Songklanagarind Journal of Nursing

Vol. 34, Supplement, January - April 2014

129

A pilot study of self-efficacy enhancing education

program on family caregivers competencies in
caring for patients with mild traumatic brain
injury
Erfin Firmawati*, Praneed Songwathana**, Luppana Kitrungrote***
Abstract
Purpose: The number of mild traumatic brain injury (TBI) has increased
as well as the care demands requiring continuing care from family at home. To
reduce the negative consequences and improve outcomes for TBI survivors, effective
educational program must be targeted to family caregivers. This pilot study was
conducted prior to the actual study to evaluate the feasibility of the self-efficacy
enhancing education program on family caregivers competencies in caring
for patients with mild TBI.

Methods: The self-efficacy enhancing education program was developed
based on Banduras self-efficacy concept. This program included exploring
feeling, teaching, watching the media, and demonstration. Three pairs of family
caregivers who cared for mild TBI patients participated in this study. The program
was implemented during hospitalization and subjects were followed-up for two
times by telephone. The family caregivers perceived confidence and performance
in caring for mild TBI patients were measured at different points of time.
Results: After completing the program, three family caregivers showed the
perceived confidence significantly greater than before. In addition, family caregivers
showed high performance and could perform symptoms assessment and management.

Conclusion: The self-efficacy enhancing education program was feasible
to do and apply to increase family caregivers confidence and performance
in caring for patients with mild TBI. However, the program must be further
evaluated and tested for its effectiveness compared to routine care.
Keywords: self-efficacy; education program; family caregivers; mild TBI
* Student, Master of Nursing Science (International Program), Faculty of Nursing, Prince of Songkla
University, Thailand
** Associate Professor, Department of Surgical Nursing, Faculty of Nursing, Prince of Songkla
University, Thailand.
*** Assistant Professor, Department of Surgical Nursing, Faculty of Nursing, Prince of Songkla
University, Thailand.

130 Songklanagarind Journal of Nursing

Vol. 34, Supplement, January - April 2014

Introduction

Traumatic brain injury (TBI) is one of the leading causes of death and
disability in the world. TBI is a contributing factor to one-third (30.5%) of all
injury-related deaths in the United States (US) (Faul, Xu & Wald, 2010). According
to the Health Department of Indonesia (as cited in Ayu, 2010), TBI is the seventh
cause of death in 2007. Moreover, in Yogyakarta, Indonesia, TBI was the second
cause of death with annual mortality rate of 12% (DIY, 2010). Mild TBI had the
highest incidence, which was 70%-90% of all treated brain injuries (Cassidy et
al., 2004). Meanwhile, the case of mild TBI in Yogyakarta, Indonesia in 2007 was
accounted for approximately 60% of all cases (Kurniawan, 2009).

Many people who sustain mild TBI have complaints that include cognitive, physical, and emotional symptoms. The symptoms occur in 38% to 80% of
mild TBI patients (Hall & Chapman, 2005). Common symptoms after mild TBI
are headache, dizziness, fatigue, and memory difficulties (Kurniawan, 2009;
Lundin, De Boussard, Edman & Borg, 2006; Srijumnong, 2010). Symptoms may
occur alone or in combination that emerged immediately or within days after injury
and up to three months. The symptoms occur 59% to 91% in the first month after
injury (Paniak et al., 2002), 45% in two months (Shocker, 2008), 41.8% to 58% in
three months (Dischinger, Ryb, Kufera, & Auman, 2009; Kashluba, Paniak, Blake,
Reynolds, Toller-Lobe, & Nagi, 2004; Lundin et al., 2006), and more than three
months around 21% to 62% (Hou et al., 2011; Roe, Sveen, Alvsaker & BautzHolter, 2009).

Mild TBI is usually not life threatening. Consequently, patients with mild
TBI are treated and released from emergency department without admission, and
receive only medication (Faul et al., 2010). However, the admission criteria for
mild TBI may be different as shown in Indonesia. According to the guideline of
treatment for patients with mild TBI in Indonesia, patients need to be hospitalized
for observation in the hospital for three days (Siswanto & Wahyu, 2012). After the
short period of hospitalization, mild TBI patients still need monitoring. Therefore,
family caregivers carry the primary responsibility to provide care after discharge
from hospital. Family can help prevent the development of mild TBI symptoms
and/or reduce their duration, number and severity (DVA/DoD, 2009) by symptoms
assessment, symptoms management, and follow-up of mild TBI symptom after
provided management. As a result, persistent symptoms and complication of mild
TBI can be prevented. In reality, family caregivers of mild TBI patients often do not
have confidence to provide care after discharge, because they lack adequate know
ledge, skill, and competency (Merwe, 2004). Therefore, nurses as a health educators
should provide education for them to increase their competency, confidence
and performance in caring for mild TBI patients.

