In not seeking hospital care included wanting to

In this assignment I will commence by analysing and reviewing current literature that explores the self management of adults that have been diagnosed with schizophrenia. Current treatments and the factors associated with how successful an individual is able to self manage will be explored. Furthermore I will be discussing the differences in the self management strategies patients use and their effectiveness in settings, both in the community and psychiatric rehabilitation centres, from two primary research studies. My focal point will be to critically analyse the way each piece of research was carried out in terms of the study design adopted and the methods used in the collection of data. The findings and recommendations produced by both studies will be linked into evidence based practise which is the core to this piece of work. 

Literature review

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Schizophrenia Disorder (SD) affects more than 21 million people worldwide yet one in two people living with schizophrenia don’t receive care for the condition (Who.int, 2018). Among those who had not been offered nor sought treatment but who perceived themselves to need help, the common reported reasons for not seeking hospital care included wanting to solve the problem on their own terms (Kessler RC. 2001). According to (Carlborg et al., 2010) the consequence of poor self management of schizophrenia often results in a cycle of relapse and admission and overtime a slow decline in mental function and social relationships. As well as that individual factors Schizophrenia can be a financial burden on society as a whole because of the potential for institutionalisation and chronic use of medical treatments (De Silver J. 2012). The estimated costs of schizophrenia in England in 2007 was £2.2 billion, rising to £3.7 billion by 2026 (NICE 2014), Knapp (2004) also highlighted were the majority of costs originated from , not only health and social care costs, but also informal care costs, criminal justice system costs and the costs of lost productivity and premature mortality.

Search strategy 

For my search engine I used CINAHL, which I accessed through the LJMU database. CINAHL is a cumulative index to nursing and allied health literature. The CINAHL database provides nursing journals and publications from the National League for Nursing and the American Nurses Association. In order to find my qualitative and quantitative research studies I had to narrow my search results by entering key words associated with the area I wanted to explore. This included ‘Schizophrenia’ and ‘Self-management’. To refine my search further, to access only primary research studies, I included an exclusion criteria which filtered out systematic reviews and meta analysis reports. Furthermore, I added a timescale of eight years to eliminate older pieces of research and only provide recent and up to date studies. Due to CINAHL providing such a range publications that have been conducted worldwide another part of the exclusion criteria was research that was non transcribed in English. 

Research

In qualitative and quantitative research you follow one of two paths. Ones identified as a scientific tradition (quantitative); the second is experiential in nature or reflective (qualitative). Although the use some of the same research skill they are used for a different purpose (Davies, 2010). 

Quantitative research gathers data in a numerical form and is concerned with the objectivity and validity of what has been observed (Rubin and Babbie, 1989). When collecting data within the quantitative paradigm it is deductive, this means it starts of as a hypothesis and is driven towards a more specific outcome in order to prove or disprove a perceived area of knowledge (Ellis, 2010). The quantitative research study I have chosen is ‘Factors associated with good self management in older adults with Schizophrenia Disorder compared to older adults with physical illnesses’ (J. Stein-Parbury 2011). The aim of this study was to highlight what factors are associated with good and poor self management of people with schizophrenia. The study was a prospective and descriptive design. A descriptive design’s goal is to assess a sample at one specific point in time and is helpful in revealing patterns and connections. However descriptive design studies can’t be used to correlate variables or determine cause and effect. A prospective study looks for outcomes over a period of study and in this study the data was collected at two time periods. The prospective approach normally has fewer potential sources of bias than retrospective studies (Viswanathan and Berkman, 2011).

Qualitative research is often used to gain an understanding through the use of opinions and motivations to discover underlying reasons (Libguides.usc.edu, 2017). Qualitative research is described at nature inductive, unlike quantitative that sets out to disprove or prove a theory qualitative generates ideas from what is being observed. Inductive research starts with specific observation towards creating a much broader generalisation described at ‘feature detecting’ (Ellis, 2010). The qualitative research study I have chosen is ‘ Psychological and physical self-management of people with schizophrenia in community psychiatric rehabilitation settings’ (Katakura N 2013). he objective of this research was to identify some of the motivations behind patients adopting self management techniques in order to control parts of their disorder and to build a framework to discern the generative process of health and unhealthy conditions. This research adopted an inductive approach as there is very little available evidence on the health self management of people with mental illness. Inductive research “involves the search for pattern from observation and the development of explanations and theories for those patterns through series of hypotheses” (Bernard, 2011). One of the advantages of the inductive approach is that it is flexible as the researcher does not have to follow any pre-determined information (Gratton and Jones, 2009). However some of the disadvantages of this approach is it often takes longer to complete and often end up by referring back to existing studies (Newell, Bernard and Newell, 2011). 

