warning signs
and symptoms occurred
2. Did you consult nurse/doctor/other health care provider when the
patient getting worse
Yes
No
APPENDIX I
Self-Efficacy enhancing Education Program Guideline
No
Topic
1
Introduction
2
Exploring the family
caregiver’s feelings
about ……………….
………………………
………………………
3
Teaching and ……….
………………………
………………………
(Verbal Persuasion)
Duration
Method
Place
3 minutes Discussion
Patients’
ward
5 minutes Discussion
………….
15
minutes
Patients’
ward
Discussion
Activities
Researcher
Explain the purpose of the
program
Participant
Actively participate in the session
Ask the family caregiver to
explore their feeling about
caring for patient with mild TBI
- What is your feeling related
to caring for your relative?
- ……………………………..
……………………………..
……………………………..
Actively participate in the session
Explore their feeling and her or his
problem related to providing care for
patient.
The researcher will provide
information regarding definition
of mild TBI, symptom of mild
TBI and warning sign, and
…………………………………
…………………………………
The researcher will ask family
caregiver
- ……………………………
……………………………
……………………………
Teaching session:
- Listen carefully and pay attention
while the researcher explained
- Answer of each question
- …………………………………..
…………………………………..
121
4
Demonstration and redemonstration
(Enactive Mastery
experiences)
15
minutes
Patients’
ward
Demonstration,
redemonstration,
and discussion
5
Sharing information
about success of
symptoms
management
……………………...
23
minutes
Patients’
ward
Discussion
The researcher will demonstrate
about symptom assessment
…………………………………
…………………………………
The researcher will ask some
questions to family caregiver
- Do you have any questions
after I showed ……………..
……………………………..
……………………………..
- What have you learned from
this demonstration?
- Is there anything that makes
you more ………………….
…………………………….
- Is it easy skills to perform or
not?
- Do you willing to practice?
- Are there any difficulties that
influence your practice?
Researcher will ask family
caregiver to re…………………
…………………………………
Researcher will share
information about success of
symptoms management and
show some pictures related to
management of mild TBI; ……
- Listen carefully and pay attention
while the researcher explained
- Family caregiver ask some
questions
- Answer of each question
- Mention about …………………
……………………………………
- Mention about her or his
difficulties to practice
- The family caregiver presents the
opinion how……………………..
……………………………………
- Family caregiver re-demonstrates
……………………………………
……………………………………
- Listen carefully and pay attention
while the researcher explained
- Family caregiver ask some
questions
- Answer of each question
122
………………………
………………………………..
………………………………..
Researcher will ask some
questions to family caregiver:
- Do you have any question
after I shared some
information and …………..
…………………………….
…………………………….
- What have you learned after
looked the pictures?
- Is it easy skills to perform or
not?
- Do you willing to practice?
- Are there any difficulties that
influence your practice?
- ………………………………
………………………………
………………………………
………………………………
- Mention about …………………..
……………………………………
- Mention about their difficulties to
practice
- The family caregiver presents the
opinion how …………………….
…………………………………...
- Family caregiver re-demonstrates
symptoms assessment and
symptom management: ………….
……………………………………
……………………………………
- Family caregiver explore her or his
confident to provide care for the
patient with mild TBI.
The researcher will make
appointment for next week via
…………………………………
- When do you have the
available time for next week?
- If you have any progress or
problem during provide care
123
to the patient, ………………
………………………………
………………………………
6
Telephone follow up
one week and ………
………………………
………………………
15
minutes
Discussion
The researcher will ask family
caregiver what family has been
done to the patient.
- Please tell me, how is your
progress in last week
regarding ………………….
…………………………….
…………………………….
…………………………….
…………………………….
…………………………….
-
-
The family caregiver responses
actively ……………………….
The family caregiver tells about
their competency to …………….
…………………………………..
The family caregiver explains
…………………………………
...................................................
