the Nurses CariNg Factors and Coping Mechanisms of Patients with pulmonary Tuberculosis undergoing directly observed treatment

short-course (DOTS) PROGRAM

BSN406-GROUP21 Aguirre, Kevin Sam Alarcon, Mikko Anthony Aliga, Keith Alupani, Queenie Ann Andalecio, Micah Grace Arboleda, Jungie Grace Bartido, Ma. Mennet Baylon, Anne Nickol Binauhan, Pauline Rubie Castro, Kathleen Cris

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

March 14, 2013

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TABLE OF CONTENTS Title page...1 Table of Contents.2 CHAPTER I Background of the Study.4 Statement of the Problem...6 Significance of the Study.7 Scope and Limitation9 CHAPTER II Review of Related Literature and Studies..10 Theoretical Framework..18 Research Hypothesis.22 The Main Variables of the Study..22 Definition of Terms.23 CHAPTER III Research Design25 Population and Sample.25 Research Locale.25 Research Instruments27 Data Collection Procedure27 Statistical Treatment of Data29 Ethical Principles....31 Reference32

CHAPTER I INTRODUCTION BACKGROUND OF THE STUDY Tuberculosis is a disease caused by a bacterium called Mycobacterium tuberculosis that is mainly acquired by inhalation of infectious droplets containing viable tubercle bacilli. The organism may attack other tissues in the body, but in Europe and North America, the lungs are most frequently the primary site of invasion-although most organs in the body can be attacked (Walsh, 2002) and this kind of tuberculosis is called Pulmonary Tuberculosis. Pulmonary Tuberculosis (PTB) is a contagious bacterial infection that involves the lungs, but may spread to other organs. Only about 10% of people infected with M. tuberculosis ever develop tuberculosis disease. Many of those who suffer TB do so in the first few years following infection, but the bacillus may lie dormant in the body for decades. Pulmonary tuberculosis frequently goes away by itself, but in 50%-60% of cases, the disease can return. People infected with TB bacteria have a lifetime risk of falling ill with TB of 10%. When a person develops active TB, the symptoms (cough, fever, night sweats, weight loss etc.) may be mild for many months. This can lead to delays in seeking care, and results in transmission of the bacteria to others. People ill with TB can infect up to 10-15 other people through close contact over the course of a year. Without proper treatment up to two thirds of people ill with TB will die (World Health Organization, 2012). Philippines has the ninth highest number of Pulmonary Tuberculosis (PTB) cases in the world and the highest in Southeast Asia (World Health Organization, 2012).

Globally, there were more than nine million new cases and about 1.7 million deaths from the disease in 2006; the WHO estimates there are more than 14 million people living with PTB, which kills 75 Filipinos each day (Department of Health, 2012). Over the years, the government, with the private sector and humanitarian community, has steadily made gains against tuberculosis. The Directly Observed Treatment Short-course (DOTS) program, recommended in the mid-1990s by the WHO, played an important role in this success (Humanitarian News and Analysis, 2012). DOTS required patients to take their medicine in front of a health worker to ensure proper compliance with the entire treatment program. It is considered as one of the most effective methods of ensuring patient compliance. With DOTS, health care providers can achieve a higher cure rate and expand services to detect more TB cases. The program is open for all suspected TB patients regardless of ones status life (Humanitarian News and Analysis, 2012). Patients who are diagnosed with TB are distressed and face challenges that they need to cope up with it. As healthcare providers, listening to these patients is important because it will help them cope up with their disease. According to Lazarus, copingis defined as constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person (Lazarus &Folkman, 1984, pp. 141). This definition is intimately related to the concept of cognitive appraisal and hence to the stress-relevant person-environment transactions. Most approaches in coping research follow Folkman and Lazarus (1980, pp. 223) efforts made to master; tolerate or reduce external and internal demands and conflicts among them (Folkman and Lazarus, 1980). Lazarus and

Folkmans concept of coping defines how a person reacts to a stressf ul event. An individuals way of coping to stressful encounters can be assessed based on the cognitive-phenomenological theory of stress and coping by Lazarus and Folkman. For instance, young people uses proportionately more active, interpersonal problemfocused forms of coping than do the other people, while the older people uses proportionately more passive, intrapersonal emotion-focused forms of coping than do the younger people. Coping, when considered as a process, is characterized by the dynamics and changes that are a function of continuous appraisals and reappraisals of the shifting person-environment relationship (Folkman, et.al, 1986). The coping of Pulmonary Tuberculosis patients undergoing DOTS in relation to Folkman and Lazarus way of coping is to describe what type of coping has the client have and these types are: confrontive coping, distancing, self-controlling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving and positive reappraisal. These coping mechanisms of TB patients may be affected by how the nurses caring factors will be applied.The carative factors deal with those features of caring that mainly involve appraising patient health preferences and requirements, planning to address those preferences, sharing to meeting patient health targets and assessing the usefulness of the caring processes in developing gradually patient health and healing (Backer , 2003 ) The changes in the health care delivery systems around the world have intensified nurses responsibilities and workloads. Nurses must now deal with patients increased acuity and complexity in regard to their health care situation. Despite such

