Journal of Psychosocial Nursing and Mental Health Services

Original Article 

Effect of a Solution-Focused Approach on Self-Efficacy and Self-Esteem in Turkish Adolescents With Attention Deficit/Hyperactivity Disorder

Dudu Karakaya, PhD; Gönül Özgür, PhD

Abstract

The aim of the current research was to evaluate the effect of a solution-focused approach on levels of self-efficacy and self-esteem in adolescents with attention-deficit/hyperactivity disorder (ADHD). A mixed design was used, where the quantitative aspect was a randomized controlled study and the qualitative aspect was a case study design. Adolescents with ADHD (N = 41) were randomized into intervention or control groups. Control groups received existing treatment in outpatient clinics, whereas interviews based on a solution-focused approach were conducted with the intervention groups. After the interventions, differences were noted between groups with time, self-efficacy, and self-esteem, with increases in self-efficacy and self-esteem. Significant differences were found between postintervention and follow-up scores. Six themes were determined in the qualitative findings. Nurses in the adolescent mental health field can use the principles and techniques of the solution-focused approach when providing care. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Abstract

The aim of the current research was to evaluate the effect of a solution-focused approach on levels of self-efficacy and self-esteem in adolescents with attention-deficit/hyperactivity disorder (ADHD). A mixed design was used, where the quantitative aspect was a randomized controlled study and the qualitative aspect was a case study design. Adolescents with ADHD (N = 41) were randomized into intervention or control groups. Control groups received existing treatment in outpatient clinics, whereas interviews based on a solution-focused approach were conducted with the intervention groups. After the interventions, differences were noted between groups with time, self-efficacy, and self-esteem, with increases in self-efficacy and self-esteem. Significant differences were found between postintervention and follow-up scores. Six themes were determined in the qualitative findings. Nurses in the adolescent mental health field can use the principles and techniques of the solution-focused approach when providing care. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Attention-deficit/hyperactivity disorder (ADHD) is a mental illness frequently seen in childhood and adolescence characterized by attention deficit, hyperactivity, and impulsivity (American Psychiatric Association, 2013). According to meta-regression analyses, worldwide frequencies of ADHD vary between 5.29% and 7.1% in children and adolescents and between 1.2% and 7.3% in adults (ADHD Institute, 2018).

ADHD can start before school age and last until adulthood, and it can present at any stage of life. Children and adolescents with ADHD have difficulties in interpersonal relationships and academic performance due to their learning difficulties, behavioral problems, and peer refusal, and are frequently stigmatized and excluded by their peers and family members (Houck, Kendall, Miller, Morrell, & Wiebe, 2011). These difficulties experienced by children and adolescents affect self-concept and self-esteem (Townsend, 2009). Self-esteem is defined as confidence in one's own worth or abilities (Rosenberg, 1965). Studies have shown that self-esteem is low in children and adolescents with ADHD (Göker, Aktepe, & Kandil 2011; Kanay & Girli, 2008; Shaw-Zirt, Popali-Lehane, Chaplin, & Bergman, 2005).

Studies have also shown how ADHD affects self-efficacy levels of individuals. Self-efficacy is defined as the belief that a person can successfully perform the necessary behaviors that can produce the desired results in a particular context (Bandura, 1986). In a study by Tabassam and Grainger (2002), a comparison was made between groups with and without learning difficulties and ADHD in terms of self-efficacy, self-esteem, and bonding styles. Self-efficacy and self-esteem of groups with learning difficulties and ADHD were found to be significantly lower. In a study of adults with and without ADHD by Newark, Elsässer, and Stieglitz (2016), self-efficacy and self-esteem of the group with ADHD was significantly lower than that of the control group. It was recommended that interventions to develop self-esteem and self-efficacy be implemented in treatment programs planned for these individuals.

A solution-focused approach was developed in America by de Shazer and Berg (1997), which was described as a “child-friendly approach” (Lethem, 2002, p. 191). This approach focuses on personal strengths and past successes rather than past problems and lack of success, aiming to talk about solutions while avoiding talking about problems and producing solutions rather than solving problems (de Shazer et al., 2006; Macdonald, 2007; Sklare, 2012). The main therapeutic function of the approach is to show how a person can think differently and how these ideas can be applied in real life. The approach is suitable for individual and group interventions. Many therapeutic communication techniques, such as listening, empathizing, asking open-ended questions, providing support, encouraging speech, defining objectives, and scaling, are used in this method (Sklare, 2012). The first interview is important, as the treatment process starts immediately and no detailed history is taken (de Shazer et al., 2006; Macdonald, 2007). Studies show that a solution-focused approach can be used in mental health institutions, inpatient mental health clinics, schools, prisons, social work institutions, universities, and family clinics (Macdonald, 2007).

