Video vs SIM on quality of life in diabetes

152 International Journal of Nursing Education, April-
June, 2015, Vol.7, No. 2
A Study to Compare the Effectiveness of Video Assisted
Teaching vs Self Instructional Module on Quality of Life
among Type 2 Diabetes
Sithara Begum
Ph.D Scholar, Saveetha University, Chennai
ABSTRACT
Diabetes is becoming the epidemic of the 21st century. Type 2
diabetes , which is more prevalent (more
than 90% of all diabetes cases) and the main driver of the
diabetes epidemic, now affects 5.9% of the
world’s adult population with almost 80% of the total in
developing countries .In addition to this, the
complications and associated with diabetes is also in the higher
rate.
Aim: The aim of study is to compare the effectiveness of of
video assisted teaching Vs Self instructional
module on quality of life among type 2 diabetes.
Methodology: The research approach adopted for the present
study is an Quantitative research
approach and the design adopted was quasi experimental design.
The se�ing for the study was
Crescent Hospital, Alathur. Palakkad, Kerala. The sample size

of the present study was 50 used simple
random sampling technique to select samples.
Finding: The Pre-test mean Score and Standard Deviation of the
type2 diabetes regarding video
assisted teaching on quality of life was 55.84 & 6.95,which
increased in post test 75.76 and 6.54. pre
test mean Score and Standard Deviation of the type 2 diabetes
regarding Self-instructional module on
quality of life was 54.4 and 4.203, which increased in post test
66.68 and 13.524.
Conclusion: The present study results shows that
comparatively the video assisted teaching is more
effective in promoting Quality of life than Self-instructional
module .
Keywords : Self instructional module(SIM) , Video assisted
teaching(VAT), Effectiveness, Compare , Quality
of life(QOL), Type 2 diabetes.
INTRODUCTION
While there are many diseases, there is, in a
sense only one health. - Park
Encyclopedia, defines diabetes is the group of
metabolic diseases which a person has high sugar,
either body does not produce enough insulin or
because the body does not produce enough insulin
or because cells do not respond to the insulin that is
produce.
Kumar and Clark (2005) Diabetes Mellitus (DM)
is a syndrome of Chronic hyperglycaemia due to
relative insulin deficiency, resistance or both It affects

more than 120 million people world wide and it is
estimated that it will affect 220 million by the year
2020. Diabetes is usually irreversible and although
patients can have a reasonably normal lifestyle, its
late complications result in reduced life expectancy.1
Dr.V. Mohan and Dr. Pradeepa (2009), conducted
a Study on Epidemiology of Diabetes in Different
Regions of India. Diabetes is fast becoming the
epidemic of the 21st century. Type 2 diabetes , which is
more prevalent (more than 90% of all diabetes cases),
now affects 5.9% of the world’s adult population with
almost 80% of the total in developing countries.2
Kumar and Clark (2005), Type II diabetes
is relatively common in all population enjoying
affluent life style. The four major determinants for
development of type II diabetes mellitus are increase
in age, obesity, ethnicity and family history.1
DOI Number: 10.5958/0974-9357.2015.00094.X
June, 2015, Vol.7, No. 2 International Journal of Nursing
Education, April-June, 2015, Vol.7, No. 2 155
The World Health Organization (2012) estimates
that nearly 200 million people all over the world
suffer from diabetes and this number is likely to
be doubled by 2030. In India, there are nearly 50
million diabetics, according to the statistics of the
International Diabetes Federation. The people should
be made aware and educated about their health and

fitness level to reduce the number of patients in
India.3
The Management of type 2 diabetes is most
difficult part. Lifestyle modifications like dietary
modifications, physical activity, some major drugs
of diabetes management, insulin therapy, foot care of
diabetes and annual screening. To manage Diabetes
patients need a well planned teaching in all aspects
of diabetic care
NEED FOR THE STUDY
Maria Polikandrioti,Helen Dokoutsidou(2009)
conducted a study on the role of exercise and
nutrition in type 2 diabetes mellitus management.
In their study concluded that the patients with type
2 diabetes should be constantly informed about
the crucial role on nutrition and exercise in the
management of the disease. Lack of understanding of
the beneficial effects of dietary choices and exercise
in the regulation of type 2 diabetes, may lead to
inappropriate treatment methods.4
Helen Altman Klein(2013) conducted a study on
Diabetes Self-Management Education: Miles to Go.
Type 2 diabetes, or non-insulin dependent diabetes
mellitus (NIDDM), accounts for 90 to 95% of all
diagnosed cases of diabetes in adults.
patients experience increased risks of
complications including blindness, kidney damage
and failure, cardiovascular disease, nerve damage,
and lower-limb amputation.5
Grace Lindsay, Kathryn Inverarity ,and Joan

R.S.McDowell (2011) conducted a study on Quality
of life in people with type 2 diabetes in Relation to
Deprivation, Gender ,and age in a new community
based model of care. The study confirms the value
of measuring HRQL for people with diabetes, living
with a chronic long term condition, to identify
changes in status as a mechanism for understanding
wider health issues and developing individualized
strategies to improve care.6
The latest global figures on diabetes, released
by the International Diabetes Federation (IDF), has
raised a serious alarm for India by saying that nearly
52% of Indians aren't aware that they are suffering
from high blood sugar.7
Kerala has a prevalence of diabetes as high as 20%
- double the national average of 8%. The prevalence
was 17% in urban, 10% in the midland, 7% in the
highland, and 4% in the coastal regions .8
These evidence clearly explains the need for
effective education in quality of life among type 2
diabetes and it suggests the need for conducting
this studyThe researcher came across many diabetes
during the time of clinical postings and found
that patients lack in self management of type 2
diabetes.Hence the researcher is interested to take
up this study to find an effective teaching method in
quality of life among type 2 diabetes.
REVIEW OF LITERATURE
Mohan D et al (2003) conducted a study on
Awareness and knowledge of diabetes in Chennai –
the Chennai Urban Rural Epidemioogy study. It was

Concluded that awareness and knowledge regarding
diabetes is still grossly inadequate in India. Massive
diabetes education programs are urgently needed
both in urban and rural India.9
Tang TS, Funnell MM, Oh M.(2012) Lasting
Effects of a 2-Year Diabetes Self-Management Support
Intervention: Outcomes at 1-Year Follow-Up. It was
concluded that participation in an empowerment
based diabetes self management support intervention
may have a positive and enduring effect on self care
behaviours and on metabolic and cardio vascular
health.10
Santhosh Thomas .Vaishali R Mohite(2014) a
Study was conducted to assess the effectiveness of
self instructional module on the knowledge regarding
diabetic diet among diabetic patients. They reported
that self instructional module was effective in
improving knowledge of diabetic patients.11
Pushpalatha K.S (2007) study conducted on
video teaching program of Home care management
of Diabetes. The researcher concluded that early
teaching program to diabetes mellitus promote the
knowledge and alleviate the misconception regarding
to practice of life style behaviors’. Timely to education
will reduce the stress and protect from complications.
12

