Asthma

Function of the respiration system

The upper respiratory is composed of the oral cavity the pharynx, nasal cavity, and the larynx.  The upper respiration tracts ensure that the air that entering the lower respiratory track is damp, warm and clean.  And lower respiratory tract includes the trachea, the left and right primary bronchial and constituent of both lungs. Their functions are to carrier air from the larynx down towards the lungs (Maghten2013)

What is asthma?

Asthma is a result of persistent inflammation of the air ways most especially the bronchioles and the bronchi. The bronchi increases bronchioles inflammation with the excess of mucus production and swelling which enlarge the mucous glands then result in reducing of the air ways.

(Bush at el 2017)

Causes a

Asthma is caused by a combination of genetic and environment interaction. This influences both its reaction and its severity to treatments. Factors such as genetic liability to the condition may increase the likeliness of developing the condition. e.g  a house hold link in asthma .

Sign and symptom

Asthma includes episodes of wheezing, and present symptoms such: as breathless, chest tightness and coughing particularly at night or in the early morning.

Diagnosis:s Diagnosis can be difficult, especially in  children  and those beneath  the age of 5 years, then again the spirometry and the measurement of peak expiratory flow (PEF) are  the lung-function equipment  most regularly used to measure airflow obstruction in children .

Asthma managementthe goal in management of asthma is to keep control of the lowest possible dose of medication, and the ICS is the first line cure of choice, and this must be initiated in all youngsters with asthma.  A very low dose is required depending on the age of the child, such as Clenil 50mcgs 2 put twice a day (very low dose) or Clenil 100mgcs 2 puffs twice a day (low dose) are the recommended dose and these are very safe

References

Bush at el( 2017)

severe asthma in children, respiratory, vol 22. Issue, https://doi-org.apollo.worc.ac.uk/10.1111/resp.13038

Kaufman. G(2011)

.ASTHMA : pathophysiology , diagnosis and management , nursing standard . 26, 5,48-56

available :

wwwworcesterbb.Blackboard.com

Maghtrn.j( 2013)


children respiratory nursing




1



^st



edition

Richard and Kerr (2016

) Asthma in children, medicine vol (4) issue( 5 )p 281-286, hhts://doi.org.10.1016/j.mpmed.2016.02.014.

Contents

iIntroduction…………………………………………………………………………..…1

Asthma definition……………………………………………………………………..…2

Trigger and factor ………………………………………………………………….……3

Asthma classification……………………………………………………………….…..

5

Atopic asthma

Non atopic

. Clinical presentation…………………………………………………………………….5

Sign and symptoms………………………………………………………………….…6

Diagnosis…………………………………………………………………………….…..7

Anatomy and physiology……………………………………………………………….8

Asthma management …………………………………………………………………..9

Inhaler technique

Pharmacotherapy option

Psychology perception therapy intervention

Conclusion……………………………………………………………………………10

Reference …………………………………………………………………………….11

Introduction

Asthma in children and young people remains a significant burden on all area of primary care. In the UK asthma occurs in 1 in 11 children and accounted for 2500 acute hospital admission. Despite advanced in its management, asthma remains a life threatening condition and many children still dying each year (Barrior at el 2006).Therefore the aim of this report is to increase health professionals’ awareness of asthma disease, and enhance their confidence and skill when dealing with children who are presented with this condition. Using different literatures research will allow the report to provide a better understanding of the disease pathophysiology as well as an insight of the underpinning and development of anatomy and physiology of children’s airways affected by the disease. As well  provide some management tips  and  therapeutic strategic that will help manage the condition  .Although  the choice of this condition results from my own experience, having looked after my own child who was affected by the condition last year.

Asthma definition

The global strategy for asthma management and prevention describe asthma as a chronic inflammatory disorder of the airways in which many cells and cellular element plays a role. Its associated with airway combination of the bronchial obstruction  within the lungs that leads to repetitive episodes of wheezing, breathless, chest tightness and coughing particularly at night or in the early morning(Richard and Kerr 2016) .

Literatures

Asthma it refers as a long-lasting disease among children, it’s a condition that linked to higher death, the condition runs in families, especially for those with bad skin (eczema) and other allergies. And study indicates that  they may be evidence to indicate that the phenomenon of childhood bronchial, asthma has increased in the past 50 years, and the reason for this stay very doubtful. While a number of life style factors, as well as genetic are involves for its causes (Bacharier at el2011)

In the UK approximate one millions of children have been diagnose with asthma, this can suggest that every classroom has one out of 11 with asthma, and it appeared to be the most common long-lasting disease in children (NICE 2011).Therefore the prevalence of childhood asthma symptoms in the UK is among the highest worldwide and contributes to the estimated of £ 1 billion annual cost of asthma care to the NHS. (Daines and MCmurray 2016). Study also indicates that the condition seem to occur more in boys than girls. Therefore boys aged 5-14 are frequently presented to primary care with 95 consultations for every 1000 registered patients.

