Research Article (Open access) |
---|
SSR Inst. Int. J. Life Sci., 9(2):
3186-3194,
March 2023
Quality of Life
and Coping Strategies among Parents of
Children Admitted to Thalassemia Ward
Laxmibai
Hadapad1, Santosh B Sajjan2*, Deelip S Natekar3
1Student, Department of Child Health Nursing, Shri
B.V.V.S Sajjalashree Institute of nursing sciences, Bagalkot, Karnataka, India
2Associate Professor, Department of Child Health
Nursing, Shri B.V.V.S Sajjalashree Institute of nursing sciences, Bagalkot, Karnataka,
India
3Principal, Department of Child Health Nursing, Shri
B.V.V.S Sajjalashree Institute of nursing sciences, Bagalkot, Karnataka, India
*Address for Correspondence: Dr. Santosh B. Sajjan, Associate Professor,
Department of Child Health Nursing, Shri B.V.V.S Sajjalashree Institute of nursing
sciences, Bagalkot, Karnataka, India
E-mail: santoshsajjan83@gmail.com
ABSTRACT
Background: Thalassemia is a hereditary disease of defective hemoglobin
synthesis. Thalassemia results from an anomaly of genes involved in the
production of hemoglobin. Every year approximately 10,000 children are born
with thalassemia in India. Parents of thalassemic children feel depressed,
frustrated, and helpless and have numerous emotional, psychosocial, and
financial sufferings.
Methods: Parent's quality of life was evaluated by a standardized WHOQOL
Bref scale and coping status was assessed using the coping health inventory
scale (CHIP), a sample of 100 parents of thalassemic children admitted to
thalassemia ward at HSK hospital, Bagalkot was selected using purposive
sampling technique, descriptive survey design was adopted. Statistical data
were tested and scrutinized using descriptive and inferential analysis.
Results: Total 70% of parents experienced moderate QOL, 9% had good and 21% parents had poor QOL. The mean percentage of QOL of parents was 48.11% with a mean and SD was 63±12. Most of the parents had moderate (88%), 08% had good and 4% of parents’ level of coping status was low. No association was found between QOL scores with study variables. A significant association was found among coping strategies with the type of family (χ2=8.66, p<0.05), previous knowledge regarding thalassemia (χ2= 4.912, p<0.05), relationship with the thalassemic child (χ2=6.37, p<0.05). A positive correlation (r= 0.0829 p<0.05) was found between QOL and coping strategies.
Conclusion: Most parents had moderate QOL and coping strategies. This study is
effective to identify the QOL and coping status of parents having a child with
thalassemia.
Key Words: Coping status, Level of coping, Quality
of life, Thalassemia, WHOQOL Bref scale
INTRODUCTION- Thalassemia is a recessive single-gene disease, which leads to the destruction of red blood cells. Thalassemia is derived from the Greek word "thalassa" meaning "the sea" because the condition was first described in populations living near the Mediterranean Sea [1]. Thalassemia becomes a serious public health problem due to ihigh incidence. Parents feel depressed, worried, frustrated, despaired, hopeless, helpless and Parents impact on child’s physical, emotional, and mental well-being and affect numerous areas of a child’s life including health development, academic progress and quality of life [2]. Yearly 50,000 to 100,000 children die from thalassemia and nearly 7% of the world's population are movers of thalassemia [3], which disturbs the overall health and daily activities of children [4]. alpha and beta thalassemia are two types, hemoglobin electrophoresis is a test which separates different molecules in the red blood cells to identify the abnormal type [3]. type and severity of the disease decide the treatment measure, treatment includes transfusion of blood, bone marrow transplant, medicines, possible surgery, iron complements, vitamins and chelation therapy [5]. without treatment measures, these children have severely conceded growth and a shortened life expectancy [6].
Iron overload, growth failure, cardiac complications, infections, and endocrine diseases are complications of thalassemia [7]. Thalassemic children are unhealthy compare to normal children. Families without appropriate coping behaviour do not afford adequate support for their sick children and it will harm the psychological health of children [8]. Long and undesirable treatment of thalassemia affects different aspects of the life of children [9]. Parents are important primary caregivers of thalassemic children. A child's quality of life depends on corresponding parents so psychological support for the caregivers is therefore central and is a vital part of inclusive treatment [10]. In 1938 first recorded case of thalassemia was found in India on the east side of Suez in a Hindu boy aged 30 months. It was the first known case of thalassemia outside the Mediterranean region [11].
