Understanding Self-Care in Incident Response with Children and Youth: A Comparative Analysis

 In order to understand self-care as a child and youth practitioner, one first needs to understand the effects of trauma have on the children and youth.  Eavan Brady advises of three types of traumatic events: experiencing or witnessing a serious injury, imminent threat of injury or death to self or others, and/or lastly a violation of self (pp3).  In Perry’s work: Effects of Traumatic Events on Children, An Introduction, it highlights the internal responses that a child experiences when experiencing the effects of a traumatic experience. The child can experience a dissociative state or a hyperarousal state, both created to cope through the traumatic event (Perry, 2003 pp4), which explains that the post traumatic experience the children will relive the traumatic experience over and over again, which then weaves a complex web of memories of the trauma (Perry, 2003 pp 5). The child then relieves the experience over and over with all the senses of their body and often stay in an aroused state long after the trauma (Perry, 2003 pp7).  These children experience impulsiveness, hyperactivity, or can be withdrawn to depressed (Perry, 2003 pp9).  So, looking at the children that come across a child and youth practitioner’s path most, if not all, have experienced some for of trauma, whether prolonged or incidental and it is noted in the thesis Secondary Traumatic Stress: The Hidden Trauma in Child and Youth Counsellors that 98% of Child and Youth Practitioners who were surveyed had worked with a child or youth that had experienced trauma (Bloom, 2004 pp38)  These children’s life events then become ours, as we empathize and treat the symptoms, which are often labelled as behaviours.

 The following is a summary of six articles that discuss the trauma effects of care professionals:

 

 

 

The Cost of Caring. Secondary Traumatic Stress and the Impact of Working with High-Risk Children and Families, By Bruce D. Perry

 Perry discusses how trauma situations can cause the organization as a whole to crumble under the ongoing pressures as staff are not able to continue to cope and manage the pressures that are brought onto them (Perry, 2014 pp 4).  The article further discusses the profound benefits of debriefing after a traumatic event, and how this helps with coping and supporting one another (Perry, 2014 pp6). A theme throughout Perry’s work is the feeling of a worker’s hopelessness when faced with the challenges of caring for children, but the outside demands supersede their best efforts.  Perry describes Post-Traumatic Stress Disorder as prolonged symptoms following a traumatic event, with can be permanent changes to one’s entire functioning (Perry, 2014 pp 9-10). With secondary trauma, this is the trauma of one person being experienced by a second person, which is not burnout as it can occur after expose to one situation (Perry 2014, pp10).  Burnout is long-term fatigue, with physical symptoms.  It is further noted that Perry speaks to the need for supervisors as being the main role in prevention of their employees developing secondary trauma; with their abilities to cope and an awareness of their employees needs (Perry, 2014 pp 13). Perry notes that as professionals it is important to focus on one’s own needs and normalized activities, with self-care activities, which include physical activity, writing, a spectator event or laughter.

Caring for Yourself is a Radical Act: Self-Care Guide for Youth Working in Community,

By Farrah Khan

 Khan indicates that ensuring self-care translates to maintaining energy and spirit to be a better person outside of work life (pp4).  Khan acknowledges that as youth practitioners the level of stress and trauma have a major impact on ourselves (pp5) and how the priority needs to be on the worker to energize. The way to self-care is to make time (pp16) and to treat at ourselves the way that we would harm reduce for a person we are providing service to (pp18).  Often times we work in places that do not value us (pp25).  Khan defines trauma on a larger community scale, describing large scale events (community shoots, war) (pp31) and then breaks down the smaller scale factors of trauma.  The article notes that trauma effects are stored in a persons emotional, psychological, and physical which can allow for learned responses (pp33).  Khan notes that vicarious trauma is the result of listening to and supporting those affected by traumatic events, and recognizing this aspect of our work is the best way to understand the need for self-care (pp42).  Khan holds to the importance of boundaries as an important aspect of ensuring work/life balance (pp51).