hardships, nurses must find ways to preserve their caring practice and Jean Wat sons caring theory can be reviewed in this study (Cara, 2003). The study aims to correlate caring abilities of nurses as perceived by patients with Pulmonary Tuberculosis (PTB) undergoing DOTS program and the patients ability to cope in the said disease. The results or solutions of this study will serve as an indicator of the quality of care rendered by nurses in practice to pulmonary tuberculosis patients. Furthermore, the results will identify the present type of coping of these patients which will help the nurses adjust the care that they are currently giving to the patients with PTB. STATEMENT OF THE PROLEM The purpose of the study is to determine the nurses caring factors and coping mechanisms of patients diagnosed with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program in a selected hospital. Specifically, the study would like to answer the following questions: 1.) What are the caring factors of nurses as perceived by patients with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program? 2.) What are the coping mechanisms of patients with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program as perceived by nurses? 3.)Is there a significant relationship between nurses caring factors and coping mechanisms of patients with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program?

SIGNIFICANCE OF THE STUDY This study will discuss the new information and evidences of the nurses caring factors and coping mechanisms of patients with PTB. Provide information that establishes the rationale for selecting the research problem as important for society in general and for nursing in particular and it is expected to contribute to the following beneficiaries: Nursing Practice The study will greatly aid the nursing practice as it will expand more thoughts to nurses in caring patients with pulmonary tuberculosis. In using the carative factors of Jean Watsons theory in the nursing practice, it will help develop a good patient -nurse interaction that could give systematic approach in decision making by developing a more enhanced interventions in the nursing practice. The patient-nurse interaction will highly contribute in the progress of the patients health condition and this will also develop a multidisciplinary approach that would ensure successful outcome. The study will provide the provision for the supportive, protective, mental, physical, sociocultural and spiritual environment in the nursing practice. Nursing Administration This research study aims to help the nursing administration to have increase knowledge to inform the members of the health care team, and to guide nursing staff to the most appropriate nursing caring factors that will surely have an effect to their patients coping and healing process. They can gather data about the research study that will help increase their ability to improve nurses caring factors.

Nursing Education In relation to nursing education, this research study can help the nursing educators in teaching their students with the proper nursing care management related to the nurses caring factors and coping mechanisms. This will help them give more knowledge and holistic care to patients with Pulmonary Tuberculosis. This will also help the nursing educators andclinical instructors in teaching thestudents about the factors of nursing care and its relation to coping mechanism of Pulmonary Tuberculosis patients under Directly Observed Treatment Short-course (DOTS) program. Nursing educators or clinical instructors will be informed based on the findings of the research study for an improved quality care for the patients. Nursing Research This research study aims to help researchers to have general information about pulmonary tuberculosis patients undergoing DOTS program in a selected hospital regarding their coping mechanisms and nurses caring factors. The results can become useful data to improve the future researchers knowledge and understanding about the topic. The study can also be a guide to have a better research studies.

SCOPE AND LIMITATION The study will cover the topics about the nurses caring factors and coping mechanisms of pulmonary tuberculosis patients undergoing Directly Observed Treatment Short-course (DOTS) conducted from a selected hospital. The study will focus on the nurses caring factors as perceived by the patients and also the coping mechanisms of patients perceived by the nurses. Through the process, the respondents of the study will be chosen randomly. The study will cover approximately 20-30 patients with pulmonary tuberculosis undergoing DOTS program from a selected hospital and about 5-10 nurses who provide care to these patients. The study will be conducted in a selected hospital in Quezon City. The hospital was selected by the researchers because it has numbers of tuberculosis patients undergoing DOTS. The study will be accomplished through a step-by-step process. Starting with data gathering procedure by means of structured interviews and surveys to the selected respondents namelythe PTB patients and the staff nurses assigned to these specified patients. The exclusion criteria includephysically, mentally and emotionally disabled patients. Only patients willing to cooperate with the researchers study a re allowed to answer the survey. The study will be conducted with a span of 2-3 months starting June 2013.

CHAPTER II REVIEW OF RELATED LITERATURE AND STUDIES In this chapter, related studies and literature about Pulmonary Tuberculosis and coping mechanism and carative factors will be discussed in relation to the research study. Tuberculosis in the Philippines The Department of Health (DOH) reported lower Tuberculosis (TB) prevalence. The Philippines has itself made great strides in fighting TB. From a high mortality rate of 38.2 deaths per 100,000 population in 1990, the Philippine Health Statistics reported a lower rate of 31/100,000. According to the WHO, more than two billion people one third of the worlds total population are infected with TB bacilli. One in every 10 of those people will become sick with active TB in their lifetime. People living with HIV are at a much greater risk. A total of 1.77 million people died from TB in 2007 (including 456,000 people with HIV), equal to about 4,800 deaths a day. TB is a disease of poverty, affecting mostly young adults in their most productive years. The Philippines is among the 22 high burden countries for tuberculosis, according to the WHO. According to the 2nd National Prevalence Survey done in 1997, most TB patients belong to the economically productive age-group (15-54 years old). Overcoming Tuberculosis Thorn (2007) stated that Isolation is the hardest part of having TB, wherein patients must stay away from other people who are vulnerable in developing and active TB disease. Isolation of the patients contributes a unique set of coping problems. The

