Quantitative Research to
Develop Knowledge in Nursing
1
Quantitative Research
• Traditional Approach Used In Science
• Reality Exists and Can be Quantified
• The Researcher is Independent from
Those Being Researched
• Objectivity is Sought
• Phenomena Can be
Measured in the
Real World
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Research Reports
3
Main Sections of the Research
Report (Published or Posters)
• Abstract (written after the study is completed)
• Overview of the purpose of the study,
research question, design, sample,
setting, data collection, data analysis,
findings and implications
• The abstract should allow the reader to
make a decision about whether the
research is of interest to them.
4
Research Report
• Introduction (not labeled as such)
• Introduction to the Study
• Need for the Study
• Support from the Literature
• Purpose of the Study or Research
Question
5
Research Report
• Review of the Literature
• Theoretical and Research
• Methodology
• Design of the Study
• Sample, inclusion/exclusion criteria,
sample size, gender, and age range
• Protection of participants
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Research Report
• Methodology (continued)
• Setting for Data Collection
• Definition of Terms – Theoretical and
Operational Definitions
• Description of the instrument(s) being
used
• Steps in Data Collection Process
• Plan for Data Analysis
7
Research Report
• Research Findings
• Statistical analysis
• Discussion
• Findings described in words
• Limitations of the Study
• Implications
• What do we do with the findings?
• References
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Style of Research Journal Articles
Often difficult to glean the “story” being
told because of:
• Compactness—page constraints
• Jargon
• Objectivity, impersonality (scientific
writing)
• Statistical information
9
Tips on Digesting
Research Reports
• Read regularly, get used to style
• Read copied articles—underline, highlight, write
notes
• Read slowly
• Look up technical terms
• Don’t be intimidated by statistics—grasp gist of
story
• You will be comfortable reading and
understanding research after taking NU 512 and
Nu 514
10
Quantitative Research
• Instruments Are Used To Collect Data
• Large Sample Size
• 30 Participants per
Concept/Variable
• Statistical Analysis
and Interpretation
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Locating Reliable and
Valid Instruments
• See What Nurse
Researchers Are
Using in their
Published Studies
• Check Reported
Alpha Coefficient
(0.80 or better)
• Search the Internet
for Instruments
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Instruments
• Instrument should be congruent with the
theoretical perspective being used
• Easy to read and complete by the participant
• Concise, yet reliable
• Search CINAHL for instruments often used to
measure concepts of interest
• Review Cronbach Alpha’s – in similar samples
• Obtain permission to use and scoring
instructions
13
Sampling of Instruments Used
in Nursing Research
• M.S. Self-Efficacy Scale
• Herth Hope Index
• Jalowiec Coping Scale
• Performance Scales
• Sense of Belonging Instrument
• Mishel Uncertainty in Illness Scale
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Common Designs for
Quantitative
Research
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Descriptive Study
• Used to Describe Phenomenon of Concern to
Nursing Practice
• Question: What types of coping strategies are
used by men with MS?
• Question: What is the level of
hope in mothers with AIDS?
STATS: Mean Scores
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Comparative Descriptive Study
Examines differences between 2 or more natural
groups
• Is There a Difference in
the Level of SelfEfficacy Between Men
and Women Starting
Cardiac Rehabilitation?
STATS: Independent t-Test
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Comparative Descriptive
Study
• Is There a Difference in
Coping Between Men
with RRMS and those
with Progressive Forms of MS?
Is There a Difference
in Fatigue Between Women
with RRMS and those with
Progressive Forms of MS?
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Correlational Study Design
• Examines relationships
between variables
• Question: Is there a
relationship between
social support and hope
in older women following
CABG surgery?
STATS: Pearson’s Correlation
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Additional Common Designs in
Nursing Research
• Comparison of three or more groups
(ANOVA) is used to analyze the data
• Psychometric Testing of Instruments
• Meta-analysis
• Critical Review of the Literature
• Multiple Regression
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Multiple Regression Study to Determine
Risk Factors for Recurrent UTI in Young Women
Independent
◼
◼
◼
◼
◼
◼
◼
Demographics
Medical History
Contraceptive History
Sexual History
Voiding Patterns
Fluid Consumption
Hot Tub Use
Dependent
◼
Recurrent Urinary Tract
Infection
Scholes, Hooton, Roberts & Stapleton (2000)
21
Research Findings Using
Multiple Regression
Significant Predictors of Recurrent UTI
Independent
◼
◼
◼
◼
◼
Intercourse Frequency
Spermicide Use
New Partner
Age at first UTI
UTI History of Mother
Dependent
◼
Recurrent Urinary Tract
Infection
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Research Designs, Selecting Instruments
and Data Collection
The Research Design
• Overall plan for answering the research
question
• Spells out the basic strategies that
researchers adopt to develop evidence that
is accurate and interpretable
• There are dozens of research designs
Intervention or Not?