Indirect Trauma: Implications for Self-Care, Supervision, the Organization, and the Academic Institution, By Carolyn Knight

 Knight notes that as other may use secondary traumatic stress, compassion fatigue and vicarious trauma as a singular term, she instead uses indirect trauma is an umbrella term to describe the difference in their experiences by practitioner (2013, pp225).  The symptoms of a practitioner are noted to be a parallel to the symptoms of those who experienced the trauma (Knight, 2013 pp225).  It is illustrated clearly how secondary traumatic stress can have two very different affects on the practitioner, but how they cause just as much distress.  It is interesting to note that the examples that caused the stress were in relation to sexual abuse, which is likely the most traumatic experience one could imagine (Knight, 2013 pp 226).  The idea of vicarious trauma and how it affects the practitioner is created that because they have listen to so much victimization, that everyone is able to victimize those around them (Knight, 2013 pp 227).  Knight notes that indirect trauma is a result of ongoing experiences with hearing and witnessing distress (2013 pp229).  The idea that being proactive is the best way to handle indirect trauma, ensures that practitioners are able to learn and work through their experiences and learning how to leave work at work (Knight, 2013 pp231).  Supervisors also play a role in assisting practitioners through indirect trauma effects, but often because of the clinical aspect of the employment the sharing of indirect trauma is not done from practitioner to supervisor (Knight, 2013 pp232). 

Honouring the Wounded: Inviting in our Successes and Mistakes, By Wolfgang Vachon

 Vachon’s article depicts the notion that when a professional works with broken individuals, but is broken themselves or has unresolved issues, those issues will impact the professionals option and how they will handle the situation, as they will be protecting them self (pp55).  Vachon brings to light that studies have indicated that those in helping roles have experienced some form of physical or emotional abuse in their early years, at a rate of more than 50 percent and choose the field to do better then what they had (pp56).  Wounded healers indicate that they show resiliency in working through their own challenges, showing empathy, compassion and greater sensitivity, being able to work with difficult people and forgiveness (Vachon pp58).  This article focuses  on the aspects that make a relationship positive between a worker and a client, as having empathy, building a relationship, being personable, being sensitive and believing in change (Vachon pp59).

Compassion Fatigue: What Is It? Why Does It Matter? Recognizing the Symptoms, Acknowledging the Impact, Developing the Tools to Prevent Compassion Fatigue, & Strengthen the Professional Already Suffering from the Effects, By Sherry E. Showalter

 Showalter describes compassion fatigue as taking the pain from the people that helping professionals work with, which then affects the professional psyche.  This occurs more because professionals are expected to do more with less (Snowalter, 2010).  The article notes that there is a cost to caring on one’s physical, mental and emotional health (Showalter, 2010), which as described often have the same affect as the trauma experience.  The affect is a neglect of self care, which highlights exercise as a major factor in balance.  Snowalter brought in the suggestion of learning to say no ensure balance.  The article also took an interesting turn in the do not list, which emphasized not making rash decisions in one’s personal life during a time of compassion fatigue, also noting how to teach family and friends how they can offer support (Snowalter, 2010).

Understanding Burnout in Child and Youth Care Workers,

By Sean Barford & William Whelton

 Whelton describes how a child and youth practitioner works with the children and youth who have experience problems related to behaviours to psychological issues, who have little connection to their family system and may be resistant to assistance or treatment (pp271-272).  The article notes that burnout is explained as an emotional overload, with three parts: emotional exhaustion, depersonalization and low personal accomplishment (Whelton, 2010 pp272).  It is further noted that there are some predictors to burnout: age, martial status and perceived social support; while personality also plays a role (Whelton, 2010 pp272).  Further noted is that it is believed that the largest contributor to burnout is the organization; how workload and manage/employee interactions are managed (Whelton, 2010 pp273).  The study had interesting outcomes, which highlighted that Child and Youth Practitioners continued to maintain pride in their work, even with being exhausted while still feeling accomplished (Whelton, 2010 pp281-282).

