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Imagery, stress and noncomplaint behaviour in immobilized hospital patients Stewart, Norma June 1984

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IMAGERY, STRESS AND N0N3OMPLIANT BEHAVIOUR IN IMMOBILIZED HOSPITAL PATIENTS By NORMA JUNE STEWART B . S . N . , The Univer s i ty of Saskatchewan, 1969 M . S . , The Univer s i ty of C a l i f o r n i a , 1974 M . A . , The Univer s i ty of Saskatchewan, 1977 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n THE FACULTY GF GRADUATE STUDIES Department of Psychology We accept t h i s thes i s as conforming to the required standard THE UNIVERSITY OF A p r i l © Norma June BRITISH COLUMBIA 1984 Stewart, 1984 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e h e a d o f my d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f Psychology The U n i v e r s i t y o f B r i t i s h C o l u m b i a 1956 Main Mall V a n c o u v e r , Canada V6T 1Y3 D a t e June 30. 1984 / A B S T R A C T The purpose of t h i s project was to investigate the e f f e c t s of immobility and environmental stimulation on imagery, s t r e s s and nonccmpliant behaviour i n two studies of h o s p i t a l i z e d p a t i e n t s . In one study, objectives a l s o included: (1) to t e s t an intervention designed to reduce s t r e s s , and (2) to examine l i f e s t r e s s and personal c o n t r o l as possible p r e d i c t o r s of dependent v a r i a b l e s . Moos and Tsu's (1977) model of p h y s i c a l i l l n e s s as c r i s i s provided a framework f o r the variables of i n t e r e s t . In Study 1, the 2 x 2 a n a l y s i s of variance design had the following f a c t o r s : (1) external immobility ( t r a c t i o n , bedrest) versus m o b i l i t y , and (2) cognitive reappraisal intervention versus no intervention. The intervention was tape recorded information which provided an expectation f o r imagery and v i v i d dreams, a p o s i t i v e set, and an environmental explanation f o r these e f f e c t s . The sample of 48 male and female patients, aged 15-65, with no p s y c h i a t r i c h i s t o r y , was obtained as emergencies were admitted to the orthopedic and surgery units at a Saskatchewan h o s p i t a l . Study 2, which examined the e f f e c t s of both external and i n t e r n a l (paralysis) immobility, had a 2 x 2 x 2 a n a l y s i s of variance and covariance design with repeated measures. The f a c t o r s were: (1) l e v e l of i n j u r y (quadriplegia vs. paraplegia), (2) degree of neurological d e f i c i t (complete vs. incomplete), and (3) environment (intensive care vs. ward), the repeated measures v a r i a b l e . The covariate was i n j e c t a b l e ( i i ) analgesics. In both studies, stepwise regression a n a l y s i s was conducted to examine other p r e d i c t o r s of dependent v a r i a b l e s . M u l t i v a r i a t e analysis of variance was used to compare imagery data across studies. The sample of 50 patients i n Study 2, with c r i t e r i a s i m i l a r to Study 1, was randomly selected from charts over a f i v e year period on a s p i n a l cord i n j u r y u n i t i n a B r i t i s h Columbia h o s p i t a l . Hypotheses were developed i n r e l a t i o n to the f i v e categories of independent v a r i a b l e s . Measures of dependent v a r i a b l e s included questionnaires, an interview and the chart record. In one study, observational data were obtained on dimensions of s o c i a l and nonsocial environmental stimulation i n patient rooms. Consistent with the Moos and Tsu framework, some support was provided within each category of hypothesis. As predicted, immobility l e d to increased imagery. This hypothesis was supported f o r both external and i n t e r n a l immobility. The type of immobilizing apparatus (e.g., c e r v i c a l tongs) was p r e d i c t i v e of imagery, but t r a c t i o n per se and duration of immobility were not pred i c t o r s of imagery. Contrary to hypothesis, immobility d i d not lead to increased general s t r e s s or noncompliance. However, immobile patients d i d report greater environmental s t r e s s r e l a t e d to personal c o n t r o l and response r e s t r i c t i o n . The intervention led to reduced s t r e s s , as predicted, without increasing the incidence of imagery. Stress r e l a t e d to imagery was unaffected by the intervention. Environmental v a r i a b l e s were s i g n i f i c a n t p r e d i c t o r s of imagery i n both studies. Medications and surgery d i d not contribute to t h i s e f f e c t . Patients had greater imagery ( i i i ) i n the intensive care u n i t than on the ward. Sleep deprivation c o r r e l a t e d with a l l three dependent v a r i a b l e s . Contrary to the hypothesis that r e s t r i c t e d s timulation would lead to imagery e f f e c t s , high l e v e l s of s o c i a l stimulation dimensions and nonsocial stimulation which had low option f o r c o n t r o l predicted imagery. High noise l e v e l s predicted both s t r e s s and noncompliance. Further p r e d i c t o r s of s t r e s s were high l e v e l s of dimensions of s o c i a l and nonsocial stimulation, whereas noncompliance was predicted by low v a r i e t y of nonsocial stimulation. In general, these data support an overload explanation of psychological e f f e c t s , consistent with Zuckerman's (1969) theory of an optimal l e v e l of stimulation. Suggestions are made f o r the development of a theory of optimal l e v e l of personal c o n t r o l . As hypothesized, personal c o n t r o l measures were inv e r s e l y r e l a t e d to s t r e s s . With regard to l i f e s t r e s s , p atients who had a high incidence of l i f e events with a negative impact during the year p r i o r to h o s p i t a l i z a t i o n had greater imagery during the h o s p i t a l stay and lower adjustment ( i . e . , high stress) on follow-up. C l i n i c a l implications of these data are discussed. (iv) TABLE OF CONTENTS PAGE Abstract i i Table of Contents v L i s t of Tables x i i L i s t o f Figures . . x i v Acknowledgments xv Introduction 1 Immobility External Immobility 5 Internal Immobility 9 The Hospital Environment Environmental Stimulation Levels 13 Intensive Care Syndrome 14 Interpersonal Use of Space 16 Personal Control D e f i n i t i o n 18 Information and Outcome Control 19 Causal A t t r i b u t i o n s and Outcome Control 20 Primary and Secondary Control 22 Noncompliance 23 Clptimal Levels of Control and Stimulation 25 (v) P A G E Mental Imagery D e f i n i t i o n 27 Theore t i ca l and Methodological Issues 28 Environmental S t imulat ion Levels 30 Imagery and Af fec t 32 Stress Hosp i t a l Stress 34 L i f e Stress . . 34 Theore t ica l Framework 36 Hypotheses Category 1: Hypotheses Related to Immobility . . . . 38 Category 2: Hypotheses Related to the Intervent ion . 40 Category 3: Hypotheses Related to the Environment . . 42 Category 4: Hypotheses Related to L i f e Stress . . . . 43 Category 5: Hypotheses Related to Personal Contro l . 44 Method 46 Study 1: Experimental Design 46 Subjects . 47 Development of the Intervention 49 Measurement of Pred ic tor Var iab les 50 Dimensions of S t imulat ion 50 General Pred ic tor s 53 (vi) PAGE Measurement of Dependent Var iab les 56 Imagery 56 Stress 58 Noncompliant Behaviour 60 Procedure 61 Study 2: Experimental Design 63 Subjects 66 Procedure 67 Resul t s 69 U n i v e r s i t y H o s p i t a l Study (Study 1) 70 Ana lys i s of Variance Results 70 Imagery • 70 Stress 73 Noncompliance 78 Summary: ANOVA Results fo r Study 1 . 78 Stepwise Regression Resul t s : Dimensions of S t imulat ion 79 Imagery 79 Stress 83 Noncompliance 85 Summary: S t imulat ion Regression Results fo r Study 1 . 85 Stepwise Regression Results - General 87 Imagery 88 Stress 88 Summary: General Regression Results fo r Study 1 . . . 96 ( v i i ) PAGE Shaughnessy H o s p i t a l Study (Study 2 ) 97 Ana lys i s of Variance Results 97 Imagery 97 Stress 103 Noncompliance 103 Summary: Ana lys i s of Variance Results fo r Study 2 . . 109 Stepwise Regression Analys i s 110 Imagery and Temperature Regulation . . . . . . . . 110 Stress and Noncompliance 112 Summary: Stepwise Regression Results for Study 2 . 114 M u l t i v a r i a t e Ana lys i s of Variance 115 C o r r e l a t i o n Ana lys i s 119 Sleep Deprivat ion 119 Imagery, Stress and Noncompliance 121 Summary: Results from 2 Studies 126 Category 1: Hypotheses Related to Immobility . . . . 126 Category 2: . Hypotheses Related to the Intervent ion (Study 1) 128 Category 3: Hypotheses Related to the Environment . . 129 R e s t r i c t e d St imulat ion versus Overload 131 Category 4: Hypotheses Related to L i f e Stress (Study 1) 132 Category 5: Hypotheses Related to Personal Contro l (Study 1) 133 ( v i i i ) P A G E Discuss ion 134 I l l n e s s Related Factors 134 External and In terna l Iitirnobility 135 Immobility and Imagery 136 Immobility and Stress . . . . . 141 Immobility and Noncompliance 145 Cognit ive Appra i sa l 147 Cognit ive Reappraisal and Stress Reduction 147 P h y s i c a l (Nonsocial) and S o c i a l Environmental Factors . . 153 St imulat ion Dimensions and Imagery 154 St imulat ion Dimensions and Stress 159 St imulat ion Dimensions and Noncompliance 162 Sleep Deprivat ion 163 Background and Personal Factors 167 L i f e Stress 167 Other Background Factors 172 Personal Contro l 174 Conclusion and C l i n i c a l Impl icat ions 175 References 185 Appendices 200 A . Consent Form 202 B. Questionnaires 202 1. L i f e Experiences Survey 202 ( ix) PAGE 2. Personal Contro l a) Nurse assessment of pat ient behaviour . . . . 211 b) Subject ive Helplessness Scale 215 3. Modifie'd Imaginal Processes Inventory 216 4. Subject ive Stress Scale 220 5. Psychosocial Adjustment to I l l n e s s Scale a) L e t t e r to subjects 221 b) Questionnaire 222 C. Observations 1. Nonparticipant observation of s o c i a l and nonsocial environment i n a p a t i e n t ' s room . . . . 233 2. Pa t ient records (chart ) : a) Demographic data [i] U n i v e r s i t y Hosp i t a l 235 [ i i ] Shaughnessy Hosp i t a l . 236 b) Medications ordered 237 c) Progress notes and medications given as needed [i] U n i v e r s i t y Hosp i t a l 238 [ i i ] Shaughnessy Hosp i t a l 239 D. Interview: Environmental Stress Scale 240 E. Cognit ive Intervent ion . 253 F. Subject C h a r a c t e r i s t i c s 1. U n i v e r s i t y H o s p i t a l : N = 48 (Study 1) 256 2. Shaughnessy H o s p i t a l : N = 50 (Study 2) 261 (x) PAGE 3. Shaughnessy H o s p i t a l : N = 19 (Mul t ivar i a te analys i s of variance) 265 G. Supplementary Analyses 1. R e l i a b i l i t y data on personal cont ro l (Study 1) . . 267 2. Ana lys i s of variance fo r noncompliance (Study 1) . 269 3. I n t e r c o r r e l a t i o n matrix of expectancy versus react ion scores (Study 1) 270 4. Stepwise regression a n a l y s i s : Dimensions of s t imula t ion as pred ic tors of s t ress (Study 1) . . 271 5. Stepwise regression a n a l y s i s : Dimensions of s t imula t ion as pred ic tors of environmental s tress (Study 1) . . . 272 6. I n t e r c o r r e l a t i o n matr ix : Dimensions of s t imula t ion and dependent var iab les (Study 1) . . 273 7. Stepwise regression ana ly s i s : General pred ic tors of noncompliance (Study 1) 275 8. I n t e r c o r r e l a t i o n matr ix : General pred ic tors and dependent var iab les (Study 1) 276 9. Ana lys i s of variance of simple e f fects fo r imagery (Study 2) 278 10. Unweighted means ana lys i s of variance f o r imagery (Study 2) 280 11. Ana lys i s of variance without covariate f o r imagery (Study 2) 281 12. Ana lys i s of variance without covariate fo r s t ress (Study 2) 282 13. Ana ly s i s of variance without covariate fo r noncompliance (Study 2) 283 14. I n t e r c o r r e l a t i o n matr ix : Predic tors (Study 2) . . 284 (xi) LIST OF TABLES Table Description Page 1 Ana ly s i s of variance fo r imagery and s tress scores i n Study 1 71 2 Mean imagery scores (Modified Imaginal Processes Inventory) i n Study 1 72 3 Ana lys i s of variance fo r subscales of Environmental Stress Scale (ESS) i n Study 1 74 4 Stepwise regression a n a l y s i s : Dimensions of s t imula t ion as pred ic tor s of imagery (MIPI) i n Study 1 80 5 Stepwise regression ana ly s i s : Dimensions of s t imula t ion as pred ic tor s of noncompliance i n Study 1 86 6 Stepwise regress ion a n a l y s i s : General predic tors of imagery (MIPI) i n Study 1 89 7 Stepwise regress ion a n a l y s i s : General pred ic tor s of the Psychologica l Subscale of the Psychosocial Adjustment to I l l n e s s Scale (PAIS) i n Study 1 90 8 Stepwise regression a n a l y s i s : General pred ic tors of environmental s tress (ESS) i n Study 1 92 9 Stepwise regress ion a n a l y s i s : General predic tors of the d i s t r e s s record i n Study 1 95 10 Analys i s of variance and covariance: Imagery i n Study 2 . . . . 99 11 Mean recorded imagery over time i n Study 2 100 ( x i i ) Table Descr ip t ion Page 12 Ana lys i s of variance and covariance: Stress i n Study 2 . . . . 104 13 Mean recorded s tress over time i n Study 2 105 14 Ana lys i s of variance and covariance: Noncompliance i n Study 2 106 15 Mean recorded noncompliant behaviour over time i n Study 2 . . . 108 16 Stepwise regression a n a l y s i s : General pred ic tors of imagery and temperature regula t ion anomaly i n Study 2 I l l 17 Stepwise regression ana ly s i s : General pred ic tors of noncompliance i n Study 2 113 18 Mean imagery scores on subscales of the MIPI as a funct ion of immobil ity f o r Study 1 and Study 2 116 19 Simple e f f e c t s : Dimensions of imagery (MIPI) - surgery (Study 1) versus s p i n a l cord i n j u r y (Study 2) pat ients . . . 118 20 Stepwise regress ion r e s u l t s : General predic tors of sleep depr iva t ion (ESS) f o r Study 1 120 21 I n t e r c o r r e l a t i o n M a t r i x : Dependent var iables and sleep depr iva t ion (Study 2) 122 ( x i i i ) LIST OF FIGURES Figure Descr ipt ion Page 1 A conceptual model: The c r i s i s of p h y s i c a l i l l n e s s 4 2 Var i a b l e s included i n the present p r o j e c t 4 (xiv) I am deeply indebted to many people who have devoted t h e i r time and energies to t h i s p r o j e c t . In p a r t i c u l a r , I am g r a t e f u l to my advisor, Dr. P. Suedfeld, who provided both i n t e l l e c t u a l stimulation and support through the various stages of these studies. The other members of my D i s s e r t a t i o n Advisory Committee, Drs. R. Knox, J . M i l e s , J . Y u i l l e , and J . Wiggins, have likewise given consistent encouragement and thoughtful suggestions throughout the development of the d i s s e r t a t i o n . I thank Dr. Miles f o r h i s h e l p f u l r o l e i n f a c i l i t a t i n g the Shaughnessy Hospital study. During the data c o l l e c t i o n and a n a l y s i s phase i n Saskatchewan, Dr. M. Hiscock was most generous i n providing h i s able guidance t o the p r o j e c t , p a r t i c u l a r l y from a s t a t i s t i c a l perspective. I very much appreciate the contributions and support of other U n i v e r s i t y of Saskatchewan academics, notably Drs. L. McMullen, B.S. Randhawa, F. Zwiers and Dean U. Ridley. I wish to thank Mr. H. Boerma f o r h i s assistance i n the development of t h i s research area and Dr. S. Painter f o r her r o l e i n the production of the intervention tape. I was fortunate to have a succession of e x c e l l e n t research a s s i s t a n t s : Ms. D. Moir, J . Lux, S. Pawlowski, G. Spracklin, L. Brehon and Mr. R. Ryhorchuk. I am e s p e c i a l l y thankful f o r the calm e f f i c i e n c y of Ms. J . Pocock, who typed and revised the manuscript with a dedication f a r beyond the c a l l of duty. (xv) Administrators and s t a f f of both h o s p i t a l s were extremely supportive of the data c o l l e c t i o n phase of t h i s p r o j e c t . At Shaughnessy H o s p i t a l i n Vancouver, appreciation i s extended to Dr. J . Schweigel, Ms. C. M e l l a l i e u , G. Clements, M. Cooper and the nursing s t a f f of the Acute Sp i n a l Cord Injury U n i t . At the U n i v e r s i t y H o s p i t a l i n Saskatoon, I wish to thank Drs. F.G. I n g l i s , W. K i r k a l d y - W i l l i s , J . Wedge, E.W. Chappell, Mr. T. Dagnone, Ms. A. Si l v e r t h o r n , I. Lafreniere, L. Jackson, B. England, M. Brennan, P. Nixon, S. Cronk and the nursing s t a f f of 2DE, Surgery 30 and Surgery 33. A very s p e c i a l thank you goes to the patients who were so receptive t o t h i s research. F i n a l l y , I wish t o thank my family and many f r i e n d s f o r standing by me through t h i s period of my l i f e . In p a r t i c u l a r , I thank the Stewart c l a n : my mother, Dale, S h i r l e y , and my daughter, Shoshana. I am g r a t e f u l t o a l l my f r i e n d s , e s p e c i a l l y Linda Kessler, V i k k i Smart, Peter Loptson and the Duncan family who hosted my numerous t r i p s to Vancouver. (xvi) 1 INTECDOCTIGN R e s t r i c t i o n o f movement has l o n g been seen t o cause problems f o r p a t i e n t s i n h o s p i t a l . S y s t e m a t i c s t u d i e s o f p h y s i c a l and p s y c h o l o g i c a l e f f e c t s o f i m m o b i l i t y d a t e back t o the 1940 ' s ( S t e i n b e r g , 1980) , w i t h most r e s e a r c h f o c u s i n g on n e g a t i v e p h y s i c a l e f f e c t s . As a consequence, e a r l y m o b i l i z a t i o n i s now s t a n d a r d p r a c t i c e i n h o s p i t a l s . Where i m m o b i l i z a t i o n cannot be a v o i d e d , however, r e l a t i v e l y few s t u d i e s have examined p s y c h o l o g i c a l e f f e c t s o r i n t e r v e n t i o n s t o reduce these e f f e c t s . Hammer and Kenan (1980, p . 126) c a t e g o r i z e i m m o b i l i t y i n terms o f e x t e r n a l and i n t e r n a l r e s t r i c t i o n o f movement. E x t e r n a l r e s t r i c t i o n i n c l u d e s d e v i c e s a p p l i e d t o t h e body ( e . g . , t r a c t i o n ) as w e l l as conf inement t o a r e s t r i c t e d space ( e . g . , b e d r e s t ) . . I n t e r n a l r e s t r i c t i o n , on the o t h e r hand , r e f e r s t o s i t u a t i o n s where p h y s i c a l movement i s p e r m i t t e d b u t n o t p o s s i b l e due t o f a c t o r s w i t h i n the i n d i v i d u a l ( e . g . , p a r a l y s i s ) . I n a p r e v i o u s s t u d y o f p a t i e n t s w i t h e x t e r n a l i m m o b i l i t y , S t e w a r t (1977) found an i n t e r a c t i o n e f f e c t i n w h i c h p a t i e n t s , aged 15 - 6 5 , who were b o t h immobi le and i s o l a t e d i n a p r i v a t e room had the g r e a t e s t i n c i d e n c e o f h a l l u c i n a t i o n - l i k e e f f e c t s and noncompl iant b e h a v i o u r . Twenty-one per c e n t o f 39 o r t h o p e d i c p a t i e n t s r e p o r t e d u n u s u a l v i s u a l , a u d i t o r y , k i n e s t h e t i c o r t a c t u a l e x p e r i e n c e s . A f f e c t i v e responses t o these e x p e r i e n c e s ranged from m i l d amusement t o t e r r o r ( r e l a t e d t o thought s o f " g o i n g c r a z y " ) . The noncompl iant behav iour u s u a l l y c o n s i s t e d o f t r y i n g t o remove t r a c t i o n o r g e t o u t o f bed . T h i s 2 b e h a v i o u r tended t o occur d u r i n g hypnagogic p e r i o d s as the p a t i e n t was f a l l i n g a s l e e p and was a s s o c i a t e d w i t h unusua l dreams o r v i v i d images. The images i n c l u d e d memory images and b i z a r r e images w h i c h R i c h a r d s o n (1965) r e f e r s t o as i m a g i n a t i o n imagery. The c h o i c e o f the term " h a l l u c i n a t i o n - l i k e e x p e r i e n c e s " r e f l e c t e d the f a c t t h a t , u n l i k e p s y c h o t i c h a l l u c i n a t i o n s , the p a t i e n t s r a r e l y b e l i e v e d t h a t the e x p e r i e n c e s were r e a l . S e n s a t i o n s o f t h i s type have been c a l l e d p s e u d o h a l l u c i n a t i o n s ( F i s h , 1967, p . 1 9 ) , r e p o r t e d v i s u a l s e n s a t i o n s (Zuckerman, 1969[a]) o r , m e n t a l imagery. The l a t t e r term i s p r e f e r a b l e here because i t does n o t connote p a t h o l o g y and i t i s n o t m o d a l i t y s p e c i f i c . The d a t a f rom the above s t u d y (S tewar t , 1977) i n c l u d e d t r a n s i e n t , q u a s i - p e r c e p t u a l e x p e r i e n c e s w h i c h o c c u r r e d d u r i n g t h e e a r l y h o s p i t a l i z a t i o n p e r i o d and c o u l d b e t t e r be e x p l a i n e d as a n o r m a l , a d a p t i v e p r o c e s s r a t h e r t h a n as m e n t a l i l l n e s s . When i m m o b i l i z e d p a t i e n t s have p s y c h o l o g i c a l r e a c t i o n s w h i c h cause a problem f o r themselves o r the s t a f f , the d e f i n i t i o n o f the problem determines the t h e r a p e u t i c approach. F o r example, i f the problem i s d e f i n e d as a p s y c h o s i s , the p a t i e n t w i l l l i k e l y be r e f e r r e d t o a p s y c h i a t r i s t and t r e a t e d w i t h a n t i p s y c h o t i c m e d i c a t i o n (Putnam & Y a g e r , 1978) . By c o n t r a s t , the d e f i n i t i o n o f the same behaviour as a n o r m a l , a d a p t i v e p r o c e s s l e a d s t o a s e a r c h f o r a l t e r n a t i v e i n t e r v e n t i o n s such as m a n i p u l a t i o n o f the s o c i a l o r n o n s o c i a l environment . The p r e s e n t p r o j e c t extended my e a r l i e r r e s e a r c h (S tewar t , 1977) by examining the p s y c h o l o g i c a l e f f e c t s o f b o t h e x t e r n a l and i n t e r n a l i m m o b i l i t y i n two s t u d i e s o f h o s p i t a l i z e d p a t i e n t s . The dependent 3 var i ab le s ( i . e . , p sycholog ica l ef fects) for both studies were imagery, s t ress and noncompliant behaviour. In one study, an informat ional in te rvent ion was tested for stress-reducing e f f e c t . This in te rvent ion was based on the premise that the psychologica l e f fec t s i n quest ion represented normal adaptation rather than psychopathology. Given the m u l t i v a r i a t e nature of c l i n i c a l s i t u a t i o n s , t h i s pro jec t a l so examined other poss ib le explanations for e f fect s such as environmental, personal , demographic and e x p e r i e n t i a l f a c t o r s . Moos and Tsu (1977) provide a conceptual model of p h y s i c a l i l l n e s s as l i f e c r i s i s . They suggest that i n d i v i d u a l d i f ference i n response to i l l n e s s i s determined by a number of factors which inf luence the person's cogn i t ive appra i sa l of the meaning of the i l l n e s s . These factors are shown i n F igure 1. The model proposed by Moos and Tsu form the framework for the independent var i ab le s of i n t e r e s t i n the present pro jec t (see F igure 2 ) . "Background and personal" factors included previous l i f e s t ress and personal c o n t r o l . Immobil ization was an " i l l n e s s - r e l a t e d " v a r i a b l e and dimensions of s o c i a l and nonsocia l s t imula t ion were "environment" f a c t o r s . The in te rvent ion tested i n t h i s research was at the l e v e l of " cogn i t ive appra i sa l " or perceived meaning, according to the Moos and Tsu model. The outcome or dependent var i ab le s studied were imagery, s t ress and noncompliant behaviour. The l i t e r a t u r e review w i l l be organized according to the major var i ab le s for study i n t h i s p r o j e c t : immobi l i ty , the h o s p i t a l environment, personal c o n t r o l , imagery and s t re s s . The sec t ion on personal c o n t r o l includes data re la ted to noncompliance and to the in te rvent ion tested here. A conceptual model: The crisis of physical i l l n e s s BACKGROUND AND PERSONAL FACTORS I ILLNESS-RELATED FACTORS I PHYSICAL AND SOCIAL ' ENVIRONMENTAL FACTORS COGNITIVE APPRAISAL (PERCEIVED ADAPTIVE COPING MEANING TASKS SKILLS OF ILLNESS) OUTCOME OF CRISIS Figure 1. (Reprinted with permission from Moos & Tsu, 1977, p. 16 ) . Variables included in the present project: Life stress Personal control I Inraobility Environmental Stimulation Dimensions 3 Cognitive Reappraisal (Inter-vention) Imagery Stress Noncom-pliance Figure 2. Note. A l l of the sample were emergency admissions to hospital. 