Module Title: Sport Research Methods

Module Code: SP7000

Student Name:

Student Number:

Word Count: 4327

Proposal Title:

Pre-Operative Health Education for Cardiac Surgery Patients

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Table of Contents

Chapter 1: Introduction.................................................................................................................3

1.0 Background of Study.............................................................................................................3

1.2 Research Problems...............................................................................................................3

1.2.1 Background to the Problem...........................................................................................3

1.2.2 Statement of the Problem.............................................................................................5

1.3 Purpose of Research.............................................................................................................6

1.4 Research Questions..............................................................................................................6

1.5 The Research Objectives.......................................................................................................6

1.6 Significance of the Study.......................................................................................................7

1.7 Theoretical Framework.........................................................................................................7

Chapter 2: Literature Review.....................................................................................................9

2.1 Introduction..........................................................................................................................9

2.2 Cardiac Surgery.....................................................................................................................9

2.3 Preoperative Preparation...................................................................................................10

2.4 Preoperative Visit...............................................................................................................11

2.5 Stressors.............................................................................................................................12

2.6 Education............................................................................................................................13

Chapter 3: Research Design and Method....................................................................................15

3.1 Research Design.................................................................................................................15

3.1.1 Quantitative Design.....................................................................................................15

3.1.2 Descriptive Design........................................................................................................15

3.2 Population and Sampling...................................................................................................16

3.2.1 Population....................................................................................................................16

3.2.2 Sample.........................................................................................................................16

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 3.3 Data Collection Instrument................................................................................................16

3.4 Reliability and Validity.......................................................................................................17

3.4.1 Reliability.....................................................................................................................17

3.4.2 Validity.........................................................................................................................17

3.5 Data Analysis......................................................................................................................17

3.6 Ethical Considerations........................................................................................................17

4.0 Conclusion..............................................................................................................................18

References....................................................................................................................................19

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 Chapter 1: Introduction

1.0 Background of Study

The pre-operative health education of the patient undergoing cardiac surgery is
essential to the post-operative care that the patient receives and the recovery process.
Pre-operative preparation for cardiac surgery patients helps fill in knowledge gaps and
reduces the risk of complications (Shuldham, Fleming & Goodman 2001:666). However,
cardiac surgery pre-operative health education presents unique challenges. Patients
undergoing cardiac surgery interact with many medical professionals, adding another
layer of complexity (van Weert et al., 2003, p. 105). Moreover, there is a need for more
information about the interdisciplinary health education process (van Weert et al., 2003,
p. 14). As such, it is helpful for everyone involved in cardiac surgery to look back at the
steps taken to get the patient ready for the procedure. Thorough pre- and post-operative
health education for cardiac surgery patients has proven to reduce complications and
boost surgical success rates (Havrilak, 2005, p. 1).

A long list of tests and intensive clinical training precedes the surgical process.
Pre-admission appointments should be scheduled well before the surgery date, allowing
for a thorough examination of the patient's test results and providing necessary
education. Candidates must be evaluated, educated, and prepared psychologically and
clinically for surgery. Considering this background, the current research aims to assess
a private hospital's pre-operative health education programme in Lagos State, Nigeria.

1.2 Research Problems

1.2.1 Background to the Problem
When patients undergoing heart surgery receive thorough pre-operative
education, they can avoid complications and recover quickly (Havrilak, 2005, p. 2).
Patients should be admitted several days before surgery to complete the necessary pre-
operative tests. With this in place, the patient's concern about cardiac surgery will likely
decrease, and the procedure can proceed smoothly. Anxious and tense patients may

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have a more difficult time recovering physically and mentally from surgery, as noted by
Nelson (1995:29). It is also essential for the nursing team to provide reassurance and
comfort to members of the patient's family and circle of friends.

The majority of patients (clients) go into surgery with some level of apprehension.
A patient's level of anxiety about surgery depends on a wide range of factors, including
how they react to stress, their mental state, their prior surgical experiences, and their
beliefs about what happens before and after surgery. Some people respond by shutting
down and withdrawing, acting like children, getting angry and clingy, or even breaking
down and crying. When admitted to a healthcare facility, most patients feel helpless.
Therefore, doctors must remember that although surgery is routine, it can be terrifying
for the patient (Springhouse, 1999, p. 458).