The results of systematic review and meta-analysis studies performed to evaluate the effectiveness of the solution-focused approach have shown that the method is effective and provides positive results (Corcoran & Pillai, 2009; Gingerich & Peterson, 2013; Kim, 2008; Kim et al., 2015; Woods, Bond, Humphrey, Symes, & Green, 2011). In a systematic review by Woods et al. (2011), it was found that the best developments providing evidence after the intervention of a solution-focused approach were in behavioral problems externalized by children, such as child and adolescent aggression and truancy, and internal behavioral problems, such as shyness, anxiety, depression, and low self-esteem and self-efficacy. According to a meta-analysis by Kim (2008), a solution-focused approach had a positive effect on internalized behavioral outputs such as depression, anxiety, self-image, and self-esteem (d = −0.46 to 1.18). Similarly, in another meta-analysis evaluating the effect of a solution-focused approach on mental health, the effect size of the method for internalized behavioral problems was large (g = 0.49 to 3.22) (Kim et al., 2015).

Examining the current literature in Turkey, only two studies could be found in which a solution-focused approach was used in the field of nursing. In a retrospective study by Bilge and Engin (2016) on the effectiveness of a solution-focused consultation process based on Peplau's theory of interpersonal relations, a five-session solution-focused therapy approach was applied to university students. After therapy, students' anxiety, depression, and problem-solving score averages decreased significantly. Sari and Günaydin (2016) investigated the effects of depression and coping training based on a solution-focused approach and found significant positive differences in favor of the intervention group.

Due to the limited research in Turkey on the solution-focused approach in nursing, as well as lack of studies performed with adolescents with ADHD, the current study sought to use the solution-focused approach to raise levels of self-esteem and self-efficacy in adolescents with ADHD. Integration of a solution-focused approach could help guide practice and research in psychiatric nursing. Thus, the aims of the current study were to: (a) investigate the effect of the solution-focused approach on self-efficacy and self-esteem in Turkish adolescents with ADHD; and (b) determine the experiences of Turkish adolescents regarding the interview process to evaluate its effectiveness based on the solution-focused approach. The two study hypotheses were: (a) self-esteem and (b) self-efficacy of adolescents with ADHD in whom a solution-focused approach has been applied will show a significant difference in pre- and postintervention levels compared to adolescents with ADHD in a control group.

Method

A mixed design of qualitative and quantitative research methods was used in the current study. The quantitative aspect comprised a single-blind randomized controlled experimental study (Figure 1). The qualitative aspect was a case study design that examined the effectiveness of the interviews (i.e., whether they had achieved their purpose) and personal experiences of adolescents regarding the interview process and their evaluations of the interviews (Yildirim & Simsek, 2004). The study was conducted at the Children and Adolescent Mental Health Outpatient Clinic of Akdeniz University between March 2015 and April 2016. In the clinic, adolescents with ADHD receive only drug treatment (i.e., no psychosocial interventions are applied).

CONSORT diagram showing participant flow through the study.

Figure 1.

CONSORT diagram showing participant flow through the study.

Population and Sample

The study population comprised adolescents with ADHD between ages 12 and 18 (mean age = 13.2 years). The sample for the quantitative aspect comprised 41 adolescents, 22 in the intervention group and 19 in the control group, who met inclusion criteria. The sample for the qualitative aspect comprised the 22 adolescents in the intervention group.

Of participants, 80.5% were boys and 19.5% were girls, with 87.8% being primary school students and having a nuclear family, respectively. All adolescents stated that they used medication for ADHD. The mean duration of psychostimulant drug use was 26.24 months, and the mean follow-up period related to ADHD was 41.88 months (Table 1).

Participant Characteristics

Table 1:

Participant Characteristics

Inclusion criteria were: receiving treatment for a diagnosis of ADHD; age between 12 and 18; residing in the city center; and willing and voluntary participation in the study. Exclusion criteria were hearing or vision problems and any hindrance to cognitive perception. Criterion for removal from the sample was non-participation in two or more of the six interviews.

Randomization and Blinding

At the beginning of the study, adolescents between ages 12 and 18 receiving treatment for ADHD were determined using physician appointment records and psychostimulant drug prescriptions. A total of 101 adolescents were identified; all were telephoned or interviewed in-person when they came to the clinic and assessed according to inclusion and exclusion criteria. Forty-one adolescents met the inclusion criteria and constituted the research sample.

In previous studies, the female/male ratio of individuals with ADHD has varied between one forth and one ninth (Ercan, 2010), and because differences in self-esteem by gender have been found (Kling, Hyde, Showers, & Buswell, 1999), stratified randomization was performed in the current study based on gender.

The closed envelope method was used for randomization. Envelopes were opened in order as each of the 41 participants came to the clinic. One-way blinding was performed by preventing adolescents from knowing whether they were in the intervention or control group. Following randomization, no differences between adolescents in the two groups were noted in terms of sociodemographic characteristics, duration of medication use, or duration of follow up at the clinic.

The dropout rate in the intervention group was 4.5% and 10.5% in the control group, or 7.3% overall. Due to dropouts in the intervention group, an Intention to Treat (ITT) analysis was performed. The mean method was used, with the mean of the sample followed for missing data (Del Re, Maisel, Blodgett, & Finney, 2013). Study data were presented along with the results of ITT analysis. The effect size of the study was 0.98 according to self-esteem scores at follow up, and the power of the study was 0.92.

