) قالوا سبحانك لا علم لنا إلا ما علمتنا انك أنت العليم الحكيم ( بسم الله الرحمن الرحيم ) قالوا سبحانك لا علم لنا إلا ما علمتنا انك أنت العليم الحكيم ( البقرة 32 صدق الله العظيم

Assistant professor in Medical-surgical Nursing 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 that uses orderly scientific methods to answer 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. 1950s - 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 1970s - 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 1970s.

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 1980s brought Nag research to anew level of development. Increase in the number of qualified nurse researchers.

Historical Evolution Cont… widespread availability of computers for the collection and analysis of information. The National center of 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 1980s (Applied Nursing Research).

Historical Evolution Cont… The 1990s- To continue to develop a scientific base of knowledge for Nursing practice. Studies concerning the effectiveness of clinical Judgments on client outcomes are expected to continue. 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 From 17-25 years 14 58.33 From 25- 39 years 33.33 From 40-50 years 2 8.33 limb amputated Lower limb 11 45.8 Upper limb More than one limb 8.4 marital status Married 13 54.2 Single

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 Primary education or less 10 41.67 Preparatory and Secondary Education 45.83 University or more 3 12.50 100 occupation status Without work 19 79.17 Work 4.17 Student 4 16.67 causes of injury Gun shot Tank shell 8 33.33 shrapnel from a rocket plane 14 58.33 Other

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). Pre test scores 1 334 2 309 3 393 4 369 5 398 6 405 7 380 8 428 9 356 10 351 11 328 12 312 Subject Pre test scores 13 361 14 387 15 340 16 380 17 319 18 348 19 375 20 317 21 306 22 376 23 311 24 432

Responsibility stress Total degree of the stress 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 1266 52.750 5.929 87.92 2 Physiological stress 1203 50.125 7.537 83.54 5 Coping stress 18 1140 47.500 5.437 87.96 1 Emotional stress 1024 42.667 6.445 79.01 6 Total degree of the stress 144 8615 358.958 37.605 83.09

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 Ranks N Mean Rank Sum of Ranks Z Asymp. Sig. 2-tailed sig. level Amputation stress Negative Ranks 24 12.5 300 4.287 0.000 * * Positive Ranks Ties Total Peer stress 4.289 Family stress * * P <0. 01

Responsibility stress Table (4) The differences between pre and post application of program (n=24)ctd Scope Ranks N Mean Rank Sum Of Z Asymp. Sig. (2-tailed) sig. level Responsibility stress Negative Ranks 24 12.5 300 4.295 0.000 * * Positive Ranks Ties Total Physiology stress 4.288 Coping stress 4.289 * * P <0. 01

Total degree of the stress Table (4) The differences between pre and post application of program (n=24) ctd Scope Ranks N Mean Rank Sum Of Z Asymp. Sig. (2-tailed) sig. level Emotional stress Negative Ranks 24 12.5 300 4.288 0.000 * * Positive Ranks Ties Total Total degree of the stress 4.287 * * P <0. 01

Responsibility stress Total degree of the stress Table (5) Means & Std. deviation for pre and immediate post test stress scores (N=24) application No. of items pre application post application scope Mean Std. Deviation 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 52.750 5.929 29.625 4.985 Physiology stress 50.125 7.537 26.708 4.349 Coping stress 18 47.500 5.437 27.542 4.978 Emotional stress 42.667 6.445 21.333 3.046 Total degree of the stress 144 358.958 37.605 184.250 14.423

The research hypothesis was supported. Table (6) Pre & immediate post test stress level scores of the study group subjects (n=24) subject Pre test Post test 1 334 157 2 309 196 3 393 194 4 369 187 5 398 190 6 405 170 7 380 198 8 428 188 9 356 10 351 174 11 328 185 12 312 183 subject Pre test Post test 13 361 198 14 387 193 15 340 169 16 380 199 17 319 188 18 348 165 19 375 180 20 317 174 21 306 147 22 376 23 311 24 432 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. Effect size Amputation stress 4.287 18.382 22.382 0.821 large Peer stress 4.289 18.392 22.392 Family stress 18.377 22.377 Responsibility stress 4.295 18.446 22.446 0.822 Physiology stress 4.288 18.384 22.384 Coping stress Emotional stress 18.390 22.390 Total degree of the stress 18.375 22.375