Comparative Analysis

 The articles all touched on the aspect that makes a Child and Youth Practitioners work both valuable and challenging.  How trauma and overcoming those experiences with our children, youth and even families can create trauma for us.  The cost of walking through the trauma as indicated in the articles can have a varying degree of affects of Child and Youth Practitioners.  It is interesting to note that the affects of direct trauma are very similar to those of those who experienced the trauma:

Trauma

Compassion fatigue/burnout

Knight highlights that those who have experienced trauma can have problems with thinking, distortions, mistrust, hostility, being powerless or vulnerable (2013, 225). Knights notes that those who have experienced trauma have ongoing thoughts and flashbacks of the incident (2013, pp226)

Sleeplessness, nightmares, physical tension, eating issues, mood shifts, patient with youth and not with family, feeling tired, hyper alert, disassociation (Khan pp34).

Knight notes that the symptoms of ongoing thoughts and flashbacks occur in the practitioner from listening to another’s traumatic event.

 In order to understand how of working through a traumatic experience as a Child and Youth Practitioner can have a number of effects on a person’s body and mind, and how those effects are manifested throughout a persons personal and professional life the terms need to be understood, first.  See Appendix A for a description of the terms.

 Khan had a definition of trauma quoted from Bonnie Burstow: “Trauma is not a disorder but a reaction to a kind of wound. It is a reaction to profoundly injurious events and situations in the real world and, indeed, to a world in which people are routinely wounded” (Khan pp31).  Khan goes on to indicate “trauma is when individuals and/or communities experience, witness, or learn or profound events that involve actual or threatened death, or serious injury to the integrity of self or others such as murder, community shooting, rape, racism, and war” (pp31).

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 It is interesting to note that Vachon’s paper focusses primarily on how those who have experienced trauma can be the best to assist others through their traumatic experiences. What Vachon did not focus on was the indirect trauma effects that could be experienced by the professionals and how to handle those effects.  Vachon analysis then completely differs with the finding in Knight’s work that indicates that survivors who enter the field are more likely to develop indirect trauma (Knight, 2013 pp230).  Showalter also notes, like Knight, that those with unresolved trauma can result in compassion fatigue (pp239).  Knight suggests that there is research that shows that practitioners can grow in self-confidence and see the needs of others (2013, pp230-231).

 Perry lists several reasons why professionals are at increased risk for developing secondary trauma: Empathy; Insufficient Recovery Time; Unresolved Personal Trauma; Children are the most vulnerable members of our Society; Isolation and Systemic Fragmentation; Lack of System Resources (Perry, 2014 11-12).  Whereas Showalter indicates that the move from human services to business models can increase compassion fatigue (pp239).  Perry provides individual indicators of secondary trauma, which notes four domains: Emotional, Physical, Personal and Workplace (Perry, 2014 pp14).  It is difficult to pin point one definition for secondary trauma, as all the authors vary in their characteristics, symptoms and even causes.

 An interesting observation throughout Whelton’s paper is the complexity of behaviours described by the children and youth that a Child and Youth Practitioner works with, but that the children’s behaviours were not described in relation to trauma.  Whelton describes the children has having behavioural or psychological disorders, or unsafe youth (to self or others), but there is no distinction of as to why these youth have been labelled (2010 pp273).  This description does not highlight the focus of being trauma informed.  Vachon highlighted very well how a youth demonstrating defiance or resistance, can in fact be protective factors and resilience, but others would have noted these as problem behaviours (pp55).  Vachon further highlights studies that indicate that individuals in the field with lived experience have a better understanding and ability to demonstrate understanding, with better outcomes for the youth (pp57). 

 As Vachon depicts how wounded healers are able to take their experiences and use them as a positive in their work (Vachon, pp58), this is important for those Child and Youth Practitioners who may not have direct experiences of trauma but can to use the times when they were emotionally drained, burnt out or experiencing secondary trauma and bring those experiences to the forefront of their work. Being able to identify times of misery, self-doubt, hopefulness to our children and youth shows them that we are human, we make mistakes, our lives are not perfect, we struggle but it is how we show determination and perseverance to overcome those struggles is how we can better serve the children and youth we work with.   This also can be used as teachable moments for things that worked for us and things that did not. It is interesting to not that unlike Vachon, Perry is concrete in the idea that burn-out and secondary traumatic stress are not the same thing describing burnout of being a result of a number of accumulated work-related aspects, whereas secondary trauma stress is in relation to a traumatic event of another person.  In the article The Importance of Self Care, it notes that as Child and Youth Practitioners we focus on the techniques needed to support and help those who have experienced trauma, but neglect the effects the trauma is having (Kostouros & McLean, 2006).