Intervention

Intervention Group. Before the intervention, an interview plan and guide were created, taking into account the basic principles, intervention recommendations, and methods of the solution-focused approach. Table A (available in the online version of this article) shows the stages and special techniques in the interviews based on the solution-focused approach (de Shazer & Berg, 1997; de Shazer et al., 2006; Macdonald, 2007; Sklare, 2012). In a meta-analysis by Kim (2008), it was found that in interviews based on a solution-focused approach, more effective results were obtained when there was an average of six sessions; therefore, the current program comprised six sessions. Each interview was approximately 45 to 60 minutes.

Interview Stages and Special Techniques of the Solution-Focused ApproachInterview Stages and Special Techniques of the Solution-Focused ApproachInterview Stages and Special Techniques of the Solution-Focused Approach

Table A:

Interview Stages and Special Techniques of the Solution-Focused Approach

Interviews were conducted in addition to routine treatment and follow up in the clinic. Interviews were conducted over a period of 6 weeks, 1 day per week, individually and face-to-face. During the interview, the researcher took notes. Audio recordings were also obtained; however, they were not used in the data analysis. Measurement instruments were completed a total of three times: before beginning the interviews and at Weeks 6 and 12 after they were completed.

Control Group. Measurement instruments were completed by adolescents at the first meeting and Weeks 6 and 12. During this time, treatment and follow up continued in the clinic. After the measurement process was completed, solution-focused interviews were conducted with adolescents who requested them.

Data Collection

Quantitative data collection was achieved using a Personal Information Form, the General Self-Efficacy Scale (GSE), and the Rosenberg Self-Esteem Scale. Documents written by adolescents themselves when answering questions that were posed at the end of each interview were used to collect qualitative data.

Personal Information Form. This form was prepared by the researcher according to the literature and comprised nine questions regarding sociodemographic information (e.g., age, gender, educational level, family type, mother and father's education level), drug treatment, and monitoring information (e.g., duration of follow up in the clinic).

General Self-Efficacy Scale. The GSE was developed by Schwarzer and Jerusalem (1995). Turkish validity and reliability studies were performed by Aypay (2010) with a Cronbach's alpha coefficient of 0.83. The GSE is a 4-point Likert-type scale comprising 10 items, with statements intended to evaluate the extent to which individuals perceive themselves as adequate in coping with difficulties. The scale can be used in individuals age 12 or older. Scores range from 10 to 40, with higher scores indicating higher self-efficacy (Aypay, 2010). Cronbach's alpha coefficients in the current study were 0.82 for preintervention, 0.89 for postintervention, and 0.88 for follow up.

Rosenberg Self-Esteem Scale. The Rosenberg Self-Esteem Scale was developed in 1963 to evaluate self-esteem (access http://www.yorku.ca/rokada/psyctest/rosenbrg.pdf). Validity and reliability testing of the Turkish version, developed specifically for the adolescent age group, was performed by Çuhadaroglu (1986). The validity coefficient was found to be 0.71, and the reliability coefficient to be 0.75. The scale comprises 63 items and 12 sub-scales. The first 10 items are the sub-scale for self-esteem (Göker et al., 2011). The scale can be evaluated in different ways. In the current study, the method used was to score positive statements positively and negative statements negatively. Thus, scores range from 0 to 30, with higher scores indicating higher levels of self-esteem. In the current study, Cronbach's alpha coefficients were 0.85 for preintervention, 0.90 for postintervention, and 0.87 for follow up.

Adolescents' Written Documents. In the last 10 minutes of each interview, a handout was given to adolescents containing questions regarding the interview that were to be answered while a message was prepared for the adolescent. The message was to remind adolescents of their strengths and summarize the interview. The message comprised three parts: praise, establishment of relations between situations, and tasks (Sklare, 2012). The records enabled immediate evaluation of the interview.

At the first five interviews, the following statements and questions were to be addressed:

  • Please write your thoughts concerning today's interview.
  • What did you see in today's interview that related to you or your life?
  • What are you successful or good at?

At the sixth interview, the following statements or questions were to be addressed:

  • Please write your thoughts concerning our 6 weeks of interviews.
  • What did you see in our 6 weeks of interviews that related to you or your life?
  • If you were to compare our 6 weeks of interviews with something, what would it be? Why?

Data Analysis

Statistical analysis was performed using SPSS for Windows version 21.0. Continuous numerical variables were expressed by mean and standard deviation and categoric variables by number and percentage. The Shapiro–Wilk test was used to determine whether the continuous numerical variables conformed to normal distribution. The existence of a difference between the intervention and control groups in terms of continuous numerical variables was examined by t test in independent groups. The chi-squared test was used to evaluate whether a difference existed between the intervention and control groups with regard to categoric variables. Interaction over time and between groups in terms of self-esteem and self-efficacy mean scores were examined with repeated measures analysis of variance (ANOVA). Independent sample t test was used to compare mean self-esteem and self-efficacy scores of adolescents in the intervention and control groups at preintervention, postintervention, and follow up. The significance level was set at p < 0.05. Effect Size (Cohen's d) Calculator for Student t-Test (access https://www.danielsoper.com/statcalc/calculator.aspx?id=48) was used to calculate the effect size, and Post-hoc Statistical Power Calculator for Student t-Test (access https://www.danielsoper.com/statcalc/calculator.aspx?id=49) was used to calculate the power of the study. The descriptive analysis method was used to evaluate the qualitative data (Yildirim & Simsek, 2004).

