Research Methodology Dr Atef Ismail Assistant professor in

Research Methodology Dr. Atef Ismail Assistant professor in Medical-surgical Nursing

INTRODUCTION

Introduction The importance of research in Nursing: Provides the basis for expanding the unique body of scientific knowledge that forms the foundation of nursing practice.

Introduction Cont… Many nurses are engaging in research to help to develop, refine, and extend the scientific base of knowledge fundamental to the practice of nursing this expansion of knowledge is essential for the continued growth of nursing profession.

Introduction Cont… Nurses who base as many of their clinical decisions as possible on scientifically documented information are being professionally accountable to their care and are helping nursing to achieve its own professional identity. The spiraling costs of health care

Introduction Cont… ● Some research findings help to eliminate nursing actions that have no effect on the achievement of desired client outcomes. ● Consumers of nursing research: read reports of studies, typically to keep up to date on information that might be relevant to their practice or to develop new skills. Nurses are increasingly expected to maintain, at a minimum, this level of involvement with research.

Introduction Cont… ● The producers of Nsg Research: Nurses who actively participate in the design and implementation of scientific studies.

Definitions of Nursing Research: - - "Systematic, formal, rigorous process used to gain solutions to problems or to discover and interpret new facts in clinical practice, Nsg education or nursing administration. - The systematic, objective process of analyzing phenomena of importance to nursing.

Systematic inquiry methods to answer that uses orderly scientific question or solve problems. Historical Evolution and future Directions of Nursing Research. The research in nursing began with Florence Nightingale in 1850, who Made detailed, recorded observations about the effects of Nsg actions during the Crimean war.

Historical Evolution Cont… 1900 -1940 Focused mainly On studies related to Nsg education. - 1950 s - An increase in the number of nurses with advanced academic preparation. - The establishment of the "Nursing Research journal“ and the availability of funding to support nursing research skills in faculty.

Historical Evolution Cont… By the 1970 s - the growing number of nurses conducting research studies and the increase in discussions of theoretical issues surrounding nursing research. Three additional journals that focus on nursing research, Advance In Nsg science, Research in nursing and health, and the western journal of Nursing Research – were established in the 1970 s.

Historical Evolution Cont… There was also a change in emphasis in nursing research studies from areas such as teaching, administration, curriculum, recruitment and nurses themselves to the improvement of client or patient care. The 1980 s brought Nag research to anew level of development. Increase in the researchers. number of qualified nurse

Historical Evolution Cont… widespread availability of computers for the collection and analysis The National center of of information. Nursing Research was established in 1986. The center for Research for nursing was created in 1983 by (ANA). An important new journal was also established in the late 1980 s (Applied Nursing Research).

Historical Evolution Cont… 1. The 1990 s- To continue to develop a scientific base of knowledge for Nursing practice. 2. Studies concerning the effectiveness of clinical Judgments on client outcomes are expected to continue. 3. In 2004 the Journal Worldviews on Evidence-Based Nursing begins publication.

Current Topics of Interest to Nurse Researcher. Research concerning the promotion of positive health practices. Research concerning the nursing process or clinical judgments. Research concerning compliance with prescribed programs of treatment. Research concerning groups at risk for specific health problems.

Current Topics of Interest to Nurse Researcher. … Cont Research concerning the description of holistic nursing situation. Research concerning Minority groups: include the identification of cultural beliefs that influence the health care practices of various ethnic groups.