Nurses are in a perfect position to offer pre-operative health education guidance,

support, and information to patients undergoing cardiac surgery and their families. To
provide pre-operative education to the client, the cardio-thoracic nurse coordinator has
the necessary knowledge, abilities, and time. Patients and loved ones must understand
the potential outcomes of the procedure thoroughly. Studies have indicated that
informing patients reduces their anxiety by making them feel more in charge of their
situation (Walsh, 1997, p. 320). In addition, receiving reassuring information before
surgery can lower anxiety, tension, and even pain levels. The result could be shorter
hospital stays due to reduced pressure (Nelson, 1995, p. 29).

Statistics from one private hospital in Nigeria during the past five years did not
indicate a rise in the number of patients requiring heart surgery (see figure 1.1). This
private hospital's cardiac unit opened in 2001 and has fourteen beds. The nurses in the
intensive care unit have always been responsible for educating their patients about their
health before surgery. This service is available to patients admitted to the intensive care
unit (ICU) after arriving for elective cardiac surgery.

The number of cardiac surgery procedures rose after 2001 but fell in 2005, as
shown in figure 1.1. Furthermore, one hundred and one individuals had heart surgery in
the year 2001. This trend showed a slight upward movement over the past five years.
However, the number of patients in 2002 was one hundred and seventy-three, with one

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hundred and eighty-five patients in 2003. An estimated one hundred eighty-
three cardiac surgical procedures got carried out in 2004.  Thus, in 2005, there were
one hundred sixty-one heart surgery procedures. Hence, the monthly average for heart
surgery at this private hospital in Nigeria is between 12 and 15; this amounts to a once-
a-week process.

1.2.2 Statement of the Problem

Life-saving cardiac surgery also vastly enhances patients' quality of life. The
effectiveness of pre-operative health education for patients undergoing heart surgery
can significantly impact surgical results. Preventing post-operative problems and
improving patients' outcomes begins with a comprehensive health education campaign
for those undergoing cardiac surgery (Havrilak, 2005, p. 1). Thus, documenting patients'
pre-operative health education in detail might help identify and address any procedural
gaps that may compromise patients' recovery.

Van Weert et al. (2003:105) research on health education for heart surgery

patients revealed inconsistencies and highlighted the importance of tailoring instruction
to each individual. Nurses spent 30% of their time discussing medical matters, which
meant they overlapped with the doctors. The research revealed a lack of educational

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resources and psychological support for patients to establish successful health
education.

However, it has yet to become apparent how well patients at this private hospital
in Nigeria who undergo cardiac surgery prepare for their procedures through pre-
operative health education. As a result, this study aims to assess the current pre-
operative health education programme.

1.3 Purpose of Research

The research examines the benefits and shortcomings of a preoperative health
education programme offered to heart surgery patients at a private hospital in Nigeria.
The findings will improve preoperative health education for heart surgery patients,
allowing them to recover more quickly and with fewer psychological issues like ICU
psychosis.

1.4 Research Questions

This study specifically examined the following questions:

1. What are the advantages of the present preoperative health education

given to patients undergoing cardiac surgery at a private hospital in
Nigeria?

2. What are the shortcomings of the preoperative health education currently

offered to patients undergoing cardiac surgery in a private hospital in
Nigeria?

1.5 The Research Objectives

The objectives of this research are to:

 Describe the positive aspects of the preoperative information currently

being provided to patients undergoing cardiac surgery at a private hospital
in Nigeria.
 Describe the flaws in the present preoperative health education provided
to patients undergoing cardiac surgery at a private hospital in Nigeria.

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  To propose recommendations to remedy any deficiencies in the current
preoperative programme.

1.6 Significance of the Study

Patients undergoing heart surgery can benefit significantly from being well-
informed before their procedures. A preoperative education program may, however, be
of benefit to nurses working in hospitals. Thus, as nurses working in intensive care, it is
their responsibility to provide this education. Therefore, this research may serve as a
springboard for future studies on the effects of preoperative education for patients
undergoing cardiac surgery.

1.7 Theoretical Framework

Roy's adaptation theory of Persons as Adaptive Systems served as the basis to
guide this study (Oermann, 1991, p. 44).

Roy's theory gives a framework to analyse how people deal with and adapt to
their surroundings and experiences. The purpose of this theory is to explain why it is
essential for health workers to recognise client requests and how clients respond to
them. As a result, health practitioners need to consider how a client's physiological and
social needs are affected by demand and help the client adjust accordingly.