• Some studies test the effect of a specific
intervention (e.g. a program to promote
breast self-exam) – experimental studies
– The researchers plays an active role by
introducing the intervention
• Other studies are non-experimental
– The researcher observes phenomena as they
naturally occur without intervening
Types of Comparison Possible
• Comparisons between two or more groups
• Comparison of a group’s status at multiple
points in time
• Comparison of a group’s status under
different circumstances
– e.g. HR during two different types of exercise
• Comparison with outcomes in other studies
– Meta-analysis
Control
• Imposing of rules by the researcher to
decrease the possibility of error and
increase the probability that the study’s
findings are an accurate reflection of reality
Controlling Extraneous Variables
Controlling external, situational factorsconstancy of conditions
•
•
•
•
Constancy of the environment
Constancy of treatment conditions
Constancy of time
Constancy of communications to subjects
Controlling Intrinsic Participant
Characteristics
•
•
•
•
•
Randomization
Repeated measures
Homogeneity of the sample
Matched group for comparison
Statistical control
Validity
• A measure of truth or accuracy of a claim:
an important concern throughout the
research process
Threats to Internal Validity
•
•
•
•
•
History - concurrent events
Selection bias - groups not equivalent
Maturation - result of time
Testing – effect of pre on post-test
Instrumentation – choice of
measurement of variable
• Mortality – loss of participants
Accessible vs. Target Population
vs. Sample
•Accessible population:
The population available for a particular study
•Target population:
The total group of people in whom a researcher is
interested and to whom results could be generalized
•Sample:
Subset of the population invited to participate in the
study
Threats to External Validity
(Generalizability of the Findings)
• Inadequate sampling
• Expectancy effects (behave a certain way due
to being in the study – Hawthorne effect)
•
•
•
•
Novelty effects (new treatment alters behavior)
Interaction of history and treatment effects
Experimenter effects (response to researcher)
Measurement effects (response to data coll.)
Timing of Data Collection
• Number of data collection points to address
the research question
• When should data be collected?
• Single data collection - cross sectional
– Economical, but weaker design
• Multiple data collection - longitudinal
– Cost in time and money, but better design
– Prospective studies - excellent design
Research Sites and Settings
• One site or multiple sites?
• Setting for data collection
–
–
–
–
–
Quiet?
Unrushed?
Anxiety-provoking?
Foreign to the participant?
Privacy?
Communication with Participants
• How much of the specific aims of the study
should be revealed to the participant?
• How will information be provided? Orally
or in writing?
• Reading and comprehension level of
participants?
• Who will provide info to the participants?
• Debriefing session following participation?
Common Research Designs
Descriptive Design
• Most commonly used design
• Descriptive – one group
• Comparative descriptive – two or more
groups
• Time dimensional designs
– longitudinal designs
– cross-sectional
– case study and survey
Correlational Design
• Explanatory level of knowledge
development
• Examines the relationship between two or
more variables (concepts)
• Usually needs a larger sample to determine
if a significant relationship exists
• Ballpark number – 30 participants per
variable in the study
Quasi-Experimental Designs
• The purpose of a quasi-experimental design
is to examine causality
• Involves manipulation (intervention), but no
control group for comparison
• One group post-test only design
• One group pre-test post-test design
• Untreated control group design with pre-test
and post-test
Quasi-Experimental Designs
• Nonequivalent control group pretestposttest design (quasi-experimental)
O1
X
O2
O1
O2
• One group pretest-posttest design (preexperimental)
O1
X
O2
Experimental Design
Characteristics of True
Experiments
• Manipulation—researcher does
something to some subjects
(intervenes)
• Control—researcher introduces
controls, including a control group
• Randomization—researcher assigns
subjects to groups at random
The Control Condition
•
•
•
•
•
An alternative intervention
A placebo
Standard methods of care
Different doses or intensities of treatment
Delayed treatment
Randomization
• Every participant has an equal chance of
being assigned to any group
• Flip of a coin
• Draw names out of a hat
• When using rolling enrollment, the first
participant is assigned to group 1, the second
participant to group 2, the third to group1,
the fourth to group 2, etc.