Application to Practice & Conclusion

  Fortunately, I do not have experience with having a history of a traumatic experience, but I am pulling on my experience with my cancer diagnosis when it comes to working through unknown situations.  I am open with my clients that I had a medical emergency and the feelings that come with not knowing what is coming next.  I am able to sympathize with them when they are worried about the next challenge that they are facing and understand the fears and anxiety that comes with the unknown.

 As a mother of two young boys (aged 6 and 9) and working in the field of Child Protection, a quote from Knight’s wrote stood out so profoundly to me: “as a result of hearing the stories of exploitation and victimization of others, particularly children, clinicians are at risk of viewing the world as an unsafe, unpredictable place” (Knight, 2013 pp227).  I am so guilty of this and I have created barriers for my children as a result, such as they are not allowed to bike or walk in the streets without an adult.  My children are not allowed to wonder out of arms reach while we are out shopping, and I am constantly talking to them about how to be safe in situations.  I have found myself coming home from a course on human trafficking and talking with my children about how to kick, screaming and run should anyone try to grab them.  I refuse to allow them to video game online. I am also hypersensitive with my husband and I about how we talk with our boys – are we being to hard on them and then will they turn to drugs or run away when they are an adolescent.  I can rationalize that we are doing right for our boys, and that my thoughts and reactions are a protect of overstimulation of negative affects from my profession, but I cannot stop the vigilance to ensure their safety, as I know what kind of world is out there.  Growing up I was not aware that there was such services as child protective services, I was naïve to the drug culture, and human trafficking was not at the explosive nature it is now, so I feel that I am the first defense in the protection of my own children.  

 Working in the field of child protection, now going on 14 years, I have witnessed, listened to, and experienced some of the most challenging life events within a family system.  Before I was trauma informed and trained on the affects that trauma have on one’s character, coping, and life as a whole, I would question behaviours expressed, most often by a parent; for instance how a parent would follow the same abusive path that they were a victim of as a child, or why would a parent abuse substances as their parent did.  It was not until I was trauma informed that I was able to understand that these are not mistakes, but learned coping tools that they have adapted to through their trauma growing up.  Most of the parents that I would with now, who people without knowledge of trauma effects would believe these people to be the worst in society, are really just people who have been broken through repeated trauma.  It takes a different lens to understand and focus on past experiences in order to work through the current challenges.

 The ways that I will incorporate a trauma-informed approach to my practice, based on the comparative analysis will be to not focus on the behaviours, but the triggers and causes of the behaviours.  Children and youth are not always able to express themselves with words, so they react, which is over described as acting out.  Also, based on the information I will be more aware of my thoughts and reactions towards my clients, especially during active crisis times. 

 Lastly, I will implement a trauma-informed approach to my self-care as a Child and Youth Practitioner by ensuring that my need to be healthy is foremost in my daily life.  It is sometimes a struggle, as I work full time, have a family, in school and have social commitments.  I am aware of my body’s signals when I am starting to feel tired or anxious, and I know when I have not had a minute of fresh air or exercise.  I also very much liked aspects of the self-care practices from the Caring for Yourself is a Radical Act booklet.  Once I am complete some assignments I am going to work through the weeks.  Understanding trauma and the affects trauma has on a person’s entire being, brings to light the reason I chose the profession of Child and Youth Work, as we look past what everyone sees to reduce the stress and anxiety that is hidden within layers of trauma.

References

Kostouros, P. & McLean, S. (2006). The importance of self-care. CYC-Online. ISSN 1605-7406. Issue 89. Retrieved October 11, 2018 from http://www.cyc-net.org/cyc-online/cycol-0606-mclean.html.