5 Immobility External Immobility Orthopedic and Medical-Surgical Patients B o l i n (1974) found that immobilized orthopedic pa t ient s reported devia t ions from t h e i r normal patterns of s leep and dreams, p a r t i c u l a r l y during the f i r s t week of h o s p i t a l i z a t i o n . Several of the 13 pat ients studied reported nightmares i n which they saw animals or r e l i v e d the trauma which brought them to h o s p i t a l . While apparently dreaming, two pat ient s exhib i ted noncompliant behaviour, i n which they attempted to remove t h e i r t r a c t i o n or get out of bed. Putnam and Yager (1978) used the l a b e l " t r a c t i o n intolerance syndrome" to refer to behavioural and emotional react ions i n pa t ient s w i t h a f ractured femur. The syndrome included removal of t r a c t i o n , angry threats to s t a f f , depressed mood and i n c o m p l i a n c e w i t h i n s t r u c t i o n s by s t a f f . Of nine pat ient s (aged 16 - 45) admitted to an orthopedic u n i t i n one year , f i v e had the syndrome and required p s y c h i a t r i c consu l ta t ion and/or the use of major psychotropic medication. M l f i v e had no previous p s y c h i a t r i c h i s t o r y ; were 16 - 26 years o l d and were i n t r a c t i o n for three weeks or more. The absence of previous p s y c h i a t r i c h i s t o r y i s cons i s tent wi th Stewart ' s (1977) data and ra i se s the quest ion o f whether p s y c h i a t r i c medication should be the in te rvent ion of choice when t r a c t i o n ( i . e . , ex terna l immobility) has been i d e n t i f i e d as the problem. 6 The f o r e g o i n g s t u d i e s s h o u l d be v iewed w i t h c a u t i o n because o f the s m a l l sample s i z e s . However, v e r y few s t u d i e s w i t h l a r g e r samples have examined the p s y c h o l o g i c a l e f f e c t s o f e x t e r n a l i m m o b i l i t y . Two n o t a b l e e x c e p t i o n s f o l l o w . I n a s t u d y o f 77 m e d i c a l - s u r g i c a l p a t i e n t s (aged 21 - 8 6 ) , Wood (1977) found t h a t p a t i e n t s i n p r i v a t e rooms had more s e n s o r y / c o g n i t i v e d i s t u r b a n c e s ( e . g . , u n u s u a l s e n s a t i o n s , confus ion) t h a n p a t i e n t s i n two-bed rooms. I m m o b i l i t y by b e d r e s t and one o r more r e s t r a i n i n g d e v i c e s i n c r e a s e d the i n c i d e n c e o f s ensory d i s t u r b a n c e f o r both g roups . Wood i n t e r p r e t e d the f i n d i n g s i n terms o f r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n . On the o t h e r hand , W i l l i a m s , H o l l o w a y , W i n n , W o l a n i n , L a w l e r , Westwich and C h i n (1979) f o u n d , i n a sample o f 91 f r a c t u r e d h i p p a t i e n t s (aged 60 - 9 4 ) , t h a t t h e r e was l e s s c o g n i t i v e d i s t u r b a n c e ( i . e . , confus ion) i n a p r i v a t e room. However, c o n s i s t e n t w i t h Wood's s tudy/ i m m o b i l i t y i n c r e a s e d the d i s t u r b a n c e . The c o n f l i c t i n g f i n d i n g s c i t e d above on p r i v a t e v e r s u s n o n p r i v a t e rooms may stem from confounding v a r i a b l e s w h i c h c o u l d n o t be c o n t r o l l e d i n the h o s p i t a l s e t t i n g . On the o t h e r hand, these s t u d i e s d i f f e r e d i n the average age o f s u b j e c t s and i n the dependent measures . As mentioned p r e v i o u s l y , S t e w a r t (1977) found g r e a t e r s ensory d i s t u r b a n c e s i n p a t i e n t s who were b o t h immobi le and i n a p r i v a t e room. However, the l a t t e r r e s u l t s were confounded by the f a c t t h a t more emergency admi s s ions f e l l i n t o the immobile - p r i v a t e room ( i s o l a t i o n ) g r o u p , whereas e l e c t i v e admis s ions more f r e q u e n t l y were a s s i g n e d t o n o n p r i v a t e rooms. F u r t h e r r e s e a r c h needs t o c o n t r o l t h i s v a r i a b l e by o t h e r means, such as r e s t r i c t i n g the sample t o emergency a d m i s s i o n s . 7 I n s o f a r as p s y c h o l o g i c a l e f f e c t s can be a t t r i b u t e d t o e x t e r n a l i m m o b i l i t y , the e x p l a n a t i o n o f a mechanism f o r the e f f e c t s remains open t o q u e s t i o n . One e x p l a n a t i o n has been t h a t these e f f e c t s r e s u l t from " s e n s o r y d e p r i v a t i o n " ( J ackson , 1969; J ohnson , 1976) . A comment about language bears ment ion h e r e . The term " s e n s o r y d e p r i v a t i o n " w i l l n o t be used because , as S u e d f e l d (1980) has p o i n t e d o u t , i t i s i m p r e c i s e and c a r r i e s n e g a t i v e c o n n o t a t i o n s . The a d j e c t i v e " s e n s o r y " i s i m p r e c i s e because i t suggests t h a t the environment l ower s the a b s o l u t e l e v e l o f s ensory i n p u t , even though t h i s l e v e l may be unchanged or even i n c r e a s e d . F u r t h e r m o r e , " d e p r i v a t i o n " l a c k s p r e c i s i o n because i t i m p l i e s an absence o f s t i m u l a t i o n , whereas a r e d u c t i o n o f e x t e r n a l s t i m u l a t i o n l e a d s t o i n c r e a s e d i n t e r n a l ( i . e . , sub jec t -produced) s t i m u l a t i o n . The e a r l y l a b o r a t o r y r e s e a r c h i n t h i s f i e l d , w i t h i t s use o f " p a n i c " b u t t o n s f o r e scape , c o u p l e d w i t h a c u l t u r a l b i a s a g a i n s t i s o l a t i o n ( S u e d f e l d , 1974) , have c o n t r i b u t e d t o a n e g a t i v e a s s o c i a t i o n w i t h the l a b e l . F o r these r e a s o n s , n e u t r a l terms such as " r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n " , as proposed by S u e d f e l d , w i l l be used h e r e . The s e c t i o n t o f o l l o w examines r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n s t u d i e s r e l a t e d t o e x t e r n a l i m m o b i l i t y . Laboratory Research The main c o n t r i b u t i o n o f l a b o r a t o r y r e s e a r c h on the p s y c h o l o g i c a l e f f e c t s o f e x t e r n a l i m m o b i l i t y came from the work o f Zubek and c o l l e a g u e s i n the 1 9 6 0 ' s . Zubek, A f t a n a s , Kovach , W i l g o s h and Winocur (1963) found t h a t s u b j e c t s s t r a p p e d i n the prone p o s i t i o n i n a box w i t h o t h e r w i s e normal s t i m u l a t i o n showed g r e a t e r c o g n i t i v e , p e r c e p t u a l , 8 e m o t i o n a l and somat ic ( i . e . , u n u s u a l body s ensa t ion ) changes than recumbent c o n t r o l s who were p r e v e n t e d o n l y from s i t t i n g o r s t a n d i n g u p . They conc luded t h a t " s e v e r e r e s t r i c t i o n o f k i n e s t h e t i c a c t i v i t y a l o n e f o r p e r i o d s up t o 24 hours can produce many o f the c l a s s i c a l s ensory and p e r c e p t u a l d e p r i v a t i o n phenomena" (p . 1 2 8 ) . The extreme type o f i m m o b i l i z a t i o n from the Zubek e t a l . s t u d y resembles t h a t produced by c e r t a i n d e v i c e s used i n h o s p i t a l ( e . g . , c e r v i c a l t o n g s , S t r y k e r f r a m e ) . C e r v i c a l t r a c t i o n i s used t o hyperextend the head and neck o f p a t i e n t s w i t h f r a c t u r e d c e r v i c a l v e r t e b r a e . Tongs a re i n s e r t e d i n t o two s m a l l b u r r h o l e s d r i l l e d i n the p a r i e t a l r e g i o n o f the s k u l l and t h i s apparatus i s a t t a c h e d t o a rope and p u l l e y system w i t h w e i g h t s hanging over the head o f the b e d . Head movement i s s e v e r e l y r e s t r i c t e d a l t h o u g h the p a t i e n t can be t u r n e d from s i d e t o s i d e over a p p r o x i m a t e l y a 9 0 ° a n g l e . The S t r y k e r frame i s a canvas bed w h i c h a l l o w s t h e p a t i e n t t o remain immobile w h i l e b e i n g t u r n e d . The p a t i e n t i s s t r apped between two canvas s e c t i o n s on a r o t a t i o n frame and t u r n e d t o the prone o r sup ine p o s i t i o n . Then the upper canvas i s removed u n t i l the n e x t t u r n . These methods o f i m m o b i l i z a t i o n r e s t r i c t the v i s u a l f i e l d as w e l l as r e s t r i c t movement. I n a summary o f Zubek ' s l a b o r a t o r y r e s e a r c h on i m m o b i l i z a t i o n , Zuckerman (1969, p . 56) conc luded t h a t " conf inement and r e l a t i v e i m m o b i l i z a t i o n emerge . . . as c r u c i a l v a r i a b l e s " i n the s t u d i e s o f • r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n . Zubek and M a c N e i l l (1967) found t h a t conf ined-recumbent c o n t r o l s u b j e c t s d i d n o t d i f f e r from p e r c e p t u a l l y r e s t r i c t e d s u b j e c t s on s u b j e c t i v e s t r e s s o r on v i v i d and 9 complex dreams. Both of these groups had a higher incidence of s t ress and dreams than d i d ambulatory c o n t r o l s . One could exp la in the confinement e f fec t i n terms of a decrease i n st imulus frequency and v a r i a b i l i t y as compared to the ambulatory s i t u a t i o n . However, Suedfeld (1979) suggests that decreased response options are the c r i t i c a l aspect of immobi l i ty , and that st imulus r e s t r i c t i o n i s of le s ser inrportance. In a l a t e r sec t ion of t h i s review, data w i l l be examined on personal c o n t r o l , which re l a te s to the question o f response opt ions . Internal Tmrnnhility Spinal Cord Injury Patients Johnson (1976) obtained a dramatic reduct ion of nightmares, h a l l u c i n a t i o n s ("seeing things") and confusion i n c e r v i c a l s p i n a l cord i n j u r y pa t ient s using an in te rvent ion derived from the r e s t r i c t e d environmental s t imula t ion l i t e r a t u r e . This in te rvent ion included an increase i n s o c i a l , s t i m u l a t i o n w i t h other p a t i e n t s , volunteers and s t a f f ; the p r o v i s i o n of information on s p i n a l cord i n j u r y i n general and the p a t i e n t ' s p a r t i c u l a r p h y s i c a l c o n d i t i o n , treatment and prognosis ; pa t i en t group meetings to discuss t h e i r i n j u r i e s ; access to c l o c k s , watches, eyeglasses, hearing a ids and m i r r o r s ; the addressing of pa t ient s by name; and the asking of permission to perform treatment or s e rv i ce s . The durat ion of symptoms i n the experimental group was reduced to l e s s than seven percent of the durat ion of symptoms i n a comparison group who were not exposed to the i n t e r v e n t i o n . A l l nine pa t ient s i n the comparison group had nightmares, h a l l u c i n a t i o n s and/or 10 c o n f u s i o n f o r p e r i o d s r a n g i n g f rom 29 t o 90 d a y s . Of t e n e x p e r i m e n t a l p a t i e n t s , s i x had symptoms f o r two t o 11 days w h i l e the o t h e r f o u r were symptom-free. S i n c e n u r s i n g r e c o r d s were u sed , no i n t r o s p e c t i v e c r i t e r i a ( i . e . , apparent r e a l i t y ) were a p p l i e d t o these d a t a c o n c e r n i n g " h a l l u c i n a t i o n s " . Conomy (1973) examined the body image d i s t o r t i o n s o f 18 s p i n a l c o r d i n j u r y p a t i e n t s , aged 10 - 68 y e a r s , who had s u s t a i n e d trauma t o the c o r d a t l e v e l s r a n g i n g f rom the t h i r d t h o r a c i c v e r t e b r a t o the f i f t h c e r v i c a l v e r t e b r a . No h i g h c e r v i c a l i n j u r i e s nor lumbar i n j u r i e s were i n c l u d e d i n the sample . P a t i e n t s were s e l e c t e d f o r t h e s t u d y based on o r d e r o f a d m i s s i o n t o a n e u r o l o g y u n i t . The group w h i c h emerged had e x p e r i e n c e d t h e i r i n i t i a l i n j u r y seven days t o 25 y e a r s p r i o r . A compar i son sample i n c l u d e d t e n p a t i e n t s w i t h c o n g e n i t a l o r d e g e n e r a t i v e problems o f t h r e e weeks' t o 24 y e a r s ' d u r a t i o n . T h i s group was a p p a r e n t l y s i m i l a r i n degree o f n e u r o l o g i c a l impairment t o the trauma group a l t h o u g h the l e v e l o f c o r d l e s i o n was n o t r e p o r t e d f o r the compar i son sample . The d e f i n i t i o n o f body image d i s t o r t i o n used by Conomy i n c l u d e d p e r c e p t u a l d i s o r d e r s o f (1) p r o p r i o c e p t i o n ( l imbs i n s p a c e ) , (2) p o s t u r e and movement, and (3) body s i z e and c o n t i n u i t y . W i t h the e x c e p t i o n o f one p a t i e n t , a l l o f the trauma cases had a t l e a s t one c a t e g o r y o f d i s o r d e r and o n e - t h i r d o f t h i s group had a l l t h r e e d i s o r d e r s . The percentage o f trauma p a t i e n t s who had e x p e r i e n c e s i n each o f the t h r e e c a t e g o r i e s were 83%, 72%, and 38% r e s p e c t i v e l y . By c o n t r a s t , the n o n - t r a u m a t i c group e x h i b i t e d no d i s t o r t i o n s o f l i m b p o s i t i o n o r body 11 s i z e and c o n t i n u i t y . O n l y one p a t i e n t (10% i n t h e compar i son group) e x p e r i e n c e d movement i l l u s i o n s . T h i s s t u d y demonstrates t h a t trauma i s more impor tan t than n e u r o l o g i c a l d e f i c i t i n the e t i o l o g y o f imagery . Conomy noted t h a t spontaneous r e p o r t s o f these e f f e c t s were r a r e l y made by p a t i e n t s even though some e x p e r i e n c e d t e r r o r s u r r o u n d i n g these e x p e r i e n c e s . T h i s l a c k o f r e p o r t p r o b a b l y r e l a t e d t o the f e a r t h a t they were becoming m e n t a l l y i l l . U n l i k e p s y c h o s i s , however, most p a t i e n t s r e a l i z e d t h a t t h e i r u n u s u a l s e n s a t i o n s were a t v a r i a n c e w i t h r e a l i t y . When q u e s t i o n e d d i r e c t l y , the m a j o r i t y o f p a t i e n t s were v e r y i n t e r e s t e d i n d i s c u s s i n g t h e i r e x p e r i e n c e s . Other u n u s u a l s e n s a t i o n s , w h i c h come from p a r a l y z e d p a r t s o f the body, may be r e p o r t e d as p a i n . Hohmann (1975) d e s c r i b e d r e p o r t s o f b u r n i n g , t i n g l i n g , h y p e r s e n s i t i v i t y and s h o o t i n g p a i n s . M e l z a c k and Loeser (1978) have drawn the compar i son between phantom l i m b p a i n i n amputees and "phantom body p a i n " i n p a r a p l e g i c s . However, as Conomy p o i n t e d o u t , the term "phantom" does n o t a c c u r a t e l y r e p r e s e n t the s p i n a l c o r d i n j u r y s i t u a t i o n i n w h i c h the l i m b s a re s t i l l p r e s e n t . I n s p i n a l c o r d i n j u r e d p a t i e n t s t h e r e may s t i l l be a f f e r e n t pathways which a re p r e s e r v e d , c o n t r a r y t o p o s t a m p u t a t i o n c a s e s . Hohmann (1975) a l s o d e s c r i b e d "phantom s e n s a t i o n s " whereby p a t i e n t s e x p e r i e n c e d s e n s a t i o n and movement i n p a r a l y z e d l i m b s w h i c h had no s e n s a t i o n o r movement on n e u r o l o g i c a l e x a m i n a t i o n . These r e p o r t s , s i m i l a r t o Conomy's "body image d i s t o r t i o n s " , were sometimes a s s o c i a t e d w i t h b u r n i n g and t i n g l i n g s e n s a t i o n s . A l t h o u g h no s p e c i f i c t rea tment e x i s t s f o r these e f f e c t s , Hohmann s t r e s s e d the n o r m a l i t y o f the 1 2 e x p e r i e n c e s and found t h a t i t was " u s e f u l t o encourage some p a t i e n t s t o amuse themselves w i t h such s e n s a t i o n s r a t h e r than b e i n g d i s t r e s s e d by t h e m . " P o l l o c k , Boshes , A r i e f f , F i n k e l m a n , Brown, D o b i n , K e s e r t , P y z i k , F i n k l e , T i g a y and Z i v i n (1957) , i n a s t u d y o f 213 i n j u r i e s o f the s p i n a l c o r d and cauda e q u i n a (the lower end o f the s p i n a l c o r d ) , a l s o suggested t h a t the term "phantom" be r e s e r v e d f o r cases where a l i m b has been amputated. They found t h a t s e n s a t i o n s o f changes i n p o s t u r e and movement were r e p o r t e d from 10.4% o f t h i s sample . T h i s s t u d y , l i k e Conomy*s , had a n e u r o l o g i c a l p e r s p e c t i v e and o n l y examined u n u s u a l body s e n s a t i o n s . No ment ion was made o f unusua l v i s u a l o r a u d i t o r y s e n s a t i o n s . I n summary, the r e s e a r c h on i m m o b i l i t y demonstrates t h a t e x t e r n a l i m m o b i l i z i n g d e v i c e s and i n t e r n a l f a c t o r s such as p a r a l y s i s can b o t h l e a d t o imagery e f f e c t s i n v a r i o u s m o d a l i t i e s . Some o f these imagery e x p e r i e n c e s have been r e p o r t e d as v e r y s t r e s s f u l . S t u d i e s o f h o s p i t a l i z e d o r t h o p e d i c p a t i e n t s ( B o l i n , 1974; S t e w a r t , 1977; Putnam & Y a g e r , 1978) a l s o suggest t h a t noncompl iant behav iour i s a v a r i a b l e w h i c h m e r i t s f u r t h e r s t u d y . E x p l a n a t i o n s f o r these e f f e c t s have i n c l u d e d r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n and decreased response o p t i o n s . The u n u s u a l s e n s a t i o n s r e p o r t e d by p a r a l y z e d p a t i e n t s may r e p r e s e n t a p h y s i o l o g i c a l a d a p t a t i o n t o t rauma. 13 The Hospital Environment Environmental Stimulation Levels I n a d d i t i o n t o the e f f e c t s o f i m m o b i l i t y , the h o s p i t a l environment i t s e l f has been suggested as a c o n t r i b u t o r t o sensory changes i n p a t i e n t s . J a c k s o n (1969) , i n a r e v i e w o f c l i n i c a l " s e n s o r y d e p r i v a t i o n " r e s e a r c h , r a i s e d the i s s u e o f the h e t e r o g e n e i t y and c o m p l e x i t y o f c l i n i c a l v a r i a b l e s . P a t i e n t s i n h o s p i t a l may e x p e r i e n c e o v e r s t i m u l a t i o n a t some t imes ( e . g . , a d m i s s i o n and surgery) and under s t i m u l a t i o n a t o t h e r t i m e s . P a i n may s i m u l t a n e o u s l y c o n t r i b u t e t o r e s t r i c t i o n o f k i n e s t h e t i c s t i m u l a t i o n due t o i n h i b i t i o n o f the d e s i r e t o move ( C a r n e v a l i & B r u e c k n e r , 1970) and t o s ensory bombardment on an e x p e r i e n t i a l l e v e l ( S c h u l t z , 1965) . Cohen (1978) proposed t h a t p r o l o n g e d a t t e n t i o n a l demands w i l l decrease the c a p a c i t y t o p r o c e s s i n f o r m a t i o n . A n e n v i r o n m e n t a l s t r e s s o r , i n these c i r c u m s t a n c e s , w i l l be more l i k e l y t o c r e a t e i n f o r m a t i o n a l o v e r l o a d because i t demands a t t e n t i o n c a p a c i t y . F o r trauma p a t i e n t s , the u n p r e d i c t a b l e e x p e r i e n c e o f trauma (see G l a s s & S i n g e r , 1972) p l u s f a c t o r s such as p o s t - a d m i s s i o n s l e e p d e p r i v a t i o n i n c r e a s e demands on a t t e n t i o n . T h i s , i n t u r n , may render a spec t s o f the p h y s i c a l and s o c i a l environment o f the h o s p i t a l as s t r e s s o r s c o n t r i b u t i n g t o i n f o r m a t i o n o v e r l o a d . I n t h i s c o n t e x t even p l e a s a n t i n p u t s , such as the presence o f c h e r i s h e d v i s i t o r s , may l e a d t o o v e r l o a d due t o a " s u r f e i t o f a t t r a c t i v e i n f o r m a t i o n i n p u t s " ( L i p o w s k i , 1974) . 