Method and Data Collection

In my quantitative research study there was four groups of 300 individuals who have chronic illnesses which included; respiratory disease, heart failure, Parkinson’s disease and schizophrenia. The selction criteria for this study was a diagnosis of a chronic condition that was at a moderate level which included chronic heart failure, chronic respiratory disease, Parkinson’s disease or to have a diagnosis of Schizophrenia (this included schizoaffective disorder). 

The data was collected at two intervals, firstly within a week of a clinic visit or home visit by a case manager and then one month later. This study used questionnaires using scaling question responses, this allows people involved in the study to chose an answer that is closest to how they truly perceive themselves. Such scales in quantitive studies usually usually take one of three forms: agreement, evaluation and frequency. In this study evaluation scales were used, because of the way they are worded they allow participants to respond more honestly than in agreement scales which often  appear directive (Ellis, 2010). However some of the disadvantages of using evaluative scales is that the responses from the participants are purely opinion based rather than fact and is down to how the participants perceive themselves which can amount to misleading data. 

Self management was assessed with the Partners in Health Scale 
(W Battersby et al., 2003). Responses were measured with 0= very good and 8= very poor. This scale measures knowledge of their diagnosed illness, level of collaboration with nurses and other staff members, medication, symptom monitoring and appointment attendance. The Partners in Health Scale had high internal consistency in the study. The scale measures a coefficient of 0.92 at time one. The term internal consistency describes the extent to which ‘all the items in a test measure the same concept or construct and hence it is connected to the inter-relatedness of the items within the test.’ (Tavakol and Dennick, 2011). Sense of coherence, which is defined as the overall sense or understand ability, was measured by using the orientation to life questionnaire (Antonovsky, 1993). The scale covers 29 areas in the three core components of comprehensibility, meaningfulness and manageability. Each area was scored on a scale of 1-7, 1 being low and 7 being higher sense of coherence. The total score ranged from 29 to 203 using a semantic differential scale. The semantic differential scale is designed to measure the meaning and attitudes towards the events and concepts. Similarly to the Partners in Health Scale, the orientation to life questionnaire had a high internal consistency with Cronbach’s Alpha and scored a coefficient of 0.92. Finally participants self-rated their overall health using the Self- Rated Health Scale. Participants rated their overall heath from 1-5, 1 being excellent and 5 being poor. According to DeSalvo et al (2005) the scale was used in a review of 22 studies with patients giving themselves a score of 5 (poor) having double the mortality of patients reporting ‘excellent’ self-rated health. 
The qualitative study consisted of 8 participants with schizophrenia attending rehabilitation centres A (support for employment),and centre B (local activity support centres). The study centres A and B provided services for people with physical and psychological disabilities which included counselling. In centre A the counselling was offered to the patients once a month for 15-30 minutes per session. In centre B however counselling was offered to a group of 10 people for about 1 hour per month. The idea of doing it as a group was to allow the opportunity for the exchange of ideas between people with mental illness. The participants included four men and four women aged between the ages of 36 and 65. The only criteria that was set was that the participants must have a diagnosis of schizophrenia and be under contract to use the rehabilitation centre.

For the researchers data collection study the authors developed an interview guide which took place during November 2009 to February 2010, the interview was a audio-recorded semi-structured interview which included three questions and were approximately 20–50 minutes. The contents of the questions included psychological and physical health self- management, difficulties experienced, and their reasons for using the rehabilitation centre. The advantages of using semi-structured interviews is that the respondent can influence the topic so potentially unexpected issues can emerge that may give the researcher additional information. The researchers can also probe in order to understand perspectives and experiences, however is a researcher is to probe in order to gather additional information this needs to be done without being directive or judgemental. The analysis of semi structured can be time-consuming and difficult to generalize the findings (Apps.who.int, 2018). One participant did refused to allow the audio recording of the interview, he did allowed the researcher to take notes and confirmed them after the interview. 