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study has considered a long period of isolation to patients and was found out that they have developed depression, anxiety and disorientation. Some patients also experienced odd sleeping patterns and mood swings. Patients were advised to temporarily isolate themselves from a great number of people to avoid spreading their disease. Isolation does greatly affect patients in a very subtle way. He also stated the benefits of DOTS program that would greatly help in coping with regards to the problems of those patients with TB having a difficulty in adjusting. According to Lewis and Newell (2009), health workers should be aware of all aspects regarding the caring and treatment they will render to patients with tuberculosis. Effective medical treatment is just one of the procedures that will help patients recover from tuberculosis. Healthcare workers should also interact with these patients so that they will be engaged in the curing process of their disease. With this, patients will have the advantage of gaining knowledge about the disease and its treatment for healthcare workers will also complement the medical treatment with health teachings about the disease. Thus, another study supports the same principle in taking care patients with tuberculosis. National Tuberculosis Controllers Association (2011) said that healthcare workers provide consistent and concise documentation throughout the case

management and treatment process. Expected documentation provides an ongoing clinical picture of the patient and the patients progress to cure, while ensuring continuity of care. Case management, with appropriate documentation, provides the framework that enables the public health nurse to ensure that the TB patient completes treatment and is able to be discharged from the TB program.

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Coping Strategies Coping is the way people act to lessen the burden they are carrying or the stress they feel. They do certain things to fit or somehow manage their current situation (Kiel,2004). Being healthy or sick is related to the knowledge the person has regarding the disease or illness and it also depend on the available coping resources. Their body feels what it feels according to their interactions to others and to their environment. It is in their will and capacity on how to deal with it for it is part of being human and permeates their whole life if they find it hard to solve thus other researchers have the same idea for it happens to each historical period of humanity (Burtson and Stichler, 2010). In the study of Lyon (2010), she paid attention with regards to reconciling the diverse views of stress, coping, and health for nursing. She used different theoretical approaches for her to be able to interrelate stress, coping, and health. And it was seen in her study that those three concepts are interrelated. Meaning, each concept indicated directly affects the other. It stated that coping involves managing the stressful situation that will lead to persons coping with his/her environment. However, another study of Naughton stated that there are effects of stress that are directly related to coping mechanisms. All of fields of psychology such as health psychology, environmental psychology, neuropsychology and developmental

psychology are the start of encompassing a huge variety of disciplines to the fields of medicine including the area of anthropology and sociology. The three broad components of coping strategies will provide a better understanding of what the seemingly immense is about.

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According to Plotnik and Kouyoumdjian (2008), there are two kinds of coping and these are Problem-focused coping which means the patient try to decrease stress by solving the problem through seeking information, changing own behavior, or taking whatever the action is needed to resolve the difficulty and second, emotion-focused coping which means that the patient do things primarily to deal with their emotional distress, such as seeking support and sympathy or avoiding or denying the situation. Reichman (2000) places the blame at the feet of the medical sector and politicians. Perhaps their reluctance to change current practice is understandable, although wrong. Changes in the design of treatment delivery do not always dramatically reduce costs to the health department; and it is these costs that health professionals and politicians care about most. But as has been shown in this study, the treatment of tuberculosis, particularly with the DOTS regime, substantially reduces the costs of the illness to patients and their families. Once these costs are taken into account, there is a compelling case for treatment for tuberculosis to be given a high priority by decisionmakers and for DOTS to be adopted as the treatment regime. Stressors, coping mechanisms and quality of life among TB patients Somaya (2012) stated that patients with TB have many related illness such as pain, financial problem and dependency, stigma and threat to self-esteem. It was stated that a patients with illness related stressors may affect their emotional, physiological and behavioral reactions. With this, according to the study, nurses could provide optimum health by proving support, information, critical analysis and alternative problem-solving strategies.

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Caring and the Professional Practice of Nursing Jean Watson stated that, Caring is a science that encompasses a humanitarian, human science orientation, human caring processes, phenomena, and experiences. Caring science includes arts and humanities as well as science . A caring science perspective is grounded in a relational ontology of being-in-relation, and a world view of unity and connectedness of all. As such, caring science is rapidly becoming an Interdisciplinary Transdisciplinary field of study. It has relevance to all the health, education human service fields and professions (Watson, 2003). Caring takes place when nurse and patient meet. Nurses interact with patient and that reveals the nature of care (Shoenhofer, 2002). Thus, caring from nurses enhance patients health and this explains that caring exists even with caring otherwise curing cannot be attain without caring (Watson, 2003). There are ten carative factors and these are: Formation of a humanistic- altruistic system of values; installation of faith-hope; cultivation of sensitivity to ones self and to others; development of a helping-trust relationship; promotion and acceptance of the expression of positive and negative feelings; systematic use of the scientific problemsolving method for decision making; promotion of interpersonal teaching-learning; provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment; Assistance with the gratification of human needs; allowance for existential-phenomenological forces (J. George, 2008). According to Watson, promotion of health, prevention of illness, caring for the sick and restoration of health are prominent factors in nursing and practice of caring in this field is based on holistic care that is essential for the well-being of patients and
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aside from the assistance given by nurses to promote quality care, nurses are also active participants for patient to gain self-actualization. Watsons theory of Human Caring Adeline (2000) states that a humanistic altruistic value system of a person begins at birth and continuously developed through consciousness and introspection by interacting with the society we live in which enhance the caring healing where it interacts with the carative factor she called as faith - hope. That allows the nurse to be authentically present with patients. She also said that human caring is influenced by the values of person such as loudness, concern, and love of self and others which enhance therapeutic effects of faith hope. According to Watson as inspired by Carl Rogers work in order for the nurse to be able to do his responsibilities to his patients, the nurse must have a balanced sensitivity to self which is the foundation to empathy. Sensitivity to self can be developed by reflecting values, beliefs, thoughts, feelings and experiences in life as well as in the clinical area and the evaluate transpersonal caring (Adeline, 2000). The transpersonal caring relationship According to Adeline (2000) Watsons have four carative factors that focus on the transpersonal caring relationship. Faith hope is one of the important carative factors on nurse patient relationship. Faith Hope extends beyond the nurses understanding of t he integration of mind, body spirit it involves posturing faith hope based on the patients belief system. Sensitivity to self is important for the preparation of nurse to care. Helping trusting is also an important carative factors that involves in nurse patient relationship,

