|Year : 2020 | Volume
| Issue : 1 | Page : 64-69
Effectiveness of video instruction on anxiety, knowledge of procedure and quality of bowel cleanliness among patients undergoing colonoscopy
Malathy Murugesan1, Jasmin Anand2, Sheela Durai2, Amit Dutta3, Gowri Mahasampath4
1 Assistant Nursing Officer, Dr. Rela Institute and Medical Centre Multi Speciality Quaternary Hospital, Chennai, Tamil Nadu, India
2 Professor, College of Nursing, CMC, Vellore, Tamil Nadu, India
3 Professor, Department of Hepatology, CMC, Vellore, Tamil Nadu, India
4 Lecturer, Department of Biostatistics, CMC, Vellore, Tamil Nadu, India
|Date of Submission||10-Jun-2019|
|Date of Decision||05-May-2020|
|Date of Acceptance||12-May-2020|
|Date of Web Publication||14-Sep-2020|
Mrs. Malathy Murugesan
Assistant Nursing Officer Dr. Rela institute and Medical Centre Multi Speciality Quartinary Hospital, No: 7, CLC Works Rd, Nagappa Nagar, Chromepet, Chennai, Tamil Nadu - 600 044
Source of Support: None, Conflict of Interest: None
Inadequate bowel preparation for colonoscopy can lead to increased procedural time, decreased diagnostic yield and an increase in complication rate. Fear, anxiety and lack of information reported by patients are barriers for optimal colonoscopy screening procedures. The successful outcome of colonoscopy procedure depends on how well the colon is prepared enhancing accurate visualisation. This study intended to determine the effectiveness of video instruction regarding bowel preparation on anxiety, knowledge of procedure and quality of bowel cleanliness among patients undergoing colonoscopy. Using quantitative approach, an experimental study was undertaken for 6 weeks. One hundred and twenty patients undergoing colonoscopy were selected using consecutive sampling techniques and were randomly allocated to the control and experimental group. State trait anxiety inventory, knowledge questionnaire and the Boston bowel preparation scale were used to collect the data. The experimental group received the video-assisted teaching on bowel preparation and the control group received the standard teaching. The quality of bowel cleanliness was found to be excellent in 25% of patients in the control group and 75% of patients in the experimental group. There was a significant decrease in the mean score of anxiety level from 45.05 to 34.40 in the experimental group. The study revealed that there was a significant relationship between knowledge of procedure and quality of bowel cleanliness in the experimental group (r = 0.35, P < 0.001). There was an increase in the knowledge of patients, which corresponded with a better quality of bowel cleanliness after the video instruction. Nurses play an important role in patient outcomes during the diagnostic procedure. This study shows that teaching with appropriate aids such as video relieves anxiety, improves knowledge and also improves outcomes in patients. It enhances the excellent quality of bowel cleanliness and aids in accurate diagnosis.
Keywords: Anxiety, colonoscopy, knowledge, quality of bowel preparation, video instruction
|How to cite this article:|
Murugesan M, Anand J, Durai S, Dutta A, Mahasampath G. Effectiveness of video instruction on anxiety, knowledge of procedure and quality of bowel cleanliness among patients undergoing colonoscopy. Indian J Cont Nsg Edn 2020;21:64-9
|How to cite this URL:|
Murugesan M, Anand J, Durai S, Dutta A, Mahasampath G. Effectiveness of video instruction on anxiety, knowledge of procedure and quality of bowel cleanliness among patients undergoing colonoscopy. Indian J Cont Nsg Edn [serial online] 2020 [cited 2020 Oct 1];21:64-9. Available from: http://www.ijcne.org/text.asp?2020/21/1/64/295046
| Introduction|| |
Many issues related to the gastrointestinal systems such as abdominal pain, abnormal stooling pattern and bleeding per rectum, need specific tests that specially help examine the function of the large intestine. The tests include barium swallows, abdominal X-rays and colonoscopy. Colonoscopy procedure is used for the prevention and early identification of colorectal neoplasia through the removal of pre-malignant tumours preventing the progression of the disease. It is useful in the detection of colorectal cancer. Colorectal cancer is the third-most common cancer in the world, with nearly 1.4 million new cases diagnosed in 2012. In India, the incidence of colorectal cancer is 4.4–4.1/100,000 among men and 3.9/100,000 among women and colorectal cancer is an 8th more common cause of death among men. Patients undergoing colorectal cancer screening with improper bowel preparation are frequently found to have missed adenomas and carcinomas. According to Chokshi et al. inadequate bowel preparation was reported on 373 patients, of which 25.7% of patients underwent repeated colonoscopy and were detected with adenoma. Jones et al. stated that 74% of patients reported fear, lack of information and time, the role of physicians and access to care as barriers for colonoscopy screening procedures. Gas or faeces in the gastrointestinal tract can impair clear visualisation of the colon resulting in inadequate diagnosis.