Thus, adaptation refers to how individuals adjust their behaviour in response to

changes in both their internal and external environments. Adaptation occurs continually,
dynamically, and in a responsive manner. According to the notion, there are three
distinct tiers on which people adapt to their environments: the individual, the group, and
the physical (biochemical reactions).

From Roy's point of view, the role of nursing is to facilitate the development of
adaptive capabilities and to release resources so that individuals can better respond to
environmental shifts. This approach classifies environmental stimuli into three broad
groups:

Focal stimuli

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 Focal stimuli are the first thing a person experiences when exposed to a
stimulus. Individuals must respond or cope with these central stimuli by taking action.
For instance, when a patient has cardiac surgery, the focal stimuli occupy their energy
and focus until action takes place to alleviate the impulses.

Contextual stimuli

Contrary to focus stimuli, contextual stimuli are outside of an individual's

immediate environment. Contextual stimuli could be the intensive care unit (ICU)
setting, where the patient stays after surgery. Pre-operative health education helps
patients adjust to their new surroundings after surgery, lowering their risk of developing
post-operative problems such as ICU psychosis and sensory overload.

Residual stimuli

Residual stimuli are potential elements that could affect aggressive, focused

stimuli. Isolation can harm a patient for various reasons, including when family members
are not present for pre-operative health education. Patients may feel more loved and
supported by their family and friends if they can visit them in the hospital.

In this framework, nursing treatments focus on stimulus management. There is a

possibility of preventing intensive care unit psychosis and other issues by letting
patients know what to expect in the intensive care unit (ICU) before surgery (Oermann,
1991, p. 44).

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 Chapter 2: Literature Review

2.1 Introduction
The forethought put into the operation will help close any loopholes and reveal
where the organisation's communication, treatment, and patient satisfaction could use
fine-tuning. The creation of standardised pre-operative orders for open heart surgery
aids in the formation of everyday practice routines that can lessen the likelihood of
mistakes, enhance the quality of instruction provided to staff, and cut down on
organisational expenses by reducing the number of superfluous tests performed.
Scripting the training is recommended when numerous care professionals are involved
in patient education to guarantee that all topics are covered similarly. Unsatisfactory
results for patients put the entire open-heart surgery initiative in jeopardy (Havrilak,
2006, p. 1).

2.2 Cardiac Surgery

Cardiovascular illnesses are still a primary cause of disability and mortality in
developed countries, despite efforts to modify and eliminate risk factors. As a result of
the development of new medicines, cardiac illness medical care has advanced.
Percutaneous transluminal angioplasty, coronary bypass surgery, and valve
replacement are all interventional procedures. Some individuals, however, continue to
favour surgical procedures (Urden et al., 2002, p. 466).

The number of people undergoing heart surgery has skyrocketed during the past
two decades, according to data compiled by Davies (2000:318). There was a 400%
increase in open-heart surgeries in the U.S. between 1979 and 1996, with 759,000
procedures performed that year. A study by the Society of Cardio-Thoracic Surgeons
(1999) indicates that 343,666 open-heart surgeries took place in the U.K. in 1997
(Davies, 2000, p. 318).

Cardiac surgery is considered a significant operation in Nigeria since it deals with

a large organ (the heart) that ends a human life if it stops working. Surgical intervention

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and preoperative care have come a long way since the mid-1970s because of  the hard
work of researchers and medical professionals. Formerly reserved for emergencies,
surgical and other intrusive procedures are now standard practice. Patients no longer
need to stay in bed for several weeks after surgery (Springhouse, 1999, p. 449).

However, preoperative care for heart surgery patients continues to be difficult,

especially in private settings. Admitting patients’ days before surgery can be challenging
due to logistical considerations such as the expense of medical aid. Because of the high
stakes involved and the high cost of heart surgery, Havrilak (2005:1) argues that it is
advisable to screen potential patients thoroughly and give them the time to learn about
and prepare for the procedure. Preoperative education that is both informative and
interactive can help patients, and their families make informed decisions and speed up
their recovery after surgery, reducing unnecessary wait times and hospitalisations.
Therefore, Davies's research (2000: 325) showed that people receiving care at a tertiary
referral centre often felt abandoned once they were no longer there.