Vaz N.C et al (2011) conducted study on
prevalence of diabetes mellitus in a rural population
of Goa, India. the study concluded that innovative
community outreach programs are required to create
awareness and for screening and treatment of diabetes
mellitus to curb the growing epidemic of diabetes in
the population.13
Farooq Mohyud Din Chaudhary (2010)et
al conducted study on Evaluation of Lifestyle
Modifications in Diabetic Patients. It was concluded
that Diabetes was more common in female and
middle age people. Healthier lifestyle modifications
were noted more frequently in males, well educated
and those on oral plus insulin medication. 14
STATEMENT OF THE PROBLEM
A study to compare the effectiveness of video
assisted teaching VS self instructional module on
quality of life among type II diabetes in Crescent
hospital, Alathur, Palakkad.
OBJECTIVES:
1. To assess the quality of life among type II
diabetic patients before and after administration
of Video assisted teaching and self instructional
module.
2. To compare the quality of life among type II
diabetic patients before and after administration of
video assisted teaching.
3. To compare the quality of life among type

II diabetic patients before and after
administration of self instructional module.
4. To compare the quality of life among type
2 diabetes after administration of video assisted
teaching and SIM.
5. To associate the quality of life among type II
diabetic patients with their selected demographic
variables in video assisted teaching group and SIM.
HYPOTHESES
H1: There is a significant difference in quality
of life before and after video assisted teaching & self
instructional module.
H2: There is a significant association between post
test quality of life scores of video assisted teaching
with their selected demographic variables.
H3: There is a significant association between post
test quality of life scores of self instructional module
with their selected demographic variables.
OPERATIONAL DEFINITION
Effectiveness: In this study effectiveness refers
to extent to improve the quality of life among
type II diabetes by video assisted teaching or self
instructional module.
VIDEO ASSISTED TEACHING
In the study it is a pre recorded video assisted
teaching of the management of type II diabetes,

which will be projected to the patients using a lap
top.
SELF INSTRUCTIONAL MODULE
In this study it refers to the educational booklet
prepared for type II diabetes regarding their
management.
DEPENDENT VARIABLES: QOL among type II
diabetes.
INDEPENDENT VARIABLES: Video assisted
teaching and self instructional module.
RESEARCH METHODOLOGY
RESEARCH APPROACH: Quantitative research
approach -Quasi experimental subtype approach is
used.
RESEARCH DESIGN: The The research design
selected for this study is quasi experimental design.
SETTING OF THE STUDY: Study was
conducted at Crescent hospital with 300 bed multi
specialty hospital. This hospital has Medical and
Surgical Wards, Which include Diabetic Clinic.
POPULATION: The Population includes patients
who are having type II diabetes in Crescent hospital,
Alathur, Palakkad.
SAMPLE: The samples in this study includes the
in patients and out patients with type II diabetes in
Crescent Hospital.

SAMLE SIZE: Sample size consists of 50type
II diabetes patients. Selected 25 for video assisted
teaching group & 25 for self instructional module
group.
SAMPLING TECHNIQUE: Simple random
sampling technique is used for selecting the sample.
INCLUSION CRITERIA
1. Patients with type II diabetes diagnosed less
than 1 year.
2. Patients known to write and speak Malayalam
and English.
EXCLUSION CRITERIA
1. Patients with documented mental illness and
anxiety disorder.
Data Collection Instrument are:
Section A : Biographic Variables
Section B : Physiological Variables
Section C : QOL For Indian Diabetes Patients

RELIABILITY& VALIDITY
The tool was given two medical experts & six
nursing experts, one statistician and the demographic
data was prepared. The standard Indian diabetic
quality of life tool was used. Final approval was
sought from the guide.
FINDINGS
Table 1: Distribution according to the demographic variables:
S.No Demographic variables SIM VAT Chi-square(table value)
P-value
1 Age
35 -45 years 48% 32% 3.125 0.210(NS)
46 -55 years 40% 36%
>55 years 12% 32%
2 Sex
Male 60% 60% 0 1.000(NS)
Female 40% 40%
3 Marital status
Married 92% 68% 7.567 .056(NS)
Unmarried 0% 12%
Widowed 4% 20%
Divorce 4% 0%
4 History of illness
1 -3 months 40% 24%
4 -6 months 32% 12% 8.673 .034(S)
7 -9 months 12% 48%
10 -12 months 16% 16%

5 Education
Primary & secondary
school 40% 36%
Diploma 16% 28%
Degree 28% 16% 1.8 .615(NS)
Others 16% 20%
6 Employment status
Cooley 12% 24%
Private 36% 52% 6.499 .090(NS)
Government 44% 12%
Others 8% 12%
In the above observation the comparison is significant only
under the category History (0.034<0.05) and no
other category is significant.
Table 2: Comparison of pre test & post test of VAT
S. No Item Mean Standard Deviation t Value
Level of
Significance
1
Blood Glucose
Pre test 142.44 15.149

10.375 0
Post Test 124.2 10.575
2
HbA1c
Pre test 7.27 0.514
2.004 0.056
Post Test 7.1 0.256
3 Urine Glucose
Pre test 0.88 0.4397
4.272 0
Post Test 0.52 0.1
4 SBP
Pre test 138 11.902
0.827 0.417
Post Test 135.6 11.576
5 DBP
Pre test 92 7.071
0.659 0.516
Post Test 90.4 10.198
6 BMI
Pre test 23.56 1.446
2.619 0.015
Post Test 23.16 1.313

7
Waist
circumference
measurement
Pre test 100.88 8.064
1.732 0.096
Post Test 99.88 7.513
8 Score
Pre test 55.84 6.95
-11.195 0
Post Test 75.76 6.54
Observation shows the comparison between pre-test and post-
test all the categories are significant. Since
the significance level is less than 0.05 in all the categories.
Table 3: Comparison of pre & post test values of SIM Group
S. No. Item Mean Standard Deviation t Value Level of
Significance
1 Blood Glucose
Pre test 148.16 14.343
8.959 0
Post Test 130.44 6.893
2 HbA1c
Pre test 7.12 0.726
-1.693 0.103

Post Test 7.28 0.542
3 Urine Glucose
Pre test 1.1 0.40825
4.437 0
Post Test 0.84 0.45
4 SBP
Pre test 128.8 13.638
3.098 0.005
Post Test 124.8 9.626
5 DBP
Pre test 82.8 5.416
1.445 0.161
Post Test 82 5
6 BMI
Pre test 22.36 1.15
3.116 0.005
Post Test 21.88 0.971
7
Waist
circumference
measurement
Pre test 92.52 3.618
0.885 0.385
Post Test 92.96 3.857

8 Score
Pre test 54.4 4.203
-4.746 0
Post Test 66.68 13.524
In the observation given above pre-test and post-test result in
all the categories plays a significant role.
Table 4 : Comparison of post test between two groups
S.NO Physiological Variables SIM VAT
t value Level of significance
Mean Std.Deviation Mean std. Deviation
1 Blood Glucose 130.44 6.893 124.2 10.575 2.472 0.017
2 HbA1c 7.28 0.542 7.1 0.256 1.536 0.131
3 Urine Glucose 0.84 0.45 0.52 0.1 3.471 0.001
4 SBP 124.8 9.626 135.6 11.576 3.587 0.001
5 DBP 82 5 90.4 10.198 3.698 0.001
6 BMI 21.88 0.971 23.16 1.313 3.919 0
7 Waist circumference measurement 92.96 3.857 99.88 7.513
4.097 0
From the above observation comparison of post test given above
the comparison shows SIM is found to be
significant in SBP, DBP, BMI & Waist circumference
measurement, whereas there seems to no significance in

the other items.
Table 5: Comparison of QOL between two groups
S.
No
Item
S I M VAT
Chi Square Level of SignificanceGood Average Poor Good
Average Poor
S I M VAT S I M VAT
1
History of ILLNESS
1 - 3 Months 0.00% 0% 45.50% 0% 50% 19.00%
4.482a 2.679 0.214 0.444
4 - 6 Months 0% 67% 27.30% 0% 0% 14.30%
7 - 9 Months 0% 33.30% 9.00% 0% 50.00% 47.60%
10 - 12 Months 0% 0% 18.20% 0% 0% 19.00%
2
Sex
0%
Male 33.30% 63.60% 0% 50% 61.90%