Sampling

For the quantitive study the sampling strategy was convenience sampling. This is where people from a target population (in this case adults with chronic illnesses) are available at the time and willing to take part, and is therefore based on convenience. The participants that were involved in this study were recruited through their community case managers or during attendance at a medication clinic. One of the weaknesses of choosing an opportunity sampling strategy is that it may not be representative as it is based on who is available not who would be best to take part in the study (McLeod, 2014). However, to make sure that their results were representative the study required selection criteria which included a diagnosis of a chronic illness and a moderate level of the disease. For the participants who had schizophrenia the moderate level was the Global Assessment of Functioning (American Psychiatric Association, 2000), were living at home, over 50 years old and able to read and write. The exclusion criteria included being hospitalised more than once within three months prior to taking part in the study. Some of the advantages of opportunity sampling are that it is  an easy way to obtain a large amount of data in a short time frame, it is efficient because it takes less time to recruit participants  and is generally cheaper than other forms of sampling (McLeod, 2014). 
 
The qualitative study had a similar approach to the quantitative sampling method, it too chose the convenience strategy to recruit its participants. The directors of the rehabilitation centres recommended these participants to the researchers to take part in the study, therefore making it a convince sample. In addition like the quantitative sampling approach they too made a criteria list in order for their sample to be more representative as that is one of the main weaknesses of a convenience sample. The criteria list included a diagnosis of schizophrenia and under contract to use the rehabilitation centre, there were no exclusion criteria which resulted in a wide range of participants. 

Ethics 
It is embedded in our professional Code of Ethics (ANA, 2001) that it is our responsibility to protect out patients from harm. Researchers themselves must be fully committed to the protecting to patients rights and must take all precaution to ensure no patients is exposed to physical or psychological harm (LoBiondo-Wood and Haber, 2006). For my quantitative study the Human research ethics committees of the area health service and the associated university approved the study, however it was not stated wether the patients had given written or oral consent. Researchers often don’t obtain informed consent when the data collection is through a questionnaire as the return of the completed questionnaire is seen as the participant consent to participate   (Polit and Beck, 2010). The gaining and maintenance of consent is regarded as an on going process that need to be carried out through the entire study ( NRES 2008). Some of the elements that make up the consent process includes the understanding of the information provided, freedom from coercion and the understanding of the right to withdraw (Ellis, 2010). In the qualitative study  written and oral explanations were given to each participant and their PHNs, all agreed to participate and completed the study and the ethics commit- tee of Chiba Prefectural University of Health Sciences (No. 2009–2020) gave approval for the study. In some qualitative studies is can be challenging to gain consent when the researches do not always know how much the study will evolve, therefore the consent should be ongoing also knows as process consent.  (LoBiondo-Wood and Haber, 2006). Another element of protecting the participant from harm is confidentiality, this is the right for the participant not to be identifiable when the findings of the research are published (Ellis, 2010). An example of how the quantitative study adheres to the participants right to confidentiality is that no names were published in the results of the questionnaire. The qualitative study likewise did not publish the participants names. The consequence of not gaining consent and not adhering to the patients right to confidentiality the participants could suffer physical or psychological harm which the researcher can legally be held accountable for (Wiles, 2006). 