2.3 Preoperative Preparation

Both the patient's body and mind need to be ready for surgery. It is standard
practice for the patient to undergo the same physiological preparations before any
surgical procedure. Preoperative education that is both informative and reassuring can
help patients feel more at ease during and after surgery, making it a crucial component
of patients' mental readiness for anesthesia and the procedure itself. There is evidence
that preoperative education for cardiac surgery patients improves outcomes by
educating patients and family members about what to expect, reducing stress, and
encouraging them to take an active role in their recovery (Milander & Bucher, 1999, p.
313). Dread and worry are common emotions patients experience during hospitalization
before cardiac surgery. Thus, patients’ anxiety is reduced owing to pre-op nursing care
(Stengrevics, Sirois, Schwartz, Friedman & Domar 1996:471). In nursing, social support
in education, emotional connection, and material aid are all used to reduce patients'
anxiety and dread (Fortner, 1998, p. 3).

The preoperative period begins when surgical intervention is required. Once the
patient has arrived in the operating room and passed to the operating room staff, this

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stage is complete. The intraoperative period starts when the patient lies on the bed.
This time frame continues until the patient moves to the recovery area. The
postoperative period begins with a patient's arrival in the recovery room and concludes
with a checkup at home or a clinic. The nurse's role is the same throughout all three
stages (Phipps et al., 1999, p. 470).

Providing high-quality patient care is only possible with effective communication

between all parties involved in the surgical process (Crawford, 1999, pp. 12-15).
Patients undergoing open-heart surgery can benefit from a more streamlined post-
admission process and fewer complications if they experience a thorough pre-
admission screening. Organisations should prioritise thorough candidate evaluation,
education, and clinical and psychological preparation for heart surgery due to its high
price tag and difficulty. These actions contribute to the programme's overall success
(Havrilak, 2005, p. 1).

2.4 Preoperative Visit

During a preoperative visit, a patient sits between being admitted to the operating
room and being escorted there. However, most people walk into medical facilities like
operating theatres or hospitals with irrational worries and anxiety. Their fear is justified
because they are uninformed about their medical condition and the nature of the
operation that will take place on them. These worries linger, which constitute a
significant factor in why post-op recovery is not always easy (Mott, 1999). Preoperative
visits from the intensive care unit nurse should occur regularly, and sufficient facilities
should be maintained (Koivula et al., 2002, p. 418). Reducing the need for analgesics
after surgery is one of the many benefits of thorough mental preparation before the
procedure (Kalideen, 1991, pp. 19-22).

Nonetheless, nurses can help patients cope with potentially life-threatening

situations by providing information that is both factual and concrete (Clark, 1997, pp.
147-155). To reduce stress, knowledge alone is insufficient. Before surgery, patients
and their families have a right to a wide range of information (Koivula et al., 2002, p.
419).

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 Levey et al. (2005:6) found that preoperative education for the patient and family
was critical for postoperative recovery. The study specifically looked at data on the
adverse effects of the therapy, alterations in physical condition, risk factors, healing, and
awareness of the disease. There was a wide range of pedagogical approaches used.
Group teaching seminars for non-urgent patients, written educational materials, and
videos outlining the surgery and recovery period were all included. Thus, to prepare
patients for what to expect following surgery, Jaarsma et al. (1995:25) suggest that an
intensive care unit (ICU) tour become part of preoperative training programmes.
Furthermore, Parent and Fortin's (2000:389) study found that preoperative anxiety
about cardiac surgery decreased after patients and family members learned what to
expect.

2.5 Stressors
Insufficient knowledge causes stress and anxiety, so disseminating facts is
recommended to calm people down (Teasdale, 1993, p. 1125). Acceptance of
hospitalisation and the potential of surgery causes significant anxiety (Teasdale, 1995,
p. 79). Patients in intensive care fear being in pain, having tubes inserted into their
mouths, being thirsty, and being sleepless (Cochran & Ganong, 1989, p. 1038). Thus,
patients on a ventilator experience anxiety and dread of death (Halm & Alpen, 1993, p.
443). Overwhelming stress is also counterproductive to healing (Stengrevics et al.,
1996, p. 471).

Anxiety in cardiac patients can diminish with an organised counseling

programme, both in the short and long term (Mott, 1999, p. 41). There is a significant
increase in worry, depression, irritability, and difficulty sleeping among the relatives of
patients undergoing cardiac surgery (Bengtson et al., 1996, p. 257). However, research
findings on the impact of patient education and social support on patients' anxieties are
contradictory (Linden, Stossel & Maurice 1996:843). Thus, the adjustment period
preceding surgery is often fraught with fear and apprehension (Bergmann et al., 2000,
p. 2).