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Watson states that the development of this factor helps in maintaining the integrity of the patient (Adeline, 2000) As noted she focus her thinking on the therapeutic relationships and communication to the work of Carl Rogers and found out that congruency, empathy and warmth are the found action that helps in the expression of patients emotions. Congruency refers to authenticity and genuiness while empathy means understanding both the content and emotion of the patient and warmth is the degree of which the nurse conveys caring to the patient. Caring processes According to Adeline (2000), the five remaining carative factors which are primarily involved in assessing patient health, prioritizingthe patient health goals and evaluating the effectiveness of caring processes in promoting client health and healing. These carative factors are effective if nurses and patient are together in deciding caring processes. These involve creative and reflective problem solving or nursing care process that is helpful in guiding content and organizing assessment of patients in which permits interaction of multiple factors that also includes the personal on intuitive, aesthetic and ethical knowledge. Transpersonal teaching learning is one of the nursing activities where in both nurse and patient will teach and learn from each other. It involves the entire significance of the patients response to the health concerns and also explores patients perception about his condition. So teaching learning is based on gaining knowledge and skills that are important in developing self-efficacy (Adeline, 2000).

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THEORETICAL FRAMEWORK The study will be conducted to determine the nurses caring factors and coping mechanisms of patients diagnosed with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program in a selected hospital. Jean Watsons Carative Factors Formation of a humanisticaltruistic system of values Installation of faith-hope Lazarus Concept of Coping Confrontive

Distancing

Cultivation of sensitivity to ones self and to others Development of a helpingtrust relationship Promotion& acceptance of the expression of positive & negative feelings Pulmonary Tuberculosis Patients undergo Directly Observed Treatment Shortcourse (DOTS) Program

Self-controlling

Seeking social support

Systematic use of the scientific problem-solving method Promotion of interpersonal teaching-learning Provision for a supportive mental, physicalenvt Assistance with the gratification of human needs Allowance for existentialphenomenological forces

Accepting responsibility

Escape-avoidance

Planful problem solving

Positive reappraisal

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Watsons Ten Carative Factors are based on a dynamic phenomenological approach related to the nurse-patient relationship. The first factor is the formation of humanistic and altruistic values. It is learned early in life but continues to be influenced through interactions with parents, family, friends, and others, including nurse educators (Neil, 2002). The second factor is the instillation of faith and hope. It integrates humanistic and altruistic values, aid the promotion of holistic nursing care and positive health within the patient population. This factor also states that by helping patients adopt health-seeking actions, the nurse can help develop an effective nurse-patient interrelationship (Neil, 2002). The third factor is the cultivation of sensitivity to self and others. It means selfacceptance and acknowledgement of feelings for both nurse and patient (Neil, 2002). The fourth factor is the development of a helping-trust relationship. It is very important for transpersonal caring. A helping-trust relationship encourages the expression of both positive and negative feelings (Neil, 2002). The fifth factor is the promotion and acceptance of the expression of positive and negative feelings. It is a risk-taking experience for both nurse and patient. Nurses should be ready for a positive or negative expression of feelings carried out by the patient (Neil, 2002). The sixth factor is the systematic use of the scientific problem-solving method for decision making. It is the utilization of the nursing process in the provision of care to patients. Thus, this factor eliminates the belief that nurses are handmaids of doctors (Neil, 2002).

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The seventh factor is the promotion of interpersonal teaching and learning. It separates nursing from curing. This factor allows the patient to have a sense of responsibility over his/her own health. The nurse helps the patient in acquiring this responsibility through teaching-learning techniques. These techniques are geared at enabling patients to provide self-care, determine personal needs, and provide opportunities for their personal growth (Neil, 2002). The eighth factor is the provision for supportive, protective and corrective mental, physical, sociocultural and spiritual environment. It implies that nurses must recognize the influence internal and external environments have on the health and illness of individuals (Neil, 2002). The ninth factor is the assistance with the gratification of human needs. It involves the nurses recognition of the biophysical, psychological, psychosocial and intrapersonal needs of patients. Following Maslows hierarchy of needs, patients must answer lower needs first before moving up to satisfy higher needs (Neil, 2002). The last factor is the allowance for existential-phenomenological forces. It describes the relevant information needed by an individual to understand the present situation. This factor aims to a better understanding of self and others (Neil, 2002). The caring factor survey tool will be used to assess the perception of care that patients with pulmonary tuberculosis receive from the nurses. Coping, when considered as a process, is characterized by dynamics and changes that are a function of continuous appraisals and reappraisals of the shifting personenvironment relationship. Shifts may result from coping efforts that are directed outward

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toward changing the environment or efforts that are directed toward changing the meaning of the event (Lazarus and Folkman, 1988). The patients perception of Watsons caring factors is assessed using the caring factor survey tool and it will describe the interrelationship to the ways of coping questionnaire by Lazarus. The caring factor survey will determine whether or not the nurses are providing the carative factors to the patients as based on the patients perception per se. the utilization of the carative factors on patient care will be correlated with the extent of the patients coping mechanism in a healthcare environment.