Degree of life is accepted as vital
and should consider a significant index of effective health care [12].
Coping strategies are intellectual and social exertions to cope with traumatic circumstances
and generate well-being feeling [13]. Effective coping styles reduce
the undesirable effects of stress and increase the capability to manage various stressors [8].
MATERIALS AND METHODS
Study
design and participants- The study was conducted
with a descriptive survey design.100 parents of children admitted to the thalassemia
ward at HSK hospital Navanagar, Bagalkot selected for study by purposive
sampling, who were ready to join in the study and parents present at the time
of data collection were involved as participants.
Instruments
WHOQOL
Bref scale and CHIP scale- WHOQOL Bref scale and
coping health inventory scale were used to examine the standard of life and
coping status. There were 26 questions on 4 aspects of QOL and 45 questions on the
coping health inventory scale among parents of children admitted to the thalassemia
ward at HSK hospital Navanagar, Bagalkot. Participants were requested to use
separate 5 points and 4 points Likert-type scales for QOL and CHIP
respectively. The intended 'r-value after spearman brown's prophecy formula is
0.84 for the WHOQOL Bref scale and 0.79 for the coping health inventory scale,
suggesting the developed tool was highly reliable.
Data collection procedures- Prior
approvals were taken from pertinent organizations before starting the
information assortment procedure. Partakers of the study were parents of
children admitted to the thalassemia ward during the study period at HSK
hospital, Bagalkot. Every parent of thalassemic children who satisfied inclusion
criteria was loomed for gathering information. Permission was attained by
contestants and the Motive of the study was explicated to partakers, who asked
questions in Kannada or the language coherent to them. The entire data
collection was built on participants' reports.
Inclusive criteria
The study included the
parents, who were,
Ř
aged
between 25-50 years.
Ř
able to read and speak Kannada
or English.
Ř accessible
during the period of data collection.
Ř enthusiastic
to take part in the study.
Ř having
children admitted to the thalassemia ward.
Exclusive
criteria
The
study excluded parents, who were,
Ř who
did not have a thalassemic child.
Ř unable
to communicate.
Ř not
willing to give written consent.
Ř sick
at the time of data collection.
Statistical Analysis
Data
gained were investigated in terms of the aims of the study through descriptive
and inferential statistics. Participants' responses are taken into
consideration and prepared a master sheet. Demographic data was examined by
getting frequencies and percentages. Answered questions were calculated by
average and SD. A Chi-square trial was applied to find out the association
between quality of life and coping strategies with their selected
socio-demographic variables accessible in tables and graphs.
Ethical Clearance- A
certificate of ethical permission was obtained from the ethical committee of
the institution.
Table
1: Percentage-wise majority of the
distribution of parents according to sample characteristics
Sample
characteristics |
Category |
Percentage
(%) |
Age |
25-30
years |
34 |
Gender |
Females |
68 |
Religion |
Hindu |
87 |
Type
of family |
Nuclear
family |
54 |
Area
of residence |
Rural
area |
68 |
Father’s
education |
Secondary school
education |
41 |
Mother’s
education |
Pre-university
education |
33 |
Father’s
occupation |
Agriculture |
41 |
Mother’s
occupation |
Housewife |
63 |
Family
monthly income |
50001-10000
Rs |
35 |
Previous
knowledge regarding thalassemia |
No |
87 |
Source
of information about thalassemia |
Health
professionals |
62 |
Family
history of thalassemia |
No |
97 |
Relation
with thalassemic child |
Mothers |
55 |
A higher percentage of parents of thalassemic children
had a Moderate Quality of life (70%), some parents had a good quality of life (9%)
and the remaining parents had poor quality of life (21%) and there were no
parents of very good and very poor quality of life. coping strategies among
Parents of thalassemic children where data reveals that most of the Parents of
thalassemic children (88%) had Moderate levels of coping strategies, (8%) had a
good level of coping strategies and (4%) had Low level of coping strategies (Table
2).