Data analysis 

According to Shamoo and Resnik (2003) the data analysis process ‘provides a way of drawing inductive inferences from data and distinguishing the signal (the phenomenon of interest) from the noise (statistical fluctuations) present in the data’. 
In the qualitative study all statistical analyses utilized SPSS (Statistical Package for the Social Sciences) version, SPSS analyses numerical data and is a widely used computer program. SSPS is unable to decide which test is to be used on the data collected but only assists by running the test itself (Bernard, 2011). The non- parametric equivalent Mann–Whitney U-test was used where data was significantly skewed, This form of data analysis does not require any assumptions on the distribution of the population, therefore it is used when you either do not know or are not willing to assume the shape of the distribution (Rice, 2007). Although the Mann–Whitney U-test is able to states whether the difference is significant or occurred by chance it is not able to explain why there is a difference (MacFarland and Yates, 2016). For the group comparisons on categorical data (e.g. gender) were made using Chi-Squared analyses, this type of analysis is used to determine whether there is a significant difference between the expected and the observed frequencies in one or more categories (Sirkin, 2006). To understand the differences in the self- management of people with a Schizophrenia , an exploratory factor analysis with principal axis factoring and oblique rotation was performed including all 11 items of the Partners in Health Scale (Battersby et al. 2003). The independent factors associated with self- management in people with SD were determined by multiple regression analysis. Multiple regression analysis allows you to use the information about the independent variables and use it to make more accurate predictions (NCSS 2018). All the assumptions for regression analysis were assessed and none was found to be violated (Field 2009). 
Data analysis in qualitative research requires four steps, reducing the raw data into something more manageable, filtering out important and less significant data, identifying themes and finally construct a hypothesis, narrative account or theory of the analysis (Ellis 2010). Katakura.N carried out the study analysis using the audiotaped interview data and field notes that were transcribed and used the open-coding procedure. Open-coding includes labeling concepts, defining and developing categories, it is part of many qualitative data analysis methodologies like Grounded Theory ( Khandkar.S.H 2018). All the codes were subsequently sorted according to similarity into categories using conceptual names representing their characteristics. A conceptual diagram was also created which showed the relationships between participants’ health self-management behaviours, motivation and progress. Conceptual diagrams are designed to clearly delineate layers of phenomena in order aid in organising and synthesising knowledge and to also designate variables. On of the limitations of conceptual diagrams it often is devoid of sufficient description in the text therefore limits the utility of these diagrams for potential users (Paradies, 2005). 

The findings and recommendations 

In the quantitive study the results supported other findings that older people who are diagnosed with Schizophrenia are often more socially isolated, poor social functioning limits a  person’s ability to engage with health-care providers (Pratt et al. 2008). The participants in the study with a higher sense of coherence were generally better at illness self-management. The findings did also identified a connection between illness management and involuntary treatment orders, however no direction could of been implied because it is a cross-sectional study. It is also clear that there was a strong connection between the participants with Schizophrenia view of their health overall and comorbid conditions and their illness self management. The main limitation of this study was that the participants were recruited through their case managers and medication clinics consequently it being not representative. In addition the the differences in self management between the participants with Schizophrenia and physical illnesses could have been a reflection on wether the illness had stabilised or was progressive. External variable that were not picked up upon or measured may have also influence the outcome of the study. The data collected from this research shows that there are specific areas that clearly impact people with a diagnosis of Schizophrenia to manage their health effectively. Therefore this could be addressed by interventions that focus on factors specifically associated with the ones highlighted in this study. 
In the qualitative study the finding showed that when the conceptual diagram was produced there were two types of participant motivations for health self-management which were ‘getting a job in the near future’ and ‘maintaining my current level of living’. One of the finding from the research was that the participants self-management behaviours were effective in their improving their psychological and physical health when their  ‘their self-management was at an appropriate level and well balanced’. In contrast participants stated their deterioration was when health managers would intervene and become ‘excessively strict’  or there was a difference in recognition between the participants and care providers. One of the limitation of this study is there are differences in age, complications, family structure and residence between the participants, these differences might have affected the results in terms of what stratigies they used for self management and what factors most affected them. Therefore, it was recommended that in future research on this topic should be with a larger number of participants to provide more generalisable results. 

Evidence based practise 

Evidence- based practice (EBP) is a diligent problem solving approach to clinical practice that based on evidence from studies performed worldwide. Patients values and preferences, and the clinicians knowledge to make the best decision about the patients care is ultimately central to evidence based practise (Alfaro-LeFevre, 2013). Evidence based comes in five main stages, asking answerable questions, finding the best available evidence, appraising the evidence for its validity and applicability, applying the results of this appraisal in clinical practice and finally evaluate its clinical effectiveness (Newelle 2011). Clinical effectiveness is one element of the evidence based practice process and is defined originally (and subject to periodic reviews) by the Department of Health (1996) as the application of the best knowledge that is sourced from research, clinical experienced and patient preferences in the hope to achieve the best outcomes for patients. The process of involves a framework that consists of informing, changing and monitoring practise. A recent survey about the EBP indicated that, while nurses had positive attitudes toward EBP and wished to gain more knowledge and skills, they still faced significant barriers in applying it in practice (Melnyk et al., 2012). One of the implementation of EBP points to the challenges of change. The evidence-based program, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), it is a systematic a approach that is designed the safety, quality and the efficiency of healthcare. TeamSTEPPS is the result of a 3-year research program that was party funded by the Agency for Healthcare Research and Quality (AHRQ)

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