1.010b 0.198 0.315 0.656
Female 66.70% 36.40% 0% 50% 38.10%
Marital Status
0%
.296a 2.241 0.862 0.326
3 Married 100.00% 90.90% 0% 100.00% 61.90%
Widowed 0% 4.50% 0% 0% 14.30%
Divorce 0% 4.50% 0% 0% 23.80%
The above table shows history of illness during
stipulated period and sex and marital status. The data
do not show a great significant variation between SIM
and VAT.
CONCLUSION
The study shows that the Pre-test mean Score and
Standard Deviation of the type 2 diabetes regarding
video assisted teaching on quality of life was 55.84
and 6.95, which increased in post test 75.76 and 6.54.
pre test mean Score and Standard Deviation of the
type 2 diabetes regarding Self-instructional module
on quality of life was 54.4 and 4.203, which increased
in post test 66.68 and 13.524.
RECOMMENDATION
- The comparative study can be done for the

newly diagnosed diabetes with chronic diabetes
patient
- A similar study can be done in public health
center.
Acknowledgement: I wish to express my
gratitude to Prof. Dr.Prasanna Baby, M.sc(N), Ph.D,
my guide for her Expert guidance. I am thankful to
Dr. Vijaya Ragaven, Director of Research department
& Dr. Gobi Asst. Director of Research department
in Saveetha University, my family for their Positive
interaction.
Conflict of Interest : None
Source of Funding : None
Ethical Clearance: Obtained from Human
institutional Ethical Clearance Commi�ee.
REFERENCE
1. Kumar P and Clark (2005), “Clinical
Medicine”6th Edition, Spain, Elsevier Limited.
Pg1106
2. Dr. Mohan.V and Pradeepa. R. “Epidemiology
of Diabetes In Different Regions of India.Health
Administrator’’ Vol:XXII Number 1&2-2009:1-

18Pg.
3. “50 million people in India have diabetes’’ Wed
Nov 14 2012, h�://www.indianexpress.co
4. Maria Polikandrioti, Helen Dokoutsidou “The
role of exercise and nutrition in type 2 diabetes
mellitus management”Health Science Journal
2009,Volume 3, Issue 4, Pp216-221.
5. Helen Altman Klein, Sarah M. Jackson,Kenley
Street, James C. Whitacre, and Gary Klein
“Diabetes Self-Management Education: Miles
to Go,Nursing Research and Practice”Volume
2013, Article ID 581012, 15 pages.h�p://
dx.doi.org/10.1155/2013/581012.
6. Grace Lindsay, Kathryn Inverarity, and Joan
R.S.McDowell “ Quality of life in people with
type 2 diabetes in Relation to Deprivation,
Gender, and age in a new community based
model of care” Nursing Reseach and practice,
volume 2011, Pp 1– 8.
7. Kounteya Sinha “ 44 lakh Indians don’t know
they are diabetic,Puplic Health Foundation
of India” TNN | Nov 19, 2012.h�://times of
india.indiatimes.com.
8. Kerala – Health Statistics ,Health
status and Public health in Kerala 2011,
www.indushealthplus.com.
9. Mohan D, Raj D, Shanthirani CS, Da�a M,
Unwin NC, Kapur A, Mohan V “Awareness and
knowledge of diabetes in Chennai--the Chennai

Urban Rural Epidemiology Study”(CUPS
14), Journal Assoc physicians,India
2003;51:771-7.
10. Tang TS, Funnell MM, Oh M “Lasting Effects
of a 2-Year Diabetes Self-Management Support
Intervention: Outcomes at 1-Year Follow-Up”
Preventing Chronic Disease, Public Health
Research, Practice and Policy, 2012:9110313.
11. Santhosh Thomas. Vaishali R Mohite
“assess the effectiveness of self instructional
module on the knowledge regarding diabetic diet
among diabetic patients” International Journal
of Science and research(IJSR):ISSN(Online):
2319-7064, Volume3, Issue6, June2014. Pp672.
12. Pushpalatha. K.S Video Teaching
Program of Home Care Management Of
Diabetes’’Nightingale Nursing Times,
December 2007, Pp 41 -44.
13. Vaz N.C, Ferreira A.M, Kulkarani M.S, Vaz
F.S “Prevalence of diabetes mellitus in a rural
population of Goa India”The National Medical
Journal of India.Vol,24.No 1,2011.Pp 16 -18.
14. Farooq Mohyud Din Chaudhary ,Sadia Mohyud
Din Chaudhary, Khalid Masood, Siddique Khan
Qadri “Evaluation of Lifestle Modifications in
Diabetic Patients’’ Nishtar Medical Journal.
Volume, No 1, January –March 2010.
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DOI: 10.1177/1474515115618569
cnu.sagepub.com
E U R O P E A N
SOCIETY OF
CARDIOLOGY ®
Introduction
An aging population and greater survival rates of patients
with acute coronary events have increased the prevalence
of individuals living with established coronary heart dis-
ease (CHD) susceptible to recurrence.1 Evidence suggests
that the disease process can be slowed or reversed through
lifestyle changes.1,2 Despite this, several studies have
reported poor disease-related knowledge in patients with
CHD,3–5 that patients desire more information and support
after discharge from the hospital6–8 and that they often fail
to maintain lifestyle changes.9
European guidelines on cardiovascular disease preven-

tion in clinical practice1 recommend health education
following discharge from the hospital to minimize adverse
events. Patient education can increase knowledge and
enhance behaviour changes10 and improve patients’
What is a good educator? A qualitative
study on the perspective of individuals
with coronary heart disease
Margrét H Svavarsdóttir1,2,3, Arun K Sigurdardottir3
and Aslak Steinsbekk1
Abstract
Background: Patient views are especially important in patient
education, as patient involvement is essential. However, no
empirical research clarifies what knowledge, skills and
competencies are needed for health professionals to competently
serve as a good educator according to the patients themselves.
Aim: To explore what qualities patients with coronary heart
disease perceive in a good educator.
Methods: A qualitative research method, with semi-structured
individual interviews, was used in this study. Purposeful
sampling was used to recruit participants from a general
hospital in Iceland and in Norway. The data were analysed
using
systematic text condensation.
Results: The participants included 17 patients who had been
through a percutaneous coronary intervention and
participated in formal patient education after discharge from
hospital. The patients saw a good educator as one who
they feel is trustworthy and who individualizes the education to
patients’ needs and context and translates general
information to their personal situation in lay language. Building
trust was dependent on the patients’ perceiving the
educator to be knowledgeable and good at connecting with the