This condition  impacts on children as well as their love ones, its decreases quality of life in children and their families, with different issue such as school non-attendance, parent work non attendant, sleep hardship and failure to take an interest in exercise.  Studies indicate that asthma can limits exercise activities by 39 % and can cause lifestyle change in 70%, study agrued that school non-attendance can also impact on children achievement and therefore limits their future education and career options (Marsh 2017)

Causes of asthma

Asthma is caused by a combination of environment and genetic interaction. These impact on its reaction to treatment as well as it severity. Study argued that genetic risk factor to the disease increases the risk of developing asthma; e.g a family link in asthma has also established the chance of developing the condition by ten times likely (Rees 2010). However, studies suggest that genetic alone does not account for the development of the disease; it also relies upon on surroundings element factor connecting with genetic tendency. Thereforeasthma has been associated with many environment elements that increase the chance of developing the disease.  This can includes allergens, air pollution, and different environment chemical such as exposure to smoking as well as smoking in the course of being pregnant or after delivering increase its severity (Holgate and Douglas 2010).

Furthermore some studies also support the hypothesis which suggests that the risk of respiratory infection and asthma were positively related to each other.  For example infection of the respiratory tract in infancy led to greater infection in the following years, and asthma symptoms in children similarly led to extra asthma symptoms the following years. The viral of upper respiratory infection have been related with 80%. Therefore asthma and the respiratory infection are the major element of acute and persistent death in childhood because they placed considerably burden on children and family member (Alban at el 2017)

Classification of asthma

Asthma is medically classified according to the frequency of symptoms and sign pressured expiratory volume in one second and peak expiratory flow. Therefore study suggest that asthma can also be classified as atopic or non-atopic , based on whether sign are precipitated with aid of allergens or no (Barrior at el 2006).Although atopic asthma, usually start in childhood then in formative year ,and this is connected along with identifiable obstructions that bother wheezing, coughing. It’s also connected with house hold history on allergic disease, which is characterised by eczema or rhinitis. Asthma disease generally happens as a result of allergy reaction to allergen such as house dust, dirt, grass, domestic pet . e.g in atopic asthma, a family history of allergy are also more likely to develop asthma desease than other children .   This increases the production of immunoglobulin (IgE) antibodies as particle after the surface on the mast cells, basophils spherical and the bronchial bloods vessel. Therefore when the allergens is motivated, the antibody responses effect of the release of the  histamine mucus secretion then the muscle shrinkage so much  slimming the airways (Waugh at el 2010).

2.



Non atopic

In the case of asthma not in all situation asthma condition is referred as being caused by environmental factors. Although factors unrelated to atopic diseases are also important to consider. This kind also takes place later in adult life yet where there is no history of infancy allergic reaction. However this is often connected along with chronic inflammation of the upper respiratory tract, such as nasal polyps, chronic bronchitis. As well as additional casual factor which includes exercise, inhaled paint fume,  air polluted that in turn can cause an asthmatic reaction in some patients(Mighten 2013). However  an  attacks also  tend to increase when the condition is worsen overtime  although  in case of   lung  damage this  can become unmanageable and  can  also cause  deficiency in the amount of oxygen reaching the tissue , pulmonary hypertension and right sided heart failure (Waugh and Grant 2010)

Sign and symptom

Asthma symptoms can include   shortens of breath, chest tightness and coughing,   particularly at night time and early morning.   A number of asthma attack usually occur progressively taking 6-48 hours to become very seriously ,but an attack in some patient with asthma can get worse very quickly than other.  Although signs of asthma are few and non-specific, relating of air from lungs. Although  this might be heard on auscultation and physical examinations because it   might also reveal signs of condition, such as bronchiectasis,  obesity or in atopic patient, eczema or allergic rhinitis (Adrew at el 2017)

Clinical presentation of asthma

Some of the symptoms of others patient might not to be easily identified from each other.  While childhood onset allergic asthma is commonly related with skin inflammation, rhinitis, food allergy, a family history of asthma  wheezing, coughing, viral respiratory infection .In childhood asthma, children have regular wheezing then adult the likelihood and  regular symptoms increase with early life allergen reaction, and passive smoking (Pride 2018).