Bloom. M. (2004) Secondary Traumatic Stress: The Hidden Trauma in Child and Youth Counsellors. Retrieved October 11, 2018 from https://scholars.wlu.ca/cgi/viewcontent.cgi ? referer=https://www.google.ca/&httpsredir=1&article=1904&context=etd.

Perry, B. (2003). Effects of Traumatic Events on Children. An Introduction. The Child Trauma Academy. Retrieved October 2, 2018 from http://traumebevisst.no/edukasjon/filer/perry-handout-effects-of-trauma.pdf.

Perry, B. (2014). The cost of caring: Secondary traumatic stress and the impact of working with high-risk children and families. Child Trauma Professional Awareness Academy, 1-18. Retrieved October 1, 2018 https://childtrauma.org/wpcontent/uploads/2014/01/Cost_of_Caring_Secondary_Traumatic_Stress_Perry_s.pdf.

Showalter, S. (2010). Compassion fatigue: What is it? Why does it matter? Recognizing the symptoms, acknowledging the impact, developing the tools to prevent compassion fatigue, and strengthen the professional already suffering from the effects. American Journal of Hospice & Palliative Medicine, 27(4), 239-242.  Retrieved October 1, 2018 from http://journals.sagepub.com.ezproxy.lib.ryerson.ca/doi/pdf/10.1177/1049909109354096.

Vachon, W. (2010). Honouring the wounded: Inviting in our successes and mistakes. Relational Child & Youth Care Practice. 23 (2), p. 54-62. Retrieved October 1, 2018 from http://www.rcycp.com.ezproxy.lib.ryerson.ca/unicol/volumes/archives/RCYCP_232_Full.pdf.

Knight, C. (2013). Indirect trauma: Implications for self-care, supervision, the organization, and the academic institution. The Clinical Supervisor, 32(2), 224-243. Retrieved October 1, 2018 from https://www-tandfonline-com.ezproxy.lib.ryerson.ca/doi/pdf/10.1080/07325223.2013.850139?needAccess=true

Barford, S., & Whelton, W. (2010) Understanding Burnout in Child and Youth Care Workers. Child and Youth Care Forum, 39, 271-287. Retrieved October 1, 2018 from https://search-proquest-com.ezproxy.lib.ryerson.ca/docview/744248955/E46C7281CAC14522PQ/4?accountid=13631

Khan, F. (2014). Caring for yourself is a radical act: Self-care guide for youth working community. Artreach. artreach. Retrieved October 1, 2018 from org https://artreach2016.files.wordpress.com/2016/01/self-care-toolkit.pdf.

Brady, E. Trauma-informed Practice in Child Welfare. PART Practice And Research Together. Retrieved October 7, 2018 from http://www.partcanada.org/.

Appendix A

indirect trauma

Khan describes vicarious trauma as a reaction of stress, as one listens to the traumas of others (pp42), which results in guilt for one’s own survival; feeling no energy, disconnected; not listening or angered (pp43).  It is also described as an accumulation of working with a number of individuals who have experienced a traumatic event (Knight, 2013 pp228).

*feeling the psychological and emotional feelings of a traumatic experience of someone else*

secondary traumatic stress

Khan: Trauma effects are stored in our bodies and can result in learned responses to future situations that resemble the initial trauma (pp33).  Knight notes that symptoms can be a preoccupation with thinking of the client, thinking of the event, dreams, hypervigilance (2013 pp226). Perry describes the symptoms in three parts: re-experiencing, avoidance of reminders and hyperactivity (pp9) and occurs when one has empathy for someone else who has been traumatized (pp10).

*because of another’s trauma, one is over caution and protective*

compassion fatigue

Knight describes this as the inability to empathize with clients (2013 pp228).

*the inability to feel for those you are working with*

Burnout

Whleton describes three dimensions of burnout: emotional exhaustion, depersonalization and reduced sense of personal accomplishment (pp2) resulting from a number of stressors within the employment (Knight, 2013 pp229).

