الفهرس 
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Abstract
Effective interpersonal problem-solving skills have been identified as an essential aspect for successful functioning in everyday life. (52) Patients with schizophrenia are often handicapped to address themselves to real-life interpersonal problem situations as well as to provide effective problem solving responses in reaching specified goals in such situations (11). Moreover, they have compromised working memory that hinders their abilities to maintain in consciousness storage of information needed to execute tasks of daily life such as interpersonal functioning (37). The inability to navigate the social environment effectively is a major factor in the poor quality of life experienced by most patients with schizophrenia and is a significant source of stress that contributes to relapse (139). So, patients with schizophrenia need to develop interpersonal problem-solving skills to be more efficient in solving problems and challenges that arise in their social context.
The present study aimed at exploring the interpersonal problem-solving ability and working memory capacity of patients with schizophrenia and assessing the effect of a problem-solving training intervention on interpersonal problem- solving ability and working memory capacity among patients with schizophrenia.
The study was conducted at El¬-Maamoura Hospital for Psychiatric Medicine, in Alexandria. Sixty male patients diagnosed with schizophrenia were recruited and divided into two groups, a study and a control groups. The following inclusion criteria were considered:
- Definite diagnosis of schizophrenia with no co-morbidity.
- Duration of illness not more than 5 years since diagnosis.
- Able to communicate in a coherent and relevant manner.
- Not under ECT treatment (in order to avoid the adverse effects of ECT on cognitive functioning).
- Able to read and write.
- Agreed to participate in the research after understanding the purpose of the study.
The data for this study is obtained using the following tools:
Tool I: Means-Ends Problem-Solving Procedure (MEPS) is an instrument developed by Spivack et al. (1985). The MEPS procedures are intended to measure the ability of a person to conceptualize the means or sequence of steps that may be necessary to carry one from a point of having an interpersonal problem that requires a resolution, to the point where the need is satisfied or the problem is solved. Stories in MEPS are designed to assess the person ability to create means, consider obstacles and time to reach the designed goals of solving the interpersonal problems .The subjects were given a score of one point for each effective mean, obstacle or time. For the overall vignettes, a total mean score is calculated at pre and post intervention.
Tool II: The Forward and Backward Digit Span Test was developed by Weschler (1981) to measure the storage capacity of working memory. The digit span test includes two components namely; digits forward and digits backward in a single subtest. The test comprises seven levels and each level consists of a number of digits that increases with a rate of one number per each level. Scoring of the digit span test was based on the sum of the forward and backward correctly repeated items. The total score ranged between 0- 28 categorized as follows: 0-9 indicates low working memory capacity, 10-19 represents moderate working memory capacity and 20-28 denotes high working memory capacity.
In addition, the socio-demographic and clinical data structured interview schedule was developed by the researcher to elicit information about the patients’ age, educational level, duration of illness, age at onset of illness, and number of previous psychiatric hospitalization.
Seven vignettes -applicable to adults of the MEPS- representing different interpersonal conflicts were translated into Arabic language. They were tested by a jury of five experts in the field of psychiatric nursing for the content validity, clarity and appropriateness of translation and consulted to select three stories suitable to the Egyptian culture. The MEPS and the Forward and Backward Digit Span tools were test-retested for reliability on 15 patients with schizophrenia, with a time lapse of two weeks in between using Pearson Chi-Square. They proved to be reliable. Cronbach’s alpha also demonstrated high internal consistency for both tools. A pilot study was carried out on another 7 patients, the results proved that the study tools were clear, understood and applicable. These patients were excluded from the actual study.
The researcher followed the problem solving training program that was developed and applied by Spivack and Siegel (1976) on patients with schizophrenia (29). With some modifications to fit the Egyptian culture. The teaching materials used in this program was designed by a professional person from the faculty of Fine Arts. Materials were revised and approved by the supervisors and some professional professors from the psychiatric nursing department after making necessary required modifications.
The field work in the present study was implemented in three phases:
The actual study was conducted during the period from the 2nd of December 2015 to the end of February 2016. It went through three phases:
Phase I: selection of the subjects:
- Male wards were ranked using simple randomization by picking their names up from a pool. The first two-selected wards were assigned for the control group and the second two were assigned for the study group. The process was repeated till the required number was obtained.
-All patients’ medical records were reviewed to identify those who meet the study criteria.
- Each recruited patient in the study group was interviewed individually by the researcher to establish rapport, explain the purpose of the study, and provide brief explanation about the training program.
- The recruited patients were then exposed to pre-testing using tools I, II and the socio-demographic and clinical data structured tool by interviewing each patient individually.
- Whenever the number of recruited patients reached 6-8 members, the problem- solving training program was implemented by the researcher on this group.
Phase II: Implementing the problem- solving training program:
- The training program was carried out for those who are selected to be in the study group, while patients in the control group were left to undergo the usual hospital routine care without any intervention from the researcher.
- The program consisted of 10 sessions; 4 days/week for three weeks, each session lasted between one to one and half hour; that increased or decreased according to the content of the session and patients’ responses.
- In each session the researcher started with an introduction about the training program, the general as well as the specific objectives of the session; and the rationale behind it’s importance.