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 Ranks N Mean Rank Sum of Ranks Z Asymp. Sig. (2-tailed) sig. level Amputation stress Negative Ranks 4 3.5 14 1.753 0.080 not sig. Positive Ranks 1 Ties 19 Total 24 Peer stress 0.447 0.655 2 22 Family stress 1.382 0.167 4.25 17 18

Responsibility stress Table (8) The differences between post and follow-up effect of program after 2 months of application (n=24). Cont’d. Responsibility stress Negative Ranks 1 1.5 0.816 0.414 not sig. Positive Ranks 2 2.25 4.5 Ties 21 Total 24 Physiology stress 1.461 0.144 3 9 20 Coping stress 1.841 0.066 4 2.5 10

Total degree of the stress Table (8) The differences between post and follow-up effect of program after 2 months of application (n=24). Cont’d. Emotional stress Negative Ranks 1.604 0.109 not sig. Positive Ranks 3 2 6 Ties 21 Total 24 Total degree of the stress 7.833 47 1.681 0.093 12 10.333 124 *P <0.05

Table (9) Means & Std. Deviation for immediate post and follow-up tests stress scores (N=24). application No. of items post application follow- up application scope 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 29.625 4.985 5.073 Physiology stress 26.708 4.349 27.292 4.563 Coping stress 18 27.542 4.978 27.875 5.059 Emotional stress 21.333 3.046 21.917 3.243 Total degree of the stress 144 184.250 14.423 186.083 15.410

Responsibility stress 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). Scope Source of variance Sum of Squares df Mean Square F Sig. Sig. level Amputation stress Between Groups 19608.333 2 9804.167 399.422 0.000 * * Within Groups 1693.667 69 24.546 Total 21302.000 71 Peer stress 15129.333 7564.667 209.947 2486.167 36.031 17615.500 Family stress 7132.194 3566.097 107.679 2285.125 33.118 9417.319 Responsibility stress 8449.694 4224.847 147.830 1971.958 28.579 10421.653 * * P <0.01

Total degree of the stress 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 Source of variance Sum of Squares df Mean Square F Sig. Sig. level Physiology stress Between Groups 8560.333 2 4280.167 133.000 0.000 * * Within Groups 2220.542 69 32.182 Total 10780.875 71 Coping stress 6268.694 3134.347 117.629 1838.583 26.646 8107.278 Emotional stress 7088.111 3544.056 173.371 1410.500 20.442 8498.611 Total degree of the stress 483297.028 241648.51 389.835 42771.292 619.874 526068.319 * * P <0.01

follow- up application Responsibility stress 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 application (I) Application (J) Mean Difference (I-J) Sig. sig. level Amputation stress pre application post application 34.583 0.000 * * follow- up application 35.417 0.833 0.844 not sig. Peer stress 30.833 30.667 -0.167 0.995 Family stress 21.458 20.750 -0.708 0.913 Responsibility stress 23.125 22.833 -0.292 0.982 * * P <0.01

follow- up application Total degree of the stress 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 application (I) Application (J) Mean Difference (I-J) Sig. sig. level Physiology stress pre application post application 23.417 0.000 * * follow- up application 22.833 -0.583 0.939 not sig. Coping stress 19.958 19.625 -0.333 0.975 Emotional stress 21.333 20.750 0.905 Total degree of the stress 174.708 172.875 -1.833 0.968 * * P <0.01

Responsibility stress Total degree of the stress 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 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 problem-solving 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

} ولا تيْأَسوا مِن رَوْحِ الله إنّه لا ييْأَسُ مِن رَوْح الله إلا القومُ الكافرون {يوسف 87

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