الفهرس 
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Abstract
Negative symptoms appear to be common and sometimes severe among patients with schizophrenia. It may have a direct negative effect on self-efficacy, self-esteem, feeling of power, motivation and the capacity to decrease relapse rates. Empowerment was superior in improving recovery rate, decreasing psychiatric symptoms and improving quality of life. Understanding the nature and the degree of negative symptoms, empowerment and motivation among patients with schizophrenia will help enlighten the way for creating psychotherapeutic intervention in adjunct with medical treatment option.
The present study aimed to identify the relationship between motivation, empowerment and severity of negative symptoms among patients with schizophrenia. The study followed a descriptive research design. It was conducted at the outpatient patient’s clinics of El-Maamoura Hospital for Psychiatric Medicine. The study Subjects comprised 200 outpatients with schizophrenia. They are between 15 and 45 years of age who can speak and communicate with others.
Four tools were used for data collection.
Tool I: The Behavioral Inhibition and Activation Scale (BIS/BAS): (Appendix I)
The Behavioral Inhibition and Activation Scale (BIS/BAS) was developed by Carver and White (1994). It is used to measure self-reported motivational tendencies. This scale consists of 20 items graded on a 4-point likert scale, ranging from 1(strongly agree) to 4 (strongly disagree). It consists of 2 subscales; behavioral inhibition (BIS) and behavioral activation (BAS).
Tool II: The Empowerment Scale (ES): (Appendix II)
The Empowerment scale was developed by Rogers (1997). It is used to evaluate the feelings of empowerment for patients with schizophrenia. The scale consists of 28 items rated on a 4-point Likert scale (ranging from1 strongly disagree to 4 strongly agree). It consists of five subscales which include; self-efficacy/self-esteem, power/powerlessness, community activism and autonomy, optimism-control over the future and righteous anger.
Tool III: Scale for the Assessment of Negative Symptoms of schizophrenia (SANS): (Appendix III)
It was developed by Andreasen (1983). It consists of 25 items that evaluate five symptom factors which includes; affective flattening or blunting, alogia, avolition/apathy, anhedonia/asociality and attention.
Tool IV: A socio-demographic and clinical interview schedule: (Appendix IV)
It was developed by the researcher based on reviewing of literature to elicit data about the patient’s socio-demographic and clinical data. Socio-demographic data include; age, sex, residence, educational level, marital status, working status and type of job. The clinical data covered items such as duration of illness, age of onset, number of hospitalization and types of medications presently taken.
Preparation phase:
The validity and reliability of the study tools:
Tools I, II and III was tested for content and face validity by a jury of seven experts in the field of psychiatric nursing at the faculty of nursing, Alexandria University.
The face and content validity of tools (I), (II) and (III) revealed that the studied tools are valid and reliable (BIS) α=0.778, (BAS) α=0.798, (ES) α=0.847 and (SANS) α=0.906).
A pilot study was carried out on 20 outpatients with schizophrenia to test the applicability, clarity and feasibility of the tools and to identify obstacles that may be faced during data collection. Those patients were excluded from the actual study sample. The pilot study proved that the study tools were clear and feasible.
The researcher was trained by the supervisors on the observation skills and application of the scale of the assessment of negative symptoms (SANS).
Actual Study:
The researcher attended outpatient clinic 3 days a week. The charts in the outpatient’s clinic were screened daily to identify those who met the inclusion criteria.
Each patient was interviewed individually to explain the study aim and establish rapport for at least 15 minute then begin to ask general open ended questions to give chance to assess the scale of assessment of the negative symptoms (Tool III) and then ask questions about others tools as behavioral (BIS) inhibition, activation scale(BAS) and empowerment scale .
Each interview lasted from 60-90 minutes according to patient’s attention, concentration and level of understanding.
Data were collected over a period of four months from December 2017 until March 2018.
Ethical Considerations:
Oral consent to participate in the study was obtained from the patients after explanation of the aim of the study. Data confidentiality was assured and respected at all phases.
The patient’s privacy, anonymity and voluntary participation and the rights to refuse to participate were considered and respected.
The following were the main results of the present study:
More than two thirds of the studied patients (72.0%) are males and 28.0% are females.
Their age ranged between 15 to 45years. More than two third of the studied patients (67.0%) are in the age groups 25 to less than 35 year and 17.5% of them were in the age group 35 to 45 year while 15.5% of them were in the age group 15 to less than 25 year with a mean age of 30.88 ±7.07 years.
More than one third of the studied patients (37.5%) had a secondary education, 35.0% of them had primary and preparatory education and only13.0% had university education.
More than half of the studied patients (59.5%) were single, 29.0% of them were married and 13.5% were divorced and widowed.
More than two thirds of the studied patients (73.0%) were not working and only 20.5. % of them were working.
Nearly two thirds of the studied patients (65.0%) lived in urban areas, while less than half of the studied patients (35.0%) lived in rural areas.
The age of the studied patients at the beginning of illness ranged between 15 to 45 years. More than half of the studied patients (54.5%) were in the age group between 20 and less than 30 years at the beginning of illness while 38.5% were in age group between 15 and less than 20 years at the beginning of illness with a mean of 23.0 ±
4.70 year.
Duration of illness ranged between two years to ten years, The majority of the studied patients (81.5%) had duration of illness between 5 to 10 year and 18.5% had duration of illness ranging between 2 to less than 5 years with a mean of 7.0 ±2.37 years.