Helplessness, impairment anxieties, the procedure's importance, fears of dying,

post-operative pain, and the look of incisions are some additional concerns that may

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arise (King, 1985, p. 579). Stressors are external factors that threaten an individual's
ability to function normally and make sense of their experiences. Patient stress factors
include noise, sleeplessness, social isolation, compelled immobility, and pain following
surgery (Rakoczy, 1977, p. 280). A severe disease necessitating hospitalisation in an
intensive care unit generates predictable pressures (Wilson, 1987, p. 267). Pain,
disconnection from support systems, death-related fear, and anxiety are all features of a
disease that can contribute to emotions of vulnerability. The milieu of intensive care
might lead to decompensation and inadequate coping.

Radwin (1987:258), in a summary piece on acute pain patients, cites

considerable research showing that patients who learn about the probable pain and
discomfort of future procedures and pain-reduction strategies report less subjective
pain. Patients have reported success in reducing the amount of analgesic medication
they require and the duration of their hospital stay in certain instances. Furthermore,
patients might feel less fear and more in charge of their situation when they are well-
informed on the procedures and sensations they can expect during their impending
therapies; this is also an illustration of facilitating problem-focused coping.

2.6 Education
Previous studies have shown that cardiac patients place a high value on the love
and care of their families (Lamarche et al., 1998, p. 390). As a result of the patient's
anxiety, the spouse may require some assistance and explanations (Stewart et
al., 2000, p. 1351). Thus, the status of the next of kin must improve in the preoperative
phase.

According to research by Koivula et al. (2000:437), nurses can significantly

impact cardiac surgery patients' health by reducing their anxiety and stress. Those who
suffer from extreme anxiety and fear would benefit from receiving lots of social support
and information. Appointments for pre-admission testing and extensive preoperative
instruction are typically organised well before the anticipated operation date: this allows
for sufficient time to evaluate the patient's rest data and to educate the patient on a
comprehensive range of topics (Koivula et al., 2000).

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 There is no substitute for a comprehensive preoperative education session for
patients undergoing any surgical procedure. Step one in any educational endeavour
should be identifying the stakeholders involved. Cardiovascular unit staff nurses, clinical
nurse specialists, and cardiac care coordinators are all excellent candidates for this role.
When a team of healthcare professionals is responsible for educating patients on their
condition, it is also best to follow a script to maintain uniformity. Although the patient
education session ought to be quick so as not to frighten the patient, it must go over
significant aspects of the patient's care, such as monitoring, invasive lines, tubes, and
alarms (Havrilak, 2000, p. 2).

Spouses can better help their surgically-treated partners after receiving reports of
higher satisfaction and decreased worries following treatment specific to the individual's
and the family's needs (Davey et al., 1990, p. 373).  Patients may not be as responsive
to instruction while experiencing discomfort, anxiety, or lack of sleep. It is crucial to help
the patient understand that their emotions are normal (Levey et al., 2005). However,
patients undergoing surgery may benefit from social support from their peers who have
been through the procedure. A possible method of reducing fear, enhancing efficacy
expectations, and boosting self-reported activity is one-on-one support from prior
surgical patients to those who are now undergoing the same procedure (Davey et al.,
1990, p. 373).

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16
 Chapter 3: Research Design and Method

3.1 Research Design

According to Burns and Grove (2001: 795), the design "serves as the study's
framework." The study design aids the researcher in preparing for and carrying out the
survey necessary to provide insights into the research topics. Accordingly, the
researcher employed a quantitative descriptive approach for this study. Due to the
statistical presentation of data as percentages and frequencies, this design decision
reflected this consideration. Below is a comprehensive description of the design.

3.1.1 Quantitative Design

For a study to be considered quantitative, it must employ numerical measures to
collect and analyse its results (Polit & Hungler, 1997, p. 466). A quantitative study's
research design details the procedures the investigator will follow to collect reliable and
meaningful data (Polit & Hungler, 1997, p. 153).

3.1.2 Descriptive Design

Description entails identifying and comprehending the nature of nursing
phenomena and, in some instances, the relationships between the phenomena (Burns
& Grove, 2001, p. 4).