RESULTS

Table (1) Socio-demographic characteristics and medical data of the sample (n=24). gender Frequency Percent Male 16 66. 7 Female 8 33. 3 Total 24 100. 0 Age Frequency Percent From 17 -25 years 14 58. 33 From 25 - 39 years 8 33. 33 From 40 -50 years 2 8. 33 Total 24 100. 0 limb amputated Frequency Percent Lower limb 11 45. 8 Upper limb 11 45. 8 More than one limb 2 8. 4 Total 24 100. 0 marital status Frequency Percent Married 13 54. 2 Single 11 45. 8 Total 24 100. 0

Table (1) Socio-demographic characteristics and medical data of the sample (n=24) Cont’d. residency Frequency Percent Northern Governorate 12 50. 0 Gaza Governorate 11 45. 8 Southern Governorate 1 4. 2 Total 24 100. 0 educational level Frequency Percent Primary education or less 10 41. 67 Preparatory and Secondary Education 11 45. 83 University or more 3 12. 50 Total 24 100 occupation status Frequency Percent Without work 19 79. 17 Work 1 4. 17 Student 4 16. 67 Total 24 100 causes of injury Frequency Percent Gun shot 1 4. 17 Tank shell 8 33. 33 shrapnel from a rocket plane 14 58. 33 Other 1 4. 17 Total 24 100

RESULTS Tables (2 & 3) related to the answer for the first stated research question: What are the different types and levels of psychological stress exhibited by the amputees in Gaza governorates during Gaza war?

Table (2) The pre test stress level scores for the study group subjects (n=24). subject Pre test scores Subject Pre test scores 1 334 13 361 2 309 14 387 3 393 15 340 4 369 16 380 5 398 17 319 6 405 18 348 7 380 19 375 8 428 20 317 9 356 21 306 10 351 22 376 11 328 23 311 12 312 24 432

Table (3) Types and ranks of psychological stress exhibited by the sample (n=24). scope No. of items Sum Mean Std. Deviation % weight rank Amputation stress 25 1548 64. 500 6. 372 86. 00 3 Peer stress 23 1386 57. 750 9. 808 83. 70 4 Family stress 20 1048 43. 667 9. 300 72. 78 7 Responsibility stress 20 1266 52. 750 5. 929 Physiological stress 20 1203 50. 125 7. 537 Coping stress 18 1140 47. 500 5. 437 87. 96 1 Emotional stress 18 1024 42. 667 6. 445 79. 01 6 Total degree of the stress 144 8615 358. 958 37. 605 83. 09 87. 92 83. 54 2 5

RESULTS Tables from 4 -7 & figure 1 are related to the first hypothesis states that: Total & subtotal mean pre-test stress scores of the study group subjects will be higher than those of the post-test stress scores.

Table (4) The differences between pre and post application of program (n=24). Scope Amputation stress Peer stress Family stress * * P <0. 01 Mean Rank Sum of Ranks N Negative Ranks 24 12. 5 300 Positive Ranks 0 0 0 Ties 0 Total 24 Z Asymp. Sig. 2 -tailed 4. 287 0. 000 sig. level ** 4. 289 0. 000 ** 4. 287 0. 000 **

Table (4) The differences between pre and post application of program (n=24)ctd Scope Responsibility stress Physiology stress Coping stress * * P <0. 01 Sum Of Ranks Z Asymp. Sig. (2 -tailed) 4. 295 0. 000 Ranks N Mean Rank Negative Ranks 24 12. 5 300 Positive Ranks 0 0 0 Ties 0 Total 24 sig. level ** 4. 288 0. 000 ** 4. 289 0. 000 **

Table (4) The differences between pre and post application of program (n=24) ctd Scope Emotional stress Total degree of the stress Z Asymp. Sig. (2 tailed) 4. 288 0. 000 Ranks N Negative Ranks 24 12. 5 300 Positive Ranks 0 0 0 Ties 0 Total 24 Negative Ranks 24 12. 5 300 Positive Ranks 0 0 0 Ties 0 Total * * P <0. 01 Sum Of Ranks Mean Rank sig. level ** 4. 287 0. 000 **