14 Intensive Care Syndrome Research c o n c e r n i n g the h o s p i t a l environment has m o s t l y been d i r e c t e d a t examining the i n t e n s i v e c a r e u n i t (ICU) env i ronment . Numerous a r t i c l e s have been w r i t t e n about " i n t e n s i v e c a r e syndrome" ( e . g . , T a y l o r , 1971) w h i c h has been d e s c r i b e d as a p s y c h i a t r i c c o m p l i c a t i o n ( K i e l y , 1973) o f the ICU env i ronment . The syndrome, w h i c h has been r e f e r r e d t o as a p s y c h o s i s o r d e l i r i u m , i n c l u d e s d i s o r i e n t a t i o n , h a l l u c i n a t i o n s , l o s s o f memory, poor judgment and l a b i l e a f f e c t . E l l i s (1972) , i n a s t u d y o f 43 p o s t - o p e r a t i v e c a r d i a c p a t i e n t s i n ICU s e t t i n g s , found t h a t 67% o f t h e sample had one o r more " i n d e t e r m i n a t e s t i m u l u s e x p e r i e n c e s " ( c a l l e d imagery i n the p r e s e n t a n a l y s i s ) . Of the group who e x p e r i e n c e d imagery , 41% found these e x p e r i e n c e s t o be modera te ly t o h i g h l y s t r e s s f u l . E l l i s conc luded t h a t terms l i k e " p s y c h o s i s " and " d e l i r i u m " were n o t a p p r o p r i a t e because p a t i e n t s knew t h a t the e x p e r i e n c e s were n o t r e a l and c o u l d t a l k r a t i o n a l l y d u r i n g them. A n a l y s i s o f the d a t a suggested t h a t sensory d i s t u r b a n c e s were m u l t i - d e t e r m i n e d and c o u l d n o t be a t t r i b u t e d t o any s i n g l e f a c t o r such as age, s e x , type o f s u r g e r y , d r u g s , p e r c e p t u a l d e p r i v a t i o n , o v e r s t i m u l a t i o n , s l e e p d e p r i v a t i o n o r p h y s i o l o g i c a l i m b a l a n c e . Other s t u d i e s have found t h a t p a r t i c u l a r e n v i r o n m e n t a l f a c t o r s do i n c r e a s e the r i s k o f p s y c h o l o g i c a l c o m p l i c a t i o n s . F o r example, W i l s o n (1972) compared 50 p a t i e n t s i n a windowless ICU w i t h 50 p a t i e n t s i n an ICU w i t h windows. The i n c i d e n c e o f " d e l i r i u m " i n the windowless u n i t 15 was more than t w i c e the i n c i d e n c e i n the u n i t w i t h windows. F o r p a t i e n t s w i t h c e r t a i n p h y s i o l o g i c a l changes (low hemoglob in , h i g h b l o o d u r e a n i t r o g e n ) the r i s k o f " d e l i r i u m " was t h r e e t imes as g r e a t i n the windowless u n i t as compared t o the ICU w i t h windows, w h i c h a g a i n sugges t s an i n t e r a c t i o n o f v a r i a b l e s . I n cases o f i n t e n s i v e c a r e syndrome, a major prob lem f o r e n v i r o n m e n t a l i n t e r v e n t i o n has r e s u l t e d from the c o n f l i c t i n g e x p l a n a t i o n s o f r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n ( e . g . , W o r r e l l , 1977) v e r s u s e x c e s s i v e s t i m u l a t i o n ( e . g . , L indenmuth , B r e u & M a l o o l e y , 1980) , w h i c h suggest o p p o s i t e i n t e r v e n t i o n approaches . Based on concerns about o v e r l o a d i n an open-ward p l a n , some h o s p i t a l s have d e s i g n e d i n d i v i d u a l c u b i c l e s f o r p a t i e n t s i n the ICU s e t t i n g . Bradburn and H e w i t t (1980) d i d n o t f i n d d i f f e r e n c e s i n the s u b j e c t i v e i m p r e s s i o n s c o n c e r n i n g ICU s t a y o f p a t i e n t s i n i n d i v i d u a l rooms as corrrpared t o the open-ward d e s i g n . I n b o t h c a s e s , the most common p a t i e n t c o n c e r n was d i f f i c u l t y s l e e p i n g . S l e e p d e p r i v a t i o n has been i d e n t i f i e d as a prob lem i n o t h e r ICU s e t t i n g s OFabi jan & G o s s e l i n , 1982) , b u t the c o n n e c t i o n between s l e e p d e p r i v a t i o n and o v e r l o a d i s not u s u a l l y made. D e p r i v a t i o n o f s l e e p means t h a t the q u a n t i t y o f i n f o r m a t i o n - p r o c e s s i n g r e q u i r e d by the i n d i v i d u a l i n c r e a s e s over 24 hours a c c o r d i n g t o the number o f waking h o u r s . A t t e n t i o n a l demands i n c r e a s e and o v e r l o a d can r e s u l t (Cohen, 1978) . M a c K i n n o n - K e s l e r (1973) suggests t h a t the ICU p a t i e n t may be a t r i s k f o r u n d e r l o a d , o v e r l o a d and s l e e p d e p r i v a t i o n . The q u e s t i o n remains as t o which f a c t o r , on b a l a n c e , i s most i m p o r t a n t . I t i s 16 d i f f i c u l t t o make recommendations f o r i n t e r v e n t i o n because o f the dilemma t h a t i n c r e a s i n g s t i m u l a t i o n t o reduce apparent u n d e r l o a d c a n i n c r e a s e e x i s t i n g o v e r l o a d i n the event t h a t the i n i t i a l s i t u a t i o n was i n c o r r e c t l y a s se s sed . I n a d d i t i o n t o the q u a n t i t y o f s t i m u l a t i o n , the meaningfu lness o f s t i m u l a t i o n has importance ( W o r r e l l , 1977) . F o r example, s t i m u l a t i o n which has r e l e v a n c e t o a p e r s o n ' s i n t e r e s t s o r needs has more meaning t h a n background n o i s e . Y a r r o w , R u b e n s t e i n , Pedersen & Jankowsk i (1972) found t h a t g l o b a l d e f i n i t i o n s o f environments as r e s t r i c t i v e o r e x c e s s i v e i n s t i m u l a t i o n had l i m i t e d u s e f u l n e s s . I n t h e i r o b s e r v a t i o n a l s t u d y o f the e f f e c t s o f s t i m u l a t i o n on i n f a n t development , t he y found i t u s e f u l t o c a t e g o r i z e d imens ions o f the s o c i a l and n o n s o c i a l environment r a t h e r than use the g l o b a l approach . Examples o f d imens ions s t u d i e d were f r e q u e n c y , v a r i e t y and c o m p l e x i t y o f s t i m u l a t i o n . There i s a need f o r a s i m i l a r o b s e r v a t i o n a l approach i n h o s p i t a l s e t t i n g s t o i d e n t i f y the r e l a t i v e importance o f dimens ions o f e n v i r o n m e n t a l s t i m u l a t i o n i n r e l a t i o n t o p s y c h o l o g i c a l v a r i a b l e s . Interpersonal Use of Space Another a spec t o f the h o s p i t a l environment w h i c h may c o n t r i b u t e t o b e h a v i o u r a l e f f e c t s i s the space a v a i l a b l e f o r p a t i e n t u se . T h i s space may be p e r c e i v e d and used by p a t i e n t s and s t a f f i n s i m i l a r o r d i f f e r e n t ways . There a r e two terms w h i c h have been used i n r e s e a r c h on i n t e r p e r s o n a l use o f space : t e r r i t o r y and p e r s o n a l space (Hayduk, 1978) . T e r r i t o r y r e f e r s t o an a r e a w i t h boundar ie s w h i c h i s marked, c l a i m e d and defended as the p e r s o n ' s own. P e r s o n a l space , by c o n t r a s t 17 (Sommer, 1959, p . 248) , i s an i n v i s i b l e a r e a w i t h the p e r s o n ' s body a t the c e n t r e . T h i s space " b u b b l e " i s c a r r i e d w i t h the p e r s o n and i n t r u s i o n s i n t o the p e r s o n a l space may l e a d t o w i t h d r a w a l o r a g g r e s s i o n . A l tman proposed t h a t p r i v a c y i s a c h i e v e d through i n t e r p e r s o n a l c o n t r o l e f f o r t s d i r e c t e d a t d i f f e r e n t l e v e l s o f b e h a v i o u r : v e r b a l , n o n v e r b a l , t e r r i t o r y and p e r s o n a l space . There has been l e s s r e s e a r c h e f f o r t i n the a r e a o f p r i v a c y t h a n p e r s o n a l space and t e r r i t o r y . However, r e s e a r c h on crowding (Baron & R o d i n , 1978) addresses the i s s u e o f s t r e s s r e l a t e d t o l a c k o f p r i v a c y . H o s p i t a l s t u d i e s r e l a t e d t o p e r s o n a l space , t e r r i t o r y and p r i v a c y have not been e x t e n s i v e . A prob lem o f d e f i n i t i o n o c c u r s because p a t i e n t s a re a s s i g n e d a space i n h o s p i t a l . Whether the p a t i e n t c l a i m s t h i s space , o r p a r t o f i t , as h i s o r her own depends upon e x p e c t a t i o n s , needs and v a l u e s . The c l a i m w i l l p r o b a b l y be g r e a t e r i f the p a t i e n t has p a i d e x t r a money f o r a p r i v a t e room. I n one s t u d y , A l l e k i a n (1973) found t h a t p a t i e n t s e x p e r i e n c e d a n x i e t y w i t h t e r r i t o r i a l i n t r u s i o n s ( e . g . , moving t h e beds ide t a b l e ) bu t n o t w i t h p e r s o n a l space i n t r u s i o n s such as t o u c h . A l l e k i a n e x p l a i n s t h i s f i n d i n g by sugge s t ing t h a t p a t i e n t s a re p s y c h o l o g i c a l l y p repared f o r the l a t t e r i n t r u s i o n s but n o t f o r the former i n t r u s i o n s w h i c h may be seen t o reduce " p e r s o n a l c o n t r o l , i n d i v i d u a l i t y and i d e n t i t y " (p. 241 ) . I n summary, two i s s u e s emerge from the e x i s t i n g l i t e r a t u r e on the h o s p i t a l env i ronment . F i r s t , the u n d e r l o a d v e r s u s o v e r l o a d q u e s t i o n needs an o b s e r v a t i o n a l base t o de termine the r e l a t i v e e f f e c t s o f v a r y i n g amounts o f e n v i r o n m e n t a l s t i m u l a t i o n . S e c o n d l y , t h e r e needs t o be an 18 e x a m i n a t i o n o f the way p a t i e n t s f e e l about t h e i r space o r l a c k o f space i n terms o f p r i o r e x p e c t a t i o n s . B o t h o f these i s s u e s must t a k e i n t o c o n s i d e r a t i o n the s o c i a l and n o n s o c i a l env i ronment . F a c t o r s such as the space a s s i g n e d t o a p a t i e n t and h o s p i t a l e n v i r o n m e n t a l s t i m u l a t i o n l e v e l s a r e s t i m u l u s v a r i a b l e s t o w h i c h a p a t i e n t re sponds . The response o p t i o n s a v a i l a b l e t o the p a t i e n t may a l s o be a f a c t o r i n the p s y c h o l o g i c a l outcome. The response f a c t o r w h i c h has been emphasized i n the r e c e n t s o c i a l p s y c h o l o g i c a l l i t e r a t u r e i s p e r s o n a l c o n t r o l . Some o f the v a r i o u s p e r s p e c t i v e s on t h i s v a r i a b l e w i l l be d i s c u s s e d i n the s e c t i o n t o f o l l o w . G i v e n the r e s t r i c t i o n o f response o p t i o n s w h i c h accompanies i m m o b i l i t y , p e r s o n a l c o n t r o l may mediate t h e p s y c h o l o g i c a l e f f e c t s o f i m m o b i l i t y by i n c r e a s i n g the a v a i l a b l e response o p t i o n s . Personal Control Definition G l a s s and S i n g e r (1972) i d e n t i f i e d two v a r i a b l e s w h i c h mediate e n v i r o n m e n t a l s t r e s s e f f e c t s : p r e d i c t a b i l i t y and c o n t r o l . A l t h o u g h t h e y r e f e r t o p e r c e i v e d c o n t r o l , o t h e r r e s e a r c h suggests t h a t an o b j e c t i v e i n c r e a s e i n c o n t r o l does n o t n e c e s s a r i l y i n c r e a s e p e r c e i v e d c o n t r o l ( A v e r i l l , 1973) and t h a t o b j e c t i v e increments o f c o n t r o l may be b e n e f i c i a l even though s e l f - r e p o r t e d p e r c e i v e d c o n t r o l remains unchanged (Langer & R o d i n , 1976) . Baron and R o d i n (1978) use the term p e r s o n a l c o n t r o l t o i n c l u d e b o t h e x p l i c i t and t a c i t awareness o f c o n t r o l - r e l e v a n t r e sponse s . They 19 d e s c r i b e two types o f p e r s o n a l c o n t r o l : d e c i s i o n freedom and outcome c o n t r o l . D e c i s i o n freedom r e f e r s e i t h e r t o an e x p l i c i t b e l i e f i n s e l f c o n t r o l o f means and ends , o r t o the i n f e r e n c e o f t a c i t c o n t r o l through such i n d i c a t o r s as the absence o f r eac tance o r p o s t d e c i s i o n r e g r e t . The second type o f p e r s o n a l c o n t r o l , a c c o r d i n g t o Baron and R o d i n , i s outcome c o n t r o l . They i d e n t i f y two c a t e g o r i e s o f outcome c o n t r o l : o n s e t and o f f s e t c o n t r o l (p. 1 5 3 ) . Onset c o n t r o l r e f e r s t o " t h e a b i l i t y t o d e l a y , a v o i d , o r i n i t i a t e c o n t a c t w i t h e n v i r o n m e n t a l c h a l l e n g e s " ; w h i l e o f f s e t c o n t r o l "de termines the p e r s o n ' s a b i l i t y t o t e r m i n a t e c o n t a c t w i t h a p o t e n t i a l s t r e s s o r " . The Baron and R o d i n d e f i n i t i o n s w i l l be used here because they a r e broad enough t o i n c l u d e bo th p r e d i c t a b i l i t y and c o n t r o l i n the G l a s s and S i n g e r sense . The d e f i n i t i o n o f o n s e t c o n t r o l presumes t h a t an i n d i v i d u a l knows what t o expec t o r c a n p r e d i c t an outcome. P r e d i c t a b i l i t y , i n t h i s d e f i n i t i o n , i s a nece s sa ry b u t i n s u f f i c i e n t p r e c o n d i t i o n f o r a c h i e v i n g outcome c o n t r o l (Baron & R o d i n , p . 1 4 8 ) . I n f o r m a t i o n and Outcome C o n t r o l S t u d i e s o f h o s p i t a l i z e d p a t i e n t s have examined the s t r e s s - r e d u c i n g a spec t s o f i n f o r m a t i o n w h i c h may mediate s t r e s s through i n c r e a s e d outcome c o n t r o l . Meyers (1964) found t h a t p a t i e n t s who r e c e i v e d s t r u c t u r e d communicat ion r e g a r d i n g a procedure had l e s s s t r e s s than p a t i e n t s who had e i t h e r i r r e l e v a n t o r no communicat ion . I n a s t u d y o f the e f f e c t s o f i n f o r m a t i o n and c o p i n g s t y l e , Andrew (1970) found t h a t i n f o r m a t i o n about s u r g e r y improved r e c o v e r y f o r p a t i e n t s w i t h a n e u t r a l s t y l e , b u t had no e f f e c t f o r s e n s i t i z e r s and impeded p r o g r e s s f o r 20 a v o i d e r s . T h i s r e s e a r c h underscores the c o m p l e x i t y o f the r e l a t i o n s h i p between p e r s o n a l c o n t r o l and s t r e s s , w h i c h has prompted A v e r i l l (1973) t o conc lu de t h a t g e n e r a l i z a t i o n s h o u l d be guarded . The meaning o f the c o n t r o l response t o the i n d i v i d u a l i n the s p e c i f i c c o n t e x t must be c o n s i d e r e d . A s e r i e s o f s t u d i e s by Johnson and c o l l e a g u e s ( Johnson, 1972; J o h n s o n , 1975; J o h n s o n , F u l l e r , Endres s & P a c e , 1978; H a r t f i e l d , Cason & C a s o n , 1982) have demonstrated t h a t s ensory i n f o r m a t i o n ( i . e . , which s e n s a t i o n s t o expec t d u r i n g a procedure) has more s t r e s s - r e d u c t i o n e f f e c t than, g e n e r a l i n f o r m a t i o n about procedures such as d i a g n o s t i c t e s t s . L a n g e r , J a n i s and W o l f e r (1975) compared the e f f e c t i v e n e s s o f two approaches d e s i g n e d t o reduce s t r e s s i n s u r g i c a l p a t i e n t s . They found t h a t a c o p i n g d e v i c e w h i c h emphasized c o g n i t i v e r e a p p r a i s a l o f a n x i e t y - p r o v o k i n g event s was more e f f e c t i v e t h a n i n f o r m a t i o n f o r the purpose o f e m o t i o n a l i n o c u l a t i o n . The c o g n i t i v e r e a p p r a i s a l m a n i p u l a t i o n i n c l u d e d c o g n i t i v e c o n t r o l through s e l e c t i v e a t t e n t i o n and c a l m i n g s e l f - t a l k . I n a m e t a - a n a l y s i s o f 49 s t u d i e s o f " p s y c h o e d u c a t i o n a l i n t e r v e n t i o n s " , i n c l u d i n g the above r e s e a r c h , Dev ine and Cook (1983) found t h a t these i n t e r v e n t i o n s reduced h o s p i t a l s t a y by about 1.25 days and t h e r e f o r e have economic as w e l l as p e r s o n a l b e n e f i t s . Causal Attributions and Outcome Control P e r s o n a l c o n t r o l has a l s o been s t u d i e d from the p e r s p e c t i v e o f c a u s a l a t t r i b u t i o n s (Wortman, 1976) . There has been c o n s i d e r a b l e r e s e a r c h on assignment o f c a u s a l i t y f o r an a c c i d e n t ( W a l s t e r , 1966; 21 L e r n e r , 1970) . However, t h i s l i t e r a t u r e has m a i n l y i n c l u d e d l a b o r a t o r y s t u d i e s d e s i g n e d t o examine r e a c t i o n s t o v i c t i m i z a t i o n and r a r e l y has i n c l u d e d d a t a f rom the v i c t i m s themse lves . R e c e n t l y , t h e r e has been some f i e l d r e s e a r c h w h i c h focused on a t t r i b u t i o n s o f i m m o b i l i z e d p a t i e n t s . I n a s t u d y o f s p i n a l c o r d i n j u r y p a t i e n t s , Bulman and Wortman (1977) found t h a t s e l f - b l a m e ( for the a c c i d e n t t h a t produced i n j u r y ) l e d t o good c o p i n g , whereas b l aming another f o r the a c c i d e n t was p r e d i c t i v e o f poor c o p i n g . I n terms o f c o n t r o l , the y found t h a t many p a t i e n t s seemed t o have " a n exaggerated n o t i o n o f t h e i r own c a u s a l powers" (p. 362) i n t h a t t h e y a t t r i b u t e d c a u s a l i t y t o themselves when e x t e r n a l f a c t o r s were more p r o b a b l e causes f rom an o b j e c t i v e s t a n d p o i n t . Bulman and Wortman a l s o found t h a t p e r c e i v e d a v o i d a b i l i t y p r e d i c t e d poor c o p i n g . P e o p l e who thought t h a t th e y c o u l d have a v o i d e d the a c c i d e n t d i d n o t cope as w e l l as those who thought t h a t the a c c i d e n t c o u l d n o t be a v o i d e d . Bulman and Wortman i n t e r p r e t t h i s a p p a r e n t l y c o n t r a d i c t o r y f i n d i n g i n terms o f c o n t r o l . T h a t i s , p e r s o n a l c o n t r o l may be a d a p t i v e i n g e n e r a l , bu t may be m a l a d a p t i v e when the per son i s f aced w i t h a permanent, u n c o n t r o l l a b l e outcome. Most o f the l i t e r a t u r e on c a u s a l a t t r i b u t i o n s f o r a c c i d e n t s g i v e s " i n d i r e c t ev idence a t b e s t f o r c o n t r o l m o t i v a t i o n " (Wortman, 1976, p . 2 8 ) . P i t t m a n and P i t t m a n (1980) p r o v i d e d i r e c t d a t a w h i c h l i n k a t t r i b u t i o n a l p roce s se s t o the c o n t r o l m o t i v a t i o n h y p o t h e s i s . They found t h a t m a n i p u l a t e d v a r i a t i o n s o f l a c k o f c o n t r o l a f f e c t e d subsequent a t t r i b u t i o n s . T h e i r d a t a suggest t h a t c o n t r o l d e p r i v a t i o n enhances a t t r i b u t i o n a l a c t i v i t y i n g e n e r a l , r e g a r d l e s s o f the 22 d e p r i v a t i o n source o r the degree t o w h i c h the a t t r i b u t i o n s c o u l d i n c r e a s e c o n t r o l i n the f u t u r e . P r i m a r y and Secondary C o n t r o l Rothbaum, Wei sz and Snyder (1982) observed t h a t the l e a r n e d h e l p l e s s n e s s model (Se l igman, 1975) and l o c u s o f c o n t r o l r e s e a r c h ( L e f c o u r t , 1976) b o t h i n t e r p r e t " i n w a r d " b e h a v i o u r s , such as p a s s i v i t y and w i t h d r a w a l , as s i g n s o f the p e r c e p t i o n o f l o s s o f c o n t r o l . A c c o r d i n g t o t h i s r e s e a r c h , h e l p l e s s i n d i v i d u a l s and those w i t h an e x t e r n a l l o c u s o f c o n t r o l t end t o have i n c r e a s e d n e g a t i v e a f f e c t . S t e w a r t (1977) found t h a t , w h i l e o r t h o p e d i c p a t i e n t s r e p o r t e d f e e l i n g s o f l o s s o f c o n t r o l over t i m e , s c o r e s f o r c o n t r o l , h e l p l e s s n e s s and l o c u s o f c o n t r o l were n o t c o r r e l a t e d w i t h n e g a t i v e a f f e c t over t i m e . The Rothbaum e t a l . p r o p o s a l does n o t a ccep t inward b e h a v i o u r s as s i g n s o f l o s s o f c o n t r o l . R a t h e r , t h e y m a i n t a i n t h a t t h e r e a re two k i n d s o f p e r c e i v e d c o n t r o l : p r i m a r y and secondary c o n t r o l . P r i m a r y c o n t r o l e x i s t s when the i n d i v i d u a l t r i e s t o change the environment ; whereas secondary c o n t r o l means chang ing the s e l f ( e . g . , inward behaviours ) t o f i t the envi ronment . T a y l o r (1979) advocated t h a t h o s p i t a l p a t i e n t s s h o u l d have i n c r e a s e d c o n t r o l through a more i n f o r m e d , p a r t i c i p a t i v e r o l e , based on the r e a c t a n c e - h e l p l e s s n e s s - c o n t r o l l i t e r a t u r e . A s Fr iedman and DeMatteo noted (1979, p . 8 ) , w h i l e t h i s p o s i t i o n may be t h e o r e t i c a l l y " c o r r e c t , " the p r e d i c t e d p o s i t i v e outcomes may n o t occur u n l e s s the c o m p l e x i t y o f s i t u a t i o n a l f a c t o r s w i t h i n the p a r t i c u l a r s e t t i n g i s accounted f o r . The i n t e r f a c e o f p a t i e n t - s t a f f r e l a t i o n s has b o t h an a f f e c t i v e (DeMatteo, 23 1979) and a power (Rodin & J a n i s , 1979) d i m e n s i o n . I f a p a t i e n t e x e r c i s e s c o n t r o l beyond t h e l i m i t s p r e s c r i b e d by h i s r o l e i n t h e power s t r u c t u r e , then he w i l l l i k e l y i n c u r s a n c t i o n s and l o s e p o s i t i v e a f f e c t f rom the s t a f f . The o t h e r prob lem w i t h T a y l o r ' s p r o p o s a l i s t h a t a p a t i e n t may n o t want a c t i v e c o n t r o l a t a c e r t a i n phase o f r e c o v e r y . Some p a t i e n t s may m a i n t a i n c o n t r o l f o r a t ime through inward o r p a s s i v e behav iour (secondary c o n t r o l ) r a t h e r than the a c t i v e , p r i m a r y c o n t r o l approach t h a t T a y l o r promoted. To t h i s p o i n t , p e r s o n a l c o n t r o l has been examined from v a r i o u s p e r s p e c t i v e s w h i c h a l l f i t i n the " p e r s o n a l f a c t o r s " s e c t i o n o f the Moos and Tsu mode l . I n f o r m a t i o n , w h i c h i s c l e a r l y an independent v a r i a b l e , c o u l d a f f e c t the c o g n i t i v e a p p r a i s a l o f an i n j u r y o r i l l n e s s . T h i s a p p r a i s a l , o r p e r c e i v e d meaning o f the e v e n t , c o u l d i n t u r n a f f e c t the p s y c h o l o g i c a l outcome o f a c r i s i s s i t u a t i o n . A t t r i b u t i o n s and p r i m a r y / s e c o n d a r y c o n t r o l c o u l d be thought o f as e i t h e r dependent o r independent v a r i a b l e s . As a response ( i . e . , dependent v a r i a b l e ) t o a g i v e n s i t u a t i o n , these c o n t r o l v a r i a b l e s c o u l d f u r t h e r c o n t r i b u t e ( i . e . , independent v a r i a b l e ) t o subsequent p s y c h o l o g i c a l e f f e c t s over t i m e . Noncompl iance , w h i c h i s another c o n t r o l - r e l a t e d v a r i a b l e , may be an outcome o f c r i s i s a c c o r d i n g t o the Moos and Tsu framework. The concept o f noncompl iance , as p r e s e n t e d be low, i s a dependent v a r i a b l e . NoncxMpliance I n the l i t e r a t u r e c o n c e r n i n g h e a l t h h a z a r d s , the term "noncompl iance" r e f e r s t o the f a i l u r e o f p a t i e n t s t o f o l l o w the a d v i c e o f h e a l t h c a r e workers (Stone, 1979) . A p a r t i c u l a r type o f 24 noncompliance w h i c h appears r e l a t e d t o imagery has been r e p o r t e d i n b o t h eye s u r g e r y p a t i e n t s ( J ackson , 1969) and o r t h o p e d i c p a t i e n t s ( S tewar t , 1977) . F o r example, Z i s k i n d , J o n e s , F i l a n t e and G o l d b e r g (1960) found t h a t p a t i e n t s w i t h b i l a t e r a l eye pa tches f o l l o w i n g s u r g e r y demonstrated noncompl iant b e h a v i o u r s o f s i t t i n g up (80% o f p a t i e n t group) and removing eye pa tches (90%) even though the y had been t o l d t h a t such a c t i v i t y ' might r e s u l t i n l o s s o f e y e s i g h t . Z i s k i n d 1 s o b s e r v a t i o n s suggest t h a t such behav iour stems from a c t i n g o u t v i v i d dreams o r hypnagogic imagery . I t appears t h a t t h i s type o f noncompliance i s i n v o l u n t a r y and p r o b a b l y does n o t r e l a t e d i r e c t l y t o p e r s o n a l c o n t r o l . A second type o f noncompliance i s v o l u n t a r y and r e l a t e s t o p e r s o n a l c o n t r o l . T h i s type o f noncompl iance , d e s c r i b e d i n the a r t i c l e by Putnam and Yager (1978) on " t r a c t i o n i n t o l e r a n c e syndrome" , resembles Brehm's (1966) concept o f r e a c t a n c e . Wortman and Brehm (1975) , i n t h e i r i n t e g r a t i o n o f the h e l p l e s s n e s s model w i t h r eac tance t h e o r y , suggest a t empora l p h a s i n g as a response t o l o s s o f c o n t r o l : r e a c t a n c e f o l l o w e d by compl i ance o r h e l p l e s s n e s s i f c o n t r o l i s n o t r e s t o r e d over t i m e . I n the terms o f Rothbaum, Wei sz and Snyder (1982) , t h i s two-phase response t o s t r e s s would be c a l l e d p r i m a r y c o n t r o l f o l l o w e d by secondary c o n t r o l . However, Rothbaum e t a l . no te t h a t " t h e ev idence i s f a r from c l e a r - c u t , and we su spec t t h a t v a c i l l a t i o n between p r i m a r y and secondary c o n t r o l i s common" (p . 