Symbolic Representation of a
Pretest-Posttest Experimental Design
Intervention: R
Control:
R
O1
O1
X
• R = Randomization
• O = An observation or measurement
• X = An intervention
O2
O2
Continuum of Designs for
Inferring Causality
• Strongest
Weakest
• _|________|________|_______|______|________|______|__
•
•
True
QuasiPrePath
Prospective Retrospective DescripExperiment Experiment Experiment Analytic Correlational Correlational tive
Methodological Designs
• Instrument development and testing
• The average length of researcher time
required to develop a research instrument to
the point appropriate to use in a study is 5
years.
Instruments for Quantitative Studies
Instruments
• Instrument should be congruent with the theoretical
perspective being used
• Easy to read and complete by the participant
• Concise, yet reliable
• Search CINAHL for instruments often used to
measure concepts of interest
• Review Cronbach Alpha’s – in similar samples. A
good instrument will have a Cronbach Alpha of .80
or more, indicating it is a reliable measure.
• Obtain permission to use and scoring instructions
Populations and samples
Populations and Samples
Population
Complete set of persons or objects that possess some common
characteristic that is of interest to the researcher
Can be broad or narrow
May not be human subjects
Target population
The entire group of people or objects to which the researcher wishes to
generalize the findings of a study. Meets the designated set of criteria of
interest of the researcher
Accessible population
Group of people or objects that is available to the researcher for a
particular study
Researchers usually sample from the accessible population
and hope to generalize to the target population
Populations and Samples
Samples
Subset of the population that is selected to represent the
population
Samples vary in quality – the overriding consideration
when critiquing a sample is its representativeness
A representative sample is one whose key characteristics
closely approximate those of the population
What is the risk of a non-representative sample?
Samples
Probability sampling
Use of random sampling procedures to select a sample
from the population
Often used in quantitative research
Includes simple, stratified, cluster, and systematic
random sampling techniques
Non probability sampling
The sample is selected from elements or members of a
population through non random methods
Often used in qualitative research
Includes convenience, quota, and purposive
Probability sampling
Random selection – each study subject or object has an
equal chance of being placed into any one of the study
groups.
Random assignment – subjects are randomly placed in
a control or treatment group.
Types
Simple
Stratified
Cluster
Systematic
Types of probability sampling
Simple random sampling
Ensures that each element of the population has an equal
chance of being chosen.
Stratified
Sample is selected after the population has been divided into
subgroups according to some variable of importance to the
research study
Cluster
Selecting groups rather than individual people from the
population
Systematic
Every xth element or member of the population is selected.
Non probability sampling
Convenience
Choosing the most readily available people or objects for
a study
Snowball sampling – study subjects assist in obtaining
other potential subjects
Quota
The researcher selects the sample to reflect certain
characteristics of the population
Purposive
Uses personal judgment to select subjects who are
considered to be representative of the population
Study designs
Longitudinal
Follows subjects over a period of time in the future
Cohort – special type of longitudinal study in which
subjects are studied who have been born during one
particular period or who have similar backgrounds
Data is gathered from the same subjects several times to
determine changes associated with the passage of time
Cross sectional
Examines subjects at one point in time
How to determine sample size?
No simple rules exist for determining the ‘correct’
sample size.
Some factors to consider are:
Homogeneity of the population
Degree of precision desired by the researcher
Type of sampling used
Sampling error and bias
Sampling error
Difference between data obtained from a random
sample and the data that would be obtained if an entire
population were measured.
Sampling bias
Samples are not carefully selected.
All non probability samples are subject to bias
Critiquing the sampling procedures
Is the target population identified?
Is the accessible population identified?
What sampling method was used?
Is the method described?
Is the method appropriate for the study?
Are demographic characteristics presented?
Is the sample size adequate?
Is the sample representative of the population?
Are sampling biases identified?
Is subject dropout discussed?