Table (5) Means & Std. deviation for pre and immediate post test stress scores (N=24) application scope No. of items pre application post application Std. Devia tion Mean Amputation stress 25 64. 500 6. 372 29. 917 4. 353 Peer stress 23 57. 750 9. 808 26. 917 2. 205 Family stress 20 43. 667 9. 300 22. 208 1. 865 Responsibility stress 20 52. 750 5. 929 29. 625 4. 985 Physiology stress 20 50. 125 7. 537 26. 708 4. 349 Coping stress 18 47. 500 5. 437 27. 542 4. 978 Emotional stress 18 42. 667 6. 445 21. 333 3. 046 Total degree of the stress 144 358. 958 37. 605 184. 250 14. 423

Table (6) Pre & immediate post test stress level scores of the study group subjects (n=24) subject Pre test Post test 1 334 157 13 361 198 2 309 196 14 387 193 3 393 194 15 340 169 4 369 187 16 380 199 5 398 190 17 319 188 6 405 170 18 348 165 7 380 198 19 375 180 8 428 188 20 317 174 9 356 198 21 306 147 10 351 174 22 376 193 11 328 185 23 311 198 12 312 183 24 432 198 The research hypothesis was supported.

Figure (1) illustrates the differences between pre-test and post-test of stress scores for total and subtotal stress scores.

Table (7) Z value and η 2 for every scope of psychological stress. Scope Z Z 2 +4 η 2 Effect size Amputation stress 4. 287 18. 382 22. 382 0. 821 large Peer stress 4. 289 18. 392 22. 392 0. 821 large Family stress 4. 287 18. 377 22. 377 0. 821 large Responsibility stress 4. 295 18. 446 22. 446 0. 822 large Physiology stress 4. 288 18. 384 22. 384 0. 821 large Coping stress 4. 289 18. 392 22. 392 0. 821 large Emotional stress 4. 288 18. 390 22. 390 0. 821 large Total degree of the stress 4. 287 18. 375 22. 375 0. 821 large

RESULTS Tables from 8 -12 & figure 2 are related to the second hypothesis states that: Total & subtotal mean stress scores of the study group subjects after two months will be the same as those of the post-test.

Table (8) The differences between post and follow-up effect of program after 2 months of application (n=24). Scope Amputation stress Peer stress Family stress Sum of Ranks Z Asymp. Sig. (2 tailed) 1. 753 0. 080 Ranks N Mean Rank Negative Ranks 4 3. 5 14 Positive Ranks 1 1 1 Ties 19 Total 24 Negative Ranks 1 1 1 Positive Ranks 1 2 2 Ties 22 Total 24 Negative Ranks 2 2 4 Positive Ranks 4 4. 25 17 Ties 18 Total 24 sig. level not sig. 0. 447 0. 655 not sig. 1. 382 0. 167 not sig.

Table (8) The differences between post and follow-up effect of program after 2 months of application (n=24). Cont’d. Responsibility stress Physiology stress Coping stress Negative Ranks 1 1. 5 Positive Ranks 2 2. 25 4. 5 Ties 21 Total 24 Negative Ranks 1 1 1 Positive Ranks 3 3 9 Ties 20 Total 24 Negative Ranks 0 0 0 Positive Ranks 4 2. 5 10 Ties 20 Total 24 0. 816 0. 414 not sig. 1. 461 0. 144 not sig. 1. 841 0. 066 not sig.

Table (8) The differences between post and follow-up effect of program after 2 months of application (n=24). Cont’d. Emotional stress Total degree of the stress *P <0. 05 Negative Ranks 0 0 0 Positive Ranks 3 2 6 Ties 21 Total 24 Negative Ranks 6 7. 833 47 Positive Ranks 12 10. 333 124 Ties 6 Total 24 1. 604 0. 109 not sig. 1. 681 0. 093 not sig.