Rigor and Trustworthiness

In qualitative aspects of research, a number of measures are taken for rigor and trustworthiness. At the end of each interview, the documents written by adolescents were read out loud by the researcher and the adolescents' written responses were clarified. In addition to the researchers, an instructor in the field of psychiatric nursing also read and evaluated adolescents' statements and made suggestions.

Ethics

Before commencing the study, ethical committee approval was obtained from the Ethics Committee of Ege University Nursing Faculty, and written institutional permission was obtained from the unit where the research was conducted. Before the study, information was provided orally and in writing to adolescents and their parents, and informed consent was obtained from adolescents and parents. Permission to audio record the interviews was obtained from adolescents.

Results

Quantitative Results

The Shapiro–Wilk test confirmed a normal distribution for all measurements (p > 0.05). According to the results of the repeated measures ANOVA, there was a difference in mean self-esteem scores of adolescents with time and between groups. Interaction between time and group was statistically significant (time: F = 45.09, p ≤ 0.001; group: F = 7.52, p ≤ 0.001; time × group: F = 26.91, p ≤ 0.001) (Figure 2). Mean general self-efficacy scores of adolescents were found to differ with time and between groups. Interaction between time and group was statistically significant (time: F = 21.00, p ≤ 0.001; group: F = 10.78, p = 0.002; time × group: F = 17.41, p ≤ 0.001) (Figure 3).

Adolescents' self-esteem scores over time.

Figure 2.

Adolescents' self-esteem scores over time.

Adolescents' self-efficacy scores over time.

Figure 3.

Adolescents' self-efficacy scores over time.

Table 2 shows the independent groups t test performed to compare mean self-esteem and self-efficacy scores at preintervention, postintervention, and follow up of the intervention and control groups. Although no statistically significant differences were found between self-esteem scores of adolescents in the intervention and control groups preintervention (t = −0.868, p = 0.391), there were statistically significant differences in favor of the intervention group postintervention (t = 5.727, p ≤ 0.001) and at follow up (t = 3.142, p = 0.003) (Table 2). Self-esteem scores of adolescents in the intervention group increased significantly postintervention and at follow up compared with adolescents in the control group. For self-esteem scores, the effect size of the mean score of adolescents in the intervention and control groups was calculated as 0.27 preintervention, 1.77 postintervention, and 0.98 at follow up (Table 2).

Comparison of Self-Esteem and Self-Efficacy Scores of Adolescents with ADHD (N = 41)

Table 2:

Comparison of Self-Esteem and Self-Efficacy Scores of Adolescents with ADHD (N = 41)

In addition, no statistically significant difference was noted between preintervention self-efficacy scores of adolescents in the intervention and control groups (t = −0.579, p = 0.566), but a significant difference was found between postintervention (t = 5.806, p < 0.001) and follow up (t = 3.767, p = 0.001) in favor of the intervention group (Table 2). Postintervention and follow-up self-efficacy scores of adolescents in the intervention group increased significantly compared with adolescents in the control group. The effect sizes for general self-efficacy scores of adolescents in the intervention and control groups were 0.18 preintervention, 1.78 postintervention, and 1.18 at follow up (Table 2).

Qualitative Findings

Six themes were derived from the adolescents' written documents that were completed at the end of the interviews.

Theme 1: Adolescents' Immediate Evaluation of the Interviews. At the end of the first interview, adolescents stated the interview went well, that they were happy, that describing themselves to another person relaxed them, and that they had introduced themselves and got to know the other person. “Today's interview went very well. We talked about what kind of person I was, it went very well and very enjoyably because we kept on talking about me” (13-year-old boy).

At the second and later interviews, adolescents stated that they were very happy because they could explain themselves and share and solve their problems. “Everything was better than I expected. Everything's got better in my life. I think it's going to be very nice, because my mum and dad aren't angry with me anymore” (12-year-old boy).

Adolescents stated that after the interviews they believed relations with their family and schoolwork would improve, their levels of awareness of themselves and their surroundings would increase, and they would try and succeed at things. “Today's interview was good because I'm on the way to developing myself. I can see that I'm getting better at school. I'm discussing what I'm good or bad at, and I'm sharing my progress” (12-year-old boy).

Theme 2: Adolescents' Immediate Evaluation of Their Awareness of Themselves and Their Lives. Adolescents stated that they had developed an awareness of characteristics of themselves and their personalities that needed to be developed, such as increases in self-confidence, the belief that they could succeed, and the ability to express themselves. They also stated that they had developed an awareness of their families and their surroundings. “I've noticed my interest in myself and my confidence in myself. I can explain myself and I can solve my problems” (12-year-old boy). “I feel very happy, I love my brother, and I love my mum and dad. I can see that I've succeeded at some things. When you want to do something, you can do it” (12-year-old boy).