330
Journal of Neuroscience Nursing
The Effect of a Creative Art Program on
Self-Esteem, Hope, Perceived Social Support,
and Self-Efficacy in Individuals With
Multiple Sclerosis: A Pilot Study
Cira Fraser, Michelle Keating
ABSTRACT
Background: Creative art has been found to be beneficial to some patients with chronic illness. Little is
understood about how creative art can benefit individuals living with multiple sclerosis (MS). Objectives:
The purpose of the pilot study was to determine if there was a difference in self-esteem, hope, perceived
social support, and self-efficacy in individuals with MS after a 4-week creative art program. Methods: A
one-group, pretest/posttest design was used. The convenience sample of 14 individuals was recruited
from MS Centers and the National MS Society. They ranged in age from 29 to 70 years (M = 51.3 years,
SD = 12.5 years). Participants included 14 women. The creative art program included week 1-watercolor,
week 2-collage making, week 3-beading, and week 4-knitting. Each of the four weekly sessions was
facilitated by a registered nurse with expertise in MS and lasted 2 hours. Creative artists instructed
participants and provided a hands-on experience for each of the creative projects. Participants were
free to share thoughts, experiences, and words of support and encouragement during each session. The
variables were measured before starting the creative art program and after the final session. The instruments
included the Rosenberg Self-Esteem Scale, the Herth Hope Index, the Modified Social Support Survey, the
MS Self-Efficacy Scale, and a sociodemographic questionnaire. The Statistical Package for the Social Sciences
Version 16.0 was used to analyze the data. Results: There was a significant increase in all variables after
the creative art program as follows: self-esteem (t = j3.05, p = 009), hope (t = j3.96, p = .002), social
support (t = j2.21, p = .046), self-efficacy to function with MS (t = j2.68, p = .019), and self-efficacy
to control MS (t = 3.22, p = .007). The power analysis revealed a large effect size for hope (d = 1.06),
self-esteem (d = 0.82), and self-efficacy (control; d = 0.86). A medium effect size was found for self-efficacy
(function; d = 0.72) and social support (d = 0.59). Conclusions: The creative art program was found to be
effective and had a positive influence on self-esteem, hope, social support, and self-efficacy to function and
control MS. Creative art has the potential to enhance the lives of those living with MS and should be
investigated with a larger sample of participants.
Keywords: creative art, hope, multiple sclerosis, perceived social support, self-efficacy, self-esteem
I
nterventions that involve creativity offer nurses a
new perspective on caring for patients. When patients engage in creative activity, the process is
thought to create hope and help them manage debilitating problems. The most remarkable aspect of using art
for healing is the simplicity of the process. Art is naturally healing, and creative arts have been found to be
successful in healthcare settings (Lane, 2005). Engagement in creative art contributes to a sense of self-esteem,
Questions orcomments about this article may be directed to Cira Fraser,
PhD RN ACNS-BC, at cirafraser@si.rr.com. She is a Professor and
Graduate Faculty, Marjorie K. Unterberg School of Nursing and
Health Studies, Monmouth University, West Long Branch, NJ.
Michelle Keating, RN OCN MSCN, is Cancer Nurse Educator,
David C. Pratt Cancer Center, St. Louis, MO.
The authors declare no conflicts of interest.
Copyright B 2014 American Association of Neuroscience Nurses
DOI: 10.1097/JNN.0000000000000094
hope, and social integration (Kennett, 2000). The potential health benefits of creative activity include growth in
self-confidence, sense of achievement, some control of
negative thoughts and feelings of stress, and the development of physical and cognitive skills (Griffiths, 2008).
Multiple sclerosis (MS) is a chronic illness that most
often affects women (Compston & Wekerle, 2006).
Lesions in MS may occur in the brain, spinal cord, and
optic nerves, and the course of MS is highly variable
(Miller, 2001). The disability of MS may include problems with fatigue, mobility, spasticity, bladder/bowel
function, sexual function, cognition, hand function, vision,
sensation, mood, speech and communication, swallowing, pain, and vertigo (Schwartz, Vollmer, Lee, & North
American Research Consortium on Multiple Sclerosis
Outcomes Study Group, 1999; Sharrack & Hughs,
1999). Persons with MS face a multitude of physical,
mental, and emotional challenges on a daily basis that
affect all aspects of their lives.
Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 46
Several recent studies have investigated psychosocial issues in MS. Fraser and Mahoney (2010) found
that, in a sample of 450 women with MS, there was a
significant inverse relationship between level of disability and self-esteem (r = j.38), hope (r = j.29), selfefficacy (function; r = j.71), and self-efficacy (control;
r = j.67). The investigators state that interventions to
improve self-esteem, hope, and self-efficacy may be
beneficial to women with MS. Strategies to enhance
self-esteem include encouraging individuals with MS
to join self-help groups and to participate in programs
and activities. Strategies to enhance self-efficacy include
reinforcing positive behaviors, providing praise, and
helping individuals to attain goals. Hope interventions
include fostering a sense of connectedness with others
and fostering renewed spiritual self through art, music,
and poetry (Fraser & Mahoney, 2010).
Social interactions and participation in leisure activities can enhance physical and mental health in MS
(Khemthong, Packer, Passmore, & Dhaliwal, 2008).
It is important for individuals with MS to find social
activities of interest to increase social networks and
interactions with other people (Fraser, Meehan, &
McGurl, 2010), especially with those who have similar
concerns and experiences.