individual patient, so that the patients feel they are being
treated as a whole person with equality and respect.
Conclusions: The patients perceived the capability of building
trust and tailoring the education to the individual as
the most prominent characteristics of a good educator. Training
skills that facilitate patients’ trust, being observant of
the patient and his learning needs and adjusting the patient
education to individual needs and situations should be key
objectives in health professionals’ training in patient education.
Keywords
Professional competence, coronary disease, health educators,
patient education as topic, secondary prevention, trust
Date received: 9 August 2015; accepted: 27 October 2015
1 Department of Public Health and General Practice, Norwegian
University of Science and Technology, Trondheim, Norway
2St Olavs Hospital, Trondheim University Hospital, Norway
3School of Health Sciences, University of Akureyri, Iceland
Corresponding author:
Margrét Hrönn Svavarsdóttir, Department of Public Health and
General
Practice, NTNU, Postbox 8905 MTFS, 7491 Trondheim,
Norway.
Email: [email protected]; [email protected]
618569CNU0010.1177/1474515115618569European Journal of
Cardiovascular NursingSvavarsdóttir et al.
research-article2015
Original Article
mailto:[email protected]
mailto:[email protected]

514 European Journal of Cardiovascular Nursing 15(7)
health-related quality of life.11 Educating patients with
CHD and their families is an integral component of sec-
ondary prevention, in which health professionals play a
key role. It is therefore essential that health professionals
have the competence necessary to serve effectively as edu-
cators for patients with CHD. Competence in patient edu-
cation refers to proficient use of communication skills,
such as the provision of information, advice and behaviour
modification methods, to influence the patients’ knowl-
edge, opinions, and health and illness behaviour.12 Yet,
few studies13 have sought to show what competencies are
needed to implement patient education for patients with
CHD.
There is a growing recognition that health professionals
can learn from patients, and the value of patient views is
increasingly being recognized. Patient views are especially
important in patient education, as patient involvement is
essential. The value of utilizing the opinion of patients has
been demonstrated in the development of patient educa-
tional material,14 educational interventions15 and in
some educational programmes the experiences of users are
regarded as equally important as the contributions of the
health professionals.16 Several studies have explored the
educational needs and preferences of patients with CHD6–
8,17 and their disease experiences.18–20 Patients’ views on
what competencies health professionals need to implement
good patient education can help to determine the knowledge
and skills needed to conduct effective education and can be
used to improve health professionals’ competencies in creat-
ing and implementing quality patient education. However,
no empirical research clarifies what competencies a good

educator needs according to the patients themselves.
The aim of this study was to explore what patients with
CHD who have participated in patient education after a
percutaneous coronary intervention (PCI) perceive as a
good educator.
Methods
A qualitative research method with semi-structured face-
to-face individual interviews was used in this study. This is
an appropriate method of data collection when the enquir-
ies relate to personal experience and perceptions21 and is
thus well suited to provide an understanding of the issues
of importance to patients.
Sample and recruitment
The aim was to recruit Icelandic and Norwegian individu-
als with CHD who had undergone PCI less than 24 months
earlier. Participants were required to have received formal
patient education after their hospital stay, to be ⩾ 18 years
of age and to be able to understand the study and study
procedure. There were no further exclusion criteria.
Participants were selected with purposeful sampling, to
ensure variation in age, gender and time since the PCI. To
further increase the variation in the sample, patients from
two countries were invited to participate. To recruit
patients, nurses in one general hospital in Iceland and one
in Norway introduced the study to eligible participants,
handed out invitation letters and enrolled volunteers.
Data collection
The data were collected between June 2014 and May 2015.

The interviews were conducted by the first author at a
location chosen by the participants. The interviews were
audiotaped and transcribed verbatim. The average inter-
view duration was 44 min (range 17–69 min).
To ensure that all participants revealed their view on the
same topic, an interview guide was used. The interview
guide was developed by the first author with the help of a
literature review, own insight and experience with the sub-
ject, and a critical review and discussions with co-authors
and a team of experienced researchers. The main question
in the interviews was: Could you please describe your
experience with patient education after your CHD inci-
dent? The main question was followed up with open ques-
tions about the participants’ experiences with patient
education after the PCI, during and after their hospital stay,
what they perceived as a good educator, what they appreci-
ated the most in educators’ ‘performance’ and what they
perceived as positive and negative aspects of the patient
education they received.
The interview guide was revised after each interview
and adjusted according to the themes that appeared in the
previous interviews. Early in the data sampling, it became
apparent that trust played a large role in the interviews, so
a question about trust in patient education and what
enhanced patient–provider trust was added. Other changes
were minor and related to clarity of wording and sequence
of questions.
Ethical considerations
The participants received written and oral information
about the study, and they were informed that they could
withdraw at any time and that confidentiality was assured.
Written informed consent was obtained from participants

before the interviews were conducted.
The study was conducted in accordance with the
Helsinki declaration22 and was approved by the regional
committee for medical research ethics in Norway
(2014/947) and the ethics committee of Akureyri Hospital
(3/2014) in Iceland.
Analysis
The data were analysed using systematic text condensation
as described by Malterud.23 We began the iterative
Svavarsdóttir et al. 515
four-step process after the first interview by reading the
transcribed interviews to obtain a general impression and
identify preliminary themes. In the second step, we sys-
tematically reviewed the transcriptions line by line, identi-
fied the units of meaning, and classified and sorted them
into themes. In the third step we sorted the units of mean-
ing into subgroups and reduced the content into a distilla-
tion of rephrased quotations, trying to maintain as much as
possible of the original terminology used by the partici-
pants. In the last step, we summarized the contents of each
code group into generalized descriptions and concepts.
Analysis was carried out by the first author and dis-
cussed and negotiated with the co-authors. To avoid pre-
conceptions affecting the reflexivity of the results, we
critically discussed the interpretation of the interviews
between the co-authors and a team of experienced research-
ers. Recruitment and interviewing of participants were
continued until no new themes were found. The analysis

was validated by reviewing the original transcripts of each
interview to make sure that they were reflected in the
results. The Icelandic and Norwegian citations were trans-
lated into English by the first author and validated by co-
authors. The citations that best illustrated the themes were
chosen to illustrate the results. Those are marked with the
participant’s sex, age, whether they underwent a primary
(p-PCI) or elective PCI (e-PCI) and time from the PCI.
Results
Seventeen Icelandic and Norwegian patients with CHD,
eight women and nine men, who had undergone PCI were
interviewed. The average length from the PCI was 6.5
months (1.5–19 months). Their average age was 59 years
(range 47–72) (Table 1).
The findings were categorized into two themes that
sum up the participants’ description of a good educator
(Table 2). Trustworthy reflects the two main factors that
contribute to the patients’ trust in the educator: that the
educator is knowledgeable with professional credibility
and is able to connect with the patients such that the
patients feel treated as whole persons with equality and
respect. The patients also wanted good educators to be
able to individualize education to their individual needs
and context.
Trustworthy
Knowledgeable. To trust the educators and be willing to
follow their advice, the patients said that they needed to
feel that the educators knew what they were talking
about. This included the educator being confident and
competent in explaining and answering questions. It