8 - 9 ) . R e t u r n i n g t o the Baron and R o d i n d e f i n i t i o n o f p e r s o n a l c o n t r o l , one c a n c l a s s i f y v o l u n t a r y noncompliance i n two ways . The compar i son o f noncompliance t o r e a c t a n c e suggests a l a c k o f d e c i s i o n freedom and hence 25 a r e a c t i o n t o l o s s o f c o n t r o l . On t h e o t h e r hand , noncompliance d e s c r i b e d as p r i m a r y c o n t r o l ( i . e . , o f f s e t c o n t r o l ) , suggests t h a t i t i s a means t o i n c r e a s e c o n t r o l . I n t h i s c a s e , noncompliance c o u l d be due t o the s e a r c h f o r s t i m u l a t i o n r e l a t e d t o boredom a s s o c i a t e d w i t h i m m o b i l i t y . More d a t a from i m m o b i l i z e d p a t i e n t s w i l l be needed t o i n d i c a t e w h i c h d e f i n i t i o n i s p r e f e r a b l e . P o s s i b l y , bo th d e f i n i t i o n s have r e l e v a n c e . As i n the case o f the Bulman and Wortman s tudy o f c a u s a l a t t r i b u t i o n s , c o n t r o l (noncompliance) may be a d a p t i v e o r m a l a d a p t i v e depending on the degree t o w h i c h the outcome i s u n c o n t r o l l a b l e i n o b j e c t i v e t e rms . Optimal Levels of Control and Stimilation The n o t i o n o f a d a p t i v e v e r s u s m a l a d a p t i v e c o n t r o l suggests t h a t t h e r e may be an o p t i m a l l e v e l o f c o n t r o l w h i c h b e s t s e r v e s the p s y c h o l o g i c a l f u n c t i o n i n g o f i m m o b i l i z e d p a t i e n t s . F o r example, some i n t e r m e d i a t e l e v e l o f p e r s o n a l c o n t r o l (as opposed t o v e r y h i g h o r low l e v e l s ) may be o p t i m a l i n terms o f c o r r e l a t i o n w i t h low s t r e s s from p a t i e n t r e p o r t s . T h i s o p t i m a l l e v e l c o u l d be i n f l u e n c e d by o t h e r f a c t o r s such as t h e a c t u a l o r p e r c e i v e d c o n t r o l l a b i l i t y o f the outcome and i n d i v i d u a l d i f f e r e n c e s o f p a t i e n t s . Another p o s s i b l e f o r m u l a t i o n o f o p t i m i z a t i o n c o u l d be based on o s c i l l a t i o n between p r i m a r y and secondary c o n t r o l , as suggested by Rothbaum e t a l . I n t h i s c a s e , one might p r e d i c t a ba l ance over t ime between e f f o r t s a t d i r e c t p r i m a r y c o n t r o l and i n d i r e c t secondary c o n t r o l . 26 The concept presented here of an optimal l e v e l of personal control parallels Zuckerman's (1969, p. 428) optimal level of stimulation theory. Zuckerman predicted that psychological effects (e.g., i l l u s i o n s , hallucinations) occur more frequently with either extremely high or low levels of stimulation. The optimal l e v e l , which i s specific to the individual, tends to be at a moderate level of stimulation. Cohen's (1978) model regarding high stimulation states that informational overload exists when "the demand for attention exceeds tot a l available capacity" (p. 18). According to Cohen, there i s less capacity for attention when a person i s exposed to lengthy demands. Thus, both amount and duration of stimulation are factors which lead to "cognitive fatigue" or "depletion of attentional capacity" (p. 13). This model may have particular relevance to immobile patients who often have a long period of hospitalization. Cohen also suggests that perceived control has a mediating effect on overload by reducing the fatigue factor. Zuckerman proposed the optimal l e v e l of stimulation theory i n the context of data from laboratory research on the effects of restricted environmental stimulation. The section to follow w i l l examine this literature as i t relates to imagery and w i l l also raise issues i n the de f i n i t i o n of mental imagery from the general psychological literature. 27 Mental Imagery Definition A definition of mental imagery with absolute criteria has not been achieved to date. Richardson (1969, pp. 2-3) distinguished imagery as "quasi-sensory" or "quasi-perceptual" conscious experiences which are nonstimulus-bound and differ in consequences from actual sensory/perceptual experiences. In a recent revision of this definition, Richardson (1983, p. 15) rejects the latter characteristic (i.e., different consequences) in view of data which shows that consequences of self-induced imagery do not differ from their sensory complement. Otherwise, the definition remains current in its identification of imagery in terms of phenomenological experience or, at least, the potential for such experience with shifts in attention. Yuille (1983) argues that intuitive definitions of imagery need to be replaced by theoretical concepts which can clearly be testable and falsifiable. Research in this field has emphasized the function of imagery over the nature of imagery (White, Sheehan & Ashton, 1977). Consequently, precise definitions of mental imagery have yet to be developed. In a cli n i c a l setting, however, Richardson's definition is useful to describe the experience of patients. In the restricted environmental stimulation literature, Zuckerman (1969) has dealt with the dispute concerning the use of the terms "hallucination" versus "reported sensations" versus "images", by classifying a l l such visual and auditory phenomena into two groups according to the degree of structure and meaningfulness of the content. 28 A c c o r d i n g l y , Type A r e p o r t e d v i s u a l s e n s a t i o n s (RVSs) i n c l u d e d u n s t r u c t u r e d o r g e o m e t r i c s e n s a t i o n s w h i l e Type B i n c l u d e d i n t e g r a t e d o r animated s cenes . U n f o r t u n a t e l y , t h i s c l a s s i f i c a t i o n does n o t i n c l u d e k i n e s t h e t i c phenomena w h i c h have g e n e r a l l y been recorded i n the i m m o b i l i z a t i o n l i t e r a t u r e as " u n u s u a l body s e n s a t i o n s " ( e . g . , Zubek, A f t a n a s , Kovach , W i l g o s h , and W i n c c u r , 1963) . S u e d f e l d and Vernon (1964) a p p l i e d i n t r o s p e c t i v e c r i t e r i a ( e . g . , apparent r e a l i t y ) t o d i f f e r e n t i a t e RVSs from h a l l u c i n a t i o n s . W i t h t h i s approach , few s u b j e c t i v e phenomena under r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n c o n d i t i o n s would be c a t e g o r i z e d as h a l l u c i n a t i o n s . Zuckerman (1969) c o n c l u d e d t h a t RVSs were more s i m i l a r t o d r u g - i n d u c e d r e a c t i o n s t h a n t o p s y c h o s i s . R i c h a r d s o n (1969, p . 93) c l a s s i f i e d " i m a g i n a t i o n imagery" t o i n c l u d e s e v e r a l forms o f imagery such as hypnagog ic , i s o l a t i o n , s l e e p d e p r i v a t i o n and drug imagery . I m a g i n a t i o n imagery does n o t have a p e r s o n a l r e f e r e n c e and may be b i z a r r e i n n a t u r e , as d i s t i n c t from memory o r thought imagery ( R i c h a r d s o n , 1969; 1983) w h i c h r e f e r s t o a r e c o g n i z a b l e o b j e c t o r e v e n t . T h e o r e t i c a l and M e t h o d o l o g i c a l I s s u e s Much o f the p s y c h o l o g i c a l l i t e r a t u r e on m e n t a l imagery r e f e r s e x c l u s i v e l y t o v i s u a l imagery . T h e o r e t i c a l debates c o n t i n u e over the i s s u e o f whether the n e u r a l r e p r e s e n t a t i o n f o r v i s u a l imagery i s the same as ( P y l y s h y n , 1981) o r d i f f e r e n t from ( P a i v i o , 1971; K o s s l y n , 1981) t h a t u n d e r l y i n g v e r b a l p r o c e s s i n g . The b e h a v i o u r a l and p h y s i o l o g i c a l d a t a a v a i l a b l e do n o t a l l o w f o r an u n e q u i v o c a l d e c i s i o n about the n e u r a l r e p r e s e n t a t i o n f o r menta l imagery (Anderson, 1978) . However, S t r o s a h l 29 and Ascough (1981) , i n a d i s c u s s i o n o f the use o f imagery i n c l i n i c a l s e t t i n g s , suggest t h a t " m u l t i p l e r e p r e s e n t a t i o n a l / p r o c e s s i n g event s o f a c o g n i t i v e and a f f e c t i v e n a t u r e t r a n s p i r e w i t h i n any one v i s u a l i z a t i o n sequence" (p. 424 ) . The s t u d y o f m e n t a l imagery was e s s e n t i a l l y n o n e x i s t e n t d u r i n g the b e h a v i o u r i s t p e r i o d i n p s y c h o l o g y ( H o l t , 1964) . F o r t h i s r e a s o n , t h e r e has been a r e l a t i v e l y s h o r t t ime span f o r m e t h o d o l o g i c a l development i n t h i s a r e a . Assessment o f imagery by s e l f - r e p o r t q u e s t i o n n a i r e s has i n c l u d e d s e v e r a l measures w i t h a c c e p t a b l e r e l i a b i l i t y and p r e d i c t i v e u s e f u l n e s s (White , Sheehan & A s h t o n , 1977) . However, c o n s t r u c t v a l i d i t y o f s c a l e s has been more d i f f i c u l t t o a c h i e v e than o t h e r p s y c h o m e t r i c p r o p e r t i e s . H i s c o c k (1978) c o n c l u d e d t h a t t h i s d i f f i c u l t y may be due t o the f a c t t h a t imagery i s n o t a u n i t a r y c o n s t r u c t and t h a t c r i t e r i a o t h e r than v i s u o s p a t i a l t e s t s s h o u l d be used i n v a l i d a t i o n s t u d i e s . N e i s s e r (1972) emphasized the complex , m u l t i d i m e n s i o n a l n a t u r e o f imagery . Indeed, the v a l i d i t y prob lem c i t e d may r e l a t e t o l a c k o f c l a r i t y i n the d e f i n i t i o n o f v a r i o u s forms o f imagery . Tower (1981) p r o v i d e s a r e v i e w o f d imens ions o f imagery i n r e l a t i o n t o the type o f r e s e a r c h q u e s t i o n asked and measures t o f i t the q u e s t i o n . I n a d d i t i o n t o s e l f - r e p o r t measures , w h i c h assume the importance o f s u b j e c t i v e e x p e r i e n c e , imagery assessment has i n c l u d e d b e h a v i o u r a l , p r o j e c t i v e and p h y s i o l o g i c a l measures . Tower (p. 83) notes t h a t the type o f q u e s t i o n may p e r t a i n t o the s t r u c t u r e , f u n c t i o n , g e n e r a t i o n or p r o c e s s o f i m a g i n g . I n c l i n i c a l s i t u a t i o n s , such as a h o s p i t a l s e t t i n g , 30 the purpose o f the q u e s t i o n a l s o needs t o be c o n s i d e r e d . That i s , the imagery assessment may c o n t r i b u t e t o d i a g n o s i s , i n t e r v e n t i o n o r e v a l u a t i o n o f c a r e . E n v i r o n m e n t a l S t d m u l a t i o n L e v e l s W i t h r e g a r d t o imagery , the l a b o r a t o r y r e s e a r c h d a t a from r e s t r i c t e d s t i m u l a t i o n environments v a r i e s a c c o r d i n g t o the d u r a t i o n o f the e x p e r i m e n t s . Zubek (1973) rev iewed l o n g d u r a t i o n s t u d i e s (1-16 days) from f o u r c o u n t r i e s and found imagery r e p o r t s were r a r e o r a b s e n t . I n one s t u d y (Zubek, TAftanas, Kovach , W i l g o s h & W i n o c u r , 1963) i n v o l v i n g severe i m m o b i l i z a t i o n f o r 14 d a y s , imagery e f f e c t s were r a r e but were more f r e q u e n t d u r i n g the even ing and n i g h t . Zubek c o n c l u d e s t h a t these e f f e c t s o c c u r when i m m o b i l i t y i s combined w i t h r e s t r i c t i o n o f one o r more sensory m o d a l i t i e s . S h o r t d u r a t i o n s t u d i e s (1 - 12 h o u r s ) , by c o n t r a s t , r e p o r t more f r e q u e n t imagery e f f e c t s . Zuckerman and c o l l e a g u e s found an i n c r e a s e i n imagery r e p o r t s a f t e r o n l y t h r e e hours (Zuckerman, L e v i n e & B i a s e , 1964) and e i g h t hours (Zuckerman, P e r s k y , L i n k & B a s u , 1968) . I n a s t u d y o f the e f f e c t s o f b e d r e s t , Downs (1974) v a r i e d a u d i t o r y i n p u t t o s i m u l a t e the h o s p i t a l s i t u a t i o n where a p a t i e n t hear s p o r t i o n s o f comments by s t a f f . I n t h i s s i t u a t i o n w i t h ambiguous a u d i t o r y i n p u t , over 20% o f 180 s u b j e c t s e x p e r i e n c e d sensory d i s t o r t i o n s i n the v i s u a l , a u d i t o r y , k i n e s t h e t i c , o l f a c t o r y and t a c t i l e m o d a l i t i e s i n l e s s t h a n 3 h o u r s . Zuckerman and Cohen (1964) , i n a survey o f the l i t e r a t u r e , found t h a t the median percentages o f imagery r e p o r t s were 43 per c e n t f o r Type A s e n s a t i o n s and 19 per c e n t f o r Type B s e n s a t i o n s . 31 I n an a n a l y s i s o f these a p p a r e n t l y d i s c r e p a n t f i n d i n g s , Zubek (1973) examined two p o s s i b l e e x p l a n a t i o n s . R e s u l t s may d i f f e r because o f r e t r o s p e c t i v e r e p o r t i n g as opposed t o ongoing spontaneous r e p o r t s . I t i s p o s s i b l e t h a t imagery changes a re more p r e v a l e n t d u r i n g t h e e a r l y e x p e r i e n c e but a re not 'remembered by the t ime o f r e t r o s p e c t i v e r e p o r t . Another e x p l a n a t i o n may r e l a t e t o how s t r i n g e n t the c r i t e r i a a re f o r r e p o r t e d s e n s a t i o n s . S t u d i e s w h i c h d e f i n e " h a l l u c i n a t i o n " i n terms o f apparent r e a l i t y w i l l have a much lower i n c i d e n c e t h a n those w h i c h i n c l u d e r e p o r t s o f he igh tened normal imagery . Zubek emphasized the importance o f the e s t a b l i s h m e n t o f normal b a s e l i n e s f o r compar i son o f r e s u l t s . Another i s s u e r e l a t e d t o imagery r e p o r t s i s whether o r not the i n d i v i d u a l i s aware o f ongoing e x p e r i e n c e s . Pope and S i n g e r (1978) suggest t h a t t h e r e i s a c o n t i n u a l " s t r e a m " o f i m a g i n a l event s i n a d u l t s throughout the day and n i g h t . These events may o r may n o t be n o t i c e d . L i k e w i s e , M c K e l l a r (1979) proposes t h a t hypnagogic imagery , w h i c h o c c u r s as one f a l l s a s l e e p , i s u n i v e r s a l b u t t h a t i n d i v i d u a l s v a r y i n t h e i r awareness o f these e x p e r i e n c e s . S c h a c t e r (1976) c o n c l u d e s t h a t , w h i l e hypnagogic imagery does n o t appear t o be a major p a r t o f r e p o r t e d s e n s a t i o n s i n r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n s t u d i e s , i t r e p r e s e n t s one a s p e c t o f the " p o t p o u r r i " (p . 465) o f i d e a t i o n w h i c h may o c c u r i n c l u d i n g daydreams, f a n t a s i e s and dreams. 32 Imagery and Affect D u r i n g the e a r l y p e r i o d o f r e v i v a l o f i n t e r e s t i n imagery , Tomkins (1962, 1963) proposed t h a t the a f f e c t i v e and c o g n i t i v e systems were c l o s e l y r e l a t e d . Much o f the r e s e a r c h s i n c e t h a t t i m e , however, has t r e a t e d imagery as a c o g n i t i v e concept w i t h l i t t l e , i f any , r e l a t i o n s h i p t o a f f e c t . Recent computer s i m u l a t i o n models (P inker & K o s s y l n , 1983) move imagery r e s e a r c h even f a r t h e r from the a f f e c t i v e domain . On the o t h e r hand, some r e c e n t w r i t i n g s ( e . g . , S i n g e r , 1979; Roger s , 1983) do emphasize the importance o f examining c o g n i t i o n i n r e l a t i o n t o a f f e c t , p a r t i c u l a r l y t o i n c r e a s e e c o l o g i c a l v a l i d i t y and the p o t e n t i a l f o r c l i n i c a l a p p l i c a t i o n . E x a m i n a t i o n o f the c l i n i c a l l i t e r a t u r e p r o v i d e s some ev idence f o r the r e l a t i o n s h i p between imagery and a f f e c t . I n the e a r l y r e s e a r c h on t h e g r i e f p r o c e s s , Lindemann (1944) found t h a t c h a r a c t e r i s t i c s o f normal g r i e v i n g i n c l u d e d v i s u a l imagery o f the deceased as w e l l as a f f e c t i v e r e a c t i o n s such as anger and sadness . I n a more r e c e n t a n a l y s i s o f the r e l a t i o n s h i p o f imagery and a f f e c t i n p s y c h o t h e r a p y , S i n g e r (1979) c o n c l u d e d t h a t " t h e s p e c i a l r o l e o f imagery may be i t s s t r e n g t h i n e v o k i n g a v a r i e d but r e l a t i v e l y i n t e n s e a f f e c t i v e response" (p. 3 6 ) . The g r i e f l i t e r a t u r e sugges t s t h a t a f f e c t evokes imagery , whereas the c u r r e n t p sychotherapy p r a c t i c e i m p l i c a t e s imagery as evoker o f a f f e c t . T h i s s u g g e s t i o n o f a b i d i r e c t i o n a l c a u s a l i t y c o n c u r s w i t h the p e r s p e c t i v e o f Rogers (1983) . 33 The s t u d i e s o f i m m o b i l i z e d p a t i e n t s , rev iewed p r e v i o u s l y , p r o v i d e f u r t h e r ev idence o f a r e l a t i o n s h i p between imagery and a f f e c t . Imagery e x p e r i e n c e s l e d t o a f f e c t i v e changes ( i . e . , i n c r e a s e d s t r e s s ) i n r e p o r t s from b o t h o r t h o p e d i c (S tewar t , 1977) and s p i n a l c o r d i n j u r y (Conomy, 1973) p a t i e n t s . The r e l a t i o n s h i p between imagery and s t r e s s has been documented i n H o r o w i t z ' s (1976) d e s c r i p t i o n o f the " s t r e s s response syndrome." D a t a from e x p e r i m e n t a l and f i e l d s t u d i e s ( H o r o w i t z , 1978, p . 215) suppor t c l i n i c a l o b s e r v a t i o n s t h a t t r a u m a t i c p e r c e p t i o n s t end t o r e c u r as "unb idden images " . Based on a F r e u d i a n d e f i n i t i o n o f trauma as e x c e s s i v e s t i m u l a t i o n , H o r o w i t z t h e o r i z e s t h a t unbidden images combine p a s t memories and p r e s e n t concerns w i t h a r e p r e s e n t a t i o n o f the t r a u m a t i c event i n a c t i v e memory s t o r a g e w h i c h tends toward r e p e t i t i o n u n t i l a c t i v e l y t e r m i n a t e d ( i . e . , u n t i l i n f o r m a t i o n - p r o c e s s i n g i s c o m p l e t e ) . T h i s sugges t s t h a t t rauma, p a s t and p r e s e n t , may i n c r e a s e imagery f r e q u e n c y . I n the f o l l o w i n g s e c t i o n , t h e concept o f s t r e s s w i l l be examined as i t r e l a t e s t o h o s p i t a l i z e d p a t i e n t s . A c o n c e p t u a l model based on c r i s i s t h e o r y , which p e r t a i n s bo c o p i n g w i t h l i f e s t r e s s , w i l l p r o v i d e a framework f o r the v a r i a b l e s i n the p r e s e n t p r o j e c t . The t h e o r e t i c a l base f o r t h i s p r o j e c t w i l l a l s o draw from t h e o r i e s o f e n v i r o n m e n t a l s t i m u l a t i o n (Zuckerman, 1969, 1979; Cohen, 1979) and p e r s o n a l c o n t r o l (Baron & R o d i n , 1978; Rothbaum, Wei sz & Snyder , 1982) . 