The numbers of hospitalization among the studied patients ranged from 1 to more than 5 times, one third of the studied patients (33.0%) had been hospitalized for five times or more, 15.0% of the studied patients hospitalized for one time, whereas 18.0% of the studied patient were not hospitalized with a mean of 3.09± 1.95.
Concerning medication types, the table shows that 44.0% received a mixture of standard and atypical antipsychotic, 30.5% of them were treated with antipsychotic and antidepressant medication and 24.0% of them received atypical antipsychotic.
More than two thirds of the studied patients (69.5%) had high avoidance motivation, 23.0% had moderate avoidance motivation while only 7.5% had low avoidance motivation. The total mean score of avoidance motivation is 12.03 ± 4.69 with mean percent score of 23.95 ± 22.35.
More than two thirds of the studied patients (68.0%) had moderate approach motivation, 21.5% had low approach motivation while 10.5% of them had high approach motivation. A total mean score of approach motivation is 31.64 ± 6.57 with mean percent score of 47.78 ± 16.85.
Less than two thirds of the studied patients (63.5%) had moderate empowerment, nearly one third of them (28.0%) had Powerlessness while 8.5% of them reported having empowerment with a mean score is 64.23 ± 12.60 and percent score of 43.13 ± 15.
Regarding empowerment factors, the community activism & autonomy has the highest mean percent score (70.42 ± 19.56) followed by self-esteem/self-efficacy (42.37 ± 24.32), optimism & control over the future (41.72 ± 20.34) and Power-powerlessness (31.40 ± 16.46).The lowest mean percent score was for righteous anger (13.75 ± 27.07).
More than half of the studied patients (57.5.5%) had moderate negative symptoms, nearly one third of them (27.0%) had severe negative symptoms and only 15.5% had mild negative symptoms with total mean score of 67.08 ± 23.80 with mean percent score of 53.67 ± 19.04.
As for domains of negative symptoms. The results revealed that avolition/apathy and anhedonia/asociality have the highest mean percent scores (67.68 ± 26.03, 67.30 ± 23.33 respectively) followed by attention (57.77 ± 31.88), affective flattening or blunting (51.36 ± 18.29). Whereas alogia has the lowest mean percent score (30.06 ± 24.82).
There are higher significant negative correlations were found between avoidance motivation and approach motivation (r=-0.562) and total empowerment (r=-0.642)
There is a higher significant positive relation was found between avoidance motivation and negative symptoms (r=0.588).
There are higher significant positive relations between total of approach motivation and total empowerment (r=0.762).
There is a higher significant negative relation between total approach motivation and total negative symptoms (r=-0.701).
There are higher negative significant relations between negative symptoms and empowerment (r=-0.755).
There are higher significant positive relations between levels of avoidance motivation and sex (2=13.187), age (2=21.278), Working status (2=16.467) and significant positive relation with types of job (2=17.055).
There was a higher significant positive relation between levels of avoidance motivation and age at the beginning of illness among the studied patients (χ2 = 23.247).
There were higher significant positive relations between levels of approach motivation (BAS) and sex (χ2= 19.071), educational level (χ2=14.483), working status (χ2=6.147) and types of job (χ2=22.024).
There was intermediate significant positive relation between levels of approach motivation and age at the beginning of illness among the studied patients (χ2 = 11.250).
There were significant positive relations between empowerment and sex (2= 10.224) and types of job (2=20.871). Also there were intermediate significant relations between empowerment and age (2=12.850), educational level (2=13.186) and working status (2=8.613).
There were significant positive relations between negative symptoms and sex (2=20.753), age (2=11.407), Working status (2=27.944) and types of job (2=33.824).
The followings are the main recommendations yielded by the study:
A-Recommendations geared toward mental health professionals:
Develop work shop for training mental health professionals on the assessment of negative symptoms, empowerment and motivation and being oriented with their inter-relation among patients with schizophrenia.
Hospital policies should consider the negative symptoms, empowerment and motivation in patients with schizophrenia into care plans on outpatient’s clinics and inpatients in psychiatric hospital.
Integrating the relationship between negative symptoms, empowerment and motivation into theoretical and practical courses in psychiatric nursing and psychiatric medicine for developing educational and practical background related to these variables among patients with schizophrenia..
B- Recommendations geared toward patients with schizophrenia and their families:
Implementation of psycho-educational programs aiming to increase awareness of patients and their families about negative symptoms of the schizophrenia and its effect on empowerment and self-motivation.
Illuminate the role of the family support in patient’s recovery process by including family/caregivers in treatment planning.
C- Recommendations geared toward the community services:
Employment and supportive financial incentive should be provided to patients with schizophrenia.
Rehabilitation centers should be broadened in general and private hospitals to increase self-empowerment and motivation.
Mass and social media should have a role in increasing awareness and providing effective programs for helping the patients with schizophrenia to deal with the disease and its symptoms to improve their quality of life.
Community role for reducing the public stigma through campaigns and medical convoys.
D- Recommendations for future research:
Studying the relationship between motivation, empowerment and severity of negative symptoms on large samples to clarify factors affecting on these variables among patients with schizophrenia.
Implementation of research projects on patients with negative symptoms for enhancing their empowerment.