was also beneficial if the information was congruent
with what other health professionals had told them, and
the patients’ prior knowledge or beliefs were also used
to determine the educator’s reliability. If the patients
suspected information to be based on convenience or
personal opinions rather than scientific knowledge,
they said they tended to lose faith in that educator.
Speaking honestly about the patients’ situation and
admitting a lack of knowledge also seemed to help in
building trust.
What is important in all this is that they just say that they don’t
know. Because, they don’t know. […] Then, you start trusting
them. (Female <60, p-PCI 10 months earlier)
Which profession the educator belonged to was not impor-
tant for most of the patients, but some said that they would
trust cardiologists more as they thought they were more
knowledgeable. Many of the patients said that knowing
that the educator was specialized or worked in cardiac care
made the educator more trustworthy.
I prefer education from a professional, for example a nurse, it
doesn’t have to be a physician, he just needs to be
professionally competent, be a specialist in the area he is
educating about. (Female ⩾60, p-PCI 5 months earlier)
Connects with the individual. Most of the patients said that
having a feeling of a personal connection with the educa-
tors enhanced their trust in them. Expressions used were to
show an interest in them, to listen to them and to consider
the effect of the disease on their whole life and physical
and mental well-being. A private chat, unrelated to their
disease, was seen as an ice-breaker and as part of connect-
ing with the educator.

Table 1. Demographic characteristics of the participants.
Number
Gender
Female 8
Male 9
Age
< 60 9
⩾ 60 8
Nationality
Norwegian 6
Icelandic 11
Education
Elementary school or less 8
Vocational training or high school 6
College or university degree 3
Marital status
Married 14
Widowed or divorced 3
Disease history
Primary PCI 14
Elective PCI 3
PCI: percutaneous coronary intervention.
They said they would be more relaxed and more recep-
tive to information when they felt the educator was present
and had time, was aware of what they had been going
through, and treated them with respect and equality. This
also helped the patients express themselves more freely and
made them more comfortable to discuss and ask questions.

He talked over your head, but she talked with you. They really
didn’t say different things, but she sat down, chatted about
various things and then this [the patient education] came in
between. It was kind of when you chat in your kitchen at
home, you don’t get defensive or nervous. […] But he would
stand at the end of the bed and talk down. […] She didn’t
spend more time in talking to me, but her time was so much
better. […] This was all so natural. It is this relaxed
atmosphere. (Female <60, p-PCI 10 months earlier)
For some of the patients, being seen as a whole person
included the educator seeing the family as a part of the
picture, and they emphasized that the educator should be
aware of the needs of their family or next of kin.
I feel badly about how uneasy this made my family, […] what
they had to go through, they were much more anxious than I
was after the event. It is challenging to take care of the family.
They were welcome to attend the patient education, which is
very good, but they really need something [support], too.
(Female <60, p-PCI 10 months earlier)
In contrast to educators who connected with them as indi-
viduals, some patients described communication with edu-
cators who did not listen to their views or respect their
knowledge but used one-way communication to convince
them to take actions they did not believe in. The patients
said that this resulted in lost faith in those educators and
that they became unreceptive to information from them.
Individualized education
The patients described having various educational needs,
but a common theme for them all was the desire for more

individualization. For example, having a health profes-
sional sit down with them and translate general informa-
tion to their personal situation in lay language. One
example mentioned by several patients was how being
shown graphical descriptions of their own coronary arter-
ies with explanations of what had been done in their PCI
Table 2. Participants’ perceptions of the characteristics of a
good educator.
Trustworthy Individualizes education
Knowledgeable Connects to the individual
Background in cardiology
Specialized in cardiac care.
Clinical experience in cardiac care.
Reliable information
Confident in explaining and answering
questions.
Bases information on scientific knowledge.
Information is congruent with information
from other health professionals.
Information is congruent with the patient’s
prior knowledge.
Sees the whole picture
Sees the patient as an individual.

Considers physical and mental
well-being.
Includes the family.
Is present and has time
Caring and friendly.
Is interested in the patient and
listens.
Shows understanding.
Shows respect and equality
Respects the patients’ views and
wishes.
Makes the patient feel comfortable
to ask and discuss.
Motivates the patient to ask and
discuss.
Is honest.
Invites information that benefits the patient
Directs the patient in his knowledge
seeking.
Tailors the education to individual needs and
context
Translates general information to the
patient’s personal situation.
Explains and answers questions in lay language
Adjusted to the patient’s level of
understanding.
Is clear and concise.
Selects the right time and condition
for education
Invites patient education when the patient

is ready.
Motivates.
Ensures privacy.
Guides the patient
Gives the patient a chance to decide when
he so desires.
Helps in decisions when the patient
desires.
Decides for the patient when so desired.
helped them in understanding. The main topics they
wanted individualized were their treatments and what had
happened, why this had happened to them and how this all
related to their symptoms.
You got some brochures with general information, but what
you really needed was detailed information about what has
been done [in the PCI] to you personally. […] What this all
means for you. (Male <60, p-PCI 7 months earlier)
The topics the patients talked about in the interviews that
they thought health professionals should be prepared to
discuss and educate about are presented in Table 3. Some
said that they did not know what knowledge would benefit
them and were thus unable to ask or request information.
They therefore appreciated it when the educator was aware
of what knowledge would benefit them and could start the
conversation about those issues and direct them in their
knowledge seeking.
Another aspect of individualized education was that an

educator must be capable of selecting the right timing and
place for patient education. Many said they had limited
benefits from the patient education they received during
their hospital stay, as they were not in a state in which they
were ready to receive information and remembered little of
what was said. All of the patients expressed a need for
more patient education after discharge from the hospital,
and many emphasized the need for the repetition of infor-
mation. Some patients gave examples of a lack of privacy
hindering them in asking, sharing or discussing informa-
tion during the hospital stay. Other patients talked about
their experience of having difficulty asking questions in a
group because they did not have the courage to speak out
in public or did not want to appear stupid.
You get a lot of information when you are discharged, but you
just don’t get it all. […] What would be better is an interview
shortly after discharge. […] It is this follow-up that is needed.
(Male <60, p-PCI 7 months earlier)
Most of the patients emphasized the importance of being
in control but expected the educators to guide them in their
choices. However, when realizing that they did not make a
good choice or had failed to follow advice, some of the
patients said that the educator should have tried to per-
suade them otherwise or been stricter. The patients also
gave examples of instances where they felt that the educa-
tor should make decisions for them or take control, for
example, when they felt their condition was too serious, or
when they felt that they did not have sufficient knowledge
to make the decision themselves.
They explained to me how big of a risk factor this is [the
smoking]. […], but they all talked very mildly about this […]
they could have said this in a more determined way, more
harsh. (Male ⩾60, p-PCI 7.5 months earlier)