Songklanagarind Journal of Nursing

Vol. 34, Supplement, January - April 2014

131

Providing education programs have been reported to increase family caregivers
competencies (Albert, Im, Brenner, Smith & Waxman, 2002). However, the
number of studies is limited. In Indonesia, one study was conducted to evaluate
the effect of health education for family caregivers with moderate and severe TBI
during hospitalization. This study measured knowledge and anxiety. The researcher
found that education program helped to increase the family caregivers knowledge
and reduce anxiety level (Shocker, 2008). Another study from Bandura in 1997
that was conducted in family caregivers with stroke found that providing education
based on self-efficacy could increase family caregivers competencies (Srijumnong,
2010). Recently, self-efficacy enhancing education program on family caregivers
competencies with mild TBI in Indonesia has not been found. Therefore, this study
is proposed to measure the effect of self-efficacy enhancing education program on
family competencies in caring for patients with mild TBI.
Purpose

The purpose of this pilot study was to evaluate the feasibility of the selfefficacy enhancing education program on family caregivers competencies in
caring for patients with mild TBI in Yogyakarta, Indonesia.
Methods

Setting

This study was conducted at the surgical ward of PKU Muhammadiyah
Hospital, Yogyakarta, Indonesia.

Sample

Three family caregivers who met inclusion criteria were recruited. The
inclusion criteria included: age between 17-70 years old, the family has the primary
responsibility in providing care for the patients , the family lives together with the
patients, do not have any history of psychiatric disorder and hearing problem, be
able to communicate in the Indonesian language both verbally and in writing, and
accessability to telephone contact. The inclusion criteria for patient were person
with mild TBI diagnosed by the doctor and age > 17 years old.

Interventions

The self-efficacy enhancing education program was conducted by the
first author in one month. The program was developed based on four sources of
self-efficacy as strategies to enhance family competencies. The program included
inactive mastery experience, vicarious experience, verbal persuasion, and
physiological state (3). The program consisted of two parts including 1) in
hospital, by 1-hour individual education session of exploring the feeling, teaching,
watching media, skill demonstration 2) after discharge, which include telephone
follow up every week for four times.

132 Songklanagarind Journal of Nursing

Vol. 34, Supplement, January - April 2014

Data Collection & instruments

Demographic Data Questionnaire (DDQ). This questionnaire was used to
collect familys demographic data.

Perceived competencies of family caregivers in caring for patient with mild
TBI. There are two domains of questionnaire to determine the family caregivers
competencies in caring for patients with mild TBI. The first questionnaire was the
Perceived Confidence Questionnaire (PCQ) and the second one was the Performance
questionnaire for family caregivers regarding caring for patients with mild TBI
(PQ).

Perceived Confidence Questionnaire (PCQ). This instrument was developed
by the researcher. It was used to measure the family caregivers confidence
regarding care for patients with mild TBI. This questionnaire included family
performance to assess warning signs and symptoms following mild TBI that
occurred in patients, management of warning signs and symptoms following mild
TBI, and evaluation of symptoms. It consisted of 20 items and used 5 items Likert
scale that was scored from 1 to 4; no confidence = 1, low confidence = 2, moderate
confidence = 3, and high confidence = 4. The total perceived confidence score
ranged from 23 to 92. Higher score implied higher level of perceived confidence
of family caregivers.

Performance questionnaire family caregiver regarding caring for patients
with mild TBI (PQ). This instrument was developed by the researcher. It was used
to measure the family caregivers performance regarding care for patient with mild
TBI. This questionnaire included family performance to assess warning signs and
symptoms following mild TBI that occurred in patients, management of warning
signs and symptoms following mild TBI, and evaluation of symptoms. It used
5-point Likert scale that was scored from 1 to 5; never = 1, rarely= 2, sometimes =
3, often = 4, and regular = 5. The performance of symptoms management consisted
of twenty one statements. The total performance score ranged from 19 to 95. The
higher score of performance regarding care for patients with mild TBI indicated
high family caregivers performance.

Ethical consideration

This study was conducted with the intention of protecting the human rights
of all family caregivers. The researcher asked for approval from the Institutional
Review Board (IRB) of the Faculty of Nursing, Prince of Songkla University,
Thailand. All of the family caregivers gave the written or verbal informed consent.
The identity of all family caregivers was coded and the researcher destroyed all of
data collected after completion of the data analysis.

Songklanagarind Journal of Nursing

Vol. 34, Supplement, January - April 2014

133

Results

Demographic characteristics of family caregivers

Generally, family caregivers were different in some characteristics including
age, gender, marital status, and relationship with mild TBI patients (Table 1).

Table 1
Demographic characteristic of family caregivers (N = 3)

Family caregivers competencies in caring for patients with mild TBI

Family caregivers competencies consisted of two domains. There are family
caregivers perceived confidence and family caregivers performance.