Participation in creative art activities can alleviate
the burden of chronic illness; however, a recent review
of the literature revealed that most studies have been
conducted in a hospital rather than being in communitybased settings (Stuckey & Nobel, 2010). Caddy, Crawford,
and Page (2012) emphasize that, in their review of the
literature, there were a limited number of quantitative
research studies and that most had methodological weaknesses. The investigators concluded that, despite the
popularity of creative art, there is a lack of evidence
regarding the relationship between participating in creative art programs and improved health. Creative and
accessible solutions to improve mental health are essential components of an effective intervention program,
and research is needed for socially oriented art to enhance health (Heenan, 2006).
Participation in a creative art program has the potential to enhance the lives of those living with MS.
Therefore, the purpose of this study is to investigate
the effect of a community-based creative art program
on self-esteem, hope, perceived social support, and selfefficacy in individuals with MS using a quantitative
approach.
Review of the Literature
To address the need for quantitative research to develop evidence on creative activity and health, Caddy
et al. (2012) conducted a chart review of 403 patients.
The participants had attended at least six sessions of
&
Number 6
&
December 2014
Creative activities to improve
mental health may be essential
components of an effective
intervention program for individuals
with multiple sclerosis and may
significantly enhance their lives.
a creative activity group while inpatients in a psychiatric hospital during 2004Y2009. The sample included
82.4% women and 17.6% men. The mean age of participants was 47.9 years. All patients had completed
standardized instruments on admission and discharge
from the hospital. The instruments included the Depression and Anxiety Stress Scale, the Quality of Life Enjoyment and Satisfaction Questionnaire, the Medical
Outcomes Short Form Questionnaire, and the Health
of the Nation Outcome Scale. The findings revealed
that the patients improved across all measures from
the time of admission to discharge from the psychiatric hospital.
Griffiths (2008) used grounded theory method to
investigate the usefulness of creative activities as a
medium in patients with mental health problems. Participants included both patients and occupational therapists. The eight patients who participated had attended
creative activities between 6 months and 3 years. Six
participants were women, and two were men. The five
occupational therapist participants included three women
and two men. The investigator found that, by participating in creative activities, skills can be developed
and confidence can be enhanced. Engagement was found
to provide a sense of purpose, a structuring of time,
and a restoration of balance between leisure and work.
Reynolds and Prior (2003) conducted a phenomenological study to investigate the meaning and functions of textile art in women living with a chronic
illness. The textile art included freestyle embroidery,
tapestry, appliqu2, quilting, and mixed-media work.
The sample included 30 women with various chronic
illnesses (cancer, chronic fatigue, severe respiratory
condition MS, postpolio syndrome, and arthritis). The
participants ranged in age from 29 to 72 years with most
being between 48 and 65 years. Thirty were interviewed,
and five provided lengthy written narratives about their
experience. The interviews were unstructured and audiotaped. The data analysis revealed the following themes:
(a) distracting thoughts from illness; (b) expressing
grief; (c) filling an occupational void; (d) increasing
choice and control; (e) increasing mindfulness/awareness;
Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
331
332
Journal of Neuroscience Nursing
(f) enabling the revising of priorities; (g) enabling
f low and spontaneity; (h) facilitating humor, joy, and
positive emotions; (i) restoring a positive self-image;
(j) building new social relationships; (k) contributing
to others and making a difference; and (l) widening
horizons, new activities, and future plans.
Reynolds and Prior (2006) also investigated the
role of art making in identity maintenance/restructure
in people living with cancer. An interpretive phenomenological approach was used. The participants included
two women and one man. They ranged in age from 47 to
59 years. Participants all engaged in textile arts, and two
also engaged in drawing and sculpture. Semistructured
interviews were used, and participants were audiotaped.
The transcribed interviews were analyzed and revealed.
Art making was found to enhance social networks and
provide continuity of identity and personal growth, a
sense of competence, enhanced self-image, optimism,
and confidence.
The influence of the creative arts on positive mental
health and well-being was evaluated by Heenan (2006).
The study was conducted in Northern Ireland. An art
program was provided for 10 hours a week for 10 weeks
and was facilitated by an art teacher. The sample included
12 women who were interviewed and 13 women who
participated in a focus group. The participants ranged in
age from 18 to 55 years. Thematic analysis of the transcribed interviews revealed that participation in the art
program improved self-esteem and self-confidence, provided a safe space, and made participants feel empowered.
The experience of terminally ill patients who made
and exhibited their creative arts was investigated by
Kennett (2000). Participants had a weekly program of
visiting artists, an art therapist, and a writer in a day
center. The creative arts included pottery, painting, crafts,
textiles, art therapy, and creative writing groups. The
sample included six men and four women who ranged
in age from 23 to 80 years. Eight participants had cancer, two had neurological conditions, and three had mental health problems. Data were collected using in-depth,
semistructured, audiotaped interviews. The researcher
concluded that all of the themes identified in this study
focused on the four attributes of hope. The essence of
the phenomenon studied was hope.