34 Stress Hospital Stress A s t r e s s o r , as d e f i n e d by Cohen (1978) , i s " s t i m u l a t i o n t h a t r e p r e s e n t s an a d a p t i v e t h r e a t o r p o t e n t i a l a d a p t i v e t h r e a t t o the o rgan i sm" (p. 1 ) . S t r e s s , i n t h i s a n a l y s i s , i s the p e r s o n ' s response t o the s t r e s s o r . I n the c o n t e x t o f h o s p i t a l i z e d p a t i e n t s , f o r example, the h o s p i t a l environment c o u l d be seen as the s t r e s s o r , whereas s t r e s s would i n c l u d e the s u b j e c t i v e e x p e r i e n c e o f a n x i e t y i n response t o h o s p i t a l i z a t i o n . I n much o f the l i t e r a t u r e , however, the terms s t r e s s and s t r e s s o r a re used i n t e r c h a n g e a b l y so t h a t " s t r e s s " may r e f e r t o e i t h e r an independent o r dependent v a r i a b l e . V o l i c e r , I senberg and Burns (1977) a n a l y z e d h o s p i t a l s t r e s s f a c t o r s ( i . e , s t r e s s o r s ) and found t h a t s u r g i c a l p a t i e n t s r e p o r t e d g r e a t e s t s u b j e c t i v e s t r e s s r e l a t e d t o u n f a m i l i a r i t y o f s u r r o u n d i n g s , l o s s o f independence and t h r e a t o f severe i l l n e s s . To the e x t e n t t h a t these r e s u l t s g e n e r a l i z e t o immobi le o r t h o p e d i c s u r g e r y p a t i e n t s , the p r e s e n t emphasis on e n v i r o n m e n t a l and p e r s o n a l c o n t r o l v a r i a b l e s appears j u s t i f i e d . V o l i c e r (1978) has a l s o c o r r e l a t e d h o s p i t a l s t r e s s w i t h r e p o r t s o f n e g a t i v e p h y s i c a l s t a t u s b o t h d u r i n g and a f t e r h o s p i t a l i z a t i o n . L i f e S t r e s s The r e l a t i o n s h i p between s t r e s s and i l l n e s s has been e x p l o r e d through r e s e a r c h on l i f e event s o r l i f e change. I n one approach , bo th p o s i t i v e and n e g a t i v e changes a re seen t o r e q u i r e an a d a p t i v e p h y s i o l o g i c a l response and hence , when e x c e s s i v e , c a n r e s u l t i n i l l n e s s 35 (Holmes & Masuda, 1974) . The t h e o r y w h i c h appears t o u n d e r l i e t h i s approach i s S e l y e ' s t h e o r y o f s t r e s s . A c c o r d i n g t o S e l y e (1974) , s t r e s s i s the " n o n s p e c i f i c response o f the body t o any demand made upon i t " (p. 1 4 ) . Another approach t o the s t u d y o f l i f e event s t r e s s and i l l n e s s has emphasized the r e l a t i o n s h i p between n e g a t i v e l i f e s t r e s s and i l l n e s s . A l t h o u g h b o t h p o s i t i v e and n e g a t i v e events i n c r e a s e p h y s i o l o g i c a l a c t i v i t y , the ev idence does n o t i m p l i c a t e these event s e q u a l l y as p r e c i p i t a n t s o f i l l n e s s . F o r example, V i n o k u r and S e l z e r (1975) found t h a t n e g a t i v e l i f e event s had a s t r o n g e r r e l a t i o n s h i p t o i l l n e s s than do p o s i t i v e l i f e e v e n t s . L a z a r u s (1966) proposed t h a t c o g n i t i v e f a c t o r s , such as a p p r a i s a l o f the s t r e s s o r , media te the p s y c h o l o g i c a l response d u r i n g a d a p t a t i o n . I n L a z a r u s ' framework t h e r e a re two types o f a p p r a i s a l : p r i m a r y a p p r a i s a l o f the importance o f an event f o r the w e l l - b e i n g o f the i n d i v i d u a l , and secondary a p p r a i s a l o f c o p i n g o p t i o n s and r e s o u r c e s . I n a d d i t i o n t o a r e l a t i o n s h i p t o p h y s i c a l i l l n e s s , l i f e s t r e s s has been c o r r e l a t e d w i t h p s y c h o l o g i c a l r e a c t i o n s such as a n x i e t y , d e p r e s s i o n and a g g r e s s i o n (Johnson & S a r a s o n , 1978, 1979) . I n g e n e r a l , the r e s e a r c h l i n k i n g l i f e s t r e s s t o p h y s i c a l i l l n e s s and p s y c h o l o g i c a l e f f e c t s has been c o r r e l a t i o n a l i n n a t u r e , w i t h modest c o r r e l a t i o n s i n the .20 t o .30 range. C l e a r l y , l i f e s t r e s s i s o n l y one v a r i a b l e i n a m u l t i v a r i a t e s i t u a t i o n . However, l i f e events w i t h a n e g a t i v e impact have been shown t o have more p r e d i c t i v e power (Johnson and S a r a s o n , 1979) than those w i t h a p o s i t i v e impact . 36 The trauma o f an acc ident , which many immobile orthopedic or s p i n a l cord i n j u r y pat ient s have endured, i s an example o f a l i f e event w i t h a negative impact. Extreme s i t u a t i o n s , such as trauma w i t h de le ter ious e f f e c t s , may lead to a c r i s i s for the i n d i v i d u a l . T h e o r e t i c a l Framework C r i s i s theory (Aguilera & Messick, 1982) concerns the way that people dea l w i t h l i f e s t resses , which may be e i ther s i t u a t i o n a l events or developmental t r a n s i t i o n s . A c r i s i s e x i s t s when the i n d i v i d u a l i s faced wi th a s i t u a t i o n which i s perceived as a psycholog ica l threat and for which previous coping mechanisms are i n e f f e c t i v e . This leads to mounting anxiety and psycholog ica l d i s e q u i l i b r i u m unless balanced by other factors such as s i t u a t i o n a l support. According to the theory, a c r i s i s i s s e l f - l i m i t i n g and e q u i l i b r i u m w i l l be restored (usual ly i n days or weeks) because a person cannot stay i n an extreme state o f d i s e q u i l i b r i u m i n d e f i n i t e l y . The outcome of t h i s adaptive process may be at a higher or lower l e v e l of psycholog ica l func t ion ing , depending on the way the c r i s i s was managed. This r e s o l u t i o n , i n t u r n , a f fect s the person's a b i l i t y to cope wi th future c r i s e s . Therefore, c r i s i s theory could p r e d i c t that previous l i f e stresses or traumatic experiences may have e i ther a p o s i t i v e or negative e f f ec t on coping wi th an e x i s t i n g c r i s i s , depending on a number of f a c t o r s . The present research examined a group of factors which may a f fec t the psycholog ica l outcome for h o s p i t a l i z e d p a t i e n t s . This research was based on the assumption that m u l t i v a r i a t e determinants e x i s t i n the h o s p i t a l s i t u a t i o n . For t h i s reason, the m u l t i v a r i a t e model presented 3 7 e a r l i e r o f p h y s i c a l i l l n e s s as c r i s i s (Moos & T s u , 1977) was u sed . The t h e o r e t i c a l background a l s o i n c l u d e d t h e o r i e s o f p e r s o n a l c o n t r o l (Baron & R o d i n , 1978; Rothbaum, Wei sz & Snyder , 1982) and e n v i r o n m e n t a l s t i m u l a t i o n (Zuckerman, 1969; Cohen , 1978) w h i c h r e l a t e t o s p e c i f i c c a t e g o r i e s o f the Moos and Tsu mode l . Hypotheses T h i s p r o j e c t i n c l u d e d f i v e c a t e g o r i e s o f hypotheses r e l a t e d t o the f o l l o w i n g independent v a r i a b l e s w h i c h f i t the Moos and Tsu mode l : i m m o b i l i t y , a c o g n i t i v e i n t e r v e n t i o n , the h o s p i t a l env i ronment , p r e v i o u s l i f e s t r e s s and p e r s o n a l c o n t r o l . S tudy 1, w h i c h examined the p s y c h o l o g i c a l e f f e c t s o f e x t e r n a l i m m o b i l i t y , i n c l u d e d p r e d i c t i o n s on a l l f i v e independent v a r i a b l e s . I n S tudy 2 , w h i c h had p a t i e n t s w i t h b o t h i n t e r n a l ( p a r a l y s i s ) and e x t e r n a l (apparatus o r conf inement) i m m o b i l i t y , p r e d i c t i o n s were made f o r o n l y two o f the independent v a r i a b l e s : i m m o b i l i t y and the h o s p i t a l env i ronment . The reason f o r t h i s d i f f e r e n c e i n approach was because S tudy 2 , w h i c h was a r e t r o s p e c t i v e s t u d y , o b t a i n e d d a t a e x c l u s i v e l y from the c h a r t s . The c h a r t d a t a d i d not have r e p o r t s on the o t h e r t h r e e independent v a r i a b l e s . S tudy 1 examined the f u l l range o f p r e d i c t o r s by a v a r i e t y o f c o n c u r r e n t d a t a c o l l e c t i o n p r o c e d u r e s : q u e s t i o n n a i r e s , o b s e r v a t i o n s and i n t e r v i e w s . I n b o t h s t u d i e s , the dependent v a r i a b l e s o f i n t e r e s t were imagery, s t r e s s and noncompl iant b e h a v i o r . Where p o s s i b l e , m u l t i p l e o p e r a t i o n i s m (Crano & Brewer , 1973) was used i n an a t tempt t o i n c r e a s e the e x t e r n a l 38 v a l i d i t y o f f i n d i n g s . That i s , s e v e r a l measures o f the same v a r i a b l e ( e . g . , s t r e s s ) were i n c l u d e d t o p r o v i d e v a l i d a t i o n from more than one source ( p a t i e n t and n u r s e ) . C a t e g o r y 1: Hypotheses R e l a t e d t o I n m o b i l i t y I t was p r e d i c t e d t h a t i m m o b i l i t y would l e a d t o an i n c r e a s e d i n c i d e n c e o f imagery , s t r e s s and noncompl iant behav iour as f o l l o w s : H y p o t h e s i s 1 ( a ) . S tudy 1 - Imagery as measured by t h e M o d i f i e d I m a g i n a l P r o c e s s e s I n v e n t o r y (Appendix B . 3 , p . 216 ) . S tudy 2 - Imagery as r e c o r d e d i n the p a t i e n t c h a r t s (Appendix C . 2 ( c ) [ i i ] , p . 239 ) . H y p o t h e s i s 1 ( b ) . S tudy 1 - S t r e s s r e l a t e d t o imagery as measured by s u b s c a l e IV o f the E n v i r o n m e n t a l S t r e s s S c a l e (Appendix D , p . 2 4 0 ) . S tudy 2 - S t r e s s r e l a t e d t o imagery as r ecorded i n the p a t i e n t c h a r t s (Appendix C . 2 ( c ) [ i i ] , p . 239 ) . H y p o t h e s i s 1 ( c ) . S tudy 1 - S t r e s s as measured by t h e : i ) S u b j e c t i v e S t r e s s S c a l e (Appendix B . 4 , p . 220) . i i ) D i s t r e s s r e c o r d from p a t i e n t c h a r t s (Appendix C . 2 ( c ) [ i ] , p . 238 ) . i i i ) E n v i r o n m e n t a l S t r e s s S c a l e - t o t a l . S tudy 2 - S t r e s s as r ecorded i n the p a t i e n t c h a r t s (Appendix C . 2 ( c ) [ i i ] , p . 239 ) . H y p o t h e s i s 1 ( d ) . S tudy 1 - Noncompl iant behav iour as measured b y : i ) Record from the p a t i e n t c h a r t s (Appendix C . 2 ( c ) [ i ] , p . 238 ) . i i ) S e l f - r e p o r t on E n v i r o n m e n t a l S t r e s s S c a l e . (Question 58 , Appendix D ) . S tudy 2 - Noncompl iant behav iour as r ecorded i n the p a t i e n t c h a r t s (Appendix C . 2 ( c ) [ i i ] , p . 239) . 39 The dependent v a r i a b l e s s e l e c t e d here have emerged from p r e v i o u s l a b o r a t o r y r e s e a r c h on i m m o b i l i t y (Zubek, 1969) and f i e l d s t u d i e s ( e . g . , J o h n s o n , 1976; S t e w a r t , 1977) o f i m m o b i l i z e d p a t i e n t s i n h o s p i t a l s e t t i n g s . The r e l a t i o n s h i p o f imagery t o e x t e r n a l i m m o b i l i t y has been suggested by some s t u d i e s ( B o l i n , 1974; Wood 1977) , bu t o t h e r r e s e a r c h (S tewar t , 1977) i n d i c a t e s t h a t v a r i a b l e s such as room as s ignment , emergency a d m i s s i o n and trauma may c o n t r i b u t e t o an e x p l a n a t i o n o f imagery e f f e c t s . S tudy 1 o f the p r e s e n t p r o j e c t i s de s igned t o p r o v i d e g r e a t e r c o n t r o l o f confounding v a r i a b l e s and g r e a t e r emphasis on measurement w i t h i n s t r u m e n t s w h i c h have had p s y c h o m e t r i c t e s t i n g t h a n p r e v i o u s h o s p i t a l s t u d i e s . Imagery e f f e c t s i n p a r a l y z e d p a t i e n t s ( i n t e r n a l i m m o b i l i t y ) have been e x p l a i n e d i n terms o f r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n ( Johnson, 1976) i n the p s y c h o l o g i c a l l i t e r a t u r e . S t u d i e s w i t h a m e d i c a l o r i e n t a t i o n , by c o n t r a s t , have d e s c r i b e d imagery e f f e c t s as body image d i s t o r t i o n s (Conomy, 1973) o r phantom s e n s a t i o n s (Hohmann, 1975) analogous t o phantom l i m b p a i n . The above s t u d i e s have focused on s i n g l e m o d a l i t i e s such as v i s u a l s e n s a t i o n s ( Johnson, 1976) o r body s e n s a t i o n s (Conomy, 1973; Hohmann, 1975) . B o t h s t u d i e s i n the p r e s e n t p r o j e c t w i l l examine the m u l t i p l e m o d a l i t i e s o f v i s u a l , a u d i t o r y and k i n e s t h e t i c imagery based on p r e v i o u s i n t e r v i e w d a t a from o r t h o p e d i c p a t i e n t s (S tewart , 1977) . S tudy 2 w i l l a l s o i n c l u d e d a t a on u n u s u a l body s e n s a t i o n s such as t a c t i l e imagery and temperature r e g u l a t i o n a n o m a l i e s . No p r e v i o u s r e s e a r c h has p r o v i d e d compara t ive imagery d a t a from p a t i e n t s w i t h e x t e r n a l i m m o b i l i t y (Study 1) and p a t i e n t s w i t h i n t e r n a l and e x t e r n a l i m m o b i l i t y (Study 2 ) . 40 Category 2; Hypotheses Related to the Intervention The c o g n i t i v e i n t e r v e n t i o n t e s t e d here was t a p e - r e c o r d e d i n f o r m a t i o n (Appendix E , p . 253) w h i c h p r o v i d e d an expectancy f o r v i v i d dreams and imagery/ a p o s i t i v e s e t , and an e n v i r o n m e n t a l e x p l a n a t i o n f o r imagery e f f e c t s . F o r Study 1 o n l y , i t was h y p o t h e s i z e d t h a t the c o g n i t i v e i n t e r v e n t i o n would l e a d t o decreased n e g a t i v e a f f e c t ( s t re s s ) as f o l l o w s : H y p o t h e s i s 2(a) S t r e s s r e l a t e d t o imagery as measured by s u b s c a l e I V o f the E n v i r o n m e n t a l S t r e s s S c a l e . H y p o t h e s i s 2(b) S t r e s s as measured by t h e : i ) S u b j e c t i v e S t r e s s S c a l e , i i ) D i s t r e s s r e c o r d from p a t i e n t c h a r t s , i i i ) E n v i r o n m e n t a l S t r e s s S c a l e - t o t a l . The r a t i o n a l e f o r these hypotheses comes from f o u r s o u r c e s : (1) the e x p e r i m e n t a l r e s e a r c h on p r e d i c t a b i l i t y and c o n t r o l (Glas s & S i n g e r , 1972) ; (2) h o s p i t a l s t u d i e s w h i c h demonstrate the a l l e v i a t i o n o f s u r g i c a l s t r e s s through c o g n i t i v e r e a p p r a i s a l and c o n t r o l (Langer , J a n i s & W o l f e r , 1975) ; (3) c l i n i c a l and l a b o r a t o r y r e s e a r c h ( Johnson, 1975) on the s t r e s s - r e d u c i n g e f f e c t s o f a c c u r a t e e x p e c t a t i o n s f o r s ensory i n f o r m a t i o n ; and (4) t h e l a b o r a t o r y r e s e a r c h on r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n ( S u e d f e l d , 1975; 1980) , i n w h i c h a p o s i t i v e s e t and n o n s t r e s s f u l atmosphere have l e d t o decreased n e g a t i v e a f f e c t a s s o c i a t e d w i t h the e x p e r i e n c e . When imagery e f f e c t s a re expected i n the l a b o r a t o r y , they may be en joyed r a t h e r t h a n f e a r e d . The i n t e r v e n t i o n w i l l i n c r e a s e p r e d i c t a b i l i t y by p r o v i d i n g i n f o r m a t i o n on what t o e x p e c t . I t w i l l a l s o p r o v i d e a b a s i s f o r 41 « c o g n i t i v e r e a p p r a i s a l o f imagery e f f e c t s as normal r a t h e r than as i n d i c a t i v e o f m e n t a l i l l n e s s , and t h e r e f o r e s h o u l d i n c r e a s e p e r c e i v e d c o n t r o l . I n f o r m a t i o n w h i c h p r o v i d e s a d e s c r i p t i o n o f a t y p i c a l s ensory e x p e r i e n c e (what i s s e e n , h e a r d , e t c . ) has been shown t o be more e f f e c t i v e i n a l l e v i a t i n g s t r e s s o f s u r g i c a l p a t i e n t s than o b j e c t i v e " t e x t b o o k " i n f o r m a t i o n about the t i m e , d u r a t i o n and mechanics o f p rocedure s ( Johnson, F u l l e r , E n d r e s s , & P a c e , 1978) . I n l i n e w i t h these f i n d i n g s r e g a r d i n g sensory i n f o r m a t i o n , the proposed i n t e r v e n t i o n focuses on v i s u a l , a u d i t o r y and k i n e s t h e t i c sensory e x p e r i e n c e s . Rather than a l t e r the i n c i d e n c e o f imagery , the i n t e r v e n t i o n aimed t o decrease n e g a t i v e a f f e c t i v e responses t o imagery . P r e v i o u s r e s e a r c h (S tewar t , 1977) demonstrated a range o f a f f e c t i v e r e a c t i o n s t o imagery , from extreme f e a r t o m i l d amusement. Recent s t u d i e s have shown t h a t imagery may as r e a d i l y have ' b e n e f i c i a l ( S i n g e r , 1979) as d e l e t e r i o u s e f f e c t s . T h e r e f o r e , t h e r e i s no nece s sa ry reason t o a t tempt t o decrease the i n c i d e n c e o f imagery so l o n g as the p a t i e n t has a n e u t r a l o r p o s i t i v e r e a c t i o n t o i t s o c c u r r e n c e . S u e d f e l d (1974) notes the p o s i t i v e r e a c t i o n s o f r e l i g i o u s i s o l a t e s who choose ( i . e . , c o n t r o l ) t h e i r e x p e r i e n c e and a re p repared f o r what t o expec t ( i . e . , p r e d i c t a b i l i t y ) as c o n t r a s t e d w i t h n e g a t i v e r e a c t i o n s o f t h o s e , such as the sh ipwreck v i c t i m , who f a c e sudden, unexpected i s o l a t i o n . The p a t i e n t admi t t ed t o h o s p i t a l as an emergency, c o n f i n e d t o bed and i s o l a t e d from normal c o n t a c t s w i l l l i k e l y f a l l i n the l a t t e r g r o u p . The i n t e r v e n t i o n r e p r e s e n t s an a t tempt t o n e u t r a l i z e n e g a t i v e r e a c t i o n s from t h i s e x p e r i e n c e . 42 An argument c a n be made from the l i t e r a t u r e t o suppor t e i t h e r the h y p o t h e s i s t h a t t h i s i n t e r v e n t i o n , w h i c h p r o v i d e s an expectancy f o r imagery , would i n c r e a s e ( Jackson & P o l l a r d , 1962) o r decrease (Zuckerman, P e r s k y , L i n k & B a s u , 1968) the i n c i d e n c e o f imagery . S i n c e some h e a l t h c a r e p r o f e s s i o n a l s use the former assumption t o v a l i d a t e t h e i r "no i n f o r m a t i o n " approach r e l a t i v e t o imagery , the i n t e r v e n t i o n w i l l be examined f o r any change i n the i n c i d e n c e o f imagery as w e l l . No p r e d i c t i o n was made f o r a s i g n i f i c a n t change i n imagery i n c i d e n c e . C a t e g o r y 3 ; Hypotheses R e l a t e d t o t h e Env i ronment I t was h y p o t h e s i z e d t h a t r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n would be p r e d i c t i v e o f i n c r e a s e d imagery and noncompl iant behav iour as f o l l o w s : H y p o t h e s i s 3 ( a ) . S tudy 1 - Imagery a s . measured by the M o d i f i e d I m a g i n a l P roce s se s I n v e n t o r y . S tudy 2 - Imagery as r e c o r d e d i n t h e p a t i e n t c h a r t s . H y p o t h e s i s 3 ( b ) . S tudy 1 - Noncompl iant behav iour as measured b y : i ) Record from the p a t i e n t c h a r t s , i i ) S e l f - r e p o r t on the E n v i r o n m e n t a l S t r e s s S c a l e . S tudy 2 - Noncompl iant behav iour as r ecorded on the p a t i e n t c h a r t s . The d e f i n i t i o n o f r e s t r i c t e d s t i m u l a t i o n was de termined d i r e c t l y i n Study 1 and i n d i r e c t l y i n Study 2 . I n the f i r s t i n s t a n c e , d i r e c t o b s e r v a t i o n s o f d imens ions o f the s o c i a l and n o n s o c i a l environment were o b t a i n e d . I n S tudy 2 , a compar i son was made between the e f f e c t s o f the i n t e n s i v e c a r e and ward env i ronment s . Based on the preponderance o f 43 articles which characterize the intensive care environment as "sensory deprivation" (e.g., Worrell, 1977), as apposed to overload, the assumption was made that intensive care could be defined as restricted stimulation. The literature is lacking a direct observational base to make this definition. , The rationale for hypotheses 3(a) and 3(b) is derived from both laboratory (Zubek, 1969) and hospital research (Johnson, 1976) on restricted environmental stimulation. Since restricted stimulation such as social isolation in a private hospital room may have positive as well as negative effects (Stewart, 1977), no consistent relationship with stress scores was predicted. These hypotheses differ from hypothesis 1(a) and 1(d) in their focus on aspects of the hospital environment other than immobility. For example, observation of dimensions of stimulation, such as variety, included nonsocial (television, radio, books) and social (nurses, doctors, visitors) stimulation, regardless of the degree of immobility. Category 4; Hypotheses Related to Life Stress For Study 1, i t was hypothesized that high l i f e stress for the year prior to admission as measured by negative change scores on the Life Experiences Survey (Appendix B.l) would be predictive of increased imagery and stress as follows: Hypothesis 4(a). Imagery as measured by the Modified Imaginal Processes Inventory. 44 H y p o t h e s i s 4 ( b ) . S t r e s s as measured by t h e : i ) E n v i r o n m e n t a l S t r e s s S c a l e , i i ) S u b j e c t i v e S t r e s s S c a l e , i i i ) D i s t r e s s r e c o r d from p a t i e n t c h a r t s , i v ) P s y c h o l o g i c a l ad justment s u b s c a l e o f the P s y c h o s o c i a l Adjus tment t o I l l n e s s S c a l e (Appendix B . 5 , p . 222) two months p o s t - d i s c h a r g e . The r e a s o n i n g b e h i n d these hypotheses comes from c r i s i s t h e o r y ( A g u i l e r a & M e s s i c k , 1982) , S a r a s o n 1 s r e s e a r c h u s i n g the L i f e E x p e r i e n c e s Survey (Sarason, Johnson & S i e g e l , 1978) , and r e s e a r c h on t r a u m a t i c images ( H o r o w i t z , 1978) . The c l a s s i c s tudy o f g r i e f as c r i s i s (Lindemann, 1944) , f o r example, found imagery t o be p a r t o f t h e normal g r i e f p r o c e s s w h i c h l a s t s f o r about one y e a r . The ana logy o f the r e a c t i o n t o sudden l o s s o f p h y s i c a l a c t i v i t y w i t h g r i e f has had some s u p p o r t through d a t a from i m m o b i l i z e d trauma p a t i e n t s ( S tewar t , 1977 ) . C r i s i s t h e o r y c a n p r e d i c t improved c o p i n g through l e a r n i n g t o d e a l e f f e c t i v e l y w i t h s t r e s s . However, i n the p r e s e n t i n s t a n c e , the h y p o t h e s i s assumes an o v e r l o a d o f s t r e s s f u l event s over the year p r e v i o u s t o h o s p i t a l i z a t i o n w i t h o u t adequate c o p i n g t i m e . I n t h i s c a se c r i s i s t h e o r y p r e d i c t s mounting a n x i e t y . C a t e g o r y 5: H y p o t h e s i s Related t o P e r s o n a l C o n t r o l P e r s o n a l c o n t r o l was de termined by nurse assessment i n h o s p i t a l ( independence s u b s c a l e , Appendix B . 2 ( a ) , p . 211) and p a t i e n t r e p o r t s o f low s u b j e c t i v e h e l p l e s s n e s s (Appendix B . 2 ( b ) , p . 215) p r i o r t o h o s p i t a l i z a t i o n . 45 H y p o t h e s i s 5 . I n S tudy 1, i t was h y p o t h e s i z e d t h a t h i g h p e r s o n a l c o n t r o l would p r e d i c t decreased s t r e s s as measured by t h e : i ) E n v i r o n m e n t a l S t r e s s S c a l e , i i ) S u b j e c t i v e S t r e s s S c a l e , i i i ) D i s t r e s s r e c o r d from p a t i e n t c h a r t s , i v ) P s y c h o l o g i c a l ad justment s u b s c a l e o f the P s y c h o s o c i a l Adjus tment t o I l l n e s s S c a l e two months p o s t - d i s c h a r g e . Support f o r t h i s h y p o t h e s i s can be found i n the l i t e r a t u r e , a l t h o u g h some f i n d i n g s suggest s h o r t - t e r m i n c r e a s e d s t r e s s and l o n g - t e r m decreased s t r e s s ( A v e r i l l , 1973) . F o r t h i s r e a s o n , the f o l l o w - u p measure was i n c l u d e d i n t h i s r e s e a r c h . I f , i n d e e d , the s t r e s s r e s u l t s show t h i s p a t t e r n o f i n c r e a s e and d e c r e a s e , they may w e l l f i t i n t o c r i s i s t h e o r y w h i c h p r e d i c t s a r e i n t e g r a t i o n a t a h i g h e r l e v e l o f f u n c t i o n i n g i n the l o n g r u n , d e s p i t e the d e b i l i t a t i n g a n x i e t y e x p e r i e n c e d d u r i n g the immediate c r i s i s p e r i o d . No hypotheses were made about the r e l a t i o n s h i p between p e r s o n a l c o n t r o l and e i t h e r imagery o r noncompl iance . I n the former c a s e , the l i t e r a t u r e p r o v i d e s no b a s i s f o r p r e d i c t i o n . As f o r noncompl iance , t h e i n i t i a l impetus f o r s t u d y o f t h i s v a r i a b l e came from p a t i e n t d a t a i n w h i c h i n v o l u n t a r y noncompliance was a s s o c i a t e d w i t h v i v i d imagery . The o n l y l o g i c a l b a s i s f o r a p r e d i c t e d r e l a t i o n s h i p between c o n t r o l and noncompliance would be f o r v o l u n t a r y noncompl iant behav iour where the p a t i e n t i s c o n s c i o u s o f h i s o r her a c t i o n s . 