124
APPENDIX J
Teaching Plan for Self-Efficacy enhancing Education Program
Method/Media/
Time
Discussion
(5 minutes)
Activities
Researcher
Participant
Explain about the - Listen carefully
purposes of
- Pay attention
education
- ………………….
program, content,
………………….
and duration.
- Ask the question
Ask the question - Provide
………………….
comments
………………….
To decrease
Exploring of family caregivers’
stress, anxiety feelings
and help …….
………………
………………
Discussion
(5 minutes)
Ask the family
caregiver to
convey her or his
feeling about
caring for patient
with mild TBI
- Convey his or her
feeling related to
…………………
- …………………
To improve
the family’s
knowledge
regarding mild
Discussion
Booklet
(10 minutes)
- Explain to the
family
caregiver
regarding
- Listen carefully
- Ask some
questions
- Answer the
Session
Topic
Objectives
Content
1
Introduction
To prepare
family
caregiver to
follow ……..
……………..
General introduction about a selfefficacy enhancing education program
2
Exploring
the family
caregiver’s
feelings
about ……..
……………
……………
……………
Mild TBI
overview
2
Mild TBI is an acute brain injury
resulting from mechanical energy to
the head from external physical
forces, signed by confusion or
125
Session
Topic
Objectives
Content
TBI:
definition,
mild TBI
symptom and
………………
………………
disorientation, loss of consciousness
for ………………………………….
………………………………………
Symptom following mild TBI consists
of three symptoms; physical
(headache, dizziness, nausea or
vomiting, fatigue, and sleep
disturbance), cognitive: (difficulties to
remember and concentration), and
emotional (irritability, anger, and
frustration)
Warning signs:
Warning signs is signs that related to
the increased intracranial pressure
(IICP).
The signs and symptoms of increased
intracranial pressure are
……………………………………..
……………………………………..
headache, vomiting projectile
repeatedly, seizure, paralysis on one
or more sides of body, and
bleeding/drainage from nose or ear.
Method/Media/
Time
Activities
Researcher
Participant
definition of
questions
mild TBI,
- Provide
symptom and
comments
warning sign,
impact, and
………………
………………
- Give
opportunity
for family
caregiver to
ask or ……….
………………
- Ask questions
related to
discussion
- Answer
family’s
questions
126
Session
3
Topic
Symptoms
assessment
Objectives
To improve
family’s
knowledge
and skill about
symptom
assessment
Content
Management symptoms:
Headache management (maintain
regular exercise, massage therapy,
neck stretches and …………………
……………………………………..
Memory difficulties ……………….
……………………………………..
Anger/irritability …………………..
……………………………………..
Symptom assessment using symptom
checklist:
- Assess the symptom every day
- Assess the warning sign
The warning signs such as
patients become unconsciousness,
worsening headache/severe
headache, vomiting projectile
repeatedly,
………………………………..
………………………………..
Method/Media/
Time
Activities
Researcher
Participant
Discussion
- Explain to the
Demonstration
family
Recaregiver
demonstration
regarding
symptom
symptoms and
assessment using
………………
symptom
………………
checklist
- Demonstrate
15 minutes
about
assessment of
symptom
- Give
opportunity
for …………
…………….
…………….
- Ask questions
- Listen carefully
and pay attention
- Ask some
questions
- Answer the
questions
- Provide
comments
- Re-demonstrate
the symptom
assessment
127
Session
Topic
Objectives
Content
Method/Media/
Time
-
4
Symptoms
management
To improve
family’s
knowledge
and
………………
………………
………………
Management symptom following mild
TBI:
Management of headache
When your patient has headache:
a. Reminding the patient to perform
deep breathing or teach the patient
to do it
b. Reminding ………………………
…………………………………..
c. Reminding to take medication
(analgesic) or giving medication to
the patient such as Paracetamol
To prevent headache:
a. Encouraging the patient to do
regular exercise: ………………..