- Modeling and role playing of a particular problem was displayed by demonstrating to the group the situation. The researcher and one or two participants played the role in front of the group.
- Throughout the training program, the researcher used different teaching materials; slide pictures, photographs, drawings and an interactive book. Moreover, different educational strategies were used like; brain storming and group discussion to encourage wide and creative thinking about topics of the sessions.
- During the training exercises, several skills and competencies were emphasized to meet the specific objectives of the training program. Such as; assertiveness, decision making skills, positive reinforcement and providing corrective feedback.
- Summary of the key issues discussed in the session was done by the researcher at the end of each session.
Phase III: Evaluation of the effectiveness of the problem- solving training program:
A posttest was implemented using tools I and II on each patient in the study group (30 patients) and control group (30 patients) after completion of the training program.
The following are the main results yielded by the present study:
- The age of the majority of both the study and control groups ranged between 30 to less than 40 years (90.00% and 93.33%, respectively). The mean age was 34.20±5.93 years for the study group compared to 33.93±5.09 years for the control one.
- Almost two thirds of the study and control groups were unemployed (66.67% and 63.34%, respectively).
- 46.67% of the study group and 50.00% of the control one had preparatory or secondary education, while those who had university education represent nearly one quarter of the study group (23.33%) and 36.67% for the control group.
- Those who were single constituted 70.00% and 73.33% of the study and the control group, respectively.
- More than three quarters (80.00%) of both the study and control groups were living in urban areas.
- The majority of the studied subjects were living with their family, distributed as 86.67% and 83.33% of the study and control groups, respectively.
- More than three quarters of both the study and control groups had a moderate socio- economic level, with minimal variations between the two groups (80.00% and 76.67%, respectively).
- The majority of both the study and control groups had a duration of illness that ranged between 3 to 5 years (86.66% and 70.00%, respectively), with a mean duration of illness equal to 4.05±1.39 years and 3.46±1.80 years, respectively.
- Those who were hospitalized from one to five times constituted 43.33% of the study group compared to 53.33% of the control group.
- 63.33% of the study group and 60.00% of the control group were discharged since less than 6 months with a total mean of 8.83±11.37 and 7.77±9.76 months, respectively.
- - Typical antipsychotics were prescribed for 56.67% of the study and 43.33% of the control group, while only 20.00% of the study group compared to 33.33% of the control one were receiving atypical antipsychotics. Mixed antipsychotics were prescribed for nearly one quarter of both the study and control groups (23.33% for each).
- Concerning the first vignette, the mean score of the number of means in the study group was 2.43±1.19 compared to 0.97±0.76 in the control one, with a highly statistically significant difference between both groups post-intervention (ZMW= -4.77, P=0.000).
- Regarding the second vignette, a highly statistically significant difference was proved when comparing the mean score of both the study and control groups pre and post- intervention (ZMW=-3.40, P=0.001). Also a statistically significant difference was observed when comparing the mean score of the number of the obstacles between both groups at post-intervention phase (ZMW=-2.74, P=0.01).
- In relation to the third vignette, the mean score for the number of means in the study group was 1.63±0.99 compared to 0.87±0.77 for the control group and the difference was highly statistically significant post- intervention (ZMW=-3.10, P=0.002). With respect to time reference dimension, the mean score between the study and control groups at post- intervention showed, a statistically significant difference between the two groups (ZMW=-2.31, P=0.02). Furthermore, at the post- intervention phase the mean score for the number of obstacles demonstrated by the study group was 0.57±0.67 compared to 0.27±0.45 for the control one and the difference between the two groups was statistically significant (ZMW=-1.90, P=0.05).
- The mean difference score of the overall means between the study and control groups post- intervention, demonstrated a highly statistically significant difference between both groups (ZMW=-4.94, P=0.000).
- The mean difference score of the overall obstacles, at post- intervention in the study group was 0.57±3.04 compared to 0.0±1.58 in the control group. A statistically significant difference between the two groups was noticed (ZMW=-2.46, P=0.01).
- At post-intervention phase, the mean difference score of the overall MEPS among the study group was 3.46±12.19 compared to -0.2±6.12 for the control group. A highly statistically significant difference between both groups was found (ZMW=-5.05, P=0.000).
- At post-intervention phase, more than three quarters of the study group had moderate working memory capacity (76.67%) compared to half of the control group (50.00%).Moreover, 6.67% of the study group had high working memory capacity compared to none of the control group.
- The total mean score of the working memory capacity increased from 8.93±2.30 before intervention to 12.27±3.49 post- intervention, with a mean difference score of 3.34±2.06. Yet, a highly statistically significant difference was found (ZWil = -3.64, P=0.000).
Accordingly the following are the main recommendations of the present study:
- Psychiatric hospitals should support the application of the problem solving training intervention as an integral component in the hospital routine care of patients with schizophrenia. In order to support, boost up their acquired skills and ensure the implementation of this learned skills in real social life situations.
- An on job training may be provided for nurses to update their knowledge and skills related to problem solving interventions.
Replication of the present study more extensively for longer period on a larger sample; including female patients to ensure proper generalization.