Chapter 3

Methodology

3.0. Introduction

       3.0.1. Study Location 

3.1 Research Paradigms                                                                         

3.2 Research Design and Methodology

3.3 Philosophical and theoretical basis for the study

3.4 Population, Sample and Sampling

3.5 Data Collection

3.6 Pilot Test/Pilot Interview

3.7 Data Analysis

3.8 Reliability and Validity

3.9 Ethical Considerations

3.10 The Summary

Figures:

Figure 1

Appendices:

Appendix 1: Information Sheet

Appendix 2: SE-PSCS Questionnaires 

Appendix 3: RCSI Approval

Appendix 4: RCSI Final amendment Approval

Appendix 5: Permission Emails

Appendix 6: MRC/IRB Approval

Appendix 7: Flyer

Chapter 3

Methodology

3.0 Introduction

The methodology chapter provides information on the procedures and instruments that are used to answer the research questions. This chapter is divided into the following sections and sub-sections: Introduction, Research Paradigms, Research Design and Methodology, Philosophical and theoretical basis for the study, Population Sample and Sampling, Data Collection, Pilot Test/Pilot Interview, Data Analysis, Issues of Reliability, Ethical Considerations and Summary.

In this study, the researcher is studying the factors that contribute to nurses’ self-efficacy level in offering cigarette smoking termination amenities among mentally-ill smokers in a psychiatric hospital. Specifically, the research answers the following question: “How does an Arab mental health nurse rate their self-efficacy in providing cigarette smoking cessation for mental health in- patient?” The study aims to assess the attitudes, beliefs and current practices of Arab mental health nurses in providing cigarette smoking cessation and their sense of self –efficacy’ in promoting free smoking policy in mental health services.

The objectives of this study are:

1. To assess Arab nurses’ attitudes and beliefs towards cigarette smoking use in Mental Health Services.
2. To assess the perceived self-efficacy of Arab nurses in promoting cigarette smoking cessation in mental health Hospital (Male/Female inpatient units, Outpatient department, community adult , Psychogeriatric, Child and Adolescent Mental Health Psychiatric Services(CAMPS).
3. To make recommendations to the psychiatric hospital on staff educational preparation approaches to cigarette smoking cessation.
4. To determine the best research approach prompts frequent debates, as all methods have their strengths and limitations (Crotty, 1989).

            Although there are many valid research paradigms, methodologies and strategies used in nursing research, none are universally recognized as superior to the others (Cordeiro V et al., 2016). Nursing research seeks, through application of a systematic processes, new knowledge that will benefit the population as a whole, across a continuum of healthcare services addressing the needs of all age profiles (Boswell&Cannon, 2012).  Fundamentally, undertaking research entails choosing which paradigm and methodology that best answers the research question (Welford et al. 2011, Jones 2014). The Quantitative descriptive cross-sectional survey design will be discussed in this chapter. The research study is formulated upon a confirmatory and predictive nature, using a positivism paradigm. The researcher explains all necessary ethical considerations in choosing the participants for the research.

            HMC was selected for the study for a number of reasons. Primarily, it is the only first provider of smoking cessation in Qatar. Secondly, it receives the highest number of tobacco smoke patients in the Gulf region (Hamad Medical Cooperation., 2018). In 2015, the smoking cessation center received over 3,600 patients seeking cessation services. The statistics show 52% of the patient’ Nationalities are south Asian, Iranians and Arabs.The pervasiveness of cigarette smoking in the Qatari populace was projected in a past study  by World et al., (2018) to be 36.5%.

            Approximately 40% of patients at HMC are heavy smokers consuming more than 30 cigarettes per day (Lasser et al., 2000, Hamad Medical Cooperation., 2018) The significant rise in the number of schizophrenic patients is 44%. A cross sectional survey of psychiatric patients found that 61% respondents were smokers and 18% were heavy smokers(Schroder et al., 2003).  The number of psychiatric patients attending cigarette smoking cessation is due to policy of the facility and the country in prohibiting the smoking at public places, indoor offices, hospital premises and restaurants.  However, smoking is still allowed on acute psychiatric wards but will be banned from 4^Th March2019 (Hamad Medical Cooperation., 2018). The Mental Health Service in Qatar provides an institutional collaboration among mental health facilities with smoking cessation that can support inpatient units. The mental health clinic works with the HMC tobacco control center to help patients with mental health problems quit tobacco smoking. The center expects to expand its cigarettes smoking cessation services from a current   800 to 1200 patients annually for the next 5 years. Therefore, the research findings of this study will be helpful for the organization in service planning and expansion (Hamad Medical Cooperation., 2018).