Discussion
Demonstration
Redemonstration
symptom
management
15 minutes
-
-
Activities
Researcher
Participant
related to ……
………………
Answer ……..
………………
Ask family
caregiver to
……………..
……………..
……………..
Provide
reinforcement
Explain to the - Listen carefully
family
and pay attention
caregiver
- ………………….
regarding
………………….
…………….. - ………………….
……………... - ………………….
Demonstrate
about
symptom
management
neck
stretching,
sleep position,
and deep
breathing
128
Session
Topic
Objectives
Content
………………………………….
………………………………….
b. Encouraging or providing the
appropriate sleep position
c. Encouraging patient to avoid
caffeine
Management of dizziness
- Reminding to take ………………
…………………………………..
- Reminding and/or helping the
patient to move/change position
slowly
- …………………………………..
………………………………….
………………………………….
- Encouraging or providing food
with low salt
Management of fatigue
a. Encouraging the patient:
- to get enough sleep and rest
- to do exercise: range of motion
- ……………………………….
……………………………….
b. Helping and/or preparing the
patient of ………………………..
…………………………………..
Method/Media/
Time
-
-
-
-
-
Activities
Researcher
Participant
Give
opportunity
for family
caregiver to
……………..
……………..
……………..
Ask questions
related to
demonstration
Answer
family’s
questions
Ask family
caregiver to
………………
………………
Provide
reinforcement
129
Session
Topic
Objectives
5
Symptoms
evaluation
To improve
family’s
…………….
…………….
6
Sharing
To improve
information family’s
about……… knowledge
and skill about
………………
………………
Content
Management of difficulty of
remembering
a. Helping the patient to practice
remembering: ……………………
……………………………………
b. Encouraging and/or helping the
patient:
- to make daily planners
- to use devices to help ………..
………………………………..
……………………………….
Evaluate symptoms after providing
care to the patients related to
……………………………………
……………………………………
The vestibular exercises were
provided to the patients
…………………………………….
…………………………………….
…………………………………….
Method/Media/
Time
Discussion
5 minutes
……………….
Activities
Researcher
Participant
- Explain to the
family
caregivers
regarding
…………….
- …………….
- …………….
- Explain to the
family
caregiver
regarding
………………
.......................
- Give
opportunity to
- ……………….
- Listen carefully
and pay attention
- Ask some
questions
- Answer the
questions
- ……………….
130
Session
Topic
Objectives
Content
Method/Media/
Time
Activities
Researcher
Participant
family
caregivers to
……………..
- Answer
family’s
questions
131
APPENDIX K
Booklet
FAMILY CAREGIVERs
&
MILD TBI PATIENT
BOOKLET
Introduction
This booklet aims to provide information about management of
mild TBI. It helps family caregivers about management for your
patients with mild TBI. It consists of definition of mild TBI,
what family caregivers should do to care the patients with mild
By
TBI after discharge, warning signs and symptoms following
mild TBI, headache management, dizziness management,
Erfin Firmawati
fatigue management, and difficulty in remembering
management.
Master of Nursing Science
Prince of Songkla University
Thailand
132
Caring for symptom assessment
Mild Traumatic Brain Injury
Definition of mild TBI
Mild traumatic brain injury is an acute brain injury
resulting from mechanical energy to the head from external
physical forces with criteria confusion or disorientation, loss of
consciousness for 30 minutes or less, post traumatic amnesia for
Family caregivers help patient with mild TBI by assess
symptoms after discharge from hospital that is to identify the
symptom of warning signs of increase intracranial pressure
especially during one week after discharge and symptoms
following mild TBI.
less than 24 hours.