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RESEARCH HYPOTHESIS Based on the specific questions raised in the statement of the problem, the researchers hypothesized the following: 1.) There is no significant relationship between the nurses caring factors to the coping mechanisms of patients with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program. THE MAIN VARIABLES OF THE STUDY The major variables under investigation are the nurses caring factors and the coping mechanisms of pulmonary tuberculosis patients undergoing Directly Observed Treatment Short-course (DOTS). The independent variable is the nurses caring factors whereas the dependent variable is the coping mechanism of pulmonary tuberculosis (PTB) patients. The researchers will be using the Caring Factors Survey developed by Jean Watson and her colleagues to measure the nurses caring factors to patients undergoing Directly Observed Treatment Short-course (DOTS) Program in the selected tertiary hospital in Quezon City. The patients would be asking to answer fifteen questions about their perception regarding the care that they receive from the nursing staff. After the study, the hospital administrator will be able to note if the caring factors of the nurses help in improving the condition of their patients. The coping mechanism will be measured using the Ways of Coping Questionnaire. This questionnaire is used to identify the extent of coping of individuals with stressful events they encounter in the institution. It comprises of thirty two item cognitive and behavioral strategies under eight-coping scales.

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DEFINITION OF TERMS For better understanding of the terms used in the study, the following terminologies were conceptually and operationally defined.

1.) Coping
It consists of constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person (Lazarus and Folkman, 1984). Refers to the patients response on the coping strategies they utilize when given a stressful situation. The extent of coping is measured in this study by using a standardized questionnaire developed by Lazarus. For each question, they will be asked to indicate, by circling 5 for always, 4 for frequently, 3 for occasionally, 2 for rarely, and 1 for never, to what extent they used it in the situation. 2.) Directly Observed Treatment Short-Course Program It is a comprehensive strategy endorsed by the World Health Organization (WHO) and International Union against Tuberculosis and Lung Diseases (IUATLD) to detect and cure TB patients. There are five elements of DOTS that need to be fulfilled. These are: political commitment; quality sputum microscopy for diagnosis; regular supply of anti-TB drugs; standardized recording and reporting of TB data; and supervised treatment by a treatment partner (Department of Health, 2012). Refers to a program by the Department of Health utilized by the patients diagnosed with pulmonary tuberculosis. The respondents of the study are those TB patients undergoing DOTS within 6-8 months. 3.) Nurses Caring Factors

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The act of providing Nursing care that attempts to honor the human dimensions of nurses work and the inner life world and subjective experiences of the people we serve (Cara, 2000). Refers to the patients response about how they feel regarding the care they are currently receiving from the nursing staff. The nurses caring factors are measured in this study by using a standardized questionnaire developed by Jean Watson and her colleagues. For each questions, they will be asked to indicate how much they agree or disagree with the statement. They would be marking their response by filling in the circle, 5 for always, 4 for frequently, 3 for occasionally, 2 for rarely, and 1 for never, that best represents their opinion.

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CHAPTER III RESEARCH METHODOLOGY RESEARCH DESIGN The study is a quantitative non-experimental correlation design, because it describes the existing phenomena which are the nurses caring factors and the patients coping mechanism without manipulating the conditions that affects the subjects responses. It also does not involve manipulation of the independent variable which is the nurses caring factors. Thus, the research tends to correlate the existing variables involve in the study. POPULATION AND SAMPLE The population of the study includes TB patients undergoing Directly Observed Treatment Short-course (DOTS) program and nurses that are contributing caring attributes to gain their optimal health on a selected hospital where the study will be obtained. The population includes 20-30 patients undergoing Directly Observed Treatment Short-course treatment (DOTS) program and 5-10 nurses who provide care to these patients as the respondents of the study. Patients who are physically, mentally and emotionally disabled are excluded in the population and sample. Randomized sampling was used as the sampling technique, wherein the willing and available participants were assigned to treatment conditions at random. Through this the researchers can avoid systemic biaswhich could affect outcome variables. RESEARCH LOCALE The study will be conducted at the selected tertiary hospital located in Quezon City, with the Pulmonary Tuberculosis patients undergoing Directly Observed Treatment