Pre-test and post-test family caregivers perceived confidence in caring
for patients with mild TBI

Based on Table 2, all of subjects had improved perceived confidence in
caring for mild TBI patients after receiving self-efficacy enhancing education
program. Both of subject No. I and No. III had the same level of perceived
confidence before and after receiving the program, but their scores were increased.
The result showed that the highest pre-test score was found in subject III (78) and
the lowest score was found in subject I (59). In addition, the range of perceived
confidence was in moderate to high level. The post-test score showed that two
subjects had high score. The highest of perceived confidence was subject III (92).
The subject II and III had high level of perceived confidence (Table 2).

134 Songklanagarind Journal of Nursing

Vol. 34, Supplement, January - April 2014

Table 2
Pre-test and post-test pamily paregivers pompetencies (perceived ponfidence) in
caring for patients with mild TBI

Family caregivers performance in caring for patients with mild TBI
in the first and fourth week after discharge

Table 3 showed that all of family caregivers had high performance in the
first week and the fourth week after discharge from the hospital (Table 3).
Table 3
Comparison of family caregivers competencies (performance) in caring for patients
with mild TBI in the first and fourth week after discharge

Discussion

According to Bandura (Bandura, 1997), self-efficacy is ones self-judgement of personal capabilities to initiate and successfully perform a specified task at
designated level, one expends greater effort, and perseveres in the face of adversity.
Self-efficacy enhancing education program was conducted in one month based on
four sources of self-efficacy. The program used in this study involved exploring
feeling, providing education by teaching, showing pictures, demonstration and redemonstration of some skills.

Based on the result of this pilot study, family caregivers competencies in
caring for patients with mild TBI were increased after receiving self-efficacy enhancing education program. Similar with the previous study, education program
could increase family caregivers competency on caring patient with mild to severe
TBI (Albert et al., 2002). Another study was providing education for family caregivers with stroke by self-efficacy promotion based on self-efficacy from Bandura
(1997). The result showed significant increase of family caregivers competencies
including perceived self-efficacy and outcome expectation (Srijumnong, 2010).

Songklanagarind Journal of Nursing

Vol. 34, Supplement, January - April 2014

135

In this study, the researcher provided booklet to help family caregivers easy
to understand. These processes were conducted based on Banduras self-efficacy
(1997). According to the previous study, the researchers provide booklet/pamphlet
to family caregivers to make family caregivers understand easily (Rivera, Elliot,
Berry & Grant, 2008).

Moreover, the researcher conducted follow up telephone calls after discharge for four times in one month. Follow-up using phone call for three times was
involved in this study. The researcher evaluated the family caregivers progress report. The researcher also asked family caregivers about concern and worries during
providing care, discussed any factors/barriers and provided information to solve
these barriers. Additionally, the researcher provided reinforcement and support.
Therefore, follow-up is one important factor to monitor and help family caregivers
after providing program. Some studies showed that education program following
follow-up provided significant effect on family caregivers competencies (Albert et
al., 2002; Srijumnong, 2010).

However, this study had some limitations. The generalization of the
result from this study may be limited because the number of sample size of family
caregivers was limited. Follow-up call could cause bias in the studys results.
Conclusion

In conclusion, this study was conducted to evaluate the effect of
self-efficacy enhancing education program on family caregivers in caring
for patients with mild TBI. The result showed that self-efficacy enhancing
education program had positive on family caregivers competencies.
Implications

This study gives evidence that self-efficacy enhancing education program
may increase competencies of family caregivers in caring for patients with mild
TBI. This program may be considered by nurses in providing care to family
caregivers to enhance their competencies in caring for mild TBI patients. It may
increase quality of care for mild TBI patients. Further study with larger sample size
is needed to enhance family caregivers competencies.

136 Songklanagarind Journal of Nursing

Vol. 34, Supplement, January - April 2014

References
Albert, S. M., Im, A., Brenner, L., Smith, M., & Waxman, R. (2002). Effect of

a social work liaison program on family caregivers to people with brain

injury. Journal Head Trauma Rehabilitation, 17, 175-189.
Ayu, I. M. (2010). Karakteristik penderita trauma kapitis rawat inap di Rumah

Sakit Haji Medan tahun 2009. Unpublished master thesis, Fakultas Kes

ehatan Masyarakat, Universitas Sumatera Utara.
Bandura, A. (1997). Self-efficacy. The exercise of control. New York: W. H. Freeman.
Cassidy, J. D., Carroll, L. J., Peloso, P.M., Borg, J., von Holst. H., Holm, L., et

al. (2004). Incidence, risk factors and prevention of mild traumatic brain

injury: Results of the WHO Collaborating Centre Task Force on Mild

Traumatic Brain Injury. Journal of Rehabilitation Medicine, 43, 2860.
Department of Veterans Affairs, Department of Defense [DVA/DoD]. (2009). VA/