Diagnosis of asthma

In children the diagnostic of asthma depends on recognition of the attribute pattern of symptoms that makes the condition more or less likely diagnosis. But it is important to understand that while asthma is common disease, however they are different causes for the sign and symptoms, and it is vital that these diagnosis are not missed. Because a wrong analysis can have profane consequences, which will can lead to unnecessary treatments and anxiety (Brooker and Rachel 2014) .However it can be difficult to give a correct diagnostic result of asthma disease, while diagnosis requires medical analysis and judgment. Because signs and symptoms of asthma can different from one patient to another and can also vary within the same patient at different time. Therefore the diagnosis can be difficult, especially in children and beneath the age of 5 years; however studies suggest that the spirometry and the measurement of peak expiratory flow (PEF) are the lung equipment regularly used to measure airflow obstruction in older children(Mighten 2013).However research suggests that there is no single test that can confirm whether a child has asthma, but  parent and health professional can work together over a period of time to ensure any diagnosis made is accurate (Hansen 2015). However to discern between over diagnosis and inactive asthma it is important to keep a record of the basis on which a diagnosis was made, so that, it can be reviewed later (warren 2012)

Anatomy and physiology of asthma.

The main lung’s function is providing oxygen to blood and remove carbon dioxides, to accomplish this, pressure gradient must be created between the terminal respiratory unit and the outside air, by contracting the diaphragm against a thoracic cavity held by the ribcage. Therefore a negative pressure is generated and air passage occurs. However In poorly controlled respiratory condition such as asthma the diaphragm works much harder than normal and can deform the chest wall as the muscle fibres attaches to the lower part of the ribcage, this deformation of chest called harrison’s sulci( Bush at el 2017). Asthma disease can cause inflammation of the airway, and these airways are the small tubes called bronchi, which transport air in and out  of the lungs. During asthma the bronchi can be very inflamed and sensitive than normal. And the cartilaginous bronchi, membranous bronchi, gas exchange bronchi consist of the air way of the lungs. Their first function is conducting airways from the nose or mouth down to the level of the terminal bronchioles. This fills with inspired air at the end of every inspiration and they also contribute to the airways resistance. However the cellular which include mast cells are involved of releasing histamine includes: basophils, neutrophils, eosinophil and macrophages these are responsible mediator which is releases in late or early stage of bronchial asthma.  And during the stage of bronchial asthma the mucous membrane and muscle layers of the bronchi can become very thick and contracted , therefore  the mucous glands become bigger and  enlarge, which result in reducing airflow in the lower respiratory tract ,and  become  inflamed . Although the cells identified in the airway inflammation includes eosinophil, epithelial cells , mast cell , and activated T lymphocyte and macrophage

(

Muralitharan  and peate 2015

)

.The airways blockage can increased resistance to airflow and decreased the exhalation of breath from the lungs. And this will result in pulmonary change mechanism and increase the work of breathing (Waugh and Grant .2010).

Although the cell that line the airways in the lungs produce mucus as part of the body defence mechanism against foreign, such as bacteria and viruses particles. When the mucus are secreted these particles are trapped, and tiny hair like projection in the air ways which is known as cilia ( this sweep the dirty mucus up and out the lung). However most bronchi increase bronchioles inflammation with  the excess of mucus production and swelling. Therefore this inflammation brings about change in the lining cells of the airways, and a number of cells that lined the airways will lose their function of their cilia which will result of the ciliate cell lost. However The ciliate cells that facilitate the clearing of secretion are therefore replaced by so called globet cell( Muralitharan  and Peate 2015

)

. But the cells help the secretion of mucus into the airways, and warm environment of mucus for growing bacteria. Therefore this mucus can became infected and discoloured from overgrown bacterial which result in further inflammation of the respiratory tract that respond to it, and therefore narrowed the airway to and from the lung alveoli and blocking the bronchi and bronchioles (Wiley 2015). And the duration of asthma attacks usually varies from minute to hours, but in severe acute attacks the bronchi may be obstructed by mucus plugs, leading to acute respiratory failure, hypoxia and possibly death (Crawford 2011).

person centred care (PCC) approaches




in asthma management

BTS guideline for management and diagnosis of asthma, describe PCC as one that recognised partnerships and team work amongst health professional, patient and their family. This approach should take into account patient preference, need, culture and ethnicity. Therefore this approach encompasses 4 area of diagnosis and management of the condition which includes: Communication, Partnerships, Health promotion and physical care.

Communication

When considering asthma management it is important to acknowledge that a correct diagnostic of asthma is not made on a single sign or symptom. History consideration is just as important as clinical feature. Because patient with asthma or serious asthma are exceptional challenging group and request a multidisciplinary approach. The need for different skills approach includes: assessment of pulmonology allergy, gastroenterology, and otolaryngology, is very important to ensure a complete assessments and diagnosis, are made accurately before management (Ramratnam at el 2017).