*the effects of work-related stress (caseload, time management, lack of self-care)*

self-care

Is the need to address the care of the practitioner in order to support those through trauma.  Khan was the first to provide supplements (vitamins) as a support to self-care (pp45). Knight describes the need to be proactive (pp231) in one’s ability to ensure balance.

*things we do to make us who we are and to recharge*

(*author’s definitions based on the readings)
 

Effectiveness of Self-Care Guidelines for Heart Attack Patients

Abstract
Heart disease is first of the largest killer diseases in the world. According world health organization estimated 17 million people worldwide coronary vascular disease. In developing country the cost of bypass surgery and angioplasty is very high. every person cannot affordable for taking treatment. this study helps to patient about self care precaution and awareness of disease and its minimizes the further complication. This study helps to myocardial infarction patient to improve their health. This study is a experimental study. The population of this study consists of medical college attached government hospitals in Gujarat state. This study includes the 35 samples in male and female. A structured questioner tool is prepared for assessing the knowledge including six component (self care, modifications, exercise, pulse monitoring, diet, stress reduction technique) and check list, ratings scale prepared for assessing the performance of their activities(pulse monitoring, muscle starching exercise, stress reduction technique) the finding is indicated that health guideline is very effective for the MI patient to improving their health and healthy life style.
Key words: Effectiveness, Health guideline, Myocardial infarction, Performance rating scale observational check list.
Introduction
The widely accepted definition of “WHO” in 1948 in preamble to its constitution which is follows “Health” is a state of complete physical, mental and social well being and not merely absence of any disease or infirmity”. So according to W.H. O. health cannot be defined as a ‘state’ but it must been as a process of continue adjustment to the changing meaning which we give to life. This is a dynamic concept.

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Heart disease is first of the largest killer disease in the world. Cardiovascular disease are major contributors to the global burden of chronic disease with 29.3% of global deaths and 9.9% of total disease burden, in terms of disability- adjusted life years lost, being reported in 2003. Low and middle income countries accounted for 78% and 86% of the CVD deaths and daily lost, respectively, worldwide in 1998.
In India CVD is projected to be the largest cause of death and disability by 2020 with 2.6 million Indians predicted to die due to coronary heart disease, each consist 54.1% of all CVD deaths.
In resent year education has come to be considered as an integral component of health care. The modern philosophy of health care in every society take in to consideration the physical, special for diet, psychological and socio cultural environment and other thing in that stress management using many technique like mediation, relaxation etc. MI is a chronic life long illness.
The basic component of self care applies to all cardiac patients but the care must be designed to fit each person individual needs and habits.
In order to meet learning needs of the patients, prepare health guideline on self care activities for the promotion of the health, prevention of further risk or complication, early diagnosis and treatment of the disease. It aims at the modification of life style – change in diet, regular exercise, avoid smoking and avoid alcohol and stress management for preventing health crisis.
Objectives of the study

To assess the knowledge of self care on myocardial infarction before and after introducing health guideline and demonstration on self care activates to myocardial patients admitted in medical ward in medical college attached government hospitals in Gujarat state.
To assess the performance of self care on myocardial infarction before and after introducing health guideline and demonstration on self care activates to myocardial patients admitted in medical ward in medical college attached government hospitals in Gujarat state.