The success of colonoscopy depends on how well the colon is prepared, including the quality of cleanliness enhancing accurate visualisation and decreasing the time necessary for the procedure. Inadequate bowel clearance could lead to procedure delays and cancellations at times. It is important that patients are educated and engaged in the colonoscopy preparation process. It has been shown that effective education significantly improves the quality of bowel cleanliness. The standard procedure of providing oral information with educational leaflet although was found useful by patients in the study institution as it is established in the literature, the increasing numbers of cancellations and postponement of procedures due inadequate preparation introduced the need for alternative educational methods. Hsueh et al. reported through their study that 'Bowel preparation educational film' is a simple and easy method to teach on the preparation of cleaning the colon and it helps to improve the quality of bowel preparation. Patients who were part of web based multimedia programme on bowel preparation and colonoscopy in another trial reported significantly less pre procedural anxiety, need for sedation and better knowledge on colonoscopy procedure. Innovative patient education interventions, therefore, appear efficacious in increasing the knowledge of procedure, reducing anxiety and also improving the quality of bowel preparation. Thus, this study was designed to evaluate the anxiety, knowledge of the procedure and quality of bowel cleanliness before and after a newly prepared video instruction.
- To evaluate the difference in anxiety, knowledge of procedure and bowel cleanliness after colonoscopy between the experimental group who had the video instruction and the control group who had the standard teaching
- To determine the correlation between knowledge of procedure and quality of bowel cleanliness after colonoscopy.
| Methods|| |
Sample size and sampling
An experimental study design was chosen for the study. The study was conducted in the Endoscopy Services Unit of a tertiary hospital in South India. A total of 120 patients (60 in the control group and 60 in the experimental group) were included for the study. This number was determined by performing sample size calculation with data available (group mean values) from the previous study on the quality of bowel preparation. To detect this 15% difference in bowel preparation, with 80% power and 5% error, the investigator needed 60 samples in the control group and 60 in the experimental group. Patients who gave written informed consent were consecutively recruited into the study and randomly allocated to experimental and control groups.
Socio demographic and clinical variables data sheet
Patient's age, gender, marital status, education, language, residence and type of family were included for socio-demographic data. Data on clinical variables, such as the presence of polyps, reason for colonoscopy and duration of the illness, were collected.
This was prepared by the investigator. It had a 20-item questionnaire which consisted of questions related to colonoscopy procedure, preparation and post-procedural care. Each item had four alternatives with one correct response. Each correct response was given a score of 1 and a wrong answer was given a score of 0 and the total scores range from 0 to 20. The validity of the knowledge questionnaire was established with the guidance and opinions of experts in both the nursing and medical field. The instrument was translated into Tamil and Hindi languages and back-translated to English. The Content Validity Index of the instrument was 0.92. The reliability of the tool was calculated statistically. The Cronbach's alpha was found to be r = 0.73 and the reliability coefficient was r = 0. 735 (P < 0.01), which showed that the tool was reliable.
Self-evaluation questionnaire on anxiety
State trait anxiety inventory (STAI) scale developed by Spielberger  was used as a tool. STAI (Y1) state anxiety deals about 'how the patient felt at a given point of time' (Scoring: 1 - not at all; 2 - somewhat; 3 - moderately so; 4 - very much so - Items 1, 2, 5, 8, 10, 11, 15, 16, 19 and 20 had reverse scores).
The higher the mean score the higher the anxiety. STAI (Y1) was a standard tool of anxiety assessment, the reliability of which had already been established. The internal consistency reliability was 0.82. Cronbach's alpha for the STAI was 0.92.