A qualitative study by Reynolds (1997) who investigated coping with chronic illness and disability through
creative needlecraft was conducted. The sample included 35 women who ranged in age from 18 to 87 years.
All had acquired the chronic illness or disability in
adulthood. Narratives were analyzed. Needlecraft was
found to provide a means of managing unstructured
time and pain as well as facilitating self-esteem and
reciprocal social roles.
The meaning of art making in women living with
chronic fatigue syndrome was examined by Reynolds,
Vivat, and Prior (2008). The sample included 10 women
who provided lengthy written responses to interview
questions about their experience. Art making was perceived as manageable in the context of a chronic illness.
When art making was established as a leisure activity,
art making increased subjective well-being by providing
positive self-image, hope, increased satisfaction with
daily life, and contact with the outside world. Participants felt that occupational and recreational counseling
should occur earlier in the illness trajectory.
Garland, Carlson, Cook, Lansdell, and Speca (2007)
compared mindfulness-based stress reduction (MBSR)
and healing through the creative arts programs on stress,
spirituality, posttraumatic growth, and mood disturbance
in patients with cancer. The participants were mostly
women and married and had breast cancer. The MBSR
group had 60 participants, and the healing-throughthe-creative-arts group had 44 participants. Both programs were found to facilitate positive growth after
traumatic life experiences. The MBSR was found to be
more helpful than the creative arts program in reducing
stress, depression, and anger and enhancing spirituality.
The effect of an art therapy program and coping
resources in women with breast cancer was investigated
by Oster et al. (2006). The sample included 41 women
who ranged in age from 37 to 69 years who have
nonmetastatic breast cancer. Participants were randomized into a study group who received art therapy (n =
20) for 1 hour per week during postoperative radiotherapy or to a control group (n = 21). The Coping Resources
Inventory was used to measure coping before and 2
and 6 months after the start of radiotherapy. There was
a significant increase in coping resources and social
domain for the women in the art therapy program.
In summary, the experience of participating in creative arts has been investigated in a number of studies
with participants who have a variety of chronic illnesses.
Most often, a qualitative approach was used to generate
new understanding of the outcomes after participation in
creative arts. A number of important concepts have been
identified using a qualitative approach. Little is understood about how creative arts can benefit individuals
living with MS. The next step in knowledge development is to use reliable and valid instruments to measure
the concepts in a larger study and focus on one type of
chronic illness. Therefore, the research question for this
study was, ‘‘Is there a difference in self-esteem, hope,
perceived social support, and self-efficacy in individuals
with MS after participation in a 4-week creative arts
program?’’
Theoretical Framework
Watson’s Theory of Human Caring will guide this study.
The theory ‘‘honors the unity of the whole human being,
Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 46
while also attending to creating a healing environment.
Caring-healing modalities and nursing arts are reintegrated as essentials to ensure attention to quality of
life, inner healing experiences, subjective meaning and
caring practices, which affect patient outcomes’’ (Watson,
2005, p. 51). Caring-healing modalities may include
massage, therapeutic touch, reflexology, aromatherapy,
sound, music, arts, and a variety of energetic modalities
(Watson, 2009). This study will focus on the art modality.
Method
Research Design
A one-group pretest/posttest design was used to determine if there was a difference in self-esteem, hope,
perceived social support, and self-efficacy in individuals with MS after participation in the creative arts
project. The variables were measured before participation in the creative art program and after completion of the program.
Creative Art Program
The creative art program included the following: week 1,
watercolor; week 2, collage making; week 3, beading;
and week 4, knitting. Each of the four weekly sessions
was facilitated by a registered nurse with expertise in
MS, and each session lasted 2 hours. Creative artists
instructed participants and provided a hands-on experience for each of the creative projects. Participants
were free to share thoughts, experiences, and words of
support and encouragement during each session.
Instruments
The Rosenberg Self-Esteem Scale is a 10-item scale
that was designed to optimize ease of administration,
economy of time, unidimensionality, and face validity. The scale has a 4-point Likert scale varying from
strongly disagree (1) to strongly agree (4), resulting
in a score range of 10Y40 with higher scores representing higher self-esteem. The scale has shown reliability with alpha coefficients ranging from 0.77 to 0.88
(Rosenberg, 1965). Fraser, Hadjimichael, and Vollmer
(2001) reported an alpha coefficient of .92 in a sample of 341 individuals with relapsing-remitting MS.