46 METHOD Study 1; Experimental Design This study invest igated the e f fec t s of immobil i ty and a cogn i t ive in te rvent ion (cognit ive reappraisal) on imagery, s t ress and noncompliant behaviour. The 2 X 2 f a c t o r i a l design had the fo l lowing two f ac tor s : ( 1 ) immobil i ty (IM) versus m o b i l i t y (MO), and ( 2 ) cogn i t ive in te rvent ion (CI) versus no in te rvent ion (NI) . The research was conducted i n a h o s p i t a l s e t t ing and the f i r s t factor was determined by the treatment regimen of nonequivalent pa t i en t groups who d i f f e r e d i n degree of m o b i l i t y . The immobile group was immobilized ( e . g . , bedrest , t rac t ion) for 5 days or more. The comparison group was mobi l ized (able to get out of bed) w i t h i n the f i r s t two days a f ter admission to h o s p i t a l or a f ter surgery. The second factor was manipulated and randomly assigned by a research a s s i s t an t . This in te rvent ion (Appendix E) was a tape recording of information which provided an expectation for imagery and v i v i d dreams, a p o s i t i v e se t , and an environmental explanation for these e f f e c t s . Double b l i n d precautions were observed. That i s , nursing s t a f f were unaware of the content of the tape (patients l i s t e n e d to the information w i t h earphones) and the experimenter d i d not know which pa t ient s heard the tape because the research a s s i s t ant d i d the random assignment. A t times pre-arranged wi th the research a s s i s t an t , the experimenter avoided the ward where a p o t e n t i a l in te rvent ion candidate was loca ted . The presence of the research a s s i s tant on the ward would 47 r e v e a l the r e s u l t s o f t h e random ass ignment because d a t a a c q u i s i t i o n was s l o w , o f t e n w i t h o n l y one p a t i e n t meet ing the sample c r i t e r i a a t a g i v e n t i m e . As a f u r t h e r p r e c a u t i o n , the r e s e a r c h a s s i s t a n t asked p a t i e n t s who heard the tape t o r e f r a i n from d i s c u s s i n g t h i s d u r i n g the subsequent i n t e r v i e w w h i c h the exper imenter c o n d u c t e d . To examine o t h e r f a c t o r s w h i c h c o u l d c o n t r i b u t e t o changes i n the t h r e e dependent v a r i a b l e s , two s t epwi se r e g r e s s i o n a n a l y s e s were per formed . The f i r s t a n a l y s i s examined the p r e d i c t i v e e f f e c t o f d imens ions o f the s o c i a l and n o n s o c i a l environment based on o b s e r v a t i o n a l d a t a . S e c o n d l y , s t e p w i s e r e g r e s s i o n a n a l y s i s was done u s i n g demographic , p e r s o n a l c o n t r o l and s i t u a t i o n a l v a r i a b l e s . D e f i n i t i o n s o f the v a r i a b l e s used f o r these a n a l y s e s a re d e s c r i b e d i n the measurement s e c t i o n t o f o l l o w . An i n t e r c o r r e l a t i o n m a t r i x was o b t a i n e d f o r v a r i a b l e s i n the r e g r e s s i o n a n a l y s i s and a l s o f o r r e a c t i o n , e x p e c t a t i o n and p r e v i o u s h o s p i t a l i z a t i o n s c o r e s from the i n t e r v i e w (Env i ronmenta l S t r e s s S c a l e , Appendix D ) . A l l s t a t i s t i c a l a n a l y s e s i n » t h i s p r o j e c t used e i t h e r BMDP (Dixon & Brown, 1979) programs deve loped f o r b i o m e d i c a l r e s e a r c h o r SPSS ( N i e , H u l l , J e n k i n s , S t e i n b r e n n e r & B e n t , 1975) programs f o r the s o c i a l s c i e n c e s . S u b j e c t s The sample f o r t h i s s tudy c o n s i s t e d o f 48 p a t i e n t s ( 1 2 / c e l l ) s e l e c t e d from the o r t h o p e d i c u n i t (2DE) and two g e n e r a l s u r g e r y u n i t s (Surgery 30 and Surgery 33) a t the U n i v e r s i t y H o s p i t a l (UH) i n S a s k a t o o n , Saskatchewan, from November 1980 t o May 1982. E x c e l l e n t suppor t f o r the s tudy was r e c e i v e d from a l l l e v e l s o f n u r s i n g , m e d i c a l 48 and a d m i n i s t r a t i v e s t a f f . Three p a t i e n t s r e f u s e d t o p a r t i c i p a t e i n the s t u d y . Of those who agreed t o p a r t i c i p a t e , a l l p a t i e n t s completed the h o s p i t a l p o r t i o n o f the s t u d y u n l e s s the y were u n e x p e c t e d l y d i s c h a r g e d b e f o r e d a t a c o l l e c t i o n c o u l d be c o m p l e t e d . There was a 77% r e t u r n r a t e on the f o l l o w - u p q u e s t i o n n a i r e two months a f t e r d i s c h a r g e . Sample c r i t e r i a i n c l u d e d : 1) Age - 15 t o 65 y e a r s . 2) M a l e o r f e m a l e . 3) Emergency a d m i s s i o n s . 4) On u n i t w i t h i n 48 hours a f t e r a d m i s s i o n ( i . e . , n o t i n the I n t e n s i v e C a r e U n i t l o n g e r than 48 h o u r s ) . 5) H o s p i t a l i z e d f o r n i n e days o r l o n g e r . 6) No p s y c h i a t r i c h i s t o r y ; no a l c o h o l o r drug abuse . 7) No s u i c i d e o r h o m i c i d e a t t e m p t s . 8) No n e u r o l o g i c a l d e f i c i t . 9) No head i n j u r y excep t m i l d c o n c u s s i o n ( i . e . , b low t o head w i t h l o s s o f c o n s c i o u s n e s s f o r a few minutes as maximum). 10) No mal ignancy o r h e a r t c o n d i t i o n . A l l admis s ions who met the c r i t e r i a were p o t e n t i a l c a n d i d a t e s f o r the r e s e a r c h . The sample c r i t e r i a were p a t t e r n e d a f t e r p r e v i o u s r e s e a r c h (S tewar t , 1977) w i t h the e x c e p t i o n t h a t the c u r r e n t sample were e x c l u s i v e l y emergency a d m i s s i o n s . A l t h o u g h random s e l e c t i o n was not s t r i c t l y p o s s i b l e , the s u b j e c t s were a random sample t o the degree t h a t emergency admis s ions t o h o s p i t a l o c c u r r e d on a random b a s i s . S u b j e c t c h a r a c t e r i s t i c s a re o u t l i n e d i n Appendix F . l . A l l u n i t s had p r i v a t e and 49 n o n p r i v a t e rooms a v a i l a b l e . The p r i v a t e rooms had an e x t r a charge u n l e s s the c o n d i t i o n o f the p a t i e n t warranted the room, i n which case t h e charge would be w a i v e d . The m a j o r i t y o f the p a t i e n t s on each ward were i n rooms w i t h two t o f o u r beds . Informed consent (Appendix A) was o b t a i n e d from each p a t i e n t . To a l l o w f o r i n i t i a l ad jus tment t i m e , consent was not o b t a i n e d u n t i l 48 hours p o s t - o p e r a t i v e o r 48 hours p o s t - a d m i s s i o n i n the event t h a t no s u r g e r y was done . Development o f t h e I n t e r v e n t i o n The s c r i p t f o r the c o g n i t i v e i n t e r v e n t i o n (Appendix E ) , w h i c h was deve loped f o r t h i s s t u d y , used d a t a from p r e v i o u s i n t e r v i e w s w i t h i m m o b i l i z e d , o r t h o p e d i c p a t i e n t s ( S tewar t , 1977) . The t h r e e - m i n u t e c a s s e t t e r e c o r d i n g was produced i n a soundproof room u s i n g a s t y l e ( e . g . , speed o f r e a d i n g , pauses) s i m i l a r t o t h a t used f o r t a p e - r e c o r d e d i n f o r m a t i o n p r e s e n t e d t o s u b j e c t s i n r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n l a b o r a t o r i e s . A female graduate s t u d e n t i n p s y c h o l o g y read the s c r i p t f o r the r e c o r d i n g . As a p r e l i m i n a r y p r e t e s t , a group o f f i v e r e s e a r c h e r s c r i t i q u e d the t a p e . Repeat r e c o r d i n g s were made u n t i l an outcome s a t i s f a c t o r y t o the group was a c h i e v e d . A second p r e t e s t was conducted a t Shaughnessy H o s p i t a l , where f o u r , s p i n a l c o r d i n j u r y p a t i e n t s l i s t e n e d t o the tape and made i n d i v i d u a l comments. Each p a t i e n t responded p o s i t i v e l y t o the t a p e . One incomple te q u a d r i p l e g i c p a t i e n t i n p a r t i c u l a r f e l t t h a t i t would have been v e r y h e l p f u l t o hear t h i s tape d u r i n g the e a r l y h o s p i t a l i z a t i o n p e r i o d . He had been e x t r e m e l y f r i g h t e n e d by h i s 50 e x p e r i e n c e s o f imagery and v i v i d dreams because he t h o u g h t , e r r o n e o u s l y , t h a t the unusua l imagery i n d i c a t e d t h a t he had permanent b r a i n damage. No f u r t h e r changes were made t o the tape as a r e s u l t o f the p a t i e n t p r e t e s t . Measurement of Predictor Variables Dimensions o f S t i m u l a t i o n . The assessment o f s t i m u l a t i o n l e v e l s f rom the s o c i a l and n o n s o c i a l environment was based on the o b s e r v a t i o n a l c a t e g o r i e s (dimensions) used by Y a r r o w , R u b e n s t e i n , Pedersen & J ankowsk i (1972) i n t h e i r r e s e a r c h c o n c e r n i n g the e f f e c t s o f e a r l y s t i m u l a t i o n on i n f a n t development . E n v i r o n m e n t a l o b s e r v a t i o n s o f one h o u r / p a t i e n t were o b t a i n e d on f o u r 15-minute o b s e r v a t i o n p e r i o d s s e l e c t e d f rom each o f the f o l l o w i n g i n t e r v a l s : 8 :30-10 :00 a . m . , 11 :00-12 :00 a . m . ; 1 :00-2 :00 p . m . and 3 :30-5 :00 p . m . (Appendix C . l ) . The d imens ions o f i n t e r e s t f o r the n o n s o c i a l environment were v a r i e t y , r e s p o n s i v e n e s s , c o m p l e x i t y , and n o i s e . V a r i e t y was measured i n terms o f the number o f d i f f e r e n t o b j e c t s , such as t e l e v i s i o n and books , w i t h i n r e a c h o f the p a t i e n t d u r i n g the o b s e r v a t i o n p e r i o d . Respons ivenes s , an i n d e x o f feedback p o t e n t i a l i n h e r e n t i n o b j e c t s , was measured a c c o r d i n g t o the degree o f change i n the v i s u a l , a u d i t o r y o r t a c t i l e p r o p e r t i e s o f o b j e c t s as a r e s u l t o f the p a t i e n t ' s b e h a v i o u r . F o r example, a r a d i o w h i c h a p a t i e n t c o u l d a d j u s t would be s c o r e d f o r r e s p o n s i v e n e s s . C o m p l e x i t y was measured as the degree t o w h i c h o b j e c t s p r o v i d e i n f o r m a t i o n t o v a r i o u s m o d a l i t i e s . T e l e v i s i o n s , f o r i n s t a n c e , i n f o r m t h e v i s u a l and a u d i t o r y m o d a l i t i e s . N o i s e was i d e n t i f i e d a c c o r d i n g t o type ( e . g . , h u m i d i f i e r ) , d u r a t i o n , and l o c a t i o n ( i n s i d e o r 51 outs ide room). A t the s ide of the observation form, the observer sketched a diagram of the p h y s i c a l layout o f the room with nonsocia l st imulus features i n r e l a t i o n to the p o s i t i o n of pa t ient s i n the room. The ongoing awareness of the pa t ient (eyes open v s . closed) was a l so noted. Observation of the s o c i a l environment included frequency and v a r i e t y of people, ( e . g . , nurses, v i s i t o r s ) i n the room. These observations were further categorized according to the l o c a t i o n of the s o c i a l s t i m u l i . Each observation o f s o c i a l s t imula t ion was coded as e i ther ins ide or outs ide the observed p a t i e n t ' s space. This space was defined as the t e r r i t o r y around the p a t i e n t , i d e n t i f i e d by boundaries such as bedside cur ta ins around the bed or fu rn i ture surrounding a pa t ient who was s i t t i n g i n a c h a i r . The type of behaviour was categorized as v e r b a l i z a t i o n to the p a t i e n t , nonverbal behaviour ( e . g . , s i t t i n g by the p a t i e n t ) , treatment/care of the p a t i e n t , o ther-d i rec ted (communication wi th someone other than the p a t i e n t ) , and d i rec ted at the p h y s i c a l environment ( e . g . , housekeeping). Contingency responses, i n which someone responded to pa t i en t behaviour, included eye contact , v e r b a l i z a t i o n and ass i s tance . F i n a l l y , there was a record of the modality ( i . e . , v i s u a l , audi tory , e tc . ) o f the above s t i m u l a t i o n . The modality record (p. 194), which was unrelated to pa t ient space, provided a measure of complexity which p a r a l l e l e d the complexity measure for nonsocia l s t imula t ion (p. 193). The experimenter developed the observat ional t o o l on the Acute S p i n a l Cord In jury U n i t of Shaughnessy H o s p i t a l . During the ear ly 52 development phase , i t became apparent t h a t s o c i a l s t i m u l a t i o n was too abundant t o a l l o w f o r r e l i a b l e c o d i n g o f each i n t e r a c t i o n . A f t e r numerous t r i a l s , the p r e s e n t format e v o l v e d . Frequency and v a r i e t y were coded s i m u l t a n e o u s l y by u s i n g a l e t t e r t o i n d i c a t e the c a t e g o r y o f p e r s o n (N f o r n u r s e , D f o r d o c t o r , e t c . ) and a number t o i n d i c a t e whether the same o r d i f f e r e n t persons e n t e r e d the space ( e . g . , N l , N2, D l ) . The r e s u l t a n t f requency and v a r i e t y s c o r e s , w h i c h had no maximum v a l u e , were summed a f t e r o b s e r v a t i o n s were c o m p l e t e . A c o r r e l a t i o n m a t r i x o f s t i m u l a t i o n d imens ions f rom l a t e r o b s e r v a t i o n s f o r S tudy 1 a t the U n i v e r s i t y H o s p i t a l r e v e a l e d t h a t f requency and v a r i e t y were h i g h l y r e l a t e d , r_ = .96 i n s i d e the p a t i e n t space ; and t_ - .93 o u t s i d e t h i s space . Due t o the h i g h degree o f shared v a r i a n c e , the r e g r e s s i o n a n a l y s i s f o r S tudy 1 o n l y i n c l u d e d one o f these v a r i a b l e s . F requency was e x c l u d e d , r a t h e r t h a n v a r i e t y , because the n o n s o c i a l s t i m u l a t i o n o b s e r v a t i o n s (p. 193) d i d n o t have a " f r e q u e n c y " c a t e g o r y but d i d have a " v a r i e t y " c a t e g o r y w h i c h c o u l d be used f o r compar i son p u r p o s e s . The o t h e r d imens ions o f s o c i a l s t i m u l a t i o n were coded by p l a c i n g one check i n the box r e p r e s e n t i n g a one-minute i n t e r v a l , i f one o r more s t i m u l i o c c u r r e d d u r i n g t h i s i n t e r v a l . I n these c a s e s , the s c o r e ranged from 0 t o a maximum o f 10 f o r the 10-minute i n t e r v a l . S e p a r a t i o n o f n o n s o c i a l and s o c i a l o b s e r v a t i o n s a l s o enhanced r e l i a b i l i t y because s imul taneous o b s e r v a t i o n o f these domains would have o v e r t a x e d the a t t e n t i o n a l c a p a c i t y o f the o b s e r v e r . R e l i a b i l i t y o f the o b s e r v a t i o n a l t o o l was t e s t e d by two s imul taneous o b s e r v e r s , the exper imenter and a r e s e a r c h a s s i s t a n t , w i t h r = . 9 9 . 53 To reduce the number o f p o s s i b l e p r e d i c t o r s f o r the s t epwi se r e g r e s s i o n a n a l y s i s o f s t i m u l a t i o n d imens ions i n S tudy 1, some o f the s o c i a l d a t a were c o l l a p s e d under the heading p a t i e n t - d i r e c t e d s t i m u l a t i o n , t h a t i s , s t i m u l a t i o n d i r e c t e d a t the p a t i e n t . T h i s v a r i a b l e i n c l u d e d v e r b a l i z a t i o n , n o n v e r b a l b e h a v i o u r , t r e a t m e n t , and c o n t i n g e n c y re sponse s , a l l w i t h i n the p a t i e n t ' s space . The s t epwi se r e g r e s s i o n a n a l y s i s i n c l u d e d 10 p r e d i c t o r s : f o u r from the n o n s o c i a l s t i m u l a t i o n ( v a r i e t y , r e s p o n s i v e n e s s , c o m p l e x i t y and no i se ) and s i x from the s o c i a l s t i m u l a t i o n ( v a r i e t y i n s i d e the p a t i e n t space , v a r i e t y o u t s i d e t h e p a t i e n t space , p a t i e n t - d i r e c t e d , o t h e r - d i r e c t e d , d i r e c t e d a t the p h y s i c a l env i ronment , and c o m p l e x i t y ) . A c o r r e l a t i o n m a t r i x o f these 10 p r e d i c t o r s and the dependent measures f o r S tudy 1 c a n be found i n Appendix G . 6 . G e n e r a l P r e d i c t o r s . A second s t epwi se r e g r e s s i o n a n a l y s i s examined the p r e d i c t i v e power o f 10 g e n e r a l v a r i a b l e s : age, s e x , p r i v a t e room, a c c i d e n t , s u r g e r y , t r a c t i o n , l i f e s t r e s s i n the year p r i o r t o h o s p i t a l i z a t i o n , h e l p l e s s n e s s p r i o r t o a d m i s s i o n , dependence and independence. Age was c a t e g o r i z e d i n t o t h r e e g roups : 15-26, 27-45 , and 46-65 y e a r s o l d . The f i r s t two c a t e g o r i e s a re the same as those used by Putnam and Yager (1978) . Sex , p r i v a t e room, a c c i d e n t , and t r a c t i o n were a l l coded as dichotomous v a r i a b l e s . Surgery was coded as the number o f t imes t h a t a p a t i e n t had a g e n e r a l a n a e s t h e t i c . D a t a on these v a r i a b l e s were o b t a i n e d f rom the demographic r e c o r d i n Appendix C . 2 ( a ) [ i ] . L i f e s t r e s s over the p a s t year was assessed u s i n g S a r a s o n ' s L i f e E x p e r i e n c e s Survey (Appendix B . l ) . T h i s 6 0 - i t e m s e l f r e p o r t measure 54 l i s t s 57 event s ( e . g . , m a r r i a g e , d e a t h o f a spouse , e t c . ) and has t h r e e b l a n k i tems t o w h i c h the s u b j e c t may add o t h e r event s e x p e r i e n c e d . F o r each event t h a t o c c u r r e d d u r i n g the p a s t y e a r , the s u b j e c t must : (1) c a t e g o r i z e the event as "good" o r " b a d " , and (2) r a t e the degree o f impact t h a t the event had on h i s o r her l i f e (no e f f e c t , some e f f e c t , moderate e f f e c t o r g r e a t e f f e c t ) . N e g a t i v e impact s c o r e s (the sum o f impact r a t i n g s f o r " b a d " events) were used f o r t h i s s t u d y based on p r e v i o u s l y c i t e d r e s e a r c h (Vinokur & S e l z e r , 1975) . S a r a s o n , Johnson and S i e g e l (1978) found t h a t t e s t - r e t e s t r e l i a b i l i t i e s over 5 - 6 weeks f o r n e g a t i v e change s c o r e s were .56 ( £ < .001) and .88 ( £ < .001) i n two s t u d i e s . They note t h a t t e s t - r e t e s t s c o r e s w i t h an i n s t r u m e n t o f t h i s t y p e t end t o undere s t imate r e l i a b i l i t y because l i f e event s c o n t i n u e t o o c c u r between t e s t i n g s . T h i s q u e s t i o n n a i r e was u s e f u l f o r h o s p i t a l i z e d p a t i e n t s because o f the r e l a t i v e ease o f i t s c o m p l e t i o n . A l t h o u g h i t appears l o n g , the p a t i e n t i s i n s t r u c t e d t o l e a v e e v e r y t h i n g b l a n k e x c e p t the event s t h a t have o c c u r r e d i n the p a s t y e a r . F o r most p e o p l e , o n l y a few events had happened. The o t h e r t h r e e measures were from s c a l e s r e l a t e d t o p e r s o n a l c o n t r o l . The f i r s t o f t h e s e , h e l p l e s s n e s s , was a p a t i e n t q u e s t i o n n a i r e . The measures o f dependence and independence were from s u b s c a l e s o f the nur se q u e s t i o n n a i r e . The p a t i e n t r e p o r t measure o f p e r s o n a l c o n t r o l was the S u b j e c t i v e H e l p l e s s n e s s S c a l e (Appendix B . 2 ( b ) ) . T h i s 2 5 - i t e m q u e s t i o n n a i r e has i n s t r u c t i o n s f o r s u b j e c t s t o r a t e the degree t h a t they were a b l e t o i n f l u e n c e o r c o n t r o l outcomes i n c l u d i n g " s o c i a l - i n t e r p e r s o n a l 55 b e h a v i o u r s ; academic , v o c a t i o n a l , a v o c a t i o n a l p u r s u i t s ; and a v a r i e t y o f b e h a v i o u r s p r o v i d i n g a means o f a c h i e v i n g s e l f - c o n f i d e n c e , r e l a x a t i o n , and g e n e r a l l i f e s a t i s f a c t i o n " (Donovan, O ' L e a r y & W a l k e r , 1979, p . 4 6 2 ) . The o r i g i n a l measure, deve loped by G l a s s (1977) , used an 1 1 - p o i n t s c a l e , b u t f o r p r e s e n t purposes a 7 - p o i n t s c a l e was used because i t was l e s s cumbersome and hence more r e a l i s t i c f o r h o s p i t a l i z e d p a t i e n t s who may be low on c o g n i t i v e energy . The i n s t r u c t i o n s were a l s o a l t e r e d f o r t h i s sample t o i n d i c a t e " b e f o r e you came t o h o s p i t a l " . G l a s s (1977) found t h a t the t e s t - r e t e s t r e l i a b i l i t y was .93 over a 3 week p e r i o d . The S u b j e c t i v e H e l p l e s s n e s s S c a l e was s i g n i f i c a n t l y c o r r e l a t e d (r = .42) w i t h the l e v e l o f d e p r e s s i o n as measure by the Beck D e p r e s s i o n I n v e n t o r y . ( G l a s s , 1977) . P e r s o n a l c o n t r o l was a s ses sed by a nurse q u e s t i o n n a i r e as w e l l as p a t i e n t s e l f - r e p o r t . A l t h o u g h the l a b e l s on the measure d i f f e r e d ( i . e . , h e l p l e s s n e s s , independence) , i t appeared t h a t these c o n s t r u c t s were a l l r e l e v a n t t o Baron and R o d i n ' s (1978) d e f i n i t i o n o f p e r s o n a l c o n t r o l . More than one measure was used t o d e f i n e a spec t s o f the domain o f p e r s o n a l c o n t r o l and t o a t tempt t o o b t a i n convergent v a l i d i t y (Campbell & F i s k e , 1959) . The o r i g i n a l t w o - p a r t q u e s t i o n n a i r e f o r n u r s i n g assessment o f p a t i e n t behav iour i n c l u d e d a s c a l e d e r i v e d from the p s y c h o l o g i c a l l i t e r a t u r e and another s c a l e from n u r s i n g r e s e a r c h l i t e r a t u r e . The former measure (Appendix B . 