Theme 3: Adolescents' Views on What They Were Good At or Successful. Boys mostly stated that they were successful at football, basketball, swimming, cycling, computer games, and in technological fields, whereas girls mentioned music, drawing, poetry, calligraphy, and caring for animals. Among the areas in which adolescents saw themselves as good or successful, individual personality characteristics, responsibilities, and interpersonal relations were noted. “Things I'm successful and good at are football, basketball, social studies lessons, computer games, being mature, and thinking about people” (13-year-old boy). “Areas I'm good at are music, playing an instrument, drawing, writing poetry, some kinds of sport, expressing myself, looking after animals, my relations with people, establishing empathy, understanding what people say and solving their problems, cleaning my room, and helping my mother” (16-year-old girl).

Theme 4: Adolescents' Evaluation of the 6 Weeks of Interviews. All adolescents stated that the 6 weeks of interviews had passed in a positive way and that they had been useful. They stressed that being able to speak and express their problems had relaxed them, and they mentioned that the interviews were enjoyable and that they had derived pleasure from them. In addition, they reported that they had experienced such results during the interview period as an increase in success at schoolwork, an improvement in relations with their family, knowing themselves, the ability to develop positive thoughts, self-development, thinking positively about themselves, and being successful at the things they wanted. “At the end of the 6 weeks of interviews, my thoughts about myself have changed. I can speak, I can explain my difficulties in front of other people, and I can solve my problems. My interest in classes has changed. I can change things relating to myself” (12-year-old boy). “All through the 6 weeks of interviews I explained myself, and I found new ideas. I realized I could make my own decisions. I saw that I could be successful when I tried” (13-year-old boy).

Theme 5: Adolescents' Evaluation of Their Awareness of Themselves and Their Lives in the 6 Weeks of Interviews. Adolescents mentioned that the interviews had helped them get to know themselves and discover and use positive aspects of themselves that had existed but which they had not been aware. In addition, the interviews brought out their love and attachment for their families and made them realize that they could get along with them better. Some adolescents stated that after the 6 weeks of interviews they could see the positive aspects of bad events and looked at the future positively, emphasizing that it strengthened their belief that they could be successful if they wanted to be. “Even though I saw myself as a boring person, I have realized that I am fun-loving. I have seen that I can do things that a lot of people can't do. I have realized that I am accommodating and sensitive” (12-year-old boy). “I have confidence in myself, and I've increased my self-confidence. I'm not very brave, but I've increased my bravery. I've seen that I can succeed at what I want. I used to be shy, but I've got over it” (15-year-old girl).

Theme 6: Adolescents' Comparisons of the 6 Weeks of Interviews. Although adolescents compared the interviews to different things, their reasons had a common point. They compared the 6 weeks of interviews to such things as “a box of secrets,” “a box of knowledge,” “an enjoyable school,” “a game,” “waves washing over you,” “a class that gives you the chance to express yourself,” “a mirror,” “Facebook®,” “a teacher,” “cooperation,” “a brother,” “a sportsman,” and “a story and a film.”

The principal comparisons that adolescents made regarding the interviews can be ranked as learning positive aspects, learning responsibilities, control and development of themselves, sharing and solving problems, seeking help, developing strategies, advancing, succeeding, the chance to express themselves, and knowing themselves. “I would compare the interviews to a box of secrets, because I learned positive aspects of myself that I didn't know made me into myself” (13-year-old boy). “I would compare the interviews to a story and a film. That's because I overcame everything, and we achieved good things” (12-year-old boy). “I would compare the 6 weeks of interviews to a sportsman, because before, you don't know anything. You get unhappy from not being able to do something. But as time goes on, you make an effort, you rely on yourself, you learn everything, and you overcome all obstacles” (15-year-old girl).

Discussion

The current study investigated effects of interviews based on a solution-focused approach on adolescents with ADHD. Examining the self-esteem scores of adolescents, although there was no statistically significant difference between preintervention scores of the intervention and control groups (p > 0.05), postintervention and follow-up scores were statistically significantly different (p < 0.05). Adolescents in the intervention group showed an increase of 8.78 in postintervention and 6.91 in follow-up measurements of self-esteem. These increases in self-esteem scores were evaluated as a positive result of the interviews. These results show that the interviews based on a solution-focused approach were effective in increasing adolescents' self-esteem and confirmed one of the hypotheses of the research—self-esteem of adolescents with ADHD to whom a solution-focused approach has been applied will show a significant difference from that of adolescents with ADHD in a control group.

To strengthen self-esteem, nursing interventions are recommended in the literature such as helping children and adolescents set realistic goals, focusing on personal strengths, helping plan activities that give a feeling of success, and providing unconditional acceptance and positive feedback for successes (Moyet-Carpenito, 2012; Townsend, 2009). In the current study, interviews based on a solution-focused approach were acceptable as a suitable instrument for applying these recommended nursing interventions.

In the interviews conducted with adolescents in the intervention group, many of the techniques particular to the solution-focused approach were used. The first and most important of these was the formation of well-defined goals (de Shazer et al., 2006; Macdonald, 2007; Sklare, 2012). At this stage, realistic, attainable, and measurable goals were set in the context of the adolescent's own life. To reach this goal, support was given for the formation of a road map, and techniques were determined such as coping questions, cheerleading, scaling questions, and exceptional circumstances. These techniques of the solution-focused approach made it easier to practice the nursing interventions recommended to increase self-esteem in adolescents.