Literature reviewed
Important education after myocardial infarction
Duryee R, “ The efficiency of inpatient educational after myocardial infarction in that the educating the patient who has experienced a MI has long been a challenge for the professional nurse. Nurse has prepared volumes of teaching materials to enlighten the patient who has experienced an MI. the purpose of this study was to review the research literature on in- patient education after MI published between 1975 and 1983 the review of 21 studies to determine what information is most important to patients whether inpatient teaching increase patient knowledge, whether lifestyle changes are affected by education and which instructional methods were most effective. Multiple teaching methods were used across the 21 studies reviewed: individual and group session led by nurse rehabilitators, slide sound presentation, videotape sessions with a nurse. The studies demonstrated that audiovisual methods are as effective as presentations by an educator.
Important of diet for heart disease
Miss Saramma Jacob “A study of the knowledge of the patients and the relatives about the importance of salt restricted diet as a therapy in some heart disease”. This study was designed to explore the knowledge of the patients and the relatives about the importance of salt restriction and also the importance of using the prescribed amount of salt. Through this of study it was found that knowledge of this patient and the relatives about the importance of salt restricted diet as a therapy and the relatives about the importance of salt restricted diet as a therapy in some of the heart disease has increased 10% to 70% proper explanation and teaching about the important of salt restricted diet is the reason for this increase in knowledge. All patients used the prescribed amount of salt within one day when they realized the importance.
Robertson d and keller C. “ Relationship among health beliefs. Self efficiency and exercise adherence in patients with coronary artery disease.” Many nursing care hours are dedicated to educating patients with coronary artery disease about their disease process and requisites life style changes in order to maximize life expectancy. New therapies may abort life threatening events, however control of the progression of coronary artery disease is ultimately dependent upon the patient’s cooperation in modifying risk factors. Too often health care recommendations go unheeded. The purpose of this study was to develop a model that would explain relationship among several variables that determined adherence to an exercise regimen. The variables were chosen from the health belief model and self efficiency theory. Study findings revealed a significant positive correlation between activity and perceived benefits and between activity and perceived self efficiency. There was significant negative relationship between activities and perceived barriers.
Hypotheses

The mean post test knowledge scores of self care of myocardial infarction patients will be significantly higher than their mean pretest scores at 0.05 level.
The mean post test of self care activities scores of self care of myocardial infarction patients will be significantly higher than their mean pretest scores at 0.05 level.

Operational definition
Effectiveness: It refers to the power of the bringing a change in the knowledge and activities of myocardial infarction patients regarding self care activities after the administration of health guide line and demonstration of exercise from the knowledge and performance scores.
Knowledge: It refers to the myocardial patients for correct responses regarding self care activities on the structured knowledge test item and evidence from knowledge score.
Activities: It refers to the myocardial infarction patient’s ability to perform activities regarding pulse monitoring muscle stretching exercise, stress reduction technique and tool as evidence from structured observational checklist and performance rating scale.
Self care: Those health generating activities that are undertaken by the person themselves.
Delimitation:

Investigator includes only medical college attached government hospitals.
Investigation take only hemodynamic stable myocardial infarction patient.