            The high number of smoking cessation service patients at the hospital emphasizes the nurses’ role and the need for their expertise. Psychiatric nurses at the hospital are expected to offer cigarette smoking cessation services by March 2019. Being in an Arab world, the organization has many Arab clinicians in different specialties (Abujaber&Katsioloudes, 2015). The research aims at assessing Arab nurses’ beliefs, attitudes and clinical practices in providing smoking cessation and free smoke policy by the hospital. The mental health services mainly offer cigarettes smoking cessation to resident and non- resident patients. Statistics show the percentage of Qatari patients is higher than non-Qataris.

            Finally, the researcher chose the location of this hospital because there is very limited research on this topic in the Gulf region. The selected location of the HMC in Qatar could also allow for applying study results to other facilities in the Gulf region.  Furthermore, the hospital was an accessible facility during submitting the IRB. The study permitted the use of descriptive cross –sectional survey design.

            3.0.1 Study Location

The research study was conducted at the Hamad Medical eCooperation (HMC) a govermental hospital located in Qatar. The facility is one of the largest not-profit premier healthcare facilities in the Gulf region. The healthcare facility (HMC) operates eight hospitals in Qatar; one of them is the Psychiatric hospital. The research took place at the Psychiatric hospital in Qatar which is part of  the largest Hamad General Hospital (HGH) in Doha. HMC receives  the highest rates of smokers among control tobbaco clinics in the country (Hamad Medical Cooperation., 2018).

3.1 Research paradigms

Healthcare related research is usually aligned with one of two main research paradigms, or theoretical perspectives. Paradigms described as “world views or ways of go through and thoughtful about the world”(Kuhn, 1974.p.55). According to Kuhn (1974) the term paradigm denotes “a research philosophy with a set of principles, morals, and conventions that a community of researchers has in common concerning the nature and manner of research”; a paradigm is a view of the world on how “things work”(Kuhn, 1974.P.87, Morgan, 2011). A paradigm is the conceptual framework that dictates all aspects of a research study (Kuhn, 1974). The choice of a research paradigm is strictly influenced by concepts of ontology (belief systems about social reality), epistemology (theoretical frameworks in place), axiology (ethics and values) and methodology (the best approach for systematic inquiry) (Kuhn, 1974, Crotty, 1989, Weaver&Olson, 2006).

 The researcher in this study adopted the positivism paradigms. This approach is associated with the self-assessment questionnaire and will answer the research question. According to (Guo et al., 2015), the same study was conducted between two different hospitals in southern and western are in Taiwan. The authors used quantitative approach with self- reported questionnaire. A positivistic paradigm commonly uses a quantitative methodology in research as it believes that a “single reality exists”, which can be known and measured and thus uses a quantitative model to measure and know this reality (Crotty, 1989.p.167). On the other hand, a constructivist paradigm observes that there is no single truth; making it necessary to interpret the reality.  Therefore, qualitative methods are used to measure these realities (Kuhn, 1974). 

3.2 Research Design and Methodology

This study utilized a expressive cross-sectional review design; employing questionnaires that were self-administered. The questionnaires were relatively quick and easy to complete by the participants Arab mental health nurses), but they did not show the differences between cause and effect (Denise&Cheryl, 2012). Descriptive research studies are often used when research questionnaire includes open questionnaire or conditions and events (Denise&Cheryl, 2012). Descriptive research involves credentials of traits of a certain phenomenon based on answers made or can involve exploring the association between two or more variable (Wahyuni, 2012).

 Nevertheless, the purpose of this descriptive design was to measure self-efficacy of Arab mental health nurses in different units (inpatient/outpatient male and female). In this case, the research design/methodology would give a snapshot of the frequency and characteristics of self-efficacy issues within the specified time period in order to allow for thorough analysis. The level of self-efficacy of Arab nurses that mental health services would be the measured rated among the population sample (Guo et al., 2015, Zhang et al., 2015, Barros et al., 2014).