2 ( a ) [ i ] ) i s a 7 - p o i n t semant ic d i f f e r e n t i a l s c a l e deve loped from r e s e a r c h w h i c h has d i f f e r e n t i a t e d two b a s i c d i m e n s i o n s , a f f i l i a t i o n and dominance, i n i n t e r p e r s o n a l r e l a t i o n s h i p s (Wigg ins , 1979) and r o l e r e l a t i o n s h i p s (Benjamin, 1974) . 56 The second nurse assessment measure (Appendix B . 2 ( a ) [ i i ] ) was deve loped u s i n g a 5 - p o i n t L i k e r t s c a l e w i t h the c a t e g o r i e s f r c m D e r d i a r i a n and d o u g h ' s (1976) o b s e r v a t i o n a l t o o l which has been used t o measure dependence and independence i n h o s p i t a l i z e d o r t h o p e d i c p a t i e n t s a d m i t t e d f o r e l e c t i v e s u r g e r y . The c a t e g o r i e s i n c l u d e f i v e dependence i tems ( e . g . , seeks a t t e n t i o n ) and f i v e independence i tems ( e . g . , t akes i n i t i a t i v e s ) based on the t h e o r y t h a t dependence and independence a re separa te b u t r e l a t e d e n t i t i e s , r a t h e r t h a n b i p o l a r i tems on the same cont inuum. The r e l i a b i l i t y d a t a f rom these q u e s t i o n n a i r e s , based on a sample o f 88 nurse s f rom the U n i v e r s i t y H o s p i t a l , can be found i n Appendix G . l . Because the dominance - a f f i l i a t i o n s c a l e l a c k e d i n t e r n a l c o n s i s t e n c y (two i tems were n e g a t i v e l y c o r r e l a t e d w i t h the s c a l e ) , t h i s measure was n o t used i n the r e g r e s s i o n a n a l y s i s . I n the case o f the dependence -independence s c a l e , i t e m s u b s c a l e c o r r e l a t i o n s were examined t o maximize t h e s u b s c a l e a l p h a . Removal o f the f o u r t h i t e m o f the independence s u b s c a l e (IND4 w h i c h i s i t e m 8 i n Appendix B . 2 [ a ] ) i n c r e a s e d the a l p h a from .80 t o . 8 5 . F o r t h i s r e a s o n , s c o r e s were receded t o d e l e t e t h i s i t e m f o r the r e g r e s s i o n a n a l y s i s . The dependence s u b s c a l e a l p h a was n o t i n c r e a s e d by d e l e t i o n o f any o f the i tems so i t was a n a l y z e d i n the o r i g i n a l f o r m . Measurement of Dependent Variables Imagery. Assessment o f imagery was o b t a i n e d through s e l f - r e p o r t on a q u e s t i o n n a i r e w h i c h was a m o d i f i c a t i o n o f S i n g e r ' s I m a g i n a l Proces se s I n v e n t o r y ( I P I ) . The o r i g i n a l I P I , w h i c h was de s igned t o tap ongoing 57 i m a g i n a l p r o c e s s e s , had 400 i tems w i t h 29 s u b s c a l e s (S inger & A n t r o b u s , 1972 ) . The M o d i f i e d I m a g i n a l P roce s se s I n v e n t o r y (Appendix B.3) i n c l u d e d t h r e e o f S i n g e r ' s o r i g i n a l s c a l e s (36 i tems) p l u s an a d d i t i o n a l 14 i tems t o a s ses s k i n e s t h e t i c imagery (nine i t e m s ) , hypnagogic imagery ( three i t e m s ) , and change i n dreams and daydreams (two items) s i n c e h o s p i t a l i z a t i o n . Another m o d i f i c a t i o n from the o r i g i n a l was the use o f a 2 - p o i n t ( t r u e - f a l s e ) s c a l e , r a t h e r than S i n g e r ' s 5 - p o i n t s c a l e , i n v i e w o f p o s s i b l e l i m i t a t i o n s i n p a t i e n t t o l e r a n c e f o r a more complex s c a l e . P s y c h o m e t r i c d a t a have been r e p o r t e d on the IP I by S i n g e r & A n t r o b u s (1972) . Normat ive d a t a on the LP I were o b t a i n e d i n a s t u d y o f 130 male and 76 female c o l l e g e ^ s t u d e n t v o l u n t e e r s f rom i n t r o d u c t o r y p s y c h o l o g y c l a s s e s . D a t a from the s c a l e s o f i n t e r e s t here were : (1) V i s u a l imagery i n daydreams - mean = 3 8 ; S . D . = 9 . 6 ; C r o n b a c h ' s a l p h a = . 8 6 ; (2) A u d i t o r y images i n daydreams - mean = 39; S . D . = 5 . 2 ; C r o n b a c h ' s a l p h a = . 3 9 ; and (3) H a l l u c i n a t o r y - v i v i d n e s s i n daydreaming - mean = 24; S . D . = 8 . 8 ; C r o n b a c h ' s a l p h a = . 8 7 . Because o f the l o w r e l i a b i l i t y o f the a u d i t o r y s u b s c a l e , the c o e f f i c i e n t a l p h a f o r the most r e c e n t v e r s i o n o f S i n g e r ' s " a u d i t o r y images i n daydreams" was o b t a i n e d on a sample o f 67 p a t i e n t s {p< = . 8 1 ) . The c o e f f i c i e n t a l p h a v a l u e s f o r the new s u b s c a l e s (n = 67 p a t i e n t s ) were : k i n e s t h e t i c = . 6 2 ; hypnagogic = . 3 1 ; and dreams and daydreams = . 5 5 . The l a t t e r two " s u b s c a l e s " were o n l y t h r e e and two i t e m s , r e s p e c t i v e l y . 58 S t r e s s . Assessment o f s t r e s s i n c l u d e d t h r e e measures o b t a i n e d d u r i n g h o s p i t a l i z a t i o n and a p o s t d i s c h a r g e q u e s t i o n n a i r e . The former measure i n c l u d e d a p a t i e n t q u e s t i o n n a i r e r e g a r d i n g s u b j e c t i v e s t r e s s , a p a t i e n t i n t e r v i e w assessment o f e n v i r o n m e n t a l s t r e s s and the n u r s i n g s t a f f r e c o r d i n the p a t i e n t c h a r t s . The S u b j e c t i v e S t r e s s S c a l e (SSS) was a 1 4 - i t e m s e l f - r e p o r t measure ( K e r l e & B i a l e k , 1958) o f s i t u a t i o n a l s t r e s s (Appendix B . 4 ) . The SSS was deve loped through a Thur s tone S c a l i n g Technique and has been t e s t e d f o r use w i t h army (Berkun, B i a l e k , K e r n & Y a g i , 1962) , s t u d e n t (Neufe ld & D a v i d s o n , 1972) , and h o s p i t a l i z e d ( P a r i s e n , R i c h & J a c k s o n , 1969) s u b j e c t s . The l a s t r e s e a r c h , w h i c h used 50 m e d i c a l - s u r g i c a l p a t i e n t s as judges f o r the s c a l i n g p r o c e d u r e , found e x t r e m e l y s i m i l a r r e s u l t s t o those o b t a i n e d f rom the o r i g i n a l s t u d y w h i c h used army p e r s o n n e l j u d g e s . T h i s s c a l e i s s t a t i s t i c a l l y a p p r o p r i a t e f o r use w i t h h o s p i t a l i z e d p a t i e n t s and has the p r a c t i c a l advantage o f o n l y r e q u i r i n g a s i n g l e r e sponse , c h o o s i n g t h e i t e m w h i c h b e s t d e s c r i b e s how the p a t i e n t f e e l s " t o - d a y " . The E n v i r o n m e n t a l S t r e s s S c a l e (ESS) was a s e m i - s t r u c t u r e d i n t e r v i e w (Appendix D) w h i c h examined e x p e c t a t i o n s and r e a c t i o n s t o t h e f o l l o w i n g p o t e n t i a l source s o f s t r e s s : (I) P e r s o n a l space and p r i v a c y , ( I I ) E n v i r o n m e n t a l s t i m u l a t i o n l e v e l s , ( I I I ) P e r s o n a l c o n t r o l and response r e s t r i c t i o n , and (IV) Dreams and imagery . These four s u b s c a l e s o f the ESS r e l a t e t o the e x t e r n a l environment ( I , I I and I I I ) and t h e i n t e r n a l environment (TV) . The i n t e r v i e w format was deve loped f o r t h i s p r o j e c t based on the l i t e r a t u r e rev iewed and the e x p e r i m e n t e r ' s r 59 e x p e r i e n c e as a nurse i n h o s p i t a l . The q u e s t i o n s on imagery , w h i c h p roceed from ambiguous t o h i g h l y s t r u c t u r e d , were based on t h e i n t e r v i e w format used i n e a r l i e r r e s e a r c h w i t h eye s u r g e r y p a t i e n t s ( E l l i s , 1976; J a c k s o n , 1969) and subsequent ly used w i t h o r t h o p e d i c p a t i e n t s (S tewar t , 1977) . A l s o i n c l u d e d were t h r e e q u e s t i o n s on a t t r i b u t i o n s (37-39) based on r e s e a r c h (Bulman & Wortman, 1977) w i t h severe a c c i d e n t v i c t i m s . A p r e t e s t o f the i n t e r v i e w was conducted w i t h two o r t h o p e d i c p a t i e n t s and n i n e s p i n a l c o r d i n j u r y p a t i e n t s . R e v i s i o n s i n format were made based on p a t i e n t comments c o n c e r n i n g ambiguous i t e m s . C o d i n g o f t h e r e a c t i o n and e x p e c t a t i o n s c o r e s f o r t h e i n t e r v i e w was accompl i shed by summation o f s c o r e s f o r a s u b s c a l e and then d i v i s i o n o f t h i s sum by the number o f i tems a p p l i c a b l e t o the p a r t i c u l a r p a t i e n t . T h i s c o r r e c t i o n f a c t o r made s c o r e s e q u i v a l e n t between p a t i e n t s and a l l o w e d f o r i n c l u s i o n o f a d d i t i o n a l areas o f e n v i r o n m e n t a l s t r e s s mentioned by the p a t i e n t ( e . g . , n o i s e ) . The D i s t r e s s Record from the p a t i e n t c h a r t s used the e x i s t i n g p r o g r e s s no te s (Appendix C . 2 ( c ) [ i ] ) r ecorded by the h e a l t h c a r e s t a f f . A l l words w h i c h r e l a t e d t o s t r e s s were summated f o r the f i r s t e i g h t days o f h o s p i t a l i z a t i o n . R e l e v a n t words i n c l u d e d : a n x i o u s , t e n s e , n e r v o u s , f r i g h t e n e d , w o r r i e d , u p s e t , d i s t r e s s e d , r e s t l e s s , apprehens ive and a g i t a t e d . O c c a s i o n a l l y , a phrase w h i c h conveyed the same meaning as one o f the above words was the u n i t o f a n a l y s i s ( e . g . , " t h r a s h i n g about i n b e d " ) . The r e l i a b i l i t y f o r the system o f c o d i n g from the c h a r t was t e s t e d a t Shaughnessy H o s p i t a l ( r = . 9 9 ) , where the same method o f c h a r t a n a l y s i s was u sed . Each word o r synonymous phrase had a s c o r e o f 1, 60 so t h a t i f s e v e r a l o f the above words appeared i n the same sentence t h e s c o r e would be the sum o f the r e l e v a n t words T The P s y c h o s o c i a l Adjus tment t o I l l n e s s S c a l e (PAIS) was deve loped by D e r o g a t i s i n 1975. I n the v e r s i o n o f the q u e s t i o n n a i r e found i n Appendix B . 5 f the word " i l l n e s s " has been r e p l a c e d w i t h " m e d i c a l p r o b l e m " . A d d i t i o n a l i tems have been added t o a s ses s r e a c t i o n s t o n u r s i n g c a r e ( i t em 5) and compl i ance t o h e a l t h - r e l a t e d i n s t r u c t i o n s ( i t em 10) a f t e r d i s c h a r g e . T h i s q u e s t i o n n a i r e was m a i l e d t o p a t i e n t s two months a f t e r d i s c h a r g e . Of the 37 p a t i e n t s who r e t u r n e d the q u e s t i o n n a i r e , o n l y 28 had completed a l l seven s e c t i o n s . I n some c a s e s , the p a t i e n t s wro te note s t o i n d i c a t e t h a t i tems were n o t a p p l i c a b l e t o t h e i r s i t u a t i o n . A l l 37 p a t i e n t s (77% o f the sample) had completed s u b s c a l e V I I on p s y c h o l o g i c a l d i s t r e s s . . Score s on s u b s c a l e V I I ( c o e f f i c i e n t ©<, = .87) were used f o r the r e g r e s s i o n a n a l y s i s . Noncompl iant B e h a v i o u r . The p r o g r e s s notes from the h e a l t h c a r e s t a f f r e c o r d s i n the p a t i e n t c h a r t s (Appendix C . 2 ( c ) [ i ] ) were used as one measure o f the i n c i d e n c e o f noncompl iance . The method o f c o d i n g and r e l i a b i l i t y f o r these d a t a were the same as f o r the D i s t r e s s Record from the c h a r t . Noncompliance i n c l u d e d r e s i s t a n c e o r r e f u s a l o f c a r e and b e h a v i o u r s w h i c h i n t e r f e r e d w i t h t rea tment ( e . g . , removal o f t r a c t i o n ) . T h i s c a t e g o r y o f behav iour a l s o i n c l u d e d a g g r e s s i v e behav iour such as v e r b a l abuse t o the n u r s e . The second measure o f noncompl iant behav iour came from p a t i e n t s e l f - r e p o r t on i n t e r v i e w . Item 58 o f the E n v i r o n m e n t a l S t r e s s S c a l e (Appendix D ) , w h i c h r e l a t e d t o whether p a t i e n t s had broken any o f the r e g u l a t i o n s on the u n i t , was the b a s i s f o r t h i s measure. 61 Procedure The exper imenter v i s i t e d the t h r e e p a r t i c i p a t i n g U n i v e r s i t y H o s p i t a l u n i t s (2DE, Surgery 30 and S u r g e r y 33) on a d a i l y b a s i s t o r e v i e w t h e a d m i s s i o n r e c o r d . A l l p a t i e n t s who met the sample c r i t e r i a were i n c l u d e d i n the s t u d y . There were no r e s t r i c t i o n s p l a c e d on sample a c q u i s i t i o n by m e d i c a l o r n u r s i n g s t a f f . T h e r e f o r e , a random sample was a c h i e v e d i n t h a t emergency admis s ions a re chance event s and each a d m i s s i o n had an e q u a l p r o b a b i l i t y o f i n c l u s i o n i n the s t u d y . B e f o r e the i n i t i a l approach t o a p a t i e n t , the exper imenter d i s c u s s e d the case w i t h the Head Nurse o r t h e A s s i s t a n t Head Nurse t o check f o r a d d i t i o n a l i n f o r m a t i o n ( i . e . , n o t i n the p a t i e n t ' s c h a r t ) w h i c h would i n d i c a t e whether o r not the p a t i e n t met the sample c r i t e r i a . The t i m i n g o f the f i r s t v i s i t was a l s o d i s c u s s e d w i t h s t a f f so t h a t the p a t i e n t ' s c o m f o r t would be d i s r u p t e d as l i t t l e as p o s s i b l e . No p a t i e n t s were approached about the s t u d y u n t i l a f t e r a 48-hour p e r i o d o f ad justment t o a d m i s s i o n o r t o s u r g e r y . On day t h r e e a f t e r a d m i s s i o n o r s u r g e r y , the exper imenter o b t a i n e d in formed consent from the p a t i e n t by d i s c u s s i n g the i n f o r m a t i o n on the consent form i n Appendix A . The exper imenter wore s t r e e t c l o t h e s and a l a b c o a t throughout the s t u d y . The d a t a c o l l e c t i o n took p l a c e on days t h r e e , f o u r , e i g h t and n i n e a f t e r a d m i s s i o n o r s u r g e r y , and the i n t e r v e n t i o n was p r e s e n t e d on day f i v e . Due t o the emergency n a t u r e o f a d m i s s i o n s , i t was i m p o s s i b l e t o do a c t u a l p r e t e s t s , b u t measures w h i c h r e l a t e d t o e x p e r i e n c e p r i o r t o h o s p i t a l i z a t i o n (Appendices B . l and B .2 (b ) ) were o b t a i n e d as e a r l y as 62 poss ib le on days three and four . On day four , the nurse quest ionnaire (Appendix B.2(a)) and nonpar t i c ipant observations (Appendix C l ) were completed. During the observation p e r i o d , the experimenter sat wi th a c l ipboard i n the p a t i e n t ' s room or immediately outside the room, i f i t was poss ib le to view the a c t i v i t y from that p o s i t i o n . P r i o r to day f i v e , the experimenter contacted a research a s s i s tant who randomly assigned pat ients to the in tervent ion or no in te rvent ion groups. The research a s s i s t an t , who was an experienced Registered Nurse, gave a b r i e f , standardized in t roduct ion to the taped in te rvent ion (Appendix E ) . None of the s t a f f nurses on the ward were aware of the content of the i n t e r v e n t i o n . The Head Nurse had read the s c r i p t for the in te rvent ion i n i t i a l l y to g ive approval for the study and indica ted that she would not discuss t h i s information wi th the s t a f f . Af te r the pa t i en t heard the tape, the research a s s i s tant had a b r i e f d i scus s ion w i t h the pa t ient to assess t h e i r immediate response. A l l pat ients had a p o s i t i v e or neut ra l response to the tape; none were negative. On day e i g h t , a s t ress quest ionnaire (Appendix B.4) , the interv iew (Appendix D) and the imagery quest ionnaire (Appendix B.3) were administered to the p a t i e n t . A l l interviews were recorded w i t h the exception of one case i n which the pa t ient requested that notes be taken ins tead . Data from the chart (Appendix C.2 (c)[ i ] ) were obtained throughout the h o s p i t a l stay up to the end of day e i g h t . A l l pa t ient s i n the study were i n h o s p i t a l for nine days or more. Two months a f ter discharge, the fol low-up quest ionnaire was mailed wi th an explanatory l e t t e r and a stamped, addressed return envelope. 63 Study 2: Experimental Design T h i s s t u d y examined the e f f e c t s o f type o f s p i n a l c o r d i n j u r y ( w i t h consequent i m m o b i l i t y ) and h o s p i t a l environment on imagery , s t r e s s and noncompl iant b e h a v i o u r . The d e s i g n was a 2 x 2 x 2 A n a l y s i s o f V a r i a n c e and C o v a r i a n c e w i t h Repeated Measures and had the f o l l o w i n g f a c t o r s : (1) L e v e l o f i n j u r y - q u a d r i p l e g i a ( p a r a l y s i s i n v o l v i n g arms and l eg s ) v e r s u s p a r a p l e g i a ( p a r a l y s i s below w a i s t ) ; (2) Degree o f i n j u r y -complete o r i n c o m p l e t e t r a n s e c t i o n o f t h e s p i n a l c o r d (which r e s u l t s i n complete o r p a r t i a l p a r a l y s i s o f the a f f e c t e d area) and ; (3) Environment - i n t e n s i v e c a r e u n i t (ICU) v e r s u s w a r d . The t h i r d f a c t o r was t h e repea ted measures v a r i a b l e i n t h a t a l l p a t i e n t s p r o g r e s s e d from i n t e n s i v e c a r e t o the ward over t i m e . Because imagery e f f e c t s c o u l d be e x p l a i n e d as s i d e e f f e c t s o f n a r c o t i c s o r o t h e r a n a l g e s i c s , a c o v a r i a t e a n a l y s i s was used t o remove the e f f e c t o f morphine , d e m e r o l , t a l w i n and c o d e i n e when g i v e n by i n j e c t i o n . A n a l g e s i c s a d m i n i s t e r e d by i n j e c t i o n were reduced t o a common u n i t based on an e q u i a n a l g e s i c t a b l e i n w h i c h morphine 10 mg. i s e q u i v a l e n t t o demerol 75 m g . , t a l w i n 60 m g . , o r c o d e i n e 130 mg. (McCaf fe ry , 1979) . O n l y i n j e c t a b l e a n a l g e s i c s were i n c l u d e d i n the c o v a r i a t e a n a l y s i s because : (1) graphs o f imagery d a t a showed t h a t imagery was g r e a t e s t d u r i n g the e a r l y h o s p i t a l i z a t i o n p e r i o d when i n j e c t a b l e , r a t h e r than o r a l , a n a l g e s i c s tend t o be g i v e n ; (2) o r a l a n a l g e s i c dosages were l e s s p o t e n t t h a n i n j e c t a b l e a n a l g e s i c s and were t h e r e f o r e l e s s l i k e l y t o have psychotomimet ic s i d e e f f e c t s ; (3) o r a l n a r c o t i c s were u s u a l l y mixed w i t h another drug ( e . g . , t y l e n o l w i t h 64 codeine) so that the equianalgesic tab le could not be appl ied accurate ly ; and (4) other drugs which might have confounded r e s u l t s ( e . g . , c o r t i s o n e , sedatives) were not given c o n s i s t e n t l y across p a t i e n t s . The time frame for the study was the f i r s t e ight weeks of h o s p i t a l i z a t i o n . Because the length of time i n ICU var i ed from pa t ient to p a t i e n t , a l l scores on dependent measures and the covar ia te were made equivalent by d i v i d i n g the ICU scores by the number of weeks i n ICU and the ward scores by the number of weeks on the ward. The ana lys i s of variance was conducted w i t h and without the covar i a t e , in j ec t ab le analges ics , for each of the three dependent measures. A subs id iary ana lys i s was done to examine the impl i ca t ions of the unequal n i n t h i s study. An unweighted means s o l u t i o n was obtained by increas ing each c e l l by enough " sub jec t s " , each w i t h a score equal to the c e l l mean, to br ing the iVcell up to the l a rges t n / c e l l which was 18 subjects . Adjustment o f the e f fec t s from the unweighted means s o l u t i o n was done by m u l t i p l y i n g by the harmonic mean (Glass & Stanley, 1970, p . 72) d iv ided by the a r t i f i c i a l N ( i . e . , 72). The F values o f t h i s s o l u t i o n were then compared w i t h the F values of the weighted means s o l u t i o n done i n o r i g i n a l ana lys i s to determine the degree of discrepancy of r e s u l t s , and hence the degree of d i s t o r t i o n produced by the unequal n . A Stepwise Regression Ana lys i s was done using the fo l lowing nine pred ic tor v a r i a b l e s : sex, age, concussion, surgery, days i n the ICU, days immobile (hor izonta l p o s i t i o n ) , employment s ta tus , sleep 65 depr iva t ion and immobil iz ing apparatus. As w e l l as the three dependent va r i ab le s of the pro jec t (imagery, s t ress and noncompliant behaviour) , a four th dependent v a r i a b l e was included i n t h i s a n a l y s i s : disturbance of temperature r egu la t ion . As far as p o s s i b l e , the d e f i n i t i o n s used here for the regress ion ana lys i s were the same as for Study 1. Concussion was e i t h e r present or absent. Days i n ICU and days immobile were ca l cu la ted according to complete days i n e i ther c o n d i t i o n . The transfer day to the ward was considered a ward day and the day mobi l ized was excluded from the number of days immobile. Employment status was a b inary v a r i a b l e : unemployed versus other status ( e . g . , employed, student, housewife). This v a r i a b l e was defined according to the admission record on the chart which included employment s ta tus . Sleep depr iva t ion was based on a t o t a l score which included s p e c i f i c reference to deprived sleep as w e l l as e f fec t s of s leep depr iva t ion ( e . g . , t i r e d , drowsy). The immobilized apparatus was a l so b inary : c e r v i c a l tongs or halo r i n g versus other immobil iz ing apparatus. i -O r i g i n a l l y , two a d d i t i o n a l var i ab le s were se lec ted : type of accident and other f r ac ture s . An i n t e r c o r r e l a t i o n matrix of the 11 var i ab le s (Appendix G.14) showed that other f ractures was s i g n i f i c a n t l y corre la ted w i t h three of the var i ab le s and type of accident corre la ted w i t h two v a r i a b l e s . Therefore, type of accident and other fractures were excluded from the stepwise regress ion a n a l y s i s . Rather than exclude other f r ac ture s , i t might have been l o g i c a l to exclude the concussion v a r i a b l e , because i t was s i g n i f i c a n t l y corre la ted wi th three 66 v a r i a b l e s as w e l l . However, when c o n c u s s i o n i s removed, o t h e r f r a c t u r e s i s s t i l l c o r r e l a t e d w i t h two v a r i a b l e s , whereas the d e c i s i o n t h a t was made l e f t c o n c u s s i o n c o r r e l a t e d w i t h o n l y one v a r i a b l e . S u b j e c t s A random sample o f h o s p i t a l r e c o r d s o f 50 p a t i e n t s were s e l e c t e d from the admis s ions t o the A c u t e S p i n a l C o r d I n j u r y U n i t (ASCIU) a t Shaughnessy H o s p i t a l (SH) i n Vancouver from 1975 - 1980. The 22-bed u n i t , w h i c h i s a r e f e r r a l c e n t r e f o r the p r o v i n c e , opened i n May 1975. F o u r beds a re used f o r i n t e n s i v e c a r e . The "p r ime p h i l o s o p h y " o f t h i s U n i t ( S c h w e i g e l , 1977, p . 