In a scan of the literature, no study was found that examined self-esteem in adolescents with ADHD using the principles of the solution-focused approach. At the same time, the solution-focused approach was seen to produce positive results in adolescents in other studies. In a randomized controlled trial performed with adolescents with learning difficulties, Daki and Savage (2010) found that the solution-focused approach had positive effects in 26 of 38 measurement instruments. In Iran, highly significant positive results were obtained in the domestic, health, and social adjustment of adolescents in whom the solution-focused approach was applied (Hosseinpour, Jadidi, Mirzaian, & Hoseiny, 2016). In a systematic review, Bond, Woods, Humphrey, Symes, and Green (2013) found that interventions performed using a solution-focused approach with children and adolescents resulted in positive developments in external behavioral problems such as aggression, obstructive behavior, and truancy and internal behavior problems, such as shyness, anxiety, depression, self-esteem, and self-efficacy. In studies performed in Turkey, a solution-focused approach also provided positive results with adolescents. Siyez and Tan Tuna (2014) found that a solution-focused psychoeducation program was effective with adolescents in reducing state anger, expressing anger, and keeping anger in. Ates and Gençdogan (2017) found that psychological counseling with a solution-focused group was effective in coping with social phobia in university students. Arslan and Akin (2016) investigated the effect of a solution-focused approach on peer bullying and showed that peer bullying levels among adolescents in the intervention group decreased and were maintained in follow-up measurements. Positive effects of the solution-focused approach were shown in adolescents in the current study, which also showed positive effects on self-esteem.

Qualitative data of the current study also suggested that the interviews based on a solution-focused approach were effective in increasing adolescents' self-esteem. Statements made by adolescents in the intervention group are related to self-acceptance and self-efficacy, reflecting the common characteristics of self-esteem. In their evaluation of the interview process, adolescents stated they had got to know themselves and discovered positive aspects of themselves. In addition, they reported that they had seen that they could reach their goals and succeed and that they were able to look at the future in a positive way. According to Rosenberg, as reported by Sahan and Duy (2013), individuals with high self-esteem have a positive outlook, feel respect for themselves, see themselves as valuable, are content with what they are, and are aware of the directions in which they need to develop. The answer given by a 15-year-old girl when asked to evaluate her realizations about herself and her life in the 6 weeks of interviews supports these views: “I wasn't self-confident, but I've increased my confidence in myself. I wasn't very brave, but I've got braver. I was shy but I've got over it.”

Examining adolescents' preintervention, postintervention, and follow-up self-efficacy scores, it can be seen that there was no statistically significant difference between preintervention scores of the intervention and control groups (p > 0.05), but there was a statistically significant difference between their postintervention and follow-up scores (p < 0.05). General self-efficacy scores of adolescents in the intervention group were found to increase to 8.77 postintervention and 6.98 at follow up. These increases show that the interviews were effective in increasing perceptions of self-efficacy in adolescents, and confirmed the second research hypothesis—self-efficacy of adolescents with ADHD to whom a solution-focused approach has been applied will show a significant difference from that of adolescents with ADHD in a control group.

Costello and Stone (2012) recommended that positive psychological principles be applied to increase self-efficacy of students with ADHD. The solution-focused approach, an extension of the positive psychology view, was effective in increasing the self-efficacy of adolescents. Similarly, in a study with adolescents who had family relation, behavioral, school, and peer problems and emotional difficulties, the solution-focused approach resulted in significant positive changes in adolescents' behavior, school success, self-efficacy, and emotions (Gostaunas, Cepukiene, Pakrosnis, & Fleming, 2005). Kvarme et al. (2010) studied the effects of the solution-focused approach on self-efficacy levels of adolescents with social shyness. After the intervention, self-efficacy of girls increased statistically significantly, but no increase was noted in boys. However, at 3-month follow up, an increase was found in the self-efficacy levels of boys and girls in the intervention group (Kvarme et al., 2010). In a study performed in Turkey, it was seen that a group leadership program based on the solution-focused approach increased students' levels of self-efficacy and was maintained in follow-up measurements (Bingöl & Akin, 2018). The results of these studies and those of the current study show that the solution-focused approach is effective in increasing self-efficacy.

The qualitative data of the current study also provide information on the increase in self-efficacy of adolescents in the intervention group. Adolescents in the intervention group stated that they had reached the goals they had made at the first interview, suggesting that their self-efficacy had increased. The solution-focused approach had allowed them to see their own experiences of success, which is one of the basic elements of self-efficacy. In addition, adolescents' statements that they could reach their goals, be successful when they wanted, and solve their problems suggested an increase in their self-efficacy levels. In other studies conducted based on the solution-focused approach, participants also made statements suggesting that this approach had positive effects on their self-efficacy levels. Lloyd and Dallos (2008), who used a solution-focused therapy approach with mothers of children with mental disability and qualitatively evaluated mothers' views, uncovered an increase in a feeling of self-efficacy and self-confidence. In a qualitative study conducted with adolescents on parole, Shin (2009) found a reduction in impulsive behavior, an improvement in work, and an improvement in communication with their parents, as well as earlier bedtimes and increased school attendance in adolescents to whom the solution-focused approach was applied. These results are of the same nature as the current results as they show an increase in self-efficacy with regard to reaching stated goals and experiences of success.