Discussion
The participants saw a good educator as one who is trust-
worthy and able to individualize the education to the
patients’ needs and context. Building trust was dependent
on the patients’ perceiving the educator to be knowledge-
able and good at connecting with the individual patient by
using communication skills that made the patients feel
seen, heard and respected.
Promoting trust in the patient–educator
relationship
The central finding in this study was that the participants
consider being trustworthy the most essential characteris-
tic of a good educator. To our knowledge, no empirical
study has described the importance of trust in patient edu-
cation or the factors that promote trusting patient–educator
relationships from the patients’ perspective.
However, trust has been described as essential in the
development of the nurse–patient relationship24 and has
been associated with successful lifestyle changes,25 adher-
ence to medication and treatment plans,26 preference for
involvement in medical care27 and perceived control over
the disease.28 It has been stated that promoting trust is a
demonstration of the provider’s ability to show interper-
sonal and technical competence, moral comportment and
vigilance to support positive patient outcomes.29 Thus, in
concordance with the patients’ perspective, knowledge and
competency in skills that facilitate a trusting patient–pro-
vider relationship are important for educators.
There are, nevertheless, some negative aspects of a
trusting patient–provider relationship that the educator

should be aware of. In contrast with our findings, patients’
trust in others has also been associated with patients being
less active and less motivated to improve their health situ-
ation.30 There might also be differences in level of trust
between groups of patients, with studies suggesting that
the elderly and less educated cardiac patients are more
trusting,28 and one study showed that cardiac patients with
less health literacy were more distrusting of their
physician.31
In this study, patients’ perceptions of the educators’
knowledge had a strong influence on their trust in the edu-
cator. Knowledge is a basic competency in patient educa-
tion13 and has been found to be necessary for the
development of a professional relationship and building
trust between health professionals and patients.32–34 In line
with our results, others have found that to be successful in
lifestyle counselling, health professionals need to have
experience and good knowledge of the subject,13,33 give a
credible impression33 and exhibit their competence and
knowledge to the patients.32 This can be the reason why
the patients in this study wanted education from health
professionals that specialized in cardiac care and had
worked with cardiac patients, as they felt these characteris-
tics made educators more knowledgeable and more likely
to have a nuanced understanding of a patient’s situation.
This is also supported by the findings of a previous study
that demonstrated that cardiac patients have a high degree
of trust in their cardiologist,28 and their preferred source of
heart disease information and lifestyle change support was
the cardiac rehabilitation staff.17 Patients’ perspectives are

increasingly being incorporated into learning programmes
and patients are used as educators for other patients.16 The
patients in this study preferred patient education from a
health professional specialized in cardiac care. This indi-
cates that when organizing patient education, health profes-
sionals should take an active part themselves and not, for
example, leave patient education to only lay educators.
The other factor contributing to trustworthiness from
the patients’ perspective was how the educator managed
to connect with the patient and the use of communication
skills that made the patients feel seen, heard and respected.
Educators themselves have also acknowledged that the
capability to connect with patients is a basic competency
in patient education.13 Connecting with the educator was
said to enable free and relaxed expression. This could
help the educator in tailoring the education to individual
needs. Building trust is considered a dynamic process,29
and taking time with the patient and continuity of care is
needed to develop trusting relationships.29,33 Similarly,
our results indicate that continuity of care and repeated
interactions are needed to promote a trusting patient–
educator relationship.
As patients perceive building trust as an essential
characteristic of a good educator, skills that promote trust
should be a key objective in health professionals’ training
in patient education. However, in a systematic review, it
Table 3. The topics that the patients wanted educators to be
prepared to discuss and provide education about.
Topic Quotes
The heart Overview of the heart and the vascular system. […]

understand how the body works, then it will
be easier to change. (M ⩾60, p-PCI 4 months earlier)
The disease He explained the disease to me and then I felt
relived. (M ⩾60, e-PCI 7.5 months earlier)
Cause Why me, what caused this.” (F ⩾60, p-PCI 5.5 months
earlier)
Reflection of the incidence I needed someone to sit down with
me and talk to me about what I had been through. (F <60,
p-PCI 3.5 months earlier)
The PCI To visually see this at the same time he was explaining
[…]. I found it very helpful […] to see
how my coronary arteries were before and after. (M <60, p-PCI
10 months earlier)
Medication I had those two pills, I figured that one of them
must be temporary and stopped taking the one
prescribed later, and then I got a chest pain. (M ⩾60, p-PCI 7
months earlier)
Symptoms It explained a lot for me, why I had so little energy
at work and to walk, and the pain in the
breastbone that had been a mystery to me. (M ⩾60, e-PCI 19
months earlier)
Seriousness Many of them were allowed to drive a car much
earlier than I was, and thus, I just assumed that
this must have been very serious. (M ⩾60, p-PCI 4 months
earlier)
Recovery Some have full recovery, and others don’t. […] What
chances do you have to go back to normal
life […] Will I be able to go back to work? (F ⩾60, p-PCI 5.5

months earlier)
Consequences There should be more information about the
consequences. It is not the end […], you can live
with it, you can have an all right life. (F ⩾60, p-PCI 5.5 months
earlier)
Dos and don’ts You need to know what to be careful with and
what is safe to do. (F ⩾60, p-PCI 5.5 months
earlier)
Recurrence If this will happen again, what then? Maybe it will
be very serious and I will be unable to call for
help. (M ⩾60, p-PCI 10.5 months earlier)
Available treatment To know that if the stent, or whatever this
is, fails and you get another occlusion, then this could
be performed again, meant a lot to me. (M ⩾60, e-PCI 19
months earlier)
Comorbidities That this was not something I was magnifying,
worries or stress, but something that follows the
disease process when you get severely ill. (F <60, p-PCI 10
months earlier)
Stress/emotional reactions Sometimes you need encouragement.
[…] This is a serious disease and it is very helpful to be
able to express yourself and talk about how you feel. (F <60, p-
PCI 9 months earlier)
How to enhance recovery To tell me how important the
physiotherapy is […] Then, I would have made other decisions.
(F
<60, p-PCI 3.5 months earlier)
Available services There are social workers and psychologists,

but people don’t know where to go. It needs to be
included in this education where you can get help. (F ⩾60, p-
PCI 5.5 months earlier)
Risk factors They constantly repeat that you should go out for a
walk. Maybe you are too lazy to go out for a
walk. We need more education about how important this is. (F
⩾60, p-PCI 5.5 months earlier)
M: male; F: female; p-PCI: primary percutaneous coronary
intervention; e-PCI: elective percutaneous coronary
intervention.
was found that efficient interventions to develop skills in
promoting trust are lacking.35 There is thus a need for
developing approaches to efficiently train educators in
the type of skills and knowledge needed to gain the
patients’ …
NRSE 4550 TEMPLATE: MODULE 2: ASSESSMENT 4:
WRITTEN ASSIGNMENT - QUANTITATIVE AND
QUALITATIVE ARTICLE ANALYSIS
Reviewing a Qualitative and Quantitative Research Article
Do not select a meta-analysis or systematic review
Qualitative Research Assignment
Directions: Type your article references in APA format and
answer the following questions in complete sentences about the
article. You do not have to provide in text citations in the

answers. (2 points for grammatical issues) APA Reference (9.5
points) Questions (0.5 points each)
Critiquing Criteria derived from LoBiondo-Wood & Haber,
2010, p. 135-136
Your selected article reference here in APA format:
1. What is the phenomenon of interest and is it clearly stated for
the reader?
2. What is the justification for using a qualitative method?
3. What are the philosophical underpinnings of the research
method?
4. What is the purpose of the study?
5. What is the projected significance of the work to nursing?
6. Is the method used to collect data compatible with the
purpose of the research?
7. Does the researcher describe data collection strategies (i.e.
interview, observation, field notes)?
8. Is protection of human participants addressed?
9. Does the researcher address the credibility, auditability, and
fittingness of the data?