Table
2: Evaluation of QOL and coping strategies
midst parents of thalassemic children
Degree of QOL |
Frequency |
Ratio (%) |
Very good QOL |
00 |
0 |
Good QOL |
9 |
9 |
Moderate QOL |
70 |
70 |
Poor QOL |
21 |
21 |
Very poor QOL |
0 |
0 |
Degree of coping strategies |
Frequency |
Percentage (%) |
Good |
8 |
8 |
Moderate |
88 |
88 |
Low |
4 |
4 |
Total
88% of parents had a moderate level of coping strategies, 08% had a good level
of coping strategies and 4% had a low level of coping strategies (Fig. 2).
Fig. 2: Percentage-wise distribution of coping status amongst parents of
children diagnosed with thalassemia
The highest mean percentage of parents of thalassemic
children (49.73%) was found for the social domain with mean and SD (7.46) and
(1.76), followed by the physical domain (48.85%) with mean and SD (17.1) and
(3.537), Environmental domain (48.27%) with mean and SD (19.31) and (4.126),
Psychological domain (47.2%) with mean and SD (14.16) and (3.356), and Overall
(45.2%) with mean and SD (4.52) and (1.507) (Table 3).
Variables |
Maximum
score |
Mean |
Sd |
Mean
(%) |
Overall
QOL |
10 |
4.52 |
1.50 |
45.2 |
Psychological
domain |
30 |
14.16 |
3.35 |
47.2 |
Physical
domain |
35 |
17.1 |
3.53 |
48.85 |
Social
Domain |
15 |
7.46 |
1.76 |
49.73 |
Environmental
domain |
40 |
19.31 |
4.12 |
48.27 |
Total
QOL |
130 |
63 |
12 |
48.115 |
Coping
strategies |
135 |
73 |
13 |
53.77 |
Findings regarding the correlation between the quality
of life and coping strategies among parents of thalassemic children show that
there is a positive correlation (0.082) exists between the quality of life and
coping strategies among parents of children admitted in the thalassemia ward. (r=
0.082; p˃0.05) (Table 4).
Table
4: Correlation between quality of life and
scores of coping strategies midst parents of thalassemic children
Correlation between quality of life
and coping strategies |
||
Correlation between quality of life and
coping strategies |
Overall QOL |
0.586* |
Physical domain |
0.53* |
|
Psychological domain |
0.5666* |
|
Social Domain |
0.38* |
|
Environmental domain |
0.4788* |
|
Total QOL |
0.0829* |
*= Positive correlation
Findings regarding the association between quality-of-life
scores with their socio-demographic variables show that there was no
significant association (p<0.05) found between the quality-of-life
scores with their selected socio-demographic variables (Table 5).
Table 5: Relationship
between scores of quality of life with their research variables
Research Variables |
Df |
Chi-square Value |
Table Value |
Parents age |
1 |
3.332 |
3.84 |
Gender of parents |
1 |
0.0239 |
3.84 |
Religion of parents |
1 |
0.2046 |
3.84 |
Type of family |
1 |
2.4784 |
3.84 |
Area of living |
1 |
0.5075 |
3.84 |
Educational status of Father |
1 |
1.1393 |
3.84 |
Educational
status of Mother |
1 |
0.5409 |
3.84 |
Occupation
of father |
1 |
0.017 |
3.84 |
Occupation of mother |
1 |
3.0899 |
3.84 |
Monthly
family income |
1 |
0.0434 |
3.84 |
Previous knowledge Regarding
thalassemia |
1 |
0.6091 |
3.84 |
Base of information About thalassemia |
1 |
0.0015 |
3.84 |
Family history of thalassemia |
1 |
0.005 |
3.84 |
Relationship
with
thalassemic child |
1 |
0.0583 |
3.84 |
There was a significant association found between the type of family (χ2=8.66,
p>0.05) previous knowledge regarding thalassemia (χ2=4.912,
p>0.05), relationship with
the thalassemic child (χ2=6.37, p>0.05) (Table 6).