Warning Signs & Symptoms
What family caregivers should do to care the patient with mild
TBI after discharge from the hospital?
a. Caring for symptom assessment
Warning signs are signs that related to increased
b. Caring for symptom management
intracranial pressure. You as family caregivers should pay
c. Caring for symptom evaluation
attention to observe or monitor the patient’s condition
within one week and two weeks after discharge from
hospital
133
Symptoms following mild TBI
Physical symptoms
Headache
Dizziness
Fatigue (loss of
getting tired easily)
Nausea
Vomiting
Tinnitus
Sleep disturbance
Blurred vision
Double vision
Light sensitivity
Cognitive symptoms
Emotional
symptoms
Difficulty concentrating Irritability
Difficulty remembering Depression
Aggression
energy/ Taking longer to think
Anger
Headache is one of the common symptoms after mild
traumatic brain injury
The types of headache after mild TBI
1. Migraine headache
This type has the following features: dull,
throbbing sensation, usually on one side of the
head, sometimes accompanied by nausea or
vomiting.
2. Tension-type headache
This type has the following features tight,
squeezing sensation, often around the entire head
or both sides.
How to manage headache?
When your patient has headache:
a. Reminding the patient to perform deep breathing or teach the patient to
do it
b. Reminding the patient to perform massage or provide massage to the
patient
c. Reminding to take medication (analgesic) or giving medication to the
patient such as Paracetamol
To prevent headache:
a. Encouraging the patient to do regular exercise: perform neck stretching,
range of motion (ROM)
b. Encouraging or providing the appropriate sleep position
c. Encouraging patient to avoid caffeine
134
Management of dizziness
Vestibular Exercises
Your patient feels loss of balance if
she/he move or change position
quickly.
How family caregivers help patient with dizziness
symptom?
- Reminding to take medication or giving medication
to the patient
- Reminding and/or helping the patient to
move/change position slowly
- Encouraging and/or guiding the patient to perform:
vestibular exercise
- Encouraging or providing food with low salt
Steps of vestibular exercise
1. Start by sitting upright in
bed
2. Turn head to the left
3. Lie back
4. Turn head to the right
5. Roll over to the right side
6. Sit up straight again
7. Repeat in the opposite
8. ………………………….
You help and/or encourage the patient to do vestibular
exercise before bedtime. If your patient gets worse of
dizziness after conduct the exercise, please consult to the
doctor/nurse.
135
Management of fatigue
Your patient feels losing of
energy and/or getting tired
easily
How family caregivers can help the patient to manage of
fatigue symptom?
1. Encouraging the patient:
- to get enough sleep and rest
- to do exercise: range of motion
- to set a regular schedule between activity and rest
2. Helping and/or preparing the patient of the adequate meals
and drinks
Management of difficulty remembering
How family caregivers help the patient to
manage this symptom?
- Helping the patient to practice
remembering: place, name, time, event
in the current day or previous day
- Encouraging and/or helping the patient:
• to make daily planners
• to use devices to help remembering:
mobile phone, calendar, diary
Using calendar
Making daily planner
136
Warning Signs (increased intracranial pressure)
Day
Day
Day
Day
Day
Day
Day
Symptom
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Unconsciousness
Severe headache
Vomiting projectile
Seizure
Weakness/paralysis one or
more sides of body
Bleeding or drainage from ear
or nose
Day
Day
Day
Day
Day
Day
Day
Symptom
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Unconsciousness
Severe headache
Vomiting projectile
Seizure
Weakness/paralysis one or
more sides of body
Bleeding or drainage from ear
or nose
137
Symptom
Sunday
Symptom Management
No Yes No
Yes
Day
Monday
Tuesday
Symptom Management Symptom Management
No Yes No
Yes No Yes No
Yes
Wednesday
Symptom Management
No Yes Yes