 

3.2.1 Cross Sectional Studies  

The most significant benefit of cross sectional studies is they are fast and  fiscally affordable since there is no follow up, less resource are essential to run the study (Boswell&Cannon, 2012). Cross sectional studies are the best way to control occurrence and are valuable at recognizing relations that can be more meticulously studied using a regiment study or randomized controlled study (Cordeiro V et al., 2016). The most significant issue with this sort of study is distinguishing cause and result from simple association.

3.3 Philosophical and theoretical basis for the study

Figure 1; showing an example of a questionnaire that has been adopted in this study        

 

The theoretical basis for the study is Self-efficacy theory (Bandura, 1977). The basic foundation is that there is a positive relationship between self-efficacy and behavior change. The questionnaire that has been adapted and shown in the figure (2), has been used to quantify attitudes, opinions, behaviors, and other defined variables with demographic variables such as age, gender, level of education and experiences years, this can be viewed in Appendix2.

This study tried to assess the opinion of the nurses and also to find common reasons why people living with mental illness smoke and continue smoking as one of the attitudes and believes in the sub scale.

3.4 Population, Sample and Sampling

Appropriate selection of study subjects aids the vital purpose of guaranteeing that findings precisely characterize what is happening within the population of interest (Cordeiro V et al., 2016, Burns&Grove, 2009). A poorly selected sample may yield biased results which affects the external validity of the study, and as such, results cannot be applied to the wider population (Denise&Cheryl, 2012). The population refers to all subjects of interest to the researcher and the sample refers to the proportion of the population selected to participate (Cordeiro V et al., 2016).

Several aspects must be taken into consideration when designing the sample size in quantitative studies.  The main considerations are: 1) the population of the study,  2) type of the design 3) the measurement and 4) practicability (Boswell&Cannon, 2012). A descriptive design is used to examine characteristics of Arab mental health nurses as the sample. According to (Burns&Grove, 2009)  in  (Boswell&Cannon, 2012),a descriptive design helps the researcher to develop the clinical practices theory to find the rationale of practice, solving  problems between the variables (dependent/ independent) in the research question. A poorly selected sample may yield biased results which affects external validity of the study, and as such, results cannot be applied to the wider population (Denise&Cheryl, 2012). The population refers to all subjects of interest to the researcher and the sample refers to the proportion of the population selected to participate (Burns&Grove, 2009).

            The research population for this study was Mental Health Nurses (MHN) at HMC  (n=250), a sample size included all Arab mental health nurses is used for this study (n=103)  (Hamad Medical Cooperation., 2018). The expected response rate to the study questionnaire is 63% this is in reference to the population in this hospital

All the Arab nurses at the hospital were provided with the questionnaire package and that most especially those that have provided outpatient/inpatient services for more than 3 months.  The sample size of 103 nurses come from six departments as follows; Male/ female inpatient units, outpatients, adult male/ female community, adult/ older psychiatry, case managers, consultation and liaison.

Although purposive sampling is viewed as a non-probability method which is subject to researchers' judgment, it ensures a proper representation of the study population. These participants are selected based on inclusion and exclusion criteria such as Nationality and different job title in the work.

The inclusion criteria:

1. Only Arab licensed nurses working in the psychiatry hospital.
2. The individuals must be over 18 years old and citizens of any country within the Middle East and North Africa
3. The nurses should have received the license three months training prior to the recruitment.

Exclusion criteria:

1. Non Arabic nurses
2. Individuals who are currently on leave for more than three months
3. Unlicensed nurses for instance the student nurses and the new graduates

3.5 Data Collection

The data pertaining to each Arab nurse was collected weekly for the duration of the study over a four week period in psychiatry hospital.

The researcher reviews all the potential individuals who can participate in the study as per the inclusion and exclusion criteria. After selection, all the individuals will be contacted through their Head Nurses units’ emails and a visit to their department to inform them. The individuals will later read the information sheet as consent form before enrolment into the study see Appendix (1). Participants will complete the survey and return it in a closed envelop to the secretary office

Two nurses returned the survey empty in the pilot phase and completed survey is (n=7) and actual study phase are (n=103). The returned survey in the actual study was (n=12) some none Arab nationality nurses answering the questionnaire and some not completed. The participants’ kept them in the return box.