Hence the objective of asthma administration in children is to attain asthma control by optimising lung function, which in turn can make differences in decreasing day and night symptoms, lessening restriction in day activities and decrease it severity (Mighten 2013). Study indicates that the corticosteroid (ICS) is the first line treatment of choice and this should be integrated in all children with asthma. A very low dose or low dose is allowed depending on the age of the child. The range of drugs  authorize for use in children  is limited and Clenil 50mcgs 2 put twice a day (very low dose) or Clenil 10 Omgcs 2 puffs twice a day (low dose) is the usual staring point, and the recommended doses is very safe. However not exceeding 400mcgs per day in children under five and 800mcgs per day (medium dose) in 5-12 years old, beyond this specialist referral is required (Francesco 2014)

Health promotion and physical care

1. Inhaler technique

Education of inhaler technique and repeated assessment tend to improve the correct usage, and this should be part of everyday asthma review. Effective inhaler technique is very important in managing asthma , and it needs some time for patient/ parents to develop the skill for correct usage.  Almost all children with asthma condition use pressurised metered dose Inhaler (Pmdi) with a spacer, but  very young children will need a spacer with a facemask , but one they can tidal breath reproducibly through a mouthpiece,  indeed a spacer without mask is preferred as soon as possible drug deposition in the airways will improved. In formative years  alternatives to an MDI and spacer, e.g dry power devices can be considered to improve adherence and new inhaler should only be prescribed after the a child has received training in the use of the device,  has also demonstrated a satisfactory technique (Harron at el 2017).Therefore physician and nurse should recognise the need to improve these behaviour aspects in patients and seeking partnership with parents/ children and setting individual  action plan ,that may be helpful in improving asthma  control (Wim and Aaldern 2012). Research study reveals that about 75% of funding was spent treating poorly managed in children with asthma, therefore it is vital that health professional encourage parents to use peak flow meters to better manage asthma and control cost. To achieve this healthcare provide should also control appropriate medication, address environment risk factor, assist with self-management. This can followed by some education provision regarding inhalers technique, compliance, asthma action plan, self-monitoring and follow up appointments (Kaplan at el 2018).

2. Pharmacotherapy option

The British Thoracic Society (BTS) based on a global plan of action for managing asthma, outlined pharmacotherapy control medication, this provides immediate relieve of bronchospasm, open airways. Minimal, and ideally no symptoms during night or day therefore no asthma episodes. this includes minimal use of a relieve medication short acting β2-agonist such as salbutamol .other includes normal activities, and function of the lung.(PEFR forced expiration volume in 1 second. and this treatment  should be start a suitable level of severity for the individual patient. when staring the inhaled treatment a suitable device should be prescribed after pressured meter dose inhaler(Chavasse and kerr 2016)

Partnership

The resilience model should also be initiated in managing asthma , this model is a frame work for families dealing with chronic health .The model explains, how stress could affect care givers as they adapt to crisis. This state of unbalance can negatively impact on the care of patient with asthma.  studies indicate those caregivers who are educated on how to manage their child asthma tend to have an increase perception of control, and this improves outcomes of patient (Paymond at el 2018).Therefore implementing peak flow meters and action plan improve knowledge of asthma and promote prevention, this approaches  improves perception of control of  child’s asthma  and increase confidence in managing the condition

Conclusion

Asthma remains a burden on families as well as primary health care, and asthma management and prevention required national attention and determination if reducing the chance of developing asthma disease is to be improved. Therefore it is important to consider how to make correct diagnosis of the condition base on history and clinical presentation, as these procedures precedes management .Therefore effort should be made to prevent wrong diagnose .however a structured clinical assessment and family history provide a solid foundation for accuracy in diagnosis, and the  ICS remains the cornerstone of asthma management and most children with asthma respond very well to very low or low dose and inhaler. While the technique is a key in paediatric asthma management while time must be taken into account at every medical review to correctly check that a child use their inhaler correctly.

Reference

• Adrew at el( 2017) severe asthma in children .
  
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• Alban at el 2017) Longitudedinal associateds between respiratory infection and asthma in young children. Doi 10.1093/aje/kwy053
• Bush at el (2017) severe asthma in children, respirology , vol 22. Issue ,https://doi-org.apollo.worc.ac.uk/10.1111/resp.13038.
• Barrio 2006 .pathology and pathophysiology , archives of pathology and laboratoire Medicine , northfiel vol 130 , issu 4 pp 447-51
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• Crawford .D (2011) nursing children and young people, Understanding
  
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• Daines and mcmurray
  
  (2016) asthma in children ,Doi:org.apollo .worc.ac.uk/10.1177/1755738016678013r
  
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  Hansen, tonje.E(2015) validation of a questionnaire against clicnicla asseement in the diasis in children. , journal of asthma, issn:0277-0903 , vol 52 ,issue 3 p:262-267, doi:10.3109/02770903.2014.966914
  
• Harron at el 2017) .
  
