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 2 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 6 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 8 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 11 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 12 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 14 Common Designs for Quantitative Research 15 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 16 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 17 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? 18 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 19 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 20 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 22 23 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 & Number 6 & December 2014 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. 333 334 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. & Number 6 & December 2014 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. References Caddy, L., Crawford, F., & Page, A. C. (2012). ‘‘Painting a path to wellness’’: Correlations between participating in a creative activity group and improved measured mental health outcome. 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