 The data collected included demographic details obtained from the nursing answers including

• Age
• Gender
• Nationality
• Educational levels
• Present job
• Experience years
• Smoking history
• Graduation years
• Unit/ work area.
• Country where obtained the professional license

 See Appendix (1). 

3.5.1 Data collection protocol

Data collection phase of the research question is carried out in two stages: The first phase includes acquiring the participants and this included getting a list of the Arab mental health nurses from which were obtained from the secretary management. The research will begin with the collection of the data from nurses. If the expected response rate is not reached after 2 weeks, the researcher will extend the participation period for two more weeks.

The list of Arab nurses that fits the inclusion / exclusion criteria was reassessed by two research assistants and a management nurse, to ensure that all included Arab nurses maintained the needed capacity for participation this study. After the completion of this step, no disagreement occurred and all nurses who fit the inclusion / exclusion criteria were approached by one of the two research assistants that were helping with this study whose main role was to ensure that everything about this study was effective and going according to plan and invited to participate in the study. Participants information sheet are provided with the survey to all participants.  Those nurses who agreed to participate were invited to complete the questionnaires with the assistance of the researcher.

The researcher did not offer any opinions to the participantsroughout the completion of the questionnaires which helped ensure validity of the exercise. A stamped MRC- HMC and a return envelope is also attached. Contact details for the PI and the research supervisor were also included in the information sheet. Participation packages were numbered in order to assess response rates and also to avoid interference with confidentiality. 

3.5.2 Instrument

This study adopted similar research questionnaire used in a different study and permission was granted by the original study author (Guo et al., 2015). The questionnaire in this study was previously used in a study in Taiwan to examine self-efficacy in smoking cessation services for psychiatric nurses (Guo et al., 2015).  The questionnaire was designed by (Zapka et al., 2000), (Sarna et al., 2001) and later developed by (Johnson et al., 2009) then (Guo et al., 2015). The research questionnaire was divided into four parts;

1. Attitudes and Beliefs

Part two collects information on nurses’ attitudes and beliefs when offering the clinical services. It includes a total of four questions with subsections testing different notions as reasons why people smoke, and barriers to receiving cessation services. Such information can assist in identifying the nurses' perception of how they deal with mental health patients in need of smoking cessation services.

2. Smoke-Free Policies

Part three of the questionnaire asks questions on the work place smoke-free policies in the institution. The section is divided into other sub-sections assessing different self-efficacy practices in the clinic. Sub-section one has questions A to M each measuring clients experience to smoke free policies in the institution. The second subsection examines nurses’ response to the same policies. The third section measures the interaction between patients and healthcare providers.

3. Cessation Practices

The final part of the questionnaire sets out to evaluate the interventions of the nurses based on the cessation policies in the facility. The part has four questions that determine the type of services and how nurses offer them to clients. Some of the questions include whether nurses assess smoking patients, provide support and encouragement to those in need of quitting smoking, type of discussions with clients.

4. The Nurse Self-Efficacy Scale

The study used a self-efficacy scale that was first developed by Zapka et al. (2000) and later modified Johnson et al. (2009) during their research to examine attitude of nurses in a mental health care setting offering cessation services to tobacco smokers. The tool has five items, which measure different confindence levels as identification of clients level of smoking, discusion of strategies to minimize the strategy, patients preparedness of leaving the smoking behavior, knowledge of effects of smoking, and suggestion of other therapies. A higher score shows the participants have  high confidence.  

This questionnaire took around 20-30 minutes according to nurse’s skills to be completed.  The questionnaire included items like; attitudes and beliefs regarding smoking by a patient; implementation of smoking free policy at work; and clinical practices experience in providing smoking cessation services (SCS) . All research tools related to SE-PSCS nurse’s measure were adopted from the original English language questionnaire (Sarna et al., 2001, Zapka et al., 2000), which was modified in some parts by (Johnson et al., 2009).  For efficiency, the questionnaire is open ended in nature such that the participants after giving an answer have the chance of explaining these answers. This is effective because it helps these participants to offer more information that is beneficial for this study.

3.5.3 Demographic information

 Part one entails collection of demographic information of the research subjects. The data provides the demographic characteristics of research subjects such as i.e. Age , Gender, Nationality, Educational  levels, Present job, Experience years, Smoking  history ,Graduation years, Unit/ work area and  the professional license country, history of smoke ciggeratte and education history related smoking cessation .