Fraser, Hadjimichael, and Vollmer (2003) reported an
alpha coefficient of .91 in 199 individuals with progressive forms of MS.
The Herth Hope Index is a 12-item adapted version
of the Herth Hope Scale. The Herth Hope Index has a
4-point Likert scale that ranges from strongly disagree
(1) to strongly agree (4). Scores range from 12 to 48,
with higher scores representing higher hope. An alpha
coefficient of .97 has been reported for this scale
(Herth, 1992). Fraser et al. (2001) reported an alpha
coefficient of .92 in a sample of 341 individuals with
relapsing-remitting MS. Fraser et al. (2003) reported
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an alpha coefficient of .90 in 199 individuals with progressive forms of MS.
The Modified Social Support Survey is an 18-item
multidimensional measure of perceived social support.
There are four subscales (tangible support, emotional/
informational support, affectionate support, and positive social interaction) as well as a total score. Each
of these scores can range from 0 to 100, with higher
scores indicating greater perceived support. The instrument has established reliability and validity (Ritvo et al.,
1997). Reliabilities in samples of patients with MS have
been reported as .99 (Osborne et al., 2006) and .93
(Williams et al., 2004).
The MS Self-Efficacy Scale (Schwartz, CoulthardMarris, Zeng, & Retzlaff, 1996) contains 18 items that
ask individuals to rate on a scale of 10Y100, where 10
is very uncertain and 100 is very certain of how they
will be able to perform specific behaviors. There are
two subscales containing nine items each with higher
scores representing a greater belief in one’s ability. The
function subscale (SEF) contains items that reflect an
individual’s sense of confidence that they can perform
behaviors that allow them to engage in activities of
daily living. The control subscale (SEC) reflects the individual’s sense of confidence that they could control
disease symptoms, reactions to disease-related limitations, and the impact of their disease on life activities. Each subscale can range in score from 90 to 900.
Schwartz et al. reported an alpha reliability of .86 for
the SEF and .90 for the SEC in the initial testing of the
instrument. Fraser et al. (2001) reported an alpha coefficient of .90 for the SEF and .94 for the SEC in a
sample of 341 individuals with relapsing-remitting MS.
Fraser et al. (2003) reported an alpha coefficient of
.90 on the SEF and .94 on the SEC in 199 individuals with progressive forms of MS. Fraser, Morgante,
Hadjimichael, and Vollmer (2004) reported .93 on the
SEF and .96 on the SEC in 108 individuals with MS
initiating glatiramer acetate.
A sociodemographic questionnaire was used to gather
data to describe the participants. In addition, a questionnaire administered after the week 4 session asked participants to describe what they liked most about participating
in the creative art program.
Sample
A convenience sample of 14 women with MS was recruited from several MS centers and an MS Society
Chapter in Missouri. Inclusion criteria were as follows:
diagnosis of MS; ability to speak, read, and understand English; and willingness to attend the four creative art sessions. Exclusion criteria were as follows:
severe cognitive dysfunction and unable or unwilling to
attend all of the creative art sessions. The participants
ranged in age from 29 to 70 years (M = 51.3 years,
Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
333
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Journal of Neuroscience Nursing
SD = 12.5 years; see Table 1 for a description of the
sample).
Data Collection Method
Institutional Review Board approval was obtained from
Monmouth University. An information letter about the
study was provided, and the study was also explained
to potential participants. They were free to ask questions about the study before participation. Participants
were advised of the ability to withdraw from the study
at any time. Those who agreed to participate completed
the instruments and sociodemographic questionnaire in
a quiet private area before the beginning of the creative
art program. The participants were given an index card
with the identification number used initially and instructed to use this number the second time the instruments were administered after completion of the 4-week
program. Participants were instructed to place the completed study questionnaires into the envelope and
to seal it before returning it to the investigator. Return
of the completed questionnaires implied consent to
participate. All envelopes were kept secure in a locked
file and remained sealed until the data analysis process began.
TABLE 1.
Description of the Sample
Female
n
%
14
100
Ethnicity
White
13
92.9
1
7.1
Married
8
57.1
Never married
2
14.3
Divorced/separated
3
21.4
Widowed
1
7.1
High school diploma
1
7.1
Associates degree
4
28.6
Bachelor’s degree
5
35.7
Masters or doctorate
4
28.6
Less than $20,000
4
28.6
$20,000Y39,999
2
14.3
$40,000Y59,999
2
14.3
$60,000Y79,999
2
14.3
$80,000Y99,999
1
7.1
Choose not to answer
3
21.4
African-American
Marital status
Education
Household income
Data Analysis
Data analysis was performed using the Statistical
Package for the Social Sciences Version 16.0. The
paired t test was used to compare the premeasurement and postmeasurement of the variables. Descriptive statistics were run.