Table 6: Association between coping strategies among parents with their research variables
Research variables |
Df |
Chi-square value |
Table value |
Parents age |
1 |
0.016 |
3.84 |
Gender of parents |
1 |
0.066 |
3.84 |
Religion of parents |
1 |
0.472 |
3.84 |
Type of family |
1 |
8.66 |
3.84 |
Area of
living |
1 |
0.717 |
3.84 |
Educational status of the father |
1 |
0.020 |
3.84 |
Educational status of the
mother |
1 |
1.515 |
3.84 |
Occupation of father |
1 |
1.086 |
3.84 |
Occupation of mother |
1 |
0.315 |
3.84 |
Monthly family income |
1 |
0.614 |
3.84 |
Previous knowledge regarding thalassemia |
1 |
4.912 |
3.84 |
Base of information About thalassemia |
1 |
0.049 |
3.84 |
Family history
of Thalassemia |
1 |
1.84 |
3.84 |
Relationship with
child |
1 |
6.37 |
3.84 |
DISCUSSION-
This section deliberates the key findings of the study and evaluations findings
from outcomes of other studies. A study was conducted to measure the degree of
life and coping status among parents of thalassemic children. To accomplish the
purposes of the study, the descriptive survey research design was adopted. By
using the purposive sampling technique 100 parents were chosen as participants.
Percentage-wise
distribution of parents according to their age depicted that, the majority of parents (34%) were
belonging to 25-30 years of age, 26% of parents were 31-35 years, 23%
were 36-40 years, 13% were
41-45 years and 4% were belonging to 46-50 years of age. The results of the present
study were reliable and supported by a previous study conducted by Arulmani et
al. [14] results displayed that mainstream parents of
children were belonging to the age of 25-30 years.
The majority of parents (68%) were females and 32% were males. The present study is steady and reinforced by another study by Pruthi et al. [15] results showed that the majority of parents were female. The educational qualification of the most of participants was graduation. The majority of parents (87%) were from the Hindu religion, 11% were Muslim, 1% were Christian and 1% were belonging to other religions. The study was similar and conducted by Biswas et al. [16] results disclosed that a greater part of parents was from the Hindu religion.
Most of the parents (54%) were from the nuclear family and 46% were from joint families. Most of the parents of thalassemic children (68%) were residing in a rural area, 24% were in an urban area and 8% were living in a semi-urban area. The majority of fathers (41%) completed their secondary school education, 22% completed pre-university education, 16% completed primary school education, 15% completed a degree and above and 6% of fathers were illiterates. Most of the mothers (33%) completed pre-university education, 25% completed secondary school education, 16% were illiterate,15% completed primary school education and 11% of mothers completed a degree and above. This study is supported by another study conducted by Othman et al. [17] results revealed that the majority of parents had completed secondary schooling, most of the parents were employed 60.3% and from a socioeconomic perspective, middle- and high-income groups outnumbered the low-income group by 38.2%.
The majority of fathers (41%) were belonging to the category of agriculture, 22% were private employees, 18% were businessmen, 14% were working for daily wages and 5% were government employees. Most mothers (63%) were housewives, 27% were daily wagers, 5% were private employees and 5% were government employees. The majority (35%) of parents' family monthly income was 50001-10000, 33% of parents were having family monthly income of 10001-20000, 16% of parents' monthly income was 20001 and above and 16% of parents’ family monthly income was below 5000. The study was similar to the previous study by Gavneet et al. [15] revealed that the monthly income of the majority of participants falls in the category of 8000–15000.
A total of 87% of Parents were not having previous knowledge regarding thalassemia and 13% of parents were having previous knowledge of thalassemia. The study is braced on a previous study led by Biswas et al. [18] results showed that 52.7% of them had satisfactory knowledge regarding the disease. The majority of parents (62%) source of information about thalassemia was from health professionals, 18% were from mass media, 14% were from friends and 6% were from relatives. A total of 97% of parents was not partaking a family history of thalassemia and 3% were having a family history. The study is consistent and reinforced by another study conducted by Goyal et al. [19] results showed that 8.18% were having a family history of thalassemia.
The majority of parents (55%) were mothers, 30% were fathers, 12% were grandparents and 3% were siblings. Findings linked to the investigation of the degree of life amongst parents showed that a higher percentage of parents had moderate QOL (70%), 9% of parents had good QOL and the remaining parents (21%) had poor QOL. The study was sustained by a study directed by Pruthi [15] results indicated that parents in the thalassemia group experienced poor QOL as compared to the control group.
Outcomes related to the analysis of average, standard deviation, and mean percentage of total QOL illustrate that, the total mean percentage of total QOL of parents was 48.11% with mean and SD (63±12). The study was reinforced by a similar study led by Padma et al. [20] results exhibited that the total average and SD score of QOL was (67.76±17.28). Most parents had moderate QOL 25 (58.1%), 14 (32.6%) had poor QOL and fewer parents had a good quality of life 4 (9.3%).