Another result of the current study that is worthy of discussion is the effect size of the intervention. The effect size was calculated as 0.98 according to the follow-up measurement of the Rosenberg Self-Efficacy Scale. In a meta-analysis conducted to evaluate the effectiveness of the solution-focused approach (Kim, 2008), the mean effect size was reported to be between 0.13 and 0.26; this result was evaluated as a small but positive effect. The effect size was found to be statistically significant in internalized behavioral problems (Kim, 2008). In a meta-analysis evaluating the effect of a solution-focused approach on problems related to mental health in China, it was reported that for internalized behavioral problems the effect size of the method varied between 0.49 and 3.22, and the cumulative effect size was 1.26, which is large (Kim et al., 2015). This result is in accordance with the effect size of the current study. In line with these results, it can be said that the solution-focused approach gave more effective results in individuals with mental health problems and those with internal behavioral problems.

Strengths and Limitations

The current study's strengths include its mixed design with qualitative and quantitative methods, where the quantitative dimension was a randomized controlled single-blind study, follow-up measurement, and a solution-focused approach tested on a specific group. The major limitations of the study were the small sample size and inclusion of a single center. Therefore, the results can only be generalized to the study group. Although the measurement tools have been validated in different countries/cultures, the current sample comprised Turkish adolescents; therefore, the results cannot be generalized to other cultures and should be considered when evaluating the results of the research. The research findings are limited to the qualities measured by the measurement instruments used in the study. Data collected in the qualitative dimension of the study are limited to the documents written by the adolescents. Another limitation of this research is that long-term results beyond 12 weeks were not studied and cannot be established.

Conclusion

Interviews based on a solution-focused approach were effective in increasing the self-efficacy and self-esteem of adolescents with ADHD. Adolescents made statements indicating an increase in their self-esteem and self-efficacy, showing that the interviews had positive effects on them. In line with these results, it is recommended that nurses in the field of child and adolescent mental health use the principles and techniques of the solution-focused approach when providing care for children and adolescents. Mental health nurses can also use the principles and techniques of the solution-focused approach when caring for patients diagnosed with low self-esteem. When caring for adolescents with ADHD, psychosocial care using the principles and techniques of the solution-focused approach can be applied in addition to medical treatment. The effect of the solution-focused approach on the self-efficacy and self-esteem of adolescents can be evaluated with long-term monitoring. Future nursing studies in the field of child and adolescent mental health can study the effect of the solution-focused approach on other variables.

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Participant Characteristics

Characteristicn (%)χ2p Value
Intervention Group (n = 22)Control Group (n = 19)Total (N = 41)
Gender0.540.817*
  Boy18 (81.8)15 (78.9)33 (80.5)
  Girl4 (18.2)4 (21.1)8 (19.5)
Educational level0.4270.513*
  Elementary20 (90.9)16 (84.2)36 (87.8)
  High school2 (9.1)3 (15.8)5 (12.2)
Family situation1.5890.207*
  Nuclear18 (81.8)18 (94.7)36 (87.8)
  Divorced4 (18.2)1 (5.3)5 (12.2)
Mother's educational level1.5600.458*
  Elementary11 (50)9 (47.4)20 (48.8)
  High school6 (27.3)8 (42.1)14 (34.1)
  University5 (22.7)2 (10.5)7 (17.1)
Father's educational level0.4130.813*
  Elementary12 (54.5)9 (47.4)21 (51.2)
  High school5 (22.7)6 (31.6)11 (26.8)
  University5 (22.7)4 (21.1)9 (22)
Mean (SD)Mean (SD)Mean (SD)tp Value
Age (years)12.82 (1.09)13.26 (1.40)13.2 (1.25)−1.1360.263*
Length of psychostimulant drug use (months)23.64 (19.43)29.26 (37.09)26.24 (28.73)−0.6200.539*
Length of follow-up in polyclinic (months)44.55 (33.03)38.79 (34.87)41.88 (33.59)0.5420.591*

Comparison of Self-Esteem and Self-Efficacy Scores of Adolescents with ADHD (N = 41)

ScaleMean (SD)tp ValueEffect Size (Cohen's d)a
Intervention Group (n =22)Control Group (n =19)
Self-esteem
  Preintervention16.90 (5.02)18.42 (6.13)−0.8680.3910.27
  Postintervention25.68 (3.95)17.42 (5.26)5.727<0.001*1.77
  Follow up23.81 (4.77)18.89 (5.28)3.1420.003*0.98
Self-efficacy
  Preintervention26.54 (6.14)27.57 (5.13)−0.5790.5660.18
  Postintervention35.31 (3.37)26.73 (5.91)5.806<0.001*1.78
  Follow up33.52 (4.72)27.69 (5.19)3.7670.001*1.18

Interview Stages and Special Techniques of the Solution-Focused Approach

FIRST INTERVIEW
Process/TechniqueExplanation
MeetingMet with adolescent.

“I know the thing that brings you here is……. But I know almost nothing about you. I would like to have some information about you befire listening the problem that you here. Can you talk about yourself?”

“What are your interests?”

“What do you like to do?”