Methodology
The present study is a quai experimental study. The methodology presents the population of the study, sample of the study, tools and technique used in this study, data collection, and plan for analysis.
POPULATION: the population of this study consists of MI patient admitted in medical college attached Government hospitals in Gujarat state.
SAMPLE AND SAMPLING TECHNIQUE: patient who has a Myocardial infarction and hemodynamic stable admitted in medical ward. Researcher take the 35 sample that were use the purposive sampling method.
TOOL USED: the investigator has prepared tool for to check knowledge as well as activities of MI patients regarding self care. For to check the knowledge she prepared structured questionnaire and for observe the practices she prepared observational checklist and performance rating scale.
PROCEDURE FOR DATA ANALYSIS: for testing the hypothesis of the study the investigator analyze the data using frequency, percentage, standard deviation, ‘t’ test and correlation.
ANALYSIS AND DISCUSSION
The data were tabulated, analyzed in terms of objectives of the study.
Descriptive statically methods were employed for the analysis of tool. in that knowledge area mainly six area those are the related to self care, medicine, exercise, pulse monitoring, diet, stress reduction technique.
Through the analysis and interpretation of data, researcher has described following major findings of the study.
Findings related to knowledge and activities area:
There was maximum gain of knowledge in exercise area. In the exercise area mean percentage of pretest was 11.4% and mean percentage of post test was 78.97%. It indicates that the 67.55% gain in area. According to the table it is the highest gain.
Findings of sample related to knowledge of diet :There was minimum gain in the area ‘diet’. In this area mean percentage of pre test was 61.42%whereas mean percentage of post test was 99.28% which suggests that 37.86% gain in the area.
Findings of sample related to activates of the self care, stress reducing exercise and pulse monitoring:
There are 62.94% and 62.87% gain in area ‘ medications’ and ‘ pulse monitoring respectively. They are 2nd and 3rd in gain after the exercise. There was approximately equal gain in self care and stress reduction technique and providing information areas. It was 45.71% and 45.75% respectively.
Finding of sample related to muscle starching exercise:
There was maximum mean percentage of post test in muscle starching exercise
All over the knowledge score of MI patients before exposing the health guideline and demonstration, mean score of the sample was 3.14 after exposing the health guideline and demonstration, mean score of the sample was 8.11 the difference in knowledge and act score suggesting the knowledge gain by sample.
Interpretation through comparing the mean percentage of pre and post performance test in each task. The data suggest that there was maximum gain in pulse monitoring it was 68.93%gain. There was 57.66 % gain in stress reduction technique and 59.61% gain in muscle starching exercise.
It indicate the mean 8.6 score obtained by sample before demonstrate the activities and 34.2 score obtained after demonstrating the activities. to the myocardial infarction patients.
Conclusion
Knowledge deficit existed in all area of self care among samples admitted in medical ward in medical college attached government hospital in Gujarat state.
The study in terms of health guideline and demonstration was found to be effective in enhancing the knowledge and skill of the samples regarding self care activities.
IMPLICATIONS AND UTILIZATIONS
The findings of the study have several implications in the nursing practice, nursing education, nursing administration and nursing research.
Nursing practice: the study is relevant for nursing professional working in the area of cardiac center in the Indian setting. Nursing personal should plan teaching programmes and provide adequate information and guidance to such client who have myocardial infarction disease and they enhance their self care ability.
Nursing education: skill development is an essential component of professional life. The responsibility of instructor is in meeting learner’s need in acquiring relevant knowledge to underpin the development skills. Attempts should be made to ensure that the learner is taught in such a way that it allows them to construct learning in a simulated context and then apply it into real situation. The focus should be on the learner under standing the process of acquisition rather than performance.
They should develop health guideline, self instructional module , audio- visual materials, booklet, pamphlet i.e. video, tap, slides etc. on cardiac self care for utilize them for teaching learning activities.
Nursing administration: the expressed learning need of client can be considered as indicator for planning structured health programmes. nursing administration should promote and support preparation of such instructional material by nursing personnel and they should be educationally prepared at different levels to undertake such endeavors in order to assist clients, and the community in developing their self care potentials.
Nursing research: self care is a fundamental therapy for cardiac patients. Many questions remain to be answered about it. Research is needed to identify the optima ways to teach self care activities to cardiac patients. Nurses are available at all the time ti the patients in hospital. Research should be directed to exploring the nurses knowledge regarding self care of myocardial infarction patients or other cardiac diseases. There should be research studies conducted in different setting and on large sample.
RECOMMENDATIONS
The following recommendations are made on the basis of the findings of the present study.

A study can be replicated on a large sample, their findings can be generalized for a large population.
Similar study can be conducted on nursing student.
A study can be conducted develop and evaluate a self guideline n the form of pictorial booklet/ pamphlet for the illiterate group.
A comparative study can be conducted for the two groups. One group gives the treatment and other group is control group.
A study can be conducted to identify life style of the cardiac patients.

References
Websites

www.Cardiac home care.org
www.Self care of myocardial patient.org
www.diet for cardiac patients.com
www.excercise for cardiac patient.com
www.guideline for cardiac patient.com

Journals

Bennet sj, Savue MJ “ cognitive deficits among patients with heart failure”. A review of literature J. cardiovascular nurse2003.
Cardiac nurse preparedness to use self help groups as a support strategy. Journal of America nursing 1995, vol 22 p 921- 928
Heart facts dallas TX; American heart association;2005

Books

Alexander R.W. and schant, Textbook of heart.8th edition, health professional division, new York: 1998
Black J.M. Medical Surgical Nursing. 5th edition W.B. Saunders company, Philadelphia: 1999
Dossey B.G. Guzzetta C.E. “ Critical care nursing Body- mind- Spirit ,3rd edition, J.B. Lippincott: Philadelphia ; 1996