Findings related to the assessment of domain-wise mean,
SD and mean% of total QOL among
parents of thalassemic children
revealed that the highest mean percentage of parents
(248.66%) was found for a social domain
with mean and SD (7.46±1.76), followed by the physical domain (244.28%)
with mean and SD (17.1±3.53), environmental domain (241.37%)
with mean and SD (19.31±4.12),
psychological domain (236%) with mean and SD
(14.16±3.35), and overall
(226%) with mean and SD (4.52±1.50). This study was supported by
the study conducted by Daliya et
al. [21] results
revealed that the mean score of total
QOL was 78.57±9.8.
Assessment of the degree of coping status among parents revealed that mainstream 88% of parents had moderate coping strategies, 08% had good and 4% had low coping strategies. Study results were reinforced by a descriptive study led by Sandra et al. [22] results showed that 74% of parents experienced severe financial stress and 57% of parents were effectively using coping mechanisms.
Findings regarding the correlation between scores of QOL
and coping strategies among parents of children with thalassemia showed a positive correlation between the quality of life
and coping strategies (positive correlation r=0.0829 p˃0.01) amongst
parents of children admitted in the thalassemia ward. This study was supported by a study conducted by Dadipoor
et al. [23] results revealed that there
was a positive correlation exist between the quality of mental health and coping
strategies.
Findings regarding the association between scores of the degree of life of parents with their study variables showed that there was no association exist amongst the quality of life scores with study variables. Findings regarding the association of coping strategies among parents with study variables showed that there was a significant association found with the type of family (χ2=8.66, p>0.05), previous knowledge regarding thalassemia (χ2=4.912, p>0.05), relationship with the thalassemic child (χ2=6.37, p>0.05). this study is supported by another study conducted by Kermansaravi et al. [24] results revealed that there was no significant relationship between the demographic data and the total score of coping behaviours of the parents.
CONCLUSIONS- Along with medical
management of thalassemia parent’s psychological status is also taken care of.
Continuous care of children put caregivers under a moderate level of burden.
There is a great need to plan and implement health awareness programs for these
caregivers. The stress experienced by caregivers is
due to a lack of caregivers' knowledge regarding available support systems in
the family and society. It is the nurse's role to help caregivers cope with
their family and hospital environment by providing satisfactory health
education and guiding necessary possessions for the caregivers.
The study is helpful to estimate the quality of life
and coping status midst parents of children with thalassemia and future
research can investigate the effective coping strategies to deal with
thalassemic children and improve the overall quality of life of parents. The improved mental health of parents
will ensure restorative care of the child and guarantee better adherence to the
treatment.
Research
concept- Dr. Deelip S.
Natekar
Research
design- Dr. Deelip S.
Natekar
Supervision- Santosh B. Sajjan
Materials- Laxmibai S. Hadapad
Data
collection- Laxmibai S.
Hadapad
Data
analysis and Interpretation- Santosh B. Sajjan
Literature
search- Laxmibai S.
Hadapad
Writing
article- Laxmibai S.
Hadapad
Critical
review- Dr. Deelip S.
Natekar
Article
editing- Santosh B. Sajjan.
Final approval- Dr. Deelip S. Natekar
REFERENCES
1.
Singh G, Mitra Y, Kaur K,
Bhardwaj K. Knowledge, attitude and practices of parents of thalassemic
children in district Patiala, Punjab, India. Int J Public Health Res., 2019;
6(1): 25-34.
2.
National centre for
biotechnology information. Genes and disease. Bethesda: national centre for
biotechnology information; thalassemia. Available at: https://www.ncbi.nlm.gov, 1998.
3.
Alzahrani RA, Almutairi
OM, Alghoraibi MS, Alabdulwahed MS, Alabaalkhail MK, et al. Quality of life in transfusion-dependent
thalassemia patients. J Taibah Univ Med Sci., 2017; 12(5): 465-70.
4.
Bala J, Sarin J,
Effectiveness of structured teaching programme (stp) for parents on care of
children with thalassemia in terms of quality of life of children with thalassemia.
Int J Cur Res., 2020; 12(7): 12777-83. doi: 10.24941.39156.
5.
Amin S. Written by
Gretchen holm Everything you need to know about thalassemia. Available at:
https://www.healthline.com/health/thalassemia, Nov 13, 2019.