 The three main parts of the questionnaire contain eleven sub divisions of sub scales and Yes/No-Agree/disagree Likert scale (Appendix2).

3.6 Pilot Test/Pilot Interview

Before the actual study, the researchers did a pilot test to ensure the research design was appropriate and the questions in the questionnaires were applicable and understandable to the study population. The strategy entailed administering the questionnaires to the selected individuals representing the study sample (n=10). After they answered the questions, researchers analyzed the data to ensure validity of the study.  The seven questionnaires response rate of ten 7/10 were included in the pilot on basis of purposive sampling. The pilot test was vital for the research as it helped in identifying questions in need of adjustment.

 

3.7 Data Analysis

Each survey was assigned a serial number so it could be used for correction and revision purposes. Statistical Package for the Social Sciences (SPSS Inc. Chicago, IL software, SPSS version 25.0 was used for statistical analysis of the data. All data was tested for normality using the associations between two or more qualitative variables (demographic variables, potential confounders, and self-efficacy for providing SCS among psychiatric nurses was assessed using Karl Pearson correlation and coefficient, t-tests and ANOVA. Descriptive statistics were generated to describe demographic data and the results of sample size outcome measures (n=61).

Quantitative data between the two independent groups (two different units within Arab mental health nurses) was analyzed using unpaired test or Mann Whitney U test as appropriate. Relationship between two quantitative variables will be examined using Pearson’s correlation coefficients. The relationship between correlates of self-efficacy in providing SCS among psychiatric nurses and main intrinsic and extrinsic risk factors (demographics and potential confounders) was compared and assessed using logistic regression models. The results were presented and reported in odds ratio (OR) and associated 95% CI. All P values presented were be two-tailed, and P values <0.05 were considered as statistically significant. Scale (Appendix 2) and the SE-PSCS.

 The researcher concurrently recorded SE-PSCS. The SE-PSCS questionnaire data was placed directly in SPSS version 25 and   all original papers kept in locked looker.

The researcher used the information sheet attached to the survey in addition to a flyer poster created by author for explaining the project. The researcher also explained any unclear sentences or questions in a very assertive and professional manner when communicating with participants. The opportunity to contact the primary investigator was voluntary and welcomed,

3.8 Reliability and Validity

According to (Gerrish&Lacey, 2010) reliability and validity are key concepts of research. Reliability in research is the ability to provide consistency in the measurement of an outcome. Equally, validity in research is described as the ability to measure what the study aimed to measure without bias (Gerrish&Lacey, 2010). Reliability is concerned with consistency, accuracy and stability (Boswell&Cannon, 2012).

Reliability and validity are imperative in research as results must be representative of the truth. New research cannot benefit clinical practice if reliability and validity cannot be proven (Denise&Cheryl, 2012). In order to ensure reliability and validity, researchers must be systematic in their approach to conducting research so that results can be replicated in future studies (Wahyuni, 2012)

There was no significant issue of the reliability and validity faces in the research questionnaire because all the questions used were open ended and thus allowed the participants to explain their answers further.  The researcher used the information sheet attached to the survey in addition to a flyer poster to explain the project to the participants to ensure that they understood what the study was all about, see Appendix 7. The researcher also explained unclear sentences or questions in a very assertive and professional manner when communicating with participants. The opportunity to contact the primary investigator was voluntary and readily welcomed. 

Some changes only done on demographic part and was in English language. The original version was also in English language and all participants can speak and understand the English Language. In each part of the questionnaire, the previous author determined the validity as the following titles;

• Attitudes and Beliefs

Individuals who are smokers and hold an attitude that smoking is right are mostly less active in offering the cessation services. The section has a total of 9-items measured on a 4-point scale. A higher score on the scale reflects fewer barriers to perception practices. (Guo et al., 2015)found that the framework is effective as it had a test– retest reliability at 2 weeks of 0.65 (P = 0.004) and Cronbach’s α was 0.85.

• Smoke-Free Policies

 (Guo et al., 2015)found the smoke free-policy framework valid as it had a reliability test of 0.80 in two weeks. .