No
Headache
• Encouraging the patient to perform regular exercise:
neck stretching
• Encouraging and/or providing the appropriate sleep
position
• Reminding the patient to take medication (analgesic) or
giving medication to the patient when patient get
headache
Fatigue
• Encouraging and/or helping the patients to perform
exercises
• Encouraging and/or monitoring and/or reminding the
patient to get enough sleep
• Monitoring and/or helping the patient has adequate
meals and drinks
Dizziness
• Encouraging and/or helping to do vestibular exercise
• Reminding or helping the patient to move/change
position slowly
• Reminding the patient to take medication and/or giving
medication to the patient when patient get dizziness
Difficulty in remembering
• Practice remembering: asking the patient about time,
place, and person
• Encouraging and/or helping the patient to make daily
planners
• Encouraging and/or helping the patient to use devices
to help remembering: mobile phone, calendar, diary
138
139
APPENDIX L
List of Experts
Three experts examined the content validity of the instruments
including the intervention program, teaching plan and booklet, the Rivermead Postconcussion Symptom Questionnaire, the Perceived Confidence Questionnaire, and the
Performance Questionnaire, they were:
1. Dr.Prapan Somporn, M. D
Nerosurgeon, Hatyai Hospital, Thailand
2. Miss Jintana Damkliang
Nursing Lecturer, Surgical Nursing Department,Faculty of Nursing,
Prince of Songkla University, Thailand
3. Narumon Anumas
APN Neurosurgical intensive care, Hatyai Hospital, Thailand
140
APPENDIX M
Permission of the Instrument
RE: Asking permission for using Rivermead Postconcussion Symptom Questionnaire
Sembunyikan Detail
Dari: Nigel King
Ke: erfin firmawati
Yes it is fine to use the questionnaire.
Good luck with your research.
Kind regards.
Dr Nigel King
From: erfin firmawati [mailto:fifinku_jogja@yahoo.co.id]
Sent: 16 May 2013 04:39
To: Nigel King
Subject: Asking permission for using Rivermead Postconcussion Symptom
Questionnaire
Dear Dr Nigel King
First of all, I would like to introduce my self. My name is Erfin Firmawati, I am a
master student at Nursing Faculty, Prince of Songkla University, Thailand.
Now, I am doing my thesis entitle "The effect of Self-Efficacy Enhancing Education
Program on Family Caregivers' Competencies in Caring for Patientswith Mild
Traumatic Brain Injury".
In my study,I would like to use the Rivermead Postconcussion Symptom
Questionnaire to assess the patients' symptoms with mild TBI.
This questionnaire is very usefull and helpull for my study.
Furthermore, I would like to publish my study in the journal of trauma.
Dr Nigel King, I would like to ask You to give me permission to use your
questionnaire.
Hopefully, Dr Nigel King would like to give me permission.
Thank You very much
Best regard
Erfin Firmawati
Master student, Faculty of Nursing, Prince of Songkla University, Thailand
My Advisor: Assoc.Prof.Dr.Praneed Songwathana, RN,Phd.
emaild address:spraneed@yahoo.com
141
VITAE
Name
Erfin Firmawati
Student ID
5410420023
Educational Attainment
Degree
Name of Institution
Year of Graduation
Bachelor of Nursing
School of Nursing, Faculty of
2006
Medicine and Health Science
Muhammadiyah University of
Yogyakarta
Scholarship Awards during Enrollment
2011 – 2013
Directorate General of Higher Education, Ministry of National
Education of Indonesia
Work – Position and Address (If Possible)
Work position
Lecturer of School of Nursing, Faculty of Medicine and Health
Science, Muhammadiyah University of Yogyakarta
Address
Jl. Lingkar Selatan, Tamantirto, Kasihan, Bantul, Yogyakarta,
Indonesia
Phone
+62274387656
Email
fifinku_jogja@yahoo.co.id
List of Publication and Proceeding
Firmawati, E., Songwathana, P., & Kitrungrote, L. (2013). A pilot study of selfefficacy enhancing education program on family caregivers’ competencies in caring
for patients with mild traumatic brain injury. The 2013 International Conference on
Health & Harmony, Nursing Values, Phuket Orchid Resort and Spa, Thailand, May 13, 2013.