  Frequency of correct use of children inhaler technique in asthmatic (3-15) in order to improve outcomes
  
  . Medicine journal 2017 .vol 9.issue 4 p248-251.4p
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The Patient Care (Feel-Link) Project (PCP(FL)) is to help students to develop a patient-centered approach to the practice of medicine. To achieve this, I and a medical student, Nicole need to follow and interview a patient in an effort to discover the patient lived experience regarding issues of health and illness. In this essay, the first PCP(FL) visit, my thoughts and feelings will be described and evaluated based on evidence from the literature sources.

Griffiths and Crookes (2006, p.186) suggest that multidisciplinary teams are needed in the health care system to provide holistic care to patients with optimal use of existing resources, and limited cost. This project is the first step in enhancing interdisciplinary co-operation and understanding between nursing and medical students. Both I and Nicole are required to fill in a problem-oriented patient record (POPR) after each visit. We have to co-operate with each other to recruit and interview one patient with the help of nurse specialist (diabetes), Ms. Shimen Au at the Ruttonjee and Tang Shiu Kin Hospitals.

The patient that we had recruited called Mrs. Leung who is a 52-year-old housewife. She is currently married and lives with her husband. Her husband was unemployed and they had financial support offered from the government. She was suffered from diabetes mellitus, hypertension, and rheumatoid arthritis about ten years ago and first diagnosed to have bipolar affective disorder at age of 22.

After we had explained the aims of this project to Mrs. Leung, she signed two identical consent forms, one copy to be kept by the patient whilst the other to be returned to the tutor. Then, Nicole asked some basic demographic data based on the personal particular form. Mrs. Leung answered one by one accordingly. The POPR also requires us to gather very specific information, such as the past medical history and family backgrounds. When I had asked Mrs. Leung whether she had any children, suddenly the atmosphere in the room became silence. Mrs. Leung was not saying anything for a few seconds, and then she stated she did not have any children. I felt surprised that a married woman at her age should have more than one child already. She explained that doctors had recommended her not to be pregnant in the past. So she was currently living with her husband only but she claimed that the relationship between she and her husband was poor. She had a conflict with her husband just before taking taxi to the hospital. She honestly knew that the reasons why her husband always grumbled about her because of her laziness to cook and buy the necessities. There were quarrels with her husband almost every day. She felt guilty about it. I thought this might be caused by her mental illness and chronic diseases.

According to Friedman (2002, p.193), social isolation is a major problem that chronically ill patients experience. Social relationships are often disrupted and jeopardized because of the patient’s decreased energy, limitations in mobility, communication impairment, or time required for symptom control. Mrs. Leung usually slept for 13-14 hours per day but she graded the quality of sleep was poor. Even she rated her current level of health as very poor. She described her mobility in daily life had been affected by rheumatoid arthritis causing the swelling the knee joints and interphalangeal joints of hands. Therefore she never did any exercise. I was worried that she would become obese and thus increase the risks of falling and having cardiovascular diseases. I felt regret I had not encouraged Mrs. Leung to do some simple exercise regularly so as to keeping active and not staying in bed for all days. I needed to find some suitable exercise for her and advise her to do exercise in the next visit.

Friedman (2002) points out “illness is especially likely to be subject to the influence of other people since it usually has important implications for a person’s friends and associates” (p.64); Mrs. Leung was concerned that her first love with a Japanese man at the tender age of 19. She was still thinking about him and she had tried to commit suicide in the past. When her husband heard about she was talking about that Japanese man, they would have quarrels for a long period of time. The negative emotions could really influence people around the patient. I was speechless at that time and I could only say to Mrs. Leung that her husband was care about her and tell her not to think about the past anymore. I thought I would perform better in the next visit as I had known some basic information of Mrs. Leung already.

In conclusion, I think it is right that a nurse must be able to express opinions clearly and confidently. Good communication skills are essential for nurses, and are important in nearly all aspects of medicine. I feel that I will be more confident in dealing with patients and more effective in taking a patient medical history, for example. Developing greater confidence in how I communicate can lead to patients having greater trust in me as their nurse. Improving my skills in this area will also make me more effective in discussing cases with colleagues, and in participating in teams when necessary.

This visit made me realized that I can talk confidently once I overcome my initial fears. It demonstrated to me that in order to make progress or create positive change you must first acknowledge that a problem exists. This is a lesson which may be useful in better understanding patient behaviour and attitudes. Often the first step to improving a situation, or dealing with a problem, is accepting that some change is necessary; and I might be more able to impart this information to patients having experienced this visit. Overall, this visit has had a positive impact on both my studies and on the development of skills needed in my future career.