Table (9) Means & Std. Deviation for immediate post and follow-up tests stress scores (N=24). application post application No. of items scope follow- up application Mean Std. Deviation Amputation stress 25 29. 917 4. 353 29. 083 3. 752 Peer stress 23 26. 917 2. 205 27. 083 2. 653 Family stress 20 22. 208 1. 865 22. 917 3. 063 Responsibility stress 20 29. 625 4. 985 29. 917 5. 073 Physiology stress 20 26. 708 4. 349 27. 292 4. 563 Coping stress 18 27. 542 4. 978 27. 875 5. 059 Emotional stress 18 21. 333 3. 046 21. 917 3. 243 Total degree of the stress 144 184. 250 14. 423 186. 083 15. 410

Table (10) The differences between pre-test, immediate posttest and follow up test of total and subtotal stress scores among the study group (N=24). Scope Amputation stress Peer stress Family stress Responsibility stress * * P <0. 01 Source of variance Sum of Squares df Mean Square Between Groups 19608. 333 2 9804. 167 Within Groups 1693. 667 69 Total 21302. 000 71 Between Groups 15129. 333 Within Groups F Sig. level 24. 546 399. 422 0. 000 ** 2 7564. 667 209. 947 0. 000 2486. 167 69 36. 031 Total 17615. 500 71 Between Groups 7132. 194 2 3566. 097 Within Groups 2285. 125 69 33. 118 Total 9417. 319 71 Between Groups 8449. 694 2 4224. 847 Within Groups 1971. 958 69 28. 579 Total 10421. 653 71 ** 107. 679 0. 000 ** 147. 830 0. 000 **

Table (10) The differences between pre-test, immediate post-test and follow up test of total and subtotal stress scores among the study group (N=24). Cont’d. Scope Physiology stress Coping stress Emotional stress Total degree of the stress * * P <0. 01 Source of variance Sum of Squares df Mean Square F Sig. Between Groups 8560. 333 2 4280. 167 133. 000 0. 000 Within Groups 2220. 542 69 32. 182 Total 10780. 875 71 Between Groups 6268. 694 2 3134. 347 Within Groups 1838. 583 69 26. 646 Total 8107. 278 71 Between Groups 7088. 111 2 3544. 056 Within Groups 1410. 500 69 20. 442 Total 8498. 611 71 Between Groups 483297. 028 2 241648. 51 Within Groups 42771. 292 69 619. 874 Total 526068. 319 71 Sig. level ** 117. 629 0. 000 ** 173. 371 0. 000 ** 389. 835 0. 000 **

Table (11) Scheffe post test Matrix To identify the direction of differences between pre-test, immediate post-test and follow up test of total and subtotal stress scores (N=24). Dependent Variable Amputation stress Peer stress Family stress Responsibility stress * * P <0. 01 application (I) Application (J) Mean Difference (IJ) pre application post application 34. 583 0. 000 ** pre application follow- up application 35. 417 0. 000 ** post application follow- up application 0. 833 0. 844 not sig. pre application post application 30. 833 0. 000 ** pre application follow- up application 30. 667 0. 000 ** post application follow- up application -0. 167 0. 995 not sig. pre application post application 21. 458 0. 000 ** pre application follow- up application 20. 750 0. 000 ** post application follow- up application -0. 708 0. 913 not sig. pre application post application 23. 125 0. 000 ** pre application follow- up application 22. 833 0. 000 ** post application follow- up application -0. 292 0. 982 not sig. Sig. sig. level

Table (11) Scheffe post test Matrix To identify the direction of differences between pre-test, immediate post-test and follow up test of total and subtotal stress scores (N=24). Cont’d. Dependent Variable Physiology stress Coping stress Emotional stress Total degree of the stress * * P <0. 01 application (I) Application (J) Mean Difference (IJ) pre application post application 23. 417 0. 000 ** pre application follow- up application 22. 833 0. 000 ** post application follow- up application -0. 583 0. 939 not sig. pre application post application 19. 958 0. 000 ** pre application follow- up application 19. 625 0. 000 ** post application follow- up application -0. 333 0. 975 not sig. pre application post application 21. 333 0. 000 ** pre application follow- up application 20. 750 0. 000 ** post application follow- up application -0. 583 0. 905 not sig. pre application post application 174. 708 0. 000 ** pre application follow- up application 172. 875 0. 000 ** post application follow- up application -1. 833 0. 968 not sig. Sig. sig. level