Boston bowel preparation scale
Boston bowel preparation scale (BBPS) was developed by Calderwood and Jacobson. Each of the three segments of the colon (Right colon–Cecum, Ascending colon, transverse colon-Hepatic and splenic flexures; Left colon-descending colon, sigmoid, rectum) is given a minimum score of 0 and maximum score of 9, where (0 = inadequate) means unprepared colon segment with mucosa not seen because of solid stool that cannot be cleared; (1 = poor) defines a portion of mucosa of the colon segment seen, but other areas of the colon segment not well seen because of the staining; (2 = good) describes minor amount of residual staining, small fragments of stool and/or opaque liquid but mucosa of colon segment well; (3 = excellent) explains entire mucosa of colon with no staining, Each of the three segment (Ascending colon, Transverse colon, descending colon) scores were summed for a total score of 0–9, in which 0 is unprepared and 9 is entirely clean.
A score of '0' was denoted as poor, 3 as fair, 6 as good and 9 as excellent. Each region (right, transverse and left) receives segment score from 0 to 3 and are summed for a total BBPS score ranging from 0 to 9. If endoscopist aborts procedure due to inadequate preparation, then any non-visualised segment is assigned a score of 0. The BBPS is a standard tool for assessing bowel cleanliness during colonoscopy. Segment scores represent a standardized way to determine adequate bowel preparation. The BBPS demonstrate a high inter-rater reliability (interclass correlation coefficient 0.91) and substantial reliability (weighted 0.78; 95%). Interrelated reliability was checked with 30 patients for this study. It revealed that concordance of 100%, which indicates perfect agreement between two raters. The scoring was done by the endoscopists.
The prepared video on colonoscopy procedure and bowel preparation education was validated by two nursing and two medical experts. Translation and back translation of the entire script was done before validation in English, Hindi, Tamil and Bengali languages. Editing of the video was also undertaken to ensure good quality visuals.
Data collection procedure
The day before the procedure
Subjects in both the experimental and control groups filled the knowledge and anxiety questionnaire after recruitment. The instruction was given using the created video instruction to the subjects in the experimental group on the day of appointment in the endoscopy room for 7 min in their own language. The control group received information by standard method.
On the day of the procedure
Before the procedure, the investigator-assessed for anxiety and knowledge of procedure with self-evaluating questionnaire for the control and experimental group. At the end of the procedure, the quality of bowel preparation of all study patients was assessed by the endoscopist using BBPS. The endoscopists were blinded to the type of instruction received by the patient.
| Results|| |
Among 120 patients, in the control group majority (56.7%) were in the age group of 41–60 years and in the experimental group, the majority were between 18 and 40 years (63.3%). Most of them (63.3% and 66.7%) were males both in control and experimental groups respectively, in the control group (3.3%) of the patients were detected with polyps during the colonoscopy procedure, whereas in the experimental group (6.6%) of the patients were detected with polyps during colonoscopy procedure. Majority (20%) of the subjects in the control group had colonoscopy to rule out inflammatory bowel disease and bleeding per rectum, whereas in the experimental group (20.8%) of the patients had colonoscopy for bleeding rectum, (20%) of the patients underwent colonoscopy for to rule out inflammatory bowel disease and for anaemia [Table 1]. Overall 59.2% of patients had an illness for >6 months.
|Table 1: Distribution of subjects based on socio-demographic and clinical variables|
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The experimental group reported significantly lower level of anxiety compared to the control group and the mean difference was statistically significant at the level of P < 0.001 [Table 2].