Results
There was a significant increase in all variables after
the creative art program (see Table 2). The self-esteem
mean score at baseline was 30.14 (SD = 6.70), with a
mean of 33.86 (SD = 4.62) at week 4 after participation in the creative art program. There was a significant increase in self-esteem (t = j3.05, p = .009).
The hope mean score at baseline was 37.29 (SD =
6.12), with a mean of 41.57 (SD = 4.26) at week 4 after
participation in the creative art program. There was a
significant increase in hope (t = j3.96, p = .002).
The social support mean score was 57.50 (SD = 22.39)
at baseline, with a mean of 63.43 (SD = 18.81) at
week 4 after participation in the creative art program.
There was a significant increase in perceived social
support (t = j2.21, p = .046). The self-efficacy to function with MS mean score was 647.14 (SD = 131.76)
at baseline, with a mean of 751.43 (SD = 111.90) at
week 4 after participation in the creative art program.
There was a significant increase in self-efficacy to
function with MS (t = j2.68, p = .019). The selfefficacy to control with MS mean score was 486.43
(SD = 151.23) at baseline, with a mean of 649.29
(SD = 113.71) at week 4 after participation in the
creative art program. There was a significant increase
in self-efficacy to control with MS (t = 3.22, p = .007;
see Table 2).
According to Cohen (1988), power analysis may
be calculated after data analysis and states that a small
effect size is .20, medium is .50, and large is .80. The
power analysis for this study revealed a large effect
size for hope (d = 1.06), self-esteem (d = 0.82), and
self-efficacy (control; d = 0.86). A medium effect
size was found for self-efficacy (function; d = 0.72)
and social support (d = 0.59).
Participants’ responses about what they liked most
about participating in the creative art program were
compiled, and themes were identified. In descending
order of frequency, the themes were as follows: (a)
being with others, (b) opportunity to be creative, (c)
feeling relaxed, (d) learning a new skill, (e) enjoyment,
(f) sharing feelings and experiences, (g) comfortable
slow pace, and (h) building self-esteem.
Upon completion of the study, the participants wanted
to continue as a group. With help from the nurse facilitator of the sessions and the National Multiple Sclerosis
Society, a monthly creative art group was maintained.
Copyright © 2014 American Association of Neuroscience Nurses. Unauthorized reproduction of this article is prohibited.
Volume 46
TABLE 2.
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Comparison of Baseline and Week 4 Scores on Self-Esteem, Hope, Social
Support, and Self-Efficacy
Baseline Mean
Score, N = 14
Week 4 Mean
Score, N = 14
Paired t Test
p Value
Self-esteem possible range: 10Y40
30.14
33.86
j3.05
.009
Hope possible range: 12Y48
37.29
41.57
j3.96
.002
57.50
63.43
j2.21
.046
Self-efficacy (function) possible range: 90Y900
647.14
751.43
j2.68
.019
Self-efficacy (control) possible range: 90Y900
486.43
649.29
j3.22
.007
Social support possible range: 0Y100
A support partner and person with MS agreed to
facilitate the monthly meetings. The group members
have led new creative art projects, and several meetings were designated as ‘‘bring your own projects’’
that needed completion or help from other members.
The group has grown to 30 members, with about 10Y15
attending each meeting.
Discussion
The creative art program significantly improved participants’ self-esteem, hope, perceived social support,
and self-efficacy to function and control MS. Self-esteem
was also identified as a finding in the qualitative research by Reynolds (1997) and Heenan (2006). Hope
was also identified as a finding in the qualitative research by Reynolds et al. (2008). Perceived social support was also identified as a finding in the qualitative
research by Griffiths (2008) and Reynolds and Prior
(2003, 2006). Similar to the qualitative studies by
Griffiths (2008), Heenan (2006), and Reynolds and
Prior (2006), who used the term ‘‘confidence’’ when
measured as self-efficacy in this study, it was found
to be significantly increased after participation in the
creative art program.
The findings of this study support the caringhealing modality and nursing arts as described by
Watson (2005). The partnership of nursing and creative artists in providing a creative art program in a
community-based setting enhanced the lives of the
participants with MS.
Conclusions
The creative art program was found to be effective
and had a positive influence on self-esteem, hope, social support, and self-efficacy to function and control MS. Although the sample size was small, findings
were found to be significant. Future research needs to
use a quantitative approach to build a solid body of
knowledge in this area. Replication of this study conducted over a longer period is needed to confirm the
findings. Creative art has the potential to enhance the
lives of those living with MS and should be investigated with a larger sample of participants.
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