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Short-course (DOTS) program and the staff nurses providing care to them as respondents. The researchers chose the tertiary hospital to get their study population for being a well-known institution for lung diseases which provides quality health care through excellent service, training and research as greatly emphasized to their mission and vision. Moreover, the researchers have already started communicating to the research and training department of the said institution. The selected tertiary hospital is situated at the heart of Quezon City. At present the center has 210 bed capacities along with numerous programs and services specifically focused on lung diseases. One of the said services where it was established in early 2000 and was a self installed public private mix DOTS clinic certified by the Department of Health (DOH), and accredited by the PhilHealth Insurance Corporation. It became a satellite DOTS Plus Clinic in the year 2004 through tripartite coordination between the DOH, Tropical Disease Foundation Inc., and the selected tertiary hospital in Quezon City. According to the institution data statistics, the treatment outcome of patients treated for pulmonary tuberculosis at the center has seen remarkable success. Eighty-eight percent of their cases were cured in 2004 and partial result for 2005 revealed a success break of one hundred percent among the smeared positive cases. These results have surpassed the expected global outcome of curing at least 85% of TB cases detected. Thus, the tertiary hospital in Quezon City being in the process of acquiring state-of-the-art facilities and providing top quality care at affordable costs to the thousands of Filipinos is indeed a place of choice for the study.

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RESEARCH INSTRUMENTS The researchers will be using three instruments for the study. The first instrument is Demographic profile. The second instrument is a 15 item Caring Factors Survey tool developed by Jean Watson and her colleagues to measure the nurses caring factors to patients undergoing Directly Observed Treatment Short course (DOTS) Program in the selected tertiary hospital in Quezon City. The researchers instrument is a standard tool and was reconstructed by eliminating items from Watsons Caring Assessment tool reducing it from 100 to 15 questions. The third instrument is the Ways of Coping Questionnaire by Lazarus that will measure the coping mechanism. It is a standard tool which comprises of 32 item cognitive and behavioral strategies under 8-coping scales. The instrument will measure the caring factor of nurses that affects the coping mechanism of tuberculosis patient undergoing Directly Observed Treatment Short Course. Lazarus ways of coping mechanisms was restructuredfrom 66 to 32 questions due to the fact that some questions have the same thought. The researchers also made sure that the questions are applicable for Filipino respondents diagnosedwith Pulmonary Tuberculosis who are currently undergoing DOTS. The questionnaires were pre tested in a pilot study that was conducted last February 5, 2013. DATA COLLECTION PROCEDURE The focus of the study is on the coping mechanism of patients undergoing Directly Observed Treatment Short course (DOTS) Program and the Caring Factors of the patients and the nurses providing care in the selected tertiary hospital in Quezon City. Before the data collection, the researchers made a letter of consent in the selected

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tertiary hospital in Quezon City. The initial visit to the selected institution was to seek their consent for the study. After getting their permission, the researchers second visit was to collect data using questionnaires developed by Jean Watson which is the Caring Factors Survey and the Ways of Coping Questionnaire by Lazarus. The design was used by the researchers is experimental randomized design wherein the table of random numbers in choosing the respondents. Due to the limited population of patients undergoing DOTS Program the researchers ended up with twenty (20) respondents. The respondents needed in the study should be undergoing DOTS Program and included in the middle age range. The researchers will collect the data starting June 30, 2013. The steps that the researchers did in data gathering procedures are as follows: First, the researchers made a letter of consent to be given in the selected tertiary hospital in Quezon City to ask for their permission for the researchers to instigate study. After the researchers made the letter and had it signed by their adviser, the researchers submitted the letter together with the questionnaire to the head of the institution and waited for the confirmation for them to initiate and collect the data needed in the study. Third, the researchers went to the selected tertiary hospital in Quezon City to collect pertinent data in the study using caring factors Survey by Jean Watson and ways to coping questionnaire by Lazarus. The day after the researchers have collected our data, the researchers tallied and interpreted the results and compared it with the norms and standard.

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STATISTICAL TREATMENT OF DATA For this study, the researchers used the weighted arithmetic mean in getting the results for questions 1 and 2. In answering question number 1and 2 which is asking for the caring factors of nurses as perceived by patients with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program and coping mechanisms of patients with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program as perceived by nurses respectively, the weighted arithmetic mean used is that: x = w1x1+w2x2+...+wnxn w1+w2+...+wn Where x = weighted arithmetic mean wx= sum of all products of x and y is the frequency of each option and x is the weight of each option w= sum of all subjects In answering question no. 3 which is asking for the significant relationship between nurses caring factors and coping mechanisms of patients with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course (DOTS) program, spearmans rho will be used. Spearmans rho is a statistical calculation that takes two rankings and produces a numerical relation from 1 to -1. A score of 1 means that the lists are identical (1,2,3,4 vs. 1,2,3,4). A score of -1 means that the lists are reversed (1,2,3,4 vs. 4,3,2,1). A score of zero means that there is no relation whatsoever
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between the two lists.It was developed by CharlesSpearman and will be used when testing the significance of the relationship between two variables. The Spearman correlation coefficient is defined as the Pearson correlation coefficient between scores the ranked variables. For a sample of size n, the n raw

are converted to ranks

, and is computed from these:

Identical values (rank ties or value duplicates) are assigned a rank equal to the average of their positions in the ascending order of the values. In applications where duplicate values (ties) are known to be absent, a simpler procedure can be used to calculate . Differences between the ranks of

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

Where di= difference of rank of order between the two variables n= number of scores in each group