(Word count: 988words)

CHAPTER FIVE: DISCUSSION

Introduction

In chapter five, major finding of the study was discussed, testing of hypothesis followed by examination of the data addressing the research question. In addition, the strengths and weakness of the study was explored. Next the implication of the study is presented followed by recommendations for future research and limitations faced as the study being conducted.

5.1 Overview of the study

The study was designed to examine the effectiveness of aromatherapy inhalation for 7 days in reducing depression, anxiety and stress during clinical practice among first year UiTM Nursing students. Numerous research studies have highlighted the relationship between effect of depression, anxiety and stress on nursing student during clinical practice.

At the beginning of clinical practice period, the researcher introduced the study objective and informed consent process to the first year nursing student of the Universiti Teknologi Mara (UiTM) Puncak Alam. Students who were interested in participating signing an informed consent form. A total of 42 students signed the informed consent and had an opportunity to ask question during initial meeting.

Participants completed the DASS questionnaire (pretest) and were selected into two groups from convenient sampling. As a result, 20 participants in experimental group and 22 in the control group for purposes of data analysis.

5.2


Baseline characteristic of participants

The sample population of this study was composed of first year nursing student from diploma program in UiTM Puncak Alam from both genders who free from taking any relaxation medication. The study groups were homogenous with respect this characteristics, so influenced of these aspect can be generalized for all the nursing students who were evaluated (p = 0.175, p = 0.716).

Summary of the result

Objective number 1

To determine the baseline level of anxiety score in experimental and control group.

The baseline mean score for depression, anxiety and stress in the control group was 16.14

±

2.765, 13.32

±

6.658 and 20.36

±

2.341 respectively and the baseline mean score for depression, anxiety and stress in the experimental group was 15.25

±

2.359, 13.20

±

5.917 and 21.65

±

2.183. An independent t-test at the 95% confidence interval and .05 level of significance was computed to compare the average depression, anxiety and stress score between both groups, and it was concluded that the sampling process effectively produced equivalent groups with respect to depression, anxiety and stress score at baseline,

t

=-1.112,

p

= 0.27,

t

= -0.61,

p

= 0.952,

t

= 1.836,

p

= 0.074. This indicated that the levels of DAS in the two groups were the same at the beginning.

5.3 Baseline DAS score in both group

In this study, for baseline score, both groups was had a moderate level of depression, anxiety and stress (DAS). Possible explanation for the higher prevalence of baseline DAS score among this study population could be due to preparation for practice require more than developing skills in the on campus lab. It entails developing an ability to provide safe and effective care to other human beings in various clinical settings. This components of developing expertise as a student nurse can be very stressful to nursing students and create anxiety.

In health professional education, the clinical perspective is identified as fundamental field for students to learn about practice in the ‘actual’ world (Egan & Jaye, 2009). Prior to the education of health professionals, in particular nurses, has switched from an apprentice-based training model where the regular practice of task and activities are highlighted, to university-based preparation that educated student to understand situation and pursue and wisely use evidence in practice. (Henderson, Cooke, Creedy & Walker, 2012)

The clinical practicum is a significant and essential element of any undergraduate nursing degree. Experiences during clinical placement are effective in shaping student attitudes to learning, practice and professional development (Henderson, Cooke, Creedy & Walker, 2012).

High levels of anxiety can affect student’s learning, performance (Sharif & Armitage, 2004; Moscaritolo, 2009) and in some cases retention within a nursing program (Moscaritolo, 2009). According to Melincavage (2011), students likely to experience anxiety when in any new learning experience and while evolve from novice to expert.

According to Burnad et al. (2008) and Pulido-Martos et al. (2012) they found that witnessing the death of patient, relationship between student and mentor and/or staff, providing care, lack of knowledge and skills, practical and assignment are common clinical stressors among nursing student. Furthermore, nursing student at both novice and experienced level believed that clinical stressor more stressful that academic and external one (related to daily life) and generate more psychosocial responses such as anxiety, cognitive symptoms and depression (Blomberg, 2014). However, previously recognized clinical stress factor are lack of knowledge and professional ability, lack of understanding with history and medical terms, heavy workload, being in an unfamiliar situation, mistakes with patients or handling of technical instruments (Basso Mussoetal.,

2008

; Chanetal.,

2009

; Jimenezetal.,

2010

). This factor might be more frequent in hospital settings. This could clarify why student more likely to experience stress during clinical placement in hospital (Blomberg, 2014).

A study conducted by Goff (2011) found that nursing students has been long perceived by nursing department and students to experience higher levels of stress than other college student. Nursing student believed that they have little leisure time because they needed to study, with assignments and clinical task (Reeve, Shumaker, Yearwood, Riley & Crowell, 2013).