Information about the interview processInformation about the interview process was given. (time of interview, the way of interview, interview rules etc.)
Goal Setting (miracle question, scaling questions)Adolescents's realistic, specific, concrete positive goals determine was provided.

“What do you expect to happen as the result of your visits to here?”

“İf what happens there will not be need to your come here?”

The “miracle question” technique was used to facilitate goal determination.

“Let's suppose that when you went to bed tonight a miracle happened and you couldn't see it because you were sleeping. Miracle has solved the problem that brings you here. In the morning, when you get up what signs would you see that makes you believe that miracle is happened?”

“If you had a magic lamp and when the lamp shakes on your head your problem would dissapear, what things could have been different? Which thing would you be that you do different?”

The scaling question was used to define how far is the goals succesed that adolescents' created.

“Imagine a scala that goes from “0” to “10”. “10” is the situation that you want to be in it when the problem solved.

“0” is the opposite of it. How many points would you give to the situation you are currently describing?”

Discovering exception status and building solutions (coping questions – cheerleading)Example / exception situations and solutions were created about the adolescent' goals. Adolescent was encouraged to act in line with the determined goals and possible obstacles were identified.

“Are there times when the problem never happened? Can you tell me?”

“Can you tell me how you deal with the problem even though you've had problems?”

At this stage, coping questions were used. In addition, cheerleading method was used to encourage and praise adolescents. Coping questions

“How did you manage this problem?”

“How did you stop things from getting worse?”

“How did you manage this situation?”

“How did you continue to struggle even though things were so bad?”

Cheerleading

“Did you really do that?“, ”What kind of courage did you show?”

“What you did really impressed me.”

“Where did you learn to do that?”

Defining obstacles to successIt was provided to determine possible situations that would prevent the adolescent from reaching his/her goals. Obstacles required to achieve 10% of their goals were determined. At this stage, it was ensured that the adolescent recognized the difficulties in achieving his/her goals and made it realistic about the study.

“Your plan looks great, but we both know that sometimes some things or some people may be obstacle in the way of what you intend to accomplish. What do you think you're going to do if you run into a situation like this?”

“What did you do to continue your way in the past when you live situation like this?”

Time-out (evaluating the interview, message, written evaluation of the interview by the adolescent)A short break was taken and a message was prepared for the adolescent. The message was composed of three parts: praise, establishment of relations between situations and tasks. In the meantime, the adolescent was asked to answer in writing the questions evaluating the interview process.

“My questions are over. Is there something you want to ask me? Is there anything else I need to know to help you?”

“If not, I'll need a few minutes to think about what you're telling me and review my notes, and I'll write you a message. While I'm writing a message for you, you can answer the questions I'll give you about our meeting today.”

Termination of the interview (reminder of strengths and resources by reading message)The message that was written to the adolescent was read aloud. After the message was read, a copy of message was given to the adolescent. It was remindered strengths and resources of adolescent' by reading the message. Interview was ended.

“Our first meeting is ends here. Is there anything you want to tell me?”

“Hope to see you next week”

SECOND AND NEXT INTERVIEWS
Process/TechniqueExplanation
Starting of interviewThe interview was started. Last week was assesed.

“How are you?”

“What have you done since last week?”

“How do you feel yourself compared to last week?”

Uncovering the good ones / changesAn attempt has been made to reveal good situations about adolescent and his / her life since the last interview.

“What is better or different since our last interview?”

“Could you tell us about the time you went up one point since we last interview?”

“What has become better?”

“What has changed?”

Explaining the effects of good changes with details, reinforcing how the things change (exception questions, coping questions, cheerleading)The effects of good situations related to adolescent and his / her life were explained in detail. At this stage, how the changes is occured were tried to be discovered. It was emphasized that the change actually started by determining the goal and that the adolescent did it. For this purpose, the exception situations, coping questions and cheerleading methods were used. The mutual / cyclic relationship that emerged as a result of the individual's efforts was elaborated.
Measuring the degree of achievement of objectives (scaling questions)The degree of achievement of the goal determined by the adolescent was evaluated.

“Did you reach your final score on your goal last week?”

“How did that happen?”

“How many points did you advance?”

“What do you have to do to get more?”

Restart by discovering additional achievementsAchievements related to the goal studied were investigated. New goals were created by using a miracle question.
Time-out (evaluating the interview, message, written evaluation of the interview by the adolescent)It was done as it was in the first interview.
Termination of the interview (reminder of strengths and resources by reading message)It was done as it was in the first interview.
Authors

Dr. Karakaya is Assistant Professor, Akdeniz University, Faculty of Nursing, Psychiatric Nursing Department, Antalya, and Dr. Özgür is Associate Professor, Ege University, Faculty of Nursing, Psychiatric Nursing Department, Izmir, Turkey.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the adolescents and their families who agreed to take part in the current study.

Address correspondence to Dudu Karakaya, PhD, Assistant Professor, Akdeniz University, Faculty of Nursing, Dumlupinar Boulevard, 07058 Campus/Antalya, Turkey; e-mail: dkarakaya@akdeniz.edu.tr.

Received: March 20, 2019
Accepted: May 28, 2019
Posted Online: July 12, 2019

10.3928/02793695-20190708-01

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