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ETHICAL PRINCIPLES Within the study it encompasses the ethical principles such as the principle of beneficence, respect for human dignity and justice. Firstly, the principle of beneficence because the studys main goal is to produce benefits and alleviate their sufferings rather than to cause harm and discomfort to the patients with pulmonary tuberculosis undergoing Directly Observed Treatment Short-course program. Also, the respondents rights from exploitation were protected by having the time allotment for the respondents to participate in the study clearly discussed and negotiated. Second is the principle of respect for human dignity wherein it gives the respondents the right to decide if they will participate in the study or not. The respondents, whoever refused to be interviewed shall not be forced nor obligated to answer the questionnaires for it is purely voluntary. The objectives and instructions of the questionnaires during the interview were also clearly elaborated to the respondents to promote full understanding of the respondents regarding the questions to be asked. The researchers even translated it in the Filipino language. Lastly, the principle of justice, for all the respondents should be treated equally and fairly regardless of their social status and so on and so forth. Their answers and other related information were also kept in confidentiality to promote and provide the respondents with privacy. Informed consent was also secured and settled. Thus, abiding all their rights into the overall ethical principles provided for each of our respondents participated in our study.

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REFERENCE Websites: 1.) Adeline, F. (2000). Watson's Philosophy, Science, and Theory of Human Caring

as a Conceptual Framework for Guiding Community Health Nursing Practice. Aspen Publishers, Inc., volume 23, pages 34-49. Retrieved from http://watsoncaringscience.org/images/features/library/Falk_Adeline.pdf 2.) Aye R., Wyss K., Abdualimova H., Saidaliev S. (2011). Factors determining

household expenditure for tuberculosis and coping strategies in Tajikistan. Retrieved from http://web.ebscohost.com/ehost/detail?vid=12&sid=6e353808-496a4853819e5230184907c2%40sessionmgr4&hid=112&bdata= JnNpdGU9ZWhvc3Q%253 d%3d#db=rzh&AN=2010969456 3.) Balita, Ph (2010). DOH reports lower TB prevalence as it marks 2010 World TB

Day. Retrieved from http://balita.ph/2010/03/25/doh-reports-lower-tb-prevalence-as-itmarks-2010-world-tb-day/ 4.) Boot, C. (2009). My Lung Disease Wont Go Away, its There to Stay: Proles

of Adaptation to Functional Limitations in Workers with Asthma and COPD. Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=04703717-e4c8-492fba62-bdce494c8370%40sessionmgr115&vid=2&hid=110 5.) Burtson, P., Stichler, J.(2010). Nursing work environment and nurse caring:

relationship among Motivational factors. Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=56109e10-88d0-49b1-b00e7c10e88aa84f%40sessionmgr4&vid=2&hid=15

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Cara, C., (n.d.). A pragmatic View of Jean Watsons Caring theory. Retrieved

from http://www.humancaring.org/conted/Pragmatic%20View.doc 7.) Damazo, L. (2012). PHILIPPINES: Tuberculosis remains a major killer. Retrieved

from http://www.irinnews.org/Report/78539/PHILIPPINES-Tuberculosis-remains-amajor-killer 8.) Drach-Zahavy, A. (2009). Patient-centred care and nurses health: the role of

nurses caring Orientation. Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=5a48b389-b890-465d-a7bd9afec0c57f8f%40sessionmgr14&vid=2&hid=15 9.) Hudacek, S. (2008). Dimensions of caring: A Qualitative Analysis of Nurses

stories. Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=db2ab9b9-02b9-4765-b87e73faa1600ef1%40sessionmgr114&vid=2&hid=9 10.) Johnson, M., et.al (2000). Patients' Perceptions of Physicians' Recommendations

for Comfort Care Differ by Patient Age and Gender, Vol.15, Number 4, pages 248-255. Retrieved from PubMed Central Database: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495435/ 11.) 12.) Krohne, H. (2002). Stress and Coping Theories. Page 4-6 Lazarus, R. (1993). Coping Theory and Research: Past, Present, and Future,

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Lewes, C., Newell, J. (2009). Improving tuberculosis care in low income

countries-a qualitative of patients understanding of patien t support in Nepal. BMC Public Health. Retrieved from http://www.biomedcentral.com/1471-2458/9/190 14.) Lyon, B. (2010). A conceptual overview: Stress, coping and health. Retrieved

from http://www.sagepub.com/upm-data/44174_1.pdf 15.) National Tuberculosis Controllers Association (2011). TUBERCULOSIS

NURSING: A comprehensive guide to nursing care, 2nd ed.. Retrieved from http://www.ndhealth.gov/disease/tb/Documents/TBNursingManual06132011.pdf 16.) Naughton, F. (1997). Stress and coping. California State University, Northridge.

Retrieved from http://www.csun.edu/~vcpsy00h/students/coping.htm 17.) Nursing theories (2012). Jean Watson's Philosophy of Nursing. Retrieved from

http://currentnursing.com/nursing_theory/Watson.html 18.) Program: Tuberculosis case finding and treatment ("DOTS" approach), 2009.

Retrieved from http://www.givewell.org/international/technical/programs/DOTS 19.) Smith, C. and Kirby, L. (n.d.). The Role of Appraisal and Emotion in Coping and

Adaptation. Handbook of Stress Science: Biology, Psychology and Health, Section III, Chapter 15, page 197. Retrieved from http://books.google.com.ph/books?id=EXVlk8pnEKIC&pg=PA197&lpg=PA197&dq=defi nition+of+coping+by+lazarus+and+folkman&source=bl&ots=nRJyFEsdNC&sig=fHYv06I fGL4jhm8ggPUFMleQe0&hl=fil&sa=X&ei=GMT4UNzZG4rprQfS7IHQBw&ved=0CEgQ6AEwAw#v=on epage&q=definition%20of%20coping%20by%20lazarus%20and%20folkman&f=false

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20.)