• Cessation Practices

The section has 18 items with a reliability score of 0.77 when applied in two weeks (Guo et al., 2015)

3.9 Ethical Considerations 

An application for ethical approval was submitted to the Royal College of Surgeons in Bahrain’s Research Ethics Committee on the 04^th April 2018 (Appendix 3). Approval was granted on 29^th April 2018 (Appendix 4).  Some amendments were requested by RCSI research committee in regards the IRB (MRC) requirements, and final RCSI committee approval commenced on the 5^th August 2018 (Appendix 5). Recruitment commenced on 11^th September 2018 after IRB date approval 12^th August 2018. Permission was granted by mail from the Chief  Medical Officer of the psychiatric hospital and Nursing director in question to conduct the study on-site on 28^th  May2018 (Appendix 6).

            Arab Mental health nursing participants were provided a Leaflet in each unit (Appendix 7) where the aims and objectives of the research were explained at this time. The aims and objectives of the study were explained to the study population at the hospital regardless of whether they are in the sample target or not. Any members who wished to participate in the study were provided with a participation pack to take home and complete at their leisure. The participation pack contained the information sheet (Appendix1), SCS survey and returned envelop (Appendix 2), which participants were asked to complete and return to the PI or return box in the secretory office in the included stamped, white envelope.  No identifiable information was included in the data collection forms. Every participant was assigned a Number / serial number used for data entry purpose in the program. Hard copies of all data collection forms were kept in a locked cabinet format. Data was electronically transferred to the researcher’s unique project folder in a computer secure drive. Where data analysis had to be carried out away from the main server for practical reasons, an encrypted USB key was utilized to ensure data security.

            The storage and use of participant data was carried out in adherence with the Data Protection Acts (Harriss&Atkinson, 2015, Moulton&Hamilton, 2004), and in accordance with the Royal College of Surgeons in Bahrain (RCSI) Data Protection Policy Guidelines (Kassim et al., 2016). Data will be stored for a period of five years, in accordance with these guidelines. 

3.10 Summary

The purpose of the study was to assess the relationship between the attitudes, beliefs and current practices of Arab mental health nurses towards cigarette smoking and tobacco use, and their sense of self -efficacy in promoting cigarette smoking cessation in mental health services. This was performed using a prospective, descriptive cross-sectional research design. This design was chosen as the writer wished to follow participants over a four week period and assess nurse’s attitudes towards the cigarette smoking cessation as determined by the self-efficacy psychiatric smoking cessation services (SE- PSCS) survey. A positivist, quantitative method was used as the researcher wished to extract data regarding the tool of SE-PSCS (survey) and examine any association between the variables. This data was analyzed to assess the presence or absence of a relationship.

Non-probability, purposive sampling was used as the writer wished to study Arab mental health nurses which would be representative of the target population. Participants had to be confident in their abilities to deliver treatment and health services to mentally ill patients. For this reason, a minimum work of period of three months and a valid license were the only inclusion criteria for the study.

Those participants who did not return envelops to participate were excluded from the study. No other exclusion criteria were applied. Arab nurses who met the inclusion criteria were invited to participate. A sample size of 61 from 103 participants was determined through power analysis.  The self-report questionnaire SCS was collected and the data was analyzed. Data was analyzed using a Statistical Package for Social Sciences (SPSS) programmer version 25. Correlation between tools was determined chi-square (χ2) test, Fisher Exact test or Yates corrected Chi-square as appropriate was used to determine the relationship between subscales.

Significance was determined through the calculation of p-values. Coded data was entered in the system then frequency showing the variables’ relationships was extracted for interpretation. With the procedures and instruments in place, the study will get accurate and reliable results. After analyzing the results, the researcher made recommendations to the psychiatric hospital on staff educational preparation approaches to cigarette smoking cessation.

Reliability and validity were ensured through the use of validated tools. The researcher was the only person assessing participants therefore eliminating unethical issues such as privacy and confidentiality concerns. The study was designed and conducted in a strict accordance with the IRB in (MRC- HMC).

 

 

 

 

 

 

 

 

 

 

 

 

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Appendices

Appendix (1): Information Sheet

 

 

 

 

 

 

Appendix2: SE-PSCS Questionnaires 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix3: RCSI Approval

 

 

 

 

 

Appendix4: RCSI Final amendment Approval.

 

 

 

 

 

Appendix5: Permission Emails.

 

 

Appendix6: MRC/IRB Approval

 

 

 

 

 

 

Appendix7: Flyer