6.
Angane AY, Kadam KS,
Ghorpade GS, Unnithan VB. Who will guard the guardians? Cross-sectional study
on prevalence of psychiatric morbidity, quality of life, and coping skills in
caregivers of children with thalassemia major. J Postgrad Med., 2022; 68(2):
72-77. doi: 10.4103/jpgm.JPGM_1128_20.
7.
Nursinganswers.net. All
mothers of children with thalassemia health and social care essay. Available
at:https://nursinganswers.net/essays/mothers-of-children-with-thalassemia-health-and-social-care-essay.phpvref=1,
2020.
8.
Kavitha K, Padmaja A.
Effectiveness of scope programme on health-related quality of life and health
status of thalassemic children: a pilot study. Int J Health Sci Res., 2019;
9(8): 282-86.
9.
Archana P, Suraskar L.
Assess the quality of life and coping strategies of parents of thalassemic children.
Global J Res Anal., 2022; 11(2): 2277-81.
10.
Punaglom N,
Kongvattananon P, Somprasert C. Experience of parents caring with thalassemia
challenges and issues for integrative review. Bangkok Med J., 2019, 15(1):
100-06.
11.
Kavita K, Padmaja A. Strategies
for enhancing quality of life in thalassemic children. Univ J Health Sci.,
2017; 2: 69-74.
12.
Telfer P, Constantinou G,
Andreou P, Christou S, Modell B, et al. Quality of life in thalassemia. Annny
Acad Sci., 2005; 1054: 273-82. doi: 10.1196/annals.1345.035.
13.
Salehi S, Morovati S.
Coping behaviors in families with children suffering from thalassemia major and
evaluating the implementation effect of nursing intervention on these
behaviors, Int J Med Res Health Sci., 2016; 5(2): 58-63.
14.
Thiyagarajan A, Bagavandas
M, Kosalram K. Assessing the role of family well-being on the quality of life
of Indian children with thalassemia. BMC Pediatr., 2019; 19: 100. doi:
10.1186/s12887-019-1466-y.
15.
Pruthi GK. A study of
quality of life among parents having children with Thalassemia. Int J Ind
Psychol., 2020; 8(2): 21-27. doi: 10.25215/0802.003.
16.
Biswas D, Sarkar AP,
Haldar D, Sarkar GN, et al. Quality of life among parents of Thalassemic
Children in Eastern India. Al Ameen J Med Sci., 2020; 13(2): 99-107.
17.
Othman A, Abdul Ghani
MSA, Taib F, Mohamad N. Psychological distress and coping strategies among the
caretakers of children with transfusion-dependent thalassemia. Front. Pediatr.,
2022; 10: 941202. doi: 10.3389/fped.2022.941202.
18.
Biswas B, Naskar NN, Basu
R, Dasgupta A, Paul B, et al. Knowledge of the caregivers of thalassemic
children regarding thalassemia: a cross-sectional study in a tertiary care
health facility of eastern india. Iraqi J Hematol., 2018; 7: 49-54.
19.
Goyal P, Hpapani T, Gagiya
H. Awareness among parents of children with thalassemia major from western
india. Int J Med Sci Public Health, 2015; 4: 1356-59.
20.
Bakthavatchalam P,
Vetriselvi P, Assessment of quality of life among parents of children with
thalassemia. Int J Adv Res., 2019; 7: 1074-83.
21.
Biswas D, Sarkar AP,
Haldar D, Sarkar GN,Saha I. Quality of life among parents of Thalassemic
Children in Eastern India. Al Ameen J Med Sci., 2020; 13(2): 99-107.
22.
Sandra JS. Stress and
coping among parents of children having thalassemia. Int J Sci Res., 2015; 4(7): 849-53.
23.
Dadipoor S, Haghighi H,
Madani A, Ghanbarnejad A, Shojaei F, et al. Investigating the mental health and
coping strategies of parents with major thalassemic children in Bandar Abbas. J
Educ Health Promon., 2015; 4: 59. doi: 10.4103/2277-9531.162375.
24.
Kermansaravi F, Najafi F,
Rigi S. Coping Behaviors in Parents of Children with Thalassemia major. Med
Surg Nurs J., 2018; 7(1): e81173. doi: 10.5812/msnj.81173.