Reichman, D. (2000). The economic impacts of tuberculosis: The stop TB

initiative, Section 2, Page 16. Retrieved from http://www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/ahlbu rg.pdf 21.) Republic of the Philippines Department of Health (2011). National Tuberculosis

Control Program. Retrieved from http://www.doh.gov.ph/node/367.html 22.) Rhodes, M., Morris, A., Lazenby, R. (2011). Nursing as its Best: Competent and

Caring. The Online Journal of Issues in Nursing (OJIN). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No2-May-2011/Articles-PreviousTopics/Nursing-at-its-Best.html 23.) Somaya, A. (2012). Stressors, coping mechanisms and quality of life among TB

patients page 156. Retrieved from https://www.lappublishing.com/catalog/details//store/gb/book/978-3-8484-88209/stressors,-coping-mechanisms-and-quality-of-life-among-tb-patients 24.) Suliman, W., et. al. (2009). Applying Watson's Nursing Theory to Assess Patient

Perceptions of Being Cared for in a Multicultural Environment. Retrieved from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=ce01b50f-df0c-4efa-a624817978847fba%40sessionmgr112&vid=2&hid=9 25.) The American Heritage Dictionary of the English language, 5th ed., 2008.

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Thorn, P. (2007). Overcoming Tuberculosis: A Handbook for Patients, chapter 1,

pages 1-4. Retrieved from http://www.tbsurvivalproject.org/OVERCOMINGinside.pdf 27.) Vance, T., (n.d.). Caring and the Professional Practice of Nursing. Retrieved

from http://rnjournal.com/journal-of-nursing/caring-and-the-professional-practice-ofnursing 28.) Ver, J. (2010). Tuberculosis in the Philippines today. Retrieved from

http://thepoc.net/thepoc-features/health-and-wellness/health-and-fitness-features/5266world-tuberculosis-day-awareness-philippines.html 29.) Watson, J. (2007). Watsons theory of human caring and subjective living

experiences: Carative factors/Caritas processes as a disciplinary guide to the professional nursing practice, volume 16, pages 129-135. Retrieved from http://www.scielo.br/pdf/tce/v16n1/a16v16n1.pdf 30.) Williams, G., et. al (2007). Best Practice for the care of patients with

tuberculosis. International Union against Tuberculosis and Lung Disease, page 23. Retrieved from https://www.google.com.ph/url?sa=f&rct=j&url=http%3A%2F%2Fwww.theunion.org%2Fi ndex.php%3Fid%3D92%26cid%3D2110%26fid%3D57%26task%3Ddownload%26optio n%3Dcom_flexicontent%26Itemid%3D240%26lang%3Den&q&esrc=s&ei=l3gxUazTOK 6yiQf7uYDYDQ&usg=AFQjCNG3vXHll8tMCzM24YAzodsRjsF0Qg 31.) World Health Organization (2012). Tuberculosis. Retrieved from

http://www.who.int/topics/tuberculosis/en/ 32.) World Health Organization (2013). Tuberculosis Fact sheet N104. Retrieved

from http://www.who.int/mediacentre/factsheets/fs104/en/

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

Lifestyle, stress and health pages 536-539. Ref#: Cir BF121 P88 2007 2.) George, J.(2008). Nursing Theories: The Base for Professional Nursing Practice, 5th ed., pages 410. Ref#: Cir RT 84.5 N8 2008 3.) Nelson, K., Williams, C. (2007). Infectious Disease Epidemiology Theory and Practice, chapter 18, pages 653-689. Ref#: Cir RA 643 I5 2007 4.) Plotnik, R., Kouyoumdjian, H. (2008). Introduction to Psychology, module 21: Health, stress, coping, 8th ed., pages 499. Ref#: Cir BF 121 P6 2008 5.) Tomey, A., Alligood, M. (n.d.). Nursing Theorists and their work, 5th ed., chapter 11, pages 145-150 6.) Walsh, M. (2002). Watsons Clinical Nursing and Related Sciences, 6th edition, page 352. Ref#: Cir RT 65 W3 2002 7.) Walsh, M., Crumbie, A. (2007). Watsons Clinical Nursing and related Sciences, 7th ed., chapter 14, pages 344-346. Ref#: Cir RT65 W3 2007 8.) Weiten, W. (2008). Briefer Version Psychology: Themes and Variation, 7th ed., chapter 13, page 381. Ref#: Cir BF121 W4 2008 Theses: 1.) Anchenar, I. (2010). Factors Affecting non-adherence to TB DOTS program

among patients: basis for a proposed health education guide. Ref#: Thesis RC 306 I5 2010

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2.)

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

and the extent of Coping of Lung Cancer patients in a selected special tertiary hospital in Quezon City. 3.) Joel, M. (2011). Proposed Sanitarium Complex: Incorporating Green Architecture

to TB disease.Ref# Cir RC 309.5 P5M4 2011

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