 A descriptive research design may be implemented in a study when:

 The researcher chooses an area of study and defines the phenomena of
interest and its variables.
 The researcher creates both conceptual and practical definitions of the
variables;
 The researcher defines the study's variables.

In Burns and Grove's (2001:30) words, "the description of the variables leads to
an interpretation of the finding's theoretical meaning. It also gives knowledge of the
variables and the study population that may prove useful for future research in the field."

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Developing theory, identifying difficulties with practice, justifying the existing approach,
making judgments, or finding out what others are doing in comparable situations are all
examples of when a descriptive study design would be appropriate, as outlined by Waltz
and Bausell (1981). Descriptive research methods paint a detailed picture of an
individual, condition, or group. Thus, to explain the pre-operative health education
provided to patients undergoing cardiac surgery, this study adopted a descriptive
methodology.

3.2 Population and Sampling

3.2.1 Population
The population consists of any or all elements or subjects that fulfill the
requirements (Burns & Grove, 2001, p. 806). Thus, patients who have undergone
cardiac surgery constituted the study population.

3.2.2 Sample
The term "sample" refers to a fraction of the population intentionally chosen to
participate in a study (Burns & Grove, 2001, p. 810). However, purposive sampling is
the method employed for this study. Patients who meet the criteria for selection
participated in this sample due to using predetermined selection criteria. Purposive
sampling is frequently employed when examining under-represented segments of the
population. Therefore, patients undergoing postoperative cardiac surgery at a private
hospital in Lagos, Nigeria, would be included in the study.

The criteria for inclusion included the following:

 The patient must have undergone cardiac surgery.

 The patient must have undergone cardiac surgery.
 The patient must have received pre-operative counseling.

3.3 Data Collection Instrument

The researcher created a checklist containing closed and open-ended questions
as a study instrument. Its purpose was to gather information about the pre-operative
education given to patients undergoing cardiac surgery at this private hospital. A

18
checklist, as per Treece and Treece (1986:353), is a set of questions in which
respondents confirm their participation in a particular activity and is used to guarantee
that no task is left undone. Thus, checklist questionnaires have many advantages,
including low resource requirements (pen and paper), adaptability, and categorical
results (subjects actively participate or not).

3.4 Reliability and Validity

3.4.1 Reliability
An instrument's reliability is determined by how consistently it measures an
attribute (Polit & Hungler, 1997, p. 295). A technique's reliability is determined by
whether it consistently produces the same outcome repeatedly when applied to the
same object. In the same way as precision does not guarantee the accuracy, neither
does reliability. Even if our measurements are 100% accurate, it does not mean they
are measuring the things we think they are measuring (Babbie, 1995, p. 124).

3.4.2 Validity
The term "validity" describes how well a measuring device measures the target
variables (Polit & Hungler, 1997, p. 229). The extent to which findings accurately reflect
reality and the subjects under study is known as internal validity (Burns & Grove, 1997,
p. 230). Thus, validity can be determined using various criteria, including face validity,
criterion-related validity, content validity, and construct validity (Babbie, 1995, p. 129).
To ensure the reliability of the data in this study, the researcher urged the patients to be
completely honest when filling out the questionnaires.

3.5 Data Analysis

The research methodology for this study relies on descriptive statistics, and the
findings will be analysed and presented using frequency and percentage distributions.
Accordingly, data analysis involves looking for patterns of similarity and difference and
then giving meaning to those patterns (Babbie, 1995, p. 303).

19
 3.6 Ethical Considerations
The researcher protected all participants' rights. In writing, consent was obtained
from patients, and their identities were kept confidential. The study's rationale and
parameters were made clear by the researcher. No participants or the institution
involved in the study will pay a fee because of this research. In addition, there was no
financial compensation for participating in the study. 

4.0 Conclusion
This background knowledge demonstrates the urgent need for further study in
this area. Before, during, and after cardiac surgery, patients and their loved ones face
unique concerns. Thus, this quantitative descriptive study aimed to determine whether
pre-operative education improved patient outcomes for cardiac surgery patients.
Following extensive research, a data-gathering checklist arose. In this study,
participants completed questionnaires under close supervision at a single hospital. The
researcher's objective was to restrict extraneous variables. To compensate for the
limited size of the sample, the researcher took extra measures to ensure the integrity of
the data, such as developing precise and repeatable inclusion criteria.

20
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