10. Can the reader follow the researcher’s thinking?
11. Does the researcher document the research process?
12. Are the findings applicable outside of the study situation?
13. Are the results meaningful to individuals not involved in the
research?
14. Do the conclusions, implications, and recommendations give
the reader a context in which to use the findings?
15. What are the recommendations for future study?
16. Do the recommendations reflect the findings?
17. How has the researcher made explicit the significance of the
study to nursing theory, research, or practice?
Quantitative Research Assignment
Your selected article reference here in APA format
Critiquing Criteria derived from LoBiondo-Wood & Haber,
2010, p. 178
18. What is the purpose of the study?
19. What quantitative research design is used?

20. Is the type of design used appropriate?
21. Who is the population?
22. Why was this population chosen?
23. Are the concepts of control consistent with the type of
research design chosen?
24. Does the design used seem to reflect consideration of
feasibility issues (cost, time, etc).?
25. What is the theoretical framework used?
26. What is the hypothesis?
27. Does the design used seem to flow from the theoretical
framework, literature review, and hypothesis?
28. What are the threats to internal validity or sources of bias?
29. What are the controls for the threats to internal validity?
30. What are the threats to external validity (generalizability)?
31. What are the controls for the threats to external validity?
32. Is the design linked to the evidence hierarchy?
33. Are the findings applicable outside of the study situation?
34. Do the conclusions, implications, and recommendations give
the reader a context in which to use the findings?
35. What are the recommendations for future study?

36. Do the recommendations reflect the findings?
37. How has the researcher made explicit the significance of the
study to nursing theory, research, or practice?
Last updated: 2/23/2020 © 2020 School of Nursing Ohio
University Page 3 of 3
In this assessment you will find a qualitative AND a
quantitative study article in the library, provide the APA
reference and answer the questions to appraise the research
studies. Please use the template provided below to complete the
assignment. REFERENCES CAN NOT BE OLDER THAN 2015.
PLEASE LIST REFERENCES USED IN APA FORMAT
Objectives
Discuss the place of qualitative and quantitative research in
evidence-based practice.
Explore the parts of a qualitative and a quantitative research
report.
Review of APA formatting
Please note it is important that it is important that you do not
use a meta-analysis or systematic review as you will not be able
to complete the assignment if you choose those types of
research articles. In addition, you should use one article that is
strictly qualitative and one that is quantitative and not one that
has both elements. If used, points will be deducted for that
entire section and there will be no opportunity for resubmission.
You can access CINAHL & other databases through the OU

library. You will use your Ohio ID to gain access. This is the
same log in credential that you use to log into Blackboard.
There are a variety of ways to find and utilize the CINAHL
database. One method includes selecting the "My Library"
feature at the top of the Blackboard screen, and then clicking on
"Database" before typing "CINAHL" into the search bar. After
reading both articles, you will:
This assignment must be submitted on the template provided to
be considered for grading.
Cite each article, and then answer a series of questions about
each
You are asked in question number 3 under the qualitative
research article about the philosophical underpinnings of the
research method--This is simply asking you to discuss the
fundamental, solid foundation of qualitative research.
This assignment must be submitted on the template that is
provided
NO use of systematic review or meta-analysis
Must use one strictly qualitative and one strictly quantitative
article
Must include 2 journal references (the articles used for the
assignment)
NO direct quotes
Answers must be 1-2 well-developed sentences and not one
word or points will be deducted
Journal articles must be 2015-2020
TextBook for class
LoBiondo-Wood & Haber 2018
Nursing Research: Methods and
Critical Appraisal for Evidence
-Based Practice

978-0323431316
Mosby, 2018,
9th edition
NRSE 4550 RUBRIC: MODULE 2: ASSESSMENT 4:
WRITTEN ASSIGNMENT – QUANTITATIVE AND
QUALITATIVE
ARTICLE ANALYSIS (30 pts)
Criteria
Levels of Achievement
Accomplished Needs
Improvement
Not Acceptable
Question 1
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
answer in a complete
sentence
0.25 to 0.25
points

Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 2
answered in
complete
sentence
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sentence
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points
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not in complete
sentence
0 to 0 points
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answer
Question 3
answered in
complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
sentence
0 to 0 points
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answer
Question 4
answered in
complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
sentence
0 to 0 points
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answer
Question 5
answered in
complete
sentence

0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
sentence
0 to 0 points
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answer
Question 6
answered in
complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
sentence
0 to 0 points
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answer

Question 7
answered in
complete
sentence
0.5 to 0.5 points
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sentence
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points
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not in complete
sentence
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answer
Question 8
answered in
complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
sentence

0 to 0 points
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answer
Question 9
answered in
complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
sentence
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answer
Question 10 0.5 to 0.5 points 0.25 to 0.25 0 to 0 points
QUALITATIVE

Criteria
Accomplished Needs
Improvement
Not Acceptable
answered in
complete
sentence
Provided correct
sentence
points
Provided answer
not in complete
sentence
Provided incorrect
answer
Question 11
answered in
complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25

points
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not in complete
sentence
0 to 0 points
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answer
Question 12
answered in
complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 13
answered in
complete
sentence
0.5 to 0.5 points
Provided correct

sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 14
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 15
answered in
complete

sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
sentence
0 to 0 points
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answer
Question 16
answered in
complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
sentence
0 to 0 points
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answer

Question 17
answered in
complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
sentence
0 to 0 points
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answer
Question 18
answered in
complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
sentence

0 to 0 points
Provided incorrect
answer
QUALITATIVE
Criteria
Accomplished Needs
Improvement
Not Acceptable
Question 19
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence

0.25 to 0.25
points
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not in complete
sentence
0 to 0 points
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answer
Question 20
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complete
sentence
0.5 to 0.5 points
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sentence
0.25 to 0.25
points
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not in complete
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0 to 0 points
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answer
Question 21
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complete
sentence
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sentence
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points
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answer
Question 22
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sentence
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sentence
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points
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sentence
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answer
Question 23
answered in

complete
sentence
0.5 to 0.5 points
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sentence
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points
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sentence
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answer
Question 24
answered in
complete
sentence
0.5 to 0.5 points
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sentence
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points
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sentence
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answer
Question 25
answered in
complete
sentence
0.5 to 0.5 points
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sentence
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points
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answer
Question 26
answered in
complete
sentence
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sentence
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points
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not in complete

sentence
0 to 0 points
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answer
Question 27
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
QUALITATIVE

Criteria
Accomplished Needs
Improvement
Not Acceptable
Question 28
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 29
answered in
complete
sentence

0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 30
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 31

answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 32
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points

Provided incorrect
answer
Question 33
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 34
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer

not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 35
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
Question 36
answered in
complete
sentence
0.5 to 0.5 points
Provided correct
sentence

0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
QUALITATIVE
Criteria
Accomplished Needs
Improvement
Not Acceptable
Question 37
answered in
complete
sentence