DoD Clinical Practice Guideline for Management of Concussion/Mild

Traumatic Brain Injury/mTBI (Versions 1.0). Washington, D. C. & United

States Army: MEDCOM.
Dischinger, P. C., Ryb, G. E., Kufera, J. A., & Auman, K. M. (2009). Early pre

dictors ofpost injury syndrome in a population of trauma patients with

mild traumatic brain injury. Journal Trauma, 66(2), 286-96.
DIY. (2010). Sekilas kesehatan Provinsi DIY [Overview of healthcare Province

DIY] Retrieved July, 31 2012 from http://mpu.dinkesjatengprov.go.id/in

dex.php
Faul, M. Xu, L., & Wald, M. M. (2010). Traumatic brain injury in the United

States: Emergency department visits, hospitalization, and deaths 2002
2006. Atlanta, GA, Centers for Disease Control and Prevention, National

Center for Injury Prevention and Control, Retrieved June, 22 2012 from

http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.
Hall, R. C. W., & Chapman, M. J. (2005). Definition, diagnosis, and forensic

implications of postconcussional syndrome. Psychosomatics,46(3), 195-202.
Hou, R., Moss-Morris, R., Peveler, R., Mogg, K., Bradley, B. P., & & Belli, A.,

(2011). When a minor head injury results in enduring symptoms: A pro

spective investigation or risk factors for postconcussional syndrome after

mild traumatic brain injury. Journal Neurology Neurosurgical Psychiatry,

1-7.
Kashluba, S., Paniak, C., Blake, T., Reynolds, S., Toller-Lobe, G., & Nagi, J.,

(2004). A longitudinal, controlled study of patient complaints following

treated mild traumatic brain injury. Archives of Clinical Neuropsychology,

19(6), 805-816.

Songklanagarind Journal of Nursing

Vol. 34, Supplement, January - April 2014

137

Kurniawan, A. (2009). Proporsi trauma kepala akibat kecelakaan lalu lintas di RS

PKU Muhammadiyah Yogyakarta periode 1 Januari 2007-31 Desember

2007. Unpublised bachelor thesis, Fakultas Kedokteran, Universitas Islam

Indonesia, Yogyakarta.
Lannsj, M., Geijerstam, J., Johansson, U., Bring, J., & Borg, J. (2009). Preva

lence and structure of symptoms at 3 months after mild traumatic brain

injury in a national cohort. Brain Injury, 23, 213-219.
Lundin, A., De Boussard, C., Edman, G., & Borg, J. (2006). Symptoms and dis

ability until 3 months after mild TBI. Brain Injury, 20, 799-806.
Merwe, J. M. V. D. (2004). Family needs following adult traumatic brain injury.

Unpublished doctoral dissertation, University of Port Elizabeth.
Paniak, C., Reynolds, S., Phillips, K., Toller-Lohe, G., Meylink, A., & Nagy, J.

(2002), Patient complaints within 1 month of mild traumatic brain injury:

A controlled study. Archives of Clinical Neuropsychology, 17, 319-334.
Rivera, P. A., Elliot, T. R., Berry, J. W., & Grant, J. S., (2008). Problem-solving

training for family caregivers of persons with traumatic brain injuries: A

randomized controlled trial. Archives of Physical Medicine and Rehabili

tation, 89, 931-941.
Roe, C., Sveen, U., Alvsaker, K., & Bautz-Holter, E. (2009). Post concussion

symptoms after mild traumatic brain injury: Influence of demographic

factors and injury severity in a 1-year cohort study. Disability and Reha

bilitation, 31, 1235-1243.
Siswanto, & Wahyu, S. (2012). Pedoman tatalaksana cedera kepala [Guideline for

management of head injury]. Retrieved July, 25 2012 from http://sisclinic.

wordpress.com/2012/04/09/pedoman-tatalaksana-cedera-kepala/.
Shocker, M. (2008). Pengaruh penyuluhan kesehatan terhadap penurunan tingkat

kecemasan keluarga pasien dengan cedera kepala (sedang-berat) di ruang

13 (akut) Rumah Sakit Dr. Saiful Anwar Malang, Unpublished master

thesis, Fakultas Keperawatan, Universitas Brawijaya.
Srijumnong, N. (2010). The effects of a self-efficacy promotion program for

family caregivers of persons with stroke at home. Unpublished master

thesis, Mahidol University.
Yang, C., Tu, Y., Hua, M., & Huang, S. (2007). The association between the

postconcussion symptoms and clinical outcomes for patients with mild

traumatic brain injury. The Journal of Trauma, Injury, Infection, and Critical

Care, 62, 657-663.