Shriver and Scott-Stiles (2000) found another leading factor to high level of stress is that clinical task demanded nursing student to spend substantial time away from campus and also require them to be responsible for the well being of patients In the other word, these activities take off student from normal social development of their friends (Reeve, Shumaker, Yearwood, Riley & Crowell, 2013).

According to Melincavage (2011), students likely to experience anxiety when in any new learning experience and while evolve from novice to expert.

Objective number 2

To compare mean of post depression, anxiety and stress score level between intervention and control group. The H1o was: There is no difference in level of depression, anxiety and stress score between intervention and control group. An independent t-test at the .05 significance level was computed to compare mean of post depression, anxiety and stress score level between intervention and control group. There was a statistically significant difference in the mean of post depression, anxiety and stress score,

t

= -2.072,

p

= 0.045,

t

= -2.625,

p

= 0.012,

t

= -3.232,

p

= 0.002 respectively. The null hypothesis was rejected. It was concluded that there is a significant difference in level of depression, anxiety and stress score between those students who did not received aromatherapy and those student who received aromatherapy after the intervention.

Both group showed a decreasing in mean score of DAS after the intervention. However, aromatherapy group significantly lower than control group. In the other word aromatherapy was effectively reduced level of DAS in the experimental group after seven day of inhalation. However, although being exposed to water, mean score of control group also show a reduction in posttest compare to pretest. But, it was not significant as aromatherapy group.

Objective no 3

To examine the mean of depression, anxiety and stress score in intervention and control group before and after introducing the intervention. A paired t-test at the 95% confidence interval and .05 significance level was computed to examine mean of depression, anxiety and stress score in experimental and control group before and after introducing the intervention. There was significant different in the mean score of DAS between pretest and posttest among student who received aromatherapy,

t

= 9.51,

p

= 0.00,

t

= 5.39,

p

= 0.00,

t

= 11.11,

p

= 0.00 respectively. The group of student who do not received aromatherapy also significant difference in the mean score of DAS between pretest and posttest t = 4.09, p = 0.001, t = 2.23, p = 0.037, t = 4.87, p = 0.000 respectively. However, mean score of depression and anxiety in the aromatherapy group significantly lower than the control group.

5.4 Reduction of DAS score

In our study, intervention group who received aromatherapy inhalation for 7 days showed significance reduction of DAS score with p value 0.045, 0.012, 0.002. The null hypothesis of the study was rejected because there was a beneficial effects and statistically significant effect from aromatherapy in reducing depression, anxiety and stress score in the sample of nursing students. We accept alternative H1 and H2 since there is difference in level of DAS between intervention and control group and intervention group has showed a reduction in level of DAS after introducing the aromatherapy. Result from this study also supports previous research on effectiveness of aromatherapy (Johnson, 2013).

This finding is similar to a study conducted among 110 nurses in the hospital. A small bottle containing 3% lavender oil was pinned on their clothes to examine the effectiveness of lavender oil to reduce stress related job among nurses. The study found that there is reduction of the number of stress symptoms for 3 to 4 days in the experimental group after aromatherapy was carried out (Chen, Fang & Fang, 2013).

Another consistent finding from a study by Yuen, Mei and Wing (2014) found that there was significant improvement in the reduction of stress level (p = 0.001) and the reduction of anxiety level (p = 0.044) when compared pre and post aromatherapy inhalation among nursing student in Hong Kong facing final examination.

The result from this study similar to previous study conducted to determine the impact of aromatherapy on the anxiety level of patients experiencing coronary angiography. The study concluded that anxiety level decreased significantly in the intervention group compared with the control group after aromatherapy (P <0.0001) (Tahmasbi, Mahmoodi, Mokhberi, Hassani, Akbarzadeh & Rahnamai, 2012).

However, in this study, participant in control group showed a reduction in the level of DAS after the intervention. This result showed that nursing students seek for other intervention or coping method to overcome the depression, anxiety and stress during clinical practice. A study carried on baccalaureate nursing students in Jordan in their initial period of clinical practice found that needed support and guidance from clinical instructors helped to reduce stress and promote a positive clinical experience. Furthermore, nursing student applied the most common used of coping strategy in relieving stress such as a problem solving behavior followed by staying enthusiastic and conversion of attention from the stressful event to other things was of coping strategies ( Shaban, Khater & Akhu-Zaheya, 2012).

Other than that, another study carried out by Por, Barriball, Fitzpatrick and Roberts (2011) found another factor that relieving stress was emotional intelligence. Emotional intelligence was absolutely related to well-being (p<0.05), problem-focused coping (p<0.05) and perceived nursing competency (p<0.05), and adveresly related to perceived stress (p<0.05). This study also suggested that increased feelings of control and emotional competence assist nursing students to implement active and effective managing strategies when dealing with stress, which in turn enhances their subjective well-being.