0.5 to 0.5 points
Provided correct
sentence
0.25 to 0.25
points
Provided answer
not in complete
sentence
0 to 0 points
Provided incorrect
answer
APA Citation and
References
9 to 9.5 points
Citations are made
appropriately;
formatted correctly in
APA style in all
instances; references
page is complete and
correctly formatted
1 to 4 points
Very few citations
are made
appropriately or
citations are not
formatted correctly
in APA style;
references page is

missing several
sources or is not
formatted correctly
0 to 0 points
No citations are
used or no
attempt at APA
style citation was
made; references
page is missing
the majority of
sources and/or is
not formatted
correctly, or is
absent
Professionally
written, no
abbreviations, no
spelling/
grammar errors
0 to 2 points
One point deducted
for each error up to
two points.
A Clean, Well-Lighted Place
BY ERNEST HEMINGWAY

It was very late and everyone had left the cafe except an old
man who sat in the
shadow the leaves of the tree made against the electric light. In
the day time the
street was dusty, but at night the dew settled the dust and the
old man liked to sit
late because he was deaf and now at night it was quiet and he
felt the difference.
The two waiters inside the cafe knew that the old man was a
little drunk, and while
he was a good client they knew that if he became too drunk he
would leave without
paying, so they kept watch on him.
"Last week he tried to commit suicide," one waiter said.
"Why?"
"He was in despair."
"What about?"
"Nothing."
"How do you know it was nothing?"
"He has plenty of money."
They sat together at a table that was close against the wall near
the door of the cafe
and looked at the terrace where the tableswere all empty except
where the old man
sat in the shadow of the leaves of the tree that moved slightly in

the wind. A girl
and a soldier went by in the street. The street light shone on the
brass number on
his collar. The girl wore no head covering and hurried beside
him.
"The guard will pick him up," one waiter said.
"What does it matter if he gets what he's after?"
"He had better get off the street now. The guard will get him.
They went by five
minutes ago."
The old man sitting in the shadow rapped on his saucer with his
glass. The younger
waiter went over to him.
"What do you want?"
The old man looked at him. "Another brandy," he said.
"You'll be drunk," the waiter said. The old man looked at him.
The waiter went
away.
"He'll stay all night," he said to his colleague. "I'm sleepy now.I
never get into bed
before three o'clock. He should have killed himself last week."
The waiter took the brandy bottle and another saucer from
thecounter inside the
cafe and marched out to the old man's table. Heput down the

saucer and poured the
glass full of brandy.
"You should have killed yourself last week," he said to the
deafman. The old man
motioned with his finger. "A little more," hesaid. The waiter
poured on into the
glass so that the brandy slopped over and ran down the stem
into the top saucer of
the pile."Thank you," the old man said. The waiter took the
bottle back inside the
cafe. He sat down at the table with his colleague again.
"He's drunk now," he said.
"He's drunk every night."
"What did he want to kill himself for?"
"How should I know."
"How did he do it?"
"He hung himself with a rope."
"Who cut him down?"
"His niece."
"Why did they do it?"
"Fear for his soul."
"How much money has he got?" "He's got plenty."
"He must be eighty years old."

"Anyway I should say he was eighty."
"I wish he would go home. I never get to bed before three
o'clock.What kind of
hour is that to go to bed?"
"He stays up because he likes it."
"He's lonely. I'm not lonely. I have a wife waiting in bed for
me."
"He had a wife once too."
"A wife would be no good to him now."
"You can't tell. He might be better with a wife."
"His niece looks after him. You said she cut him down."
"I know." "I wouldn't want to be that old. An old man is a nasty
thing."
"Not always. This old man is clean. He drinks without
spilling.Even now, drunk.
Look at him."
"I don't want to look at him. I wish he would go home. He has
no regard for those
who must work."
The old man looked from his glass across the square, then over
at the waiters.

"Another brandy," he said, pointing to his glass. The waiter who
was in a hurry
came over.
"Finished," he said, speaking with that omission of syntax
stupid people employ
when talking to drunken people or foreigners. "Nomore tonight.
Close now."
"Another," said the old man.
"No. Finished." The waiter wiped the edge of the table with a
towel and shook his
head.
The old man stood up, slowly counted the saucers, took a
leathercoin purse from
his pocket and paid for the drinks, leaving half a peseta tip. The
waiter watched him
go down the street, a very oldman walking unsteadily but with
dignity.
"Why didn't you let him stay and drink?" the unhurried waiter
asked. They were
putting up the shutters. "It is not half-past two."
"I want to go home to bed."
"What is an hour?"
"More to me than to him."

"An hour is the same."
"You talk like an old man yourself. He can buy a bottle and
drinkat home."
"It's not the same."
"No, it is not," agreed the waiter with a wife. He did not wish to
be unjust. He was
only in a hurry.
"And you? You have no fear of going home before your usual
hour?"
"Are you trying to insult me?"
"No, hombre, only to make a joke."
"No," the waiter who was in a hurry said, rising from pulling
down the metal
shutters. "I have confidence. I am all confidence."
"You have youth, confidence, and a job," the older waiter
said."You have
everything."
"And what do you lack?"
"Everything but work."
"You have everything I have."
"No. I have never had confidence and I am not young."
"Come on. Stop talking nonsense and lock up."

"I am of those who like to stay late at the cafe," the older
waitersaid.
"With all those who do not want to go to bed. With all those
who need a light for
the night."
"I want to go home and into bed."
"We are of two different kinds," the older waiter said. He was
now dressed to go
home. "It is not only a question of youth and confidence
although those things are
very beautiful. Each night I am reluctant to close up because
there may be some
one who needs the cafe."
"Hombre, there are bodegas open all night long."
"You do not understand. This is a clean and pleasant cafe. It is
well lighted. The
light is very good and also, now, there are shadows of the
leaves."
"Good night," said the younger waiter.
"Good night," the other said. Turning off the electric light he
continued the
conversation with himself, It was the light of course but it is
necessary that the
place be clean and pleasant. You do not want music. Certainly
you do not want
music. Nor can you stand before a bar with dignity although

that is all that
isprovided for these hours. What did he fear? It was not a fear
ordread, It was a
nothing that he knew too well. It was all anothing and a man
was a nothing too. It
was only that and light was all it needed and a certain cleanness
and order. Some
lived init and never felt it but he knew it all was nada y pues
nada y naday pues
nada. Our nada who art in nada, nada be thy name thy kingdom
nada thy will be
nada in nada as it is in nada. Give usthis nada our daily nada
and nada us our nada
as we nada our nadas and nada us not into nada but deliver us
from nada; pues
nada. Hail nothing full of nothing, nothing is with thee. He
smiled and stood before
a bar with a shining steam pressure coffee machine.
"What's yours?" asked the barman.
"Nada."
"Otro loco mas," said the barman and turned away.
"A little cup," said the waiter.
The barman poured it for him.
"The light is very bright and pleasant but the bar is
unpolished,"the waiter said.
The barman looked at him but did not answer. It was too late at
night for
conversation.

"You want another copita?" the barman asked.
"No, thank you," said the waiter and went out. He disliked bars
and bodegas. A
clean, well-lighted cafe was a very different thing. Now,
without thinking further,
he would go home to his room. Hewould lie in the bed and
finally, with daylight,
he would go to sleep. After all, he said to himself, it's probably
only insomnia.
Many must have it.

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