Effects of the Teach-back Method of Self-care Education on the Pain Intensity and Sleep Quality of Rheumatoid Arthritis Patients

Rheumatoid arthritis is a chronic, inflammatory, and progressive autoimmune disease with variable clinical symptoms, which could also be the main cause of disability, short life, and even death. Pain is the most common symptom of rheumatoid arthritis, which plays a key role in the pattern of sleep and rest, and approximately 80% of patients with rheumatoid arthritis complain of sleep disorders. Among the other influential factors in the sleep pattern are inactivity and medication use. Sleep disturbance could increase pain, fatigue with depression, inflammation, and even disease and symptom deterioration. The patients mostly refer on an outpatient basis and receive routine training. However, the management of chronic diseases requires the empowerment of the patients in terms of disease management, care, and participation in the treatment. Therefore, these patients must receive comprehensive education about the disease, symptoms, and complications (especially the correct methods of self-care) in order to achieve the desired outcomes. Self-care education is an important task of nurses, which promotes healthy behavior. As a result, adult patients learn and take actions to maintain their survival, quality of life, and wellbeing. The feedback-based method is a client-oriented educational approach, which is often preferred over other educational methods. Assessing the proper understanding of the individuals toward the training materials provides feedback to ensure that they have received the training information accurately and completely, which has a significant impact on the quality of self-care and patient satisfaction with the treatment and care. The main complaints of patients with rheumatoid arthritis are pain and sleep disorders, along with daily symptoms, fatigue, drowsiness, depression, mood and cognitive disorders, decreased concentration, and anxiety. Therefore, it is paramount to evaluate the impact of self-care education on the pain management and sleep disorders of these patients. The present study aimed to investigate the effects of feedback-oriented self-care training on the pain intensity and sleep quality of patients with rheumatoid arthritis. We also compared sleep quality and pain intensity before and after the intervention with the assumption that sleep quality would improve and pain intensity would decrease after the intervention.

This study was conducted based on the one-group evaluation of effect with a pretest-posttest design, in which we evaluated the effects of self-care training by the feedback method on the pain intensity and sleep quality of the patients with rheumatoid arthritis referring to the rheumatology clinic of Imam Reza (AS) Hospital in Amol city, Iran. The study was performed during one year (August 2019-July 2020), and 60 patients were selected via continuous sampling within six months (October 2019-April 2020) considering attrition. Four patients were also excluded. The inclusion criteria were rheumatoid arthritis diagnosed by a physician, age of 18-60 years, at least one year of disease history, complaints of pain and poor sleep quality (scores >5), basic literacy, awareness of time and location, ability to understand the Persian language, and no psychological disorders based on medical records. The exclusion criteria were employment in the health system, other chronic diseases (e.g., cardiovascular diseases, asthma, cancer, and mental illnesses), using psychotropic drugs, absence in one training session, and unwillingness or the impossibility of continuing participation. The training was implemented in three sessions using the feedback method. At the pre-training stage and one month post-training, data were collected using the Pittsburgh visual pain scale and sleep quality index, which were completed and compared. Data of 56 patients were analyzed in SPSS version 16 using descriptive statistics, paired t-test, and Wilcoxon test at the significance level of P<0.001.

The mean age of the subjects was 45.04 ± 8.83 years. The majority of the patients (89.3%) were female, married (87.5%), had an undergraduate degree (71.5%), and poor economic status (71.4%). In addition, 32.1% were unemployed, 55.3% were housewives, 58.9% had no history of other diseases, and 64.3% had a history of surgery. Also, 64.3% of the patients had a family history of rheumatoid arthritis, and 35.7% the duration of the disease to be 6-10 years. The highest involvement was with the joints of the upper torso (55.4%), while 76.8% of the patients did not use sleeping pills, 92.9% did not smoke, and 96.4% did not consume alcohol. Before the intervention, the sleep quality of the majority of the patients (96.4%) was poor. After the intervention, the sleep quality of the majority (92.9%) was observed to be favorable, and the sleep quality scores in all the domains were significantly lower after the intervention compared to before the intervention (P<0.001). According to Table 4, pain intensity was high in 58.9% of the subjects before the intervention, and none of the patients had low pain intensity. After the intervention, the majority (67.9%) experienced moderate pain intensity, and high pain intensity was observed in none of the subjects. Furthermore, the mean pain intensity score was significantly lower after the intervention compared to before the intervention (P<0.001).

According to the results, feedback-based training could reduce pain intensity and improve sleep quality in the patients with rheumatoid arthritis. Considering the key role of education in the empowerment of patients with chronic diseases, it is suggested that feedback-based educational approaches be used along with other training methods in order to decrease pain intensity, improve sleep quality, and increase the satisfaction of rheumatoid arthritis patients.