The experimental group had a significant increase in mean knowledge score compared to the control group and the difference was statistically significant at the level of P < 0.001 [Table 3].
|Table 3: Comparison of knowledge of procedure scores in experimental and control group|
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The majority (75%) of patients in the experimental group had excellent bowel cleanliness, whereas in the control group, only 25% of the patients had excellent bowel cleanliness [Figure 1].
|Figure 1: Quality of bowel cleanliness after colonoscopy in both control and experimental group of patients undergoing colonoscopy|
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The experimental group patients had a higher mean score for bowel cleanliness with a BBP mean score of 8.2 out of 9. The quality of bowel cleanliness was significantly higher compared to the control group P < 0.001 [Table 4].
|Table 4: Comparison of quality of bowel cleanliness score of experimental and control group|
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There was a positive correlation between knowledge of the procedure and quality of bowel cleanliness, which is significant at the level of P < 0.001. The result shows that the quality of bowel cleanliness increases as knowledge increases [Table 5].
|Table 5: Correlation between knowledge and quality of bowel cleanliness (n=120)|
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| Discussion|| |
Endoscopic procedures such as colonoscopy are generally uncomfortable and sometimes painful and patient's cooperation is essential to improve the quality of preparation and avoid unnecessary repetitions of the procedure. As it is an invasive procedure it also causes anxiety and fear in many patients., Better knowledge and understanding of the procedure have shown to improve results in diagnostic endoscopic procedures. In this study, the effect of video instruction on anxiety, knowledge of procedure and quality of bowel preparation was evaluated. The current study findings revealed that the mean score of knowledge of procedure in the experimental group after the video instruction increased from 9.30 to 14.36 with a mean difference of 5.33 and was statistically significant (P < 0.001). There was an increase in knowledge level from 9.43 to 9.87 in the control group as well and this could be from obtaining information from standard instruction, which is also meticulously delivered for all patients in the unit generally. As projected in the earlier study, the use of video had potential benefits in facilitating knowledge acquisition. Another study on the comparison of video instruction with leaflets against leaflets alone, the video group showed a higher knowledge acquisition on cancer risk in ulcerative colitis. This study augments the findings from the above two studies showing that video-assisted teaching enhances better knowledge acquisition than conventional methods like oral instructions or a leaflet.
The mean score of the anxiety of the patients in the experimental group in this study decreased from 45.05 to 34.40, whereas in the control group, it increased from 44.45 to 45.43. This indicates that there was no difference in the control group with the standard method of teaching, but the video instruction was effective in reducing anxiety in patients. The teaching given using video before any procedure helped the patients to prepare mentally, thus leading to reduced anxiety. The findings are congruent with earlier studies, which also showed a similar effect of reduction in pre-procedural anxiety in patients who had Video information. Although the evidence on the use of video is positive video-based/assisted teaching may not be applicable or useful for all patient care education situations. A study done by Salzwedel et al. on video-assisted anaesthesia risk reduction education, there was no reduction in anxiety, but it led to an increase in anxiety because the patients had a better understanding of the procedure and risks of the procedure. Therefore, the choice of using video should carefully be planned based on the type of procedure when the anxiety of the patient is considered.
The experimental group in this study also showed a high mean score for bowel preparation, demonstrating that video instruction was effective in colonoscopy outcome. As Hsueh et al. have stated through their study 'Bowel preparation educational film' that it is simple and easy is very useful for patients as they can easily follow the method for preparation of cleaning the colon. Thus, it helps to have a good quality of bowel preparation.
There was a positive correlation between knowledge of the procedure and quality of bowel cleanliness, which was statistically significant at the level of P < 0.001. As knowledge increased, the quality of bowel cleanliness increased. The present findings were supported by the study done by Tae et al. which showed a perfect correlation between knowledge and excellent bowel cleanliness. Shieh et al. concluded in their study that there was the perfect positive correlation between knowledge and quality of bowel cleanliness among patients undergoing colonoscopy procedure, which was statistically significant at the level of P < 0.001. Although there are multiple evidence on the relationship between knowledge and bowel preparation, what is important to note is that a novel approach to education such as an educational handbook  or as in this study, video instruction may be superior to standard methods.
| Conclusion|| |
Nurses play an important role in promoting positive patient outcomes during the diagnostic procedure. This study shows that appropriate teaching aids, such as video relieves anxiety in patients. It enhances knowledge and excellent quality of bowel cleanliness. Good preparation aids in accurate diagnosis, reduced cancellation rates, lower waiting times of patients and saves time of health-care personnel by avoiding procedure repetitions. Efforts should be made by nurses and physicians for accurate and adequate information on colonoscopy preparation, as it helps patients to cope with their anxiety level, and improve practice and preparation of patients for colonoscopy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]