5.5 Recommendation

The results of this pretest, posttest design study revealed that the effect of aromatherapy oil on depression, anxiety and stress among first year nursing students during clinical practice was statistically significant. Based on previous discussions in this chapter and the rationale for this study, future research is recommended in nursing education with large sample and close room to allow the aroma ventilated in the room. Other as this study has shown the effectiveness of aromatherapy in reducing depression, anxiety and stress among nursing student, this evidence based will be suggested to UiTM Nursing Department to apply this method to nursing student especially during attending clinical practice. Other than that, aromatherapy also can use for nursing student before attending exam especially objective structured clinical examination (OSCE).

5.6 Implication of the study

The implication of the study are that, it can increase awareness to the nursing department about problem of nursing student during clinical practice and the negative effect toward nursing curricular. It also exposed and encourages the lecturer or staff in the nursing department on the utilization of the aromatherapy among nursing student.

The finding of this study can provide a nursing student with stress coping method using aromatherapy. With the use of aromatherapy, student can focus on learning and perform procedure in the clinical area effectively and increasing the quality of patient care.

Furthermore, aromatherapy is a safe, cost-effective, time appreciative intervention that can be implemented in nursing education.

5.7 Limitation

The following limitations were identified during the administration and analysis of the current study to assess the effect of aromatherapy on depression, anxiety and stress among first year nursing students during clinical practice. The purpose of this section is to provide a critical assessment of the study’s limitations.

The primary researcher did not have control over where the duration of inhalation during the intervention due to participants freely to stay in any room instead of their own room. As a result, the duration of inhalation may have contributed to the significance of pre and posttest in the control group. Participant in the control group may stay in the room of participant in experimental group. Thus, the participant was indirectly inhaled the aromatherapy oil. It would be beneficial to place the both group in different block of residential college.

Summary

In conclusion, the overall study’s findings were statistically and clinically significant in demonstrating that aromatherapy is able to reduce level of depression, anxiety and stress during clinical practice among first year nursing student. Theses results are similar to those study demonstrated by Johnson (2013) Chen, Fang & Fang (2013) andYuen, Mei & Wing (2014) with the aim to measure the effectiveness of aromatherapy in reducing depression stress and anxiety among nursing student and nursing staff. An extension of this study over a longer time period with a larger sample size and using Randomized Control Trial (RCT) design may provide better results in future studies.

Conclusion

This quasi-experimental study set out to examine the effectiveness of aromatherapy in reducing depression, anxiety and stress during clinical practice among first year nursing student. The result showed that such students perceived moderate level of depression, anxiety and stress prior to attending clinical placement in hospital.

The purpose of reducing depression, anxiety and stress among nursing student is part of strategy to promote effective learning environment especially during attachment in hospital. Depression, anxiety and stress can hinder student’s self confidence to perform nursing care to patient. Other than that, it gives a bad impression toward nursing department as their student unable to show a competency during performs a procedure in the hospital. Since clinical practice is vital element in nursing education, students are believes to apply the basic nursing skills in the clinical areas that enable the application of theoretical knowledge to develop. However, if the students unable to relieve their depression, anxiety and stress, these objectives are unable to be achieve and give a loss to student and nursing department. Therefore, there is a need for nursing department to encourage student to utilize the evidence based-practice especially during attending clinical practice with recommended solution which is aromatherapy inhalation. The research gap has been addressed and the findings showed consistent with previous studies. Research question of this study has been answered and the study null hypothesis was rejected based on the data analysis.

The overall finding showed that aromatherapy has a positive effect in reducing depression, anxiety and stress among nursing student. The finding identified pointed to rejection of study null hypothesis because the use of lavender aromatherapy significantly reduce the level of depression, anxiety and stress in nursing student compared to use of water. Hence, aromatherapy was proven as an effective coping strategy in this study in addition to others in the literature. This result supported previous studies on same setting and population (Johnson, 2013).

It is critical for nursing student to overcome depression, anxiety and stress and aromatherapy can facilitate to relieve these problems. Although sample size in this study was small, there exists quantitative evidence that aromatherapy has a role to play in nursing curricular especially among students attending clinical area. The design and results of this study will hopefully inspired nursing researcher to explore the phenomenon of depression, anxiety and stress during clinical practice and create innovative practices to minimize it in the future. Nursing faculty must continue to create advanced method to facilitate success for student who experience depression, anxiety and stress The increasing diversity of nursing students in age, gender, and ethnicity will continue to grow in future years, and nursing faculty will require more expertise that addresses students holistically (Jeffreys, 2012).