Table (12) Compression between Means & Std. Deviation for pre, immediate post and follow-up tests of total & subtotal stress scores (N=24). application pre test Immediate post test follow- up test scope Mean Std. Deviation Amputation stress 64. 500 6. 372 29. 917 4. 353 29. 083 3. 752 Peer stress 57. 750 9. 808 26. 917 2. 205 27. 083 2. 653 Family stress 43. 667 9. 300 22. 208 1. 865 22. 917 3. 063 Responsibility stress 52. 750 5. 929 29. 625 4. 985 29. 917 5. 073 Physiology stress 50. 125 7. 537 26. 708 4. 349 27. 292 4. 563 Coping stress 47. 500 5. 437 27. 542 4. 978 27. 875 5. 059 Emotional stress 42. 667 6. 445 21. 333 3. 046 21. 917 3. 243 Total degree of the stress 358. 958 37. 605 184. 250 14. 423 186. 083 15. 410

Figure (2) illustrates the differences between pre-test, immediate post -test and follow up test (after 2 months) of stress levels for total and subtotal stress scores.

The second research hypothesis was supported. The result revealed that there was no statistically significant difference among age, gender, limb amputation, marital status, residency, level of education, occupational status and levels of psychological stress of the amputees in Gaza governorates during Gaza war in pre-post and follow up tests.

CONCLUSION

Conclusion Based on the result of present study, it can be concluded that: The amputees exhibited high stress scores and they had challenges on many levels; the most frequent types of stresses exhibited by them were Coping stress, Responsibility stress, Physiology stress, Amputation stress Peer stress, Emotional stress and Family stress. The training counseling program had a positive effect in reducing the level of physiological stress among the amputees. And group counseling based on Rational Emotive Behavior Therapy was found to be effective in changing the subject’s belief irrational to a rational belief system.

Conclusion … Cont The result of sessions' evaluation form analysis revealed that; the session about the development of the scientific problem solving approach in different situations occupied the first rank and the amputees benefit from instruction in effective problemsolving skills.

RECOMMENDATIONS

Recommendations According to the results of the current study, the following recommendations are suggested: For amputees: Teaching the amputee to examine and modify his or her irrational perceptions and beliefs to minimize the misconceptions and self-defeating outlook on life and to maximize coping skills and a more realistic philosophy of life.

Recommendations …Cont Skills training include teaching amputees to control their emotions, and get rid of negative emotions and teaching them the problem-solving skills for the prevention of irrational ideas to reduce their level of stress. Realism in dealing with stressful situations that the amputee understands his real capabilities and potential in order not to expose himself to the feeling of helplessness and failure and disappointment.

Recommendations …Cont Encouraging amputees to participate in group teaching stress management activities. To re-apply the training counseling program used in this study to the rest of the wounded amputees in Palestine.

Recommendations …Cont For institutions that provide rehabilitation services for amputees: Give more attention to Group counseling of amputees for its importance in early detection of mental and emotional problems. Provide female counselor for amputated women who expressed their belief that they would feel more at ease working with a woman.

Recommendations …Cont Need to prepare leaflets and brochures according to the Rational Emotive Behavior theory to guide and help amputees of rational thinking. Conducting workshops in the field of psychological counseling in order to gain access to certain criteria to help alleviate the stress effects of amputees.

Recommendations …Cont For research: - further studies be undertaken in understanding the scope and impact of amputation within the Palestine context as no data on this could be found. to expand this research in the other settings in Palestine. More research is needed of psychological stress correlates the battle and non-battle amputees.

Recommendations …Cont further study on the associations between problem solving and psychosocial outcomes and coping with difficulties and challenges in order to facilitate adaptation and prevent problems in psychosocial functions among wounded amputees. Replicate the study in other settings with a larger and probability sample

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