390) i s " e a r l y m o b i l i z a t i o n " . U s i n g d e v i c e s such as the h a l o t h o r a c i c brace f o r p r o t e c t i o n , and s u r g e r y t o s t a b i l i z e the s p i n e when n e c e s s a r y , most p a t i e n t s a re m o b i l i z e d w i t h i n two t o t h r e e weeks a f t e r i n j u r y . There i s a h i g h s t a f f / p a t i e n t r a t i o w i t h p h y s i o t h e r a p y , o c c u p a t i o n a l t h e r a p y , a s o c i a l worker and s e x u a l h e a l t h c o u n s e l l o r s on the U n i t . An a c t i v e r e h a b i l i t a t i o n program beg ins a t a d m i s s i o n and p a t i e n t s have a v e r y f u l l s c h e d u l e . A f t e r an average s t a y o f t h r e e months, p a t i e n t s a r e u s u a l l y t r a n s f e r r e d t o G . F . S t r o n g f o r c o n t i n u e d r e h a b i l i t a t i o n i n a l e s s s t a f f - i n t e n s i v e atmosphere. A l l p a t i e n t s on the ASCIU have a n e u r o l o g i c a l d e f i c i t w i t h motor and/or s ensory l o s s . I n S tudy 2 , t h e r e were 12 complete q u a d r i p l e g i c s , 12 incomple te q u a d r i p l e g i c s , 18 complete p a r a p l e g i c s , and 8 i n c o m p l e t e p a r a p l e g i c s . Sample c r i t e r i a were the same as f o r S tudy 1 except f o r the n e u r o l o g i c a l d e f i c i t . See Appendix F . 2 f o r s u b j e c t c h a r a c t e r i s t i c s . A second sample o f n i n e p a t i e n t s was o b t a i n e d from t h e admis s ions t o the ASCIU from June - August 1980. Each new a d m i s s i o n was a 67 p o t e n t i a l c a n d i d a t e f o r the r e s e a r c h . However, the ASCIU i s a s m a l l u n i t and sample a c q u i s i t i o n was s l o w . The same sample c r i t e r i a were used as f o r the above s t u d y and the s u b j e c t c h a r a c t e r i s t i c s a r e l i s t e d i n Appendix F . 3 . T h i s sample was used t o p r e t e s t the i n t e r v i e w , t o d e v e l o p an o b s e r v a t i o n a l t o o l and t o p r o v i d e d e s c r i p t i v e d a t a from d i r e c t p a t i e n t c o n t a c t f o r compar i son w i t h the above s t u d y f o r which d a t a were o b t a i n e d from c h a r t s . The imagery q u e s t i o n n a i r e (Appendix B . 3) was a d m i n i s t e r e d t o these n i n e p a t i e n t s and an a d d i t i o n a l 10 p a t i e n t s (Appendix F . 3 ) . The l a t t e r 10 p a t i e n t s were c o n t a c t e d by a r e s e a r c h a s s i s t a n t a f t e r August 1980 when the exper imenter began d a t a c o l l e c t i o n a t the U n i v e r s i t y H o s p i t a l i n Sa sk a toon . Procedure D a t a f o r t h e s t u d y o f 50 c h a r t s were c o l l e c t e d on each o f t h r e e s h i f t s per day f o r an e ight-week p e r i o d a f t e r a d m i s s i o n (see Appendix C . 2 ( c ) [ i i ] ) . The word " imagery" was n o t used i n the c h a r t s bu t imagery r e p o r t s were coded from notes d e s c r i b i n g u n u s u a l s e n s a t i o n s . These s e n s a t i o n s were u s u a l l y v i s u a l ( e . g . , c r a w l i n g b u g s ) , k i n e s t h e t i c ( e . g . , f e e l i n g the room r o t a t i n g ) , o r t a c t i l e ( e . g . , f e e l i n g w e i g h t on p a r a l y z e d l i m b s ) . I n c i d e n t s coded as " tempera ture anomaly" i n c l u d e d p a t i e n t s ta tements o f b e i n g c o l d o r h o t . The nurse s o f the ASCIU mentioned t h a t t h i s was a f r u s t r a t i n g a spect o f n u r s i n g c a r e because n u r s i n g c a r e measures ( e . g . , b l a n k e t s , fans) tended t o be i n e f f e c t i v e . Records o f dreams and h a l l u c i n a t i o n s were coded as imagery . Dreams are n o t g e n e r a l l y r e c o r d e d i n the c h a r t s so t h a t when they a re r ecorded they tend t o be u n u s u a l i n some way ( e . g . , e x t r e m e l y v i v i d ) . 6 8 The s t ress score from the chart was a g l o b a l d i s t r e s s score rather than s tress re l a ted to the environment because much of the record of a f f e c t i v e changes d i d not refer to an area of concern. Occas iona l ly , s t res s re la ted to imagery was recorded ( e . g . , pa t i ent quotes about "going bonkers") but these were too infrequent to meri t separate ana lys i s and were included as a subscore of s t re s s . Noncompliant behaviour included interference wi th care or removal of some apparatus required for treatment. The coding method was the same as for Study 1. Demographic data were obtained on the form shown i n Appendix C . 2 ( a ) [ i i ] . The measures used i n Study 1 were pretested w i t h the nine pa t ient s on the ASCIU. The observat ional t o o l was developed through observations i n both the intens ive care and ward environment. 69 KKSUIiTS The three dependent var i ab le s common to both studies were examined by both ana lys i s of variance and stepwise regress ion a n a l y s i s . In Study 1, which was conducted at the U n i v e r s i t y H o s p i t a l , the design was a 2 x 2 (Immobility x Cogni t ive Intervention) ana lys i s of var iance . The Shaughnessy H o s p i t a l study (Study 2) was based on a 2 x 2 x 2 (Level x Degree x Environment) repeated measures ana lys i s of variance and covariance design w i t h repeated measures on the environment ( intensive care v s . ward) v a r i a b l e . Leve l (quadriplegia v s . paraplegia) and degree (complete v s . incomplete) o f i n j u r y were i n t e r n a l immobil i ty v a r i a b l e s . A subsequent m u l t i v a r i a t e ana lys i s of variance was conducted to examine the e f fect s o f immobil i ty on the dimensions o f imagery as assessed by the subscales of the imagery quest ionnaire . For t h i s a n a l y s i s , three l e v e l s of immobil i ty were obtained by inc lud ing the two l e v e l s from the U n i v e r s i t y H o s p i t a l study and an a d d i t i o n a l group from the Shaughnessy H o s p i t a l Study. The s p i n a l cord i n j u r y pat ients i n the l a t t e r study have the most extreme immobil i ty of the three groups due to the combination of the immobil iz ing impact of p a r a l y s i s as w e l l as devices such as t r a c t i o n . Subsidiary analyses of s leep d e p r i v a t i o n , as a dependent v a r i a b l e , explored pred ic tor s of s leep depr iva t ion (Study 1) and c o r r e l a t i o n s of s leep depr iva t ion wi th imagery, s t ress and noncompliant behaviour over time (Study 2 ) . 70 The s t e p w i s e r e g r e s s i o n a n a l y s e s i n c l u d e d p r e d i c t o r s from demographic d a t a , e n v i r o n m e n t a l d a t a , q u e s t i o n n a i r e s and d a t a r e l a t e d t o i n j u r y . F o r the U n i v e r s i t y H o s p i t a l s t u d y o n l y , a s t e p w i s e r e g r e s s i o n a n a l y s i s was a l s o conducted t o examine the p r e d i c t i v e v a l u e o f d imens ions o f s o c i a l and n o n s o c i a l s t i m u l a t i o n from o b s e r v a t i o n o f the h o s p i t a l env i ronment . university Hospital Study  Analysis of Variance Results I n S tudy 1, the purpose o f the a n a l y s i s o f v a r i a n c e was t o t e s t the hypotheses r e l a t e d t o i m m o b i l i t y and the c o g n i t i v e i n t e r v e n t i o n . D e s c r i p t i o n o f the r e s u l t s w i l l be o r g a n i z e d under headings o f the dependent v a r i a b l e s : imagery , s t r e s s and noncompl iant b e h a v i o u r . Imagery. H y p o t h e s i s 1(a) p r e d i c t e d t h a t i m m o b i l i t y would l e a d t o an i n c r e a s e d i n c i d e n c e o f imagery as measured by t h e M o d i f i e d I m a g i n a l P roce s se s I n v e n t o r y ( M I P I ) . The r e s u l t s (see T a b l e 1) p r o v i d e suppor t f o r t h i s h y p o t h e s i s i n t h a t t h e r e was a main e f f e c t f o r i m m o b i l i t y , F ( 1 , 44) = 4 . 1 1 , £ = . 0 5 . C e l l means c a n be found i n T a b l e 2 . The mean imagery s c o r e f o r immobi le p a t i e n t s was 1 6 . 8 0 , whereas m o b i l e p a t i e n t s had a mean imagery s c o r e o f 11 .63 on the M I P I . As e x p e c t e d , the c o g n i t i v e i n t e r v e n t i o n d i d n o t i n c r e a s e the i n c i d e n c e o f imagery on the M I P I , F ( 1 , 44) = 1 .39 , NS. M o b i l e p a t i e n t s who were exposed t o the i n t e r v e n t i o n had a low mean imagery s c o r e as compared t o the o t h e r t h r e e g r o u p s . However, the i n t e r a c t i o n between i m m o b i l i t y and the i n t e r v e n t i o n on the MIPI was n o n s i g n i f i c a n t , F , ( 1 , 44) = 1 .63 . TABLE 1 U n i v e r s i t y H o s p i t a l Study A n a l y s i s o f V a r i a n c e f o r Imagery and S t r e s s Scores M o d i f i e d Imaginal Processes Inventory (MIPI) S u b j e c t i v e S t r e s s S c a l e (SSS) D i s t r e s s Record E n v i r o n m e n t a l S t r e s s S c a l e T o t a l Source d f MS F MS F MS F MS F I m m o b i l i t y (IM) 1 320.33 4 . 1 1 * 7.52 1.49 8 .33 1.75 2 .91 2.28 C o g n i t i v e I n t e r v e n t i o n (CI) 1 108.00 1.39 20.02 3 .96 * 8 .33 1.75 .04 < 1 IM X C I 1 126.75 1.63 .52 < 1 4.08 < 1 .82 < 1 E r r o r 44 77.97 5.05 4 .75 1.47 * £ < .05 72 TABLE 2 UNIVERSITY HOSPITAL STUDY MEAN IMAGERY SCORES (MODIFIED IMAGINAL PROCESSES INVENTORY) IMMOBILE MOBILE I n t e r v e n t i o n M. 16.92 8 .5 SD 10.65 7.09 No i n t e r v e n t i o n M 16.67 14 .75 SD 8.08 9 . 1 1 MEAN STRESS SCORES (SUBJECTIVE STRESS SCALE) IMMOBILE MOBILE I n t e r v e n t i o n M 3.17 4 .17 SD 0.84 2 .41 No i n t e r v e n t i o n M 4 .67 5.25 SD 2.02 3 .11 73 S t r e s s . I n h y p o t h e s i s 1 ( b ) , i t was p r e d i c t e d t h a t i i t i m o b i l i t y would l e a d t o g r e a t e r s t r e s s r e l a t e d t o imagery as measured by Subsca l e IV o f t h e E n v i r o n m e n t a l S t r e s s S c a l e (ESS) . T h i s p r e d i c t i o n was not suppor ted (Table 3) on t h i s s u b s c a l e , w h i c h measured i n t e n s i t y o f s t r e s s r e l a t e d t o imagery and dreams, F < 1. However, t h e r e was a main e f f e c t f o r i m m o b i l i t y on s u b s c a l e I I I (Table 3 ) , w h i c h measured r e a c t i o n t o p e r s o n a l c o n t r o l and response r e s t r i c t i o n , F ( 1 , 44) = 1 2 . 9 1 , £ < . 0 0 1 . Immobile p a t i e n t s had a mean r e a c t i o n s c o r e o f 0 . 7 6 , w h i l e m o b i l e p a t i e n t s had a mean s c o r e o f 0 .37 on the r e a c t i o n t o p e r s o n a l c o n t r o l and response r e s t r i c t i o n s u b s c a l e . None o f the o t h e r ESS s u b s c a l e s showed s i g n i f i c a n t i m m o b i l i t y e f f e c t s . A f u r t h e r p r e d i c t i o n , a c c o r d i n g t o h y p o t h e s i s 1 ( c ) , was t h a t i m m o b i l i t y would l e a d t o i n c r e a s e d s t r e s s as measured by the S u b j e c t i v e S t r e s s S c a l e (SSS) , the D i s t r e s s R e c o r d , and the t o t a l ESS . There were no s i g n i f i c a n t e f f e c t s f o r i m m o b i l i t y on any o f these measures (Table 1 ) . The c o g n i t i v e i n t e r v e n t i o n demonstrated s t r e s s - r e d u c i n g e f f e c t on the SSS measure (Table 1 ) , l e n d i n g suppor t t o h y p o t h e s i s 2 ( b ) . As p r e d i c t e d , p a t i e n t s i n the i n t e r v e n t i o n group r e p o r t e d l e s s s t r e s s (M = 3.67) than d i d the p a t i e n t s who were n o t exposed t o the i n t e r v e n t i o n (M = 4 . 9 0 ) , F ( 1 , 44) = 3 . 9 6 , £ = . 0 5 . T h i s f i n d i n g was n o t c o n f i r m e d by nur se r e p o r t s i n the p a t i e n t c h a r t s . C o n t r a r y t o p r e d i c t i o n , t h e r e was no i n t e r v e n t i o n e f f e c t on the D i s t r e s s R e c o r d , F ( 1 , 44) = 1 .75 , NS. TABLE 3 UNIVERSITY HOSPITAL STUDY ANALYSIS OF VARIANCE FOR SUBSCALES OF ENVIRONMENTAL STRESS SCALE (ESS) I . PERSONAL SPACE I I . ENVIRONMENTAL I I I . PERSONAL CONTROL & I V . IMAGERY AND AND PRIVACY STIMULATION RESPONSE RESTRICTION DREAMS SOURCE d f MS MS MS MS F IMMOBILITY (IM) 1 .12 < 1 .01 < 1 1.68 1 2 . 9 1 * * * .00 < 1 COGNITIVE (CI) INTERVENTION 1 .09 < 1 .00 < 1 .06 < 1 .04 < 1 IM X C I .21 < 1 .02 < 1 .11 < 1 .07 < 1 ERROR 44 .21 .10 .13 .39 * * * £ < .001 75 The SSS measured n o n s p e c i f i c s t r e s s , whereas the o t h e r s e l f - r e p o r t measure (the E S S ) , examined s t r e s s r e l a t e d t o the e x t e r n a l and i n t e r n a l env i ronment . H y p o t h e s i s 2 ( a ) , w h i c h p r e d i c t e d t h a t the i n t e r v e n t i o n wou ld decrease s t r e s s r e l a t e d t o imagery and dreams, was n o t suppor ted by d a t a from s u b s c a l e IV o f the ESS (Table 3 ) , F < 1 . S i m i l a r l y , t h e r e was no i n t e r v e n t i o n e f f e c t on the t o t a l ESS (Table 1 ) , c o n t r a r y t o h y p o t h e s i s 2 ( b ) , F < 1. The i n t e r v e n t i o n was d e v i s e d on the b a s i s o f the h i s t o r y o f l a b o r a t o r y r e s e a r c h on r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n i n w h i c h p r i o r e x p e c t a t i o n s f o r imagery have c o u n t e r a c t e d n e g a t i v e p s y c h o l o g i c a l r e a c t i o n s over t i m e . I n t h e e a r l y l a b o r a t o r y s t u d i e s d u r i n g the 1950 ' s ( e . g . , H e r o n , 1957) , n e i t h e r s u b j e c t nor exper imenter expected the p e r c e p t u a l (imagery) e f f e c t s . C o n s e q u e n t l y , the e x p e r i e n c e was e x t r e m e l y d i s t r e s s i n g . As t ime and e x p e r i m e n t a t i o n have p r o g r e s s e d , s u b j e c t s now t e n d t o expec t the p o s s i b l e imagery consequences o f s t i m u l u s r e s t r i c t i o n so t h a t the e x p e r i e n c e i s no l o n g e r n e g a t i v e and may, i n d e e d , have b e n e f i c i a l e f f e c t s ( S u e d f e l d , 1975) . The p r e s e n t s t u d y sought t o a p p l y t h i s e x p e c t a t i o n i n the h o s p i t a l s e t t i n g i n o r d e r t o reduce d i s t r e s s w h i c h c o u l d be t r i g g e r e d by imagery . To examine the r e l a t i o n s h i p between e x p e c t a t i o n s and r e a c t i o n s f o r a h o s p i t a l sample , two e x p e c t a n c y - r e l a t e d measures were i n c l u d e d i n the i n t e r v i e w (Env i ronmenta l S t r e s s S c a l e ) . One measure i n c l u d e d e x p e c t a t i o n q u e s t i o n s from the f i r s t t h r e e s u b s c a l e s o f the E n v i r o n m e n t a l S t r e s s S c a l e (ESS) . The second measure was a q u e s t i o n r e g a r d i n g the number o f p r e v i o u s h o s p i t a l i z a t i o n s , based on the 76 assumpt ion t h a t e x p e c t a t i o n s would be deve loped through p r e v i o u s e x p e r i e n c e i n h o s p i t a l . Appendix G . 3 p r o v i d e s an i n t e r c o r r e l a t i o n m a t r i x o f expectancy and r e a c t i o n measures . I t i s i n t e r e s t i n g t o note t h a t t h r e e o f the r e a c t i o n measures (R2, R3 and RT) were i n v e r s e l y r e l a t e d t o p r e v i o u s h o s p i t a l i z a t i o n (PH), r_ = - . 3 6 , £ < . 0 1 ; r_ = - . 2 6 , £ < . 0 5 ; r_ = - . 2 9 , £ < . 0 5 , r e s p e c t i v e l y . That i s , p a t i e n t s who had n o t been p r e v i o u s l y h o s p i t a l i z e d had h i g h e r r e a c t i o n ( i . e . , s t r e s s ) s c o r e s . However, none o f the e x p e c t a t i o n s c o r e s was s i g n i f i c a n t l y c o r r e l a t e d w i t h p r e v i o u s h o s p i t a l i z a t i o n . On i n t e r v i e w , many p a t i e n t s expres sed d i f f i c u l t y i n answering q u e s t i o n s r e g a r d i n g e x p e c t a t i o n s . I n one s e c t i o n o f the i n t e r v i e w , some p a t i e n t s i n s i s t e d t h a t they had no e x p e c t a t i o n s and y e t , i n a l a t e r s e c t i o n o f the i n t e r v i e w , t h e same p a t i e n t s expres sed unmet e x p e c t a t i o n s . F o r example, when asked about e x p e c t a t i o n s r e g a r d i n g p r i v a c y , p e r s o n a l space and e n v i r o n m e n t a l s t i m u l a t i o n l e v e l s ( q u e s t i o n 4 , 1 1 , and 23 o f the ESS , Appendix D ) , a p a t i e n t would make a g e n e r a l i z e d s tatement t h a t he o r she had no e x p e c t a t i o n s about the h o s p i t a l i z a t i o n e x p e r i e n c e . By c o n t r a s t , when asked q u e s t i o n s (16, 49 , and 56 o f the ESS) about v i s i t o r s , use o f the c a l l s i g n a l , and a d m i n i s t r a t i o n o f m e d i c a t i o n s , the same p a t i e n t had d e f i n i t e e x p e c t a t i o n s . A reason t h a t some p a t i e n t s gave f o r not h a v i n g e x p e c t a t i o n s was t h a t they had t u r n e d themselves over t o the c a r e o f o t h e r s and hence were prepared t o accept what the h o s p i t a l and s t a f f had t o o f f e r . 77 The most vehement e x p r e s s i o n o f unmet e x p e c t a t i o n s came from a h i g h s t a t u s p r o f e s s i o n a l who l i v e d i n an urban s e t t i n g . T h i s r a i s e d the q u e s t i o n o f whether e x p e c t a t i o n s were r e l a t e d t o o c c u p a t i o n o r r u r a l - u r b a n r e s i d e n c e . Pear son product-moment c o r r e l a t i o n s d i d n o t suppor t a r e l a t i o n s h i p f o r e i t h e r v a r i a b l e w i t h t o t a l e x p e c t a t i o n s (ET) . The o c c u p a t i o n a l d a t a , (Appendix C . 2 ( a ) ) , which were indexed a c c o r d i n g t o H o l l i n g s h e a d and R e d l i c h (1958) , d i d not c o r r e l a t e w i t h E T , r_ = + .185, NS. S i m i l a r l y , the r u r a l - u r b a n d a t a showed no r e l a t i o n s h i p w i t h E T , r = +.002, NS. The i n t e r c o r r e l a t i o n m a t r i x o f Appendix G . 3 i n c l u d e s 21 s i g n i f i c a n t c o r r e l a t i o n s and 15 n o n s i g n i f i c a n t f i n d i n g s . The s i g n i f i c a n t r e s u l t s i n c l u d e d p o s i t i v e c o r r e l a t i o n s o f r e a c t i o n v e r s u s r e a c t i o n , e x p e c t a t i o n v e r s u s e x p e c t a t i o n , and r e a c t i o n v e r s u s e x p e c t a t i o n . Subsca l e s I and I I I o f the ESS had s i g n i f i c a n t e x p e c t a t i o n - r e a c t i o n c o r r e l a t i o n s w i t h i n and between s u b s c a l e s . T h i s r e f l e c t s the tendency f o r p a t i e n t s w i t h h i g h e n v i r o n m e n t a l s t r e s s s c o r e s t o have unmet e x p e c t a t i o n s . The e x p e c t a t i o n s c o r e (El ) f o r s u b s c a l e I ( p e r s o n a l space and p r i v a c y ) was p o s i t i v e l y c o r r e l a t e d w i t h the p a r a l l e l r e a c t i o n s c o r e ( R I ) , r_ = +.32, £ < . 0 1 . Subsca l e I I I ( p e r s o n a l c o n t r o l and response r e s t r i c t i o n ) a l s o had a p o s i t i v e E3-R3 c o r r e l a t i o n , r_ = +.72, £ < . 0 0 1 . F u t h e r m o r e , e x p e c t a t i o n on s u b s c a l e I I I (E3) had a d i r e c t r e l a t i o n s h i p t o r e a c t i o n on s u b s c a l e I ( R I ) , r_ = +.27, £ < . 0 5 . T o t a l e x p e c t a t i o n (ET) was p o s i t i v e l y c o r r e l a t e d w i t h R l , r_ = +.36, £ < . 0 1 ; w i t h R 3 , r_ = +.47, £ < . 0 0 1 ; and w i t h RT, r_ = +.35, £ < . 0 1 . 78 Noncompliance. Hypothesis 1(d) predicted that immobil i ty would lead to increased noncompliant behaviour. As the table i n Appendix G .2 i n d i c a t e s , there were no s i g n i f i c a n t r e s u l t s on e i ther of the measures: record i n pa t ient char t s , or pa t i en t s e l f - r e p o r t on interview (ESS). Summary: ANOVA R e s u l t s f o r S tudy 1 The ana lys i s of variance tested the f i r s t two categories o f hypotheses which made pred ic t ions about the e f fect s of immobil i ty (category 1) and the cogn i t ive in tervent ion (category 2 ) . For Study 1 , conducted at the U n i v e r s i t y H o s p i t a l i n Saskatoon, the fo l lowing r e s u l t s were demonstrated: Hypothesis 1(a) was supported. Immobility l e d to increased se l f - repor ted imagery (MIPI). Hypothesis 1(b) was not supported. Immobile pa t ient s d i d not report greater s tress re l a ted to imagery (ESS - subscale I V ) . However, immobil i ty d i d lead to greater environmental s t ress re l a ted to personal c o n t r o l and response r e s t r i c t i o n (ESS - subscale I I I ) . Hypothesis 1(c) and 1(d) were not supported. There were no immobil i ty e f fec t s on any o f the s e l f - r e p o r t or s t a f f measures o f e i t h e r s t ress or noncompliant behaviour. Hypothesis 2(a) was not supported. The in te rvent ion d i d not lead to decreased s tress re l a ted to imagery (ESS - subscale I V ) . Hypothesis 2(b) was supported on the measure of subject ive s t ress (SSS), but not on e i ther the measure of environmental s t ress (ESS -to ta l ) or the nurse record i n the pa t i ent charts (Distress Record). The 79 c o g n i t i v e in te rvent ion l e d to decreased se l f - r epor t s of negative a f f ec t on the nonspeci f ic measure (SSS) but not on the measure s p e c i f i c to the environment (ESS). There were no di f ferences i n s tress recorded by s t a f f i n the pa t i en t charts for the in te rvent ion group as opposed to the group who were not exposed to the i n t e r v e n t i o n . Stepwise Regression Results - Dimensions of Stimilation A second ana lys i s for Study 1 was stepwise regress ion used to te s t hypotheses re l a ted to environmental s t i m u l a t i o n . This ana lys i s examined the p r e d i c t i v e value of dimensions of the s o c i a l and nonsocia l environment on two of the dependent v a r i a b l e s : imagery and noncompliant behaviour. Dimensions of the p h y s i c a l environment observed were v a r i e t y , responsiveness, complexity and noise . Observations of the s o c i a l environment were grouped according to whether s o c i a l s t i m u l a t i o n occurred w i t h i n the p a t i e n t ' s space (area w i t h i n bedside curta ins) or outside t h i s space. Dimensions o f s o c i a l s t imula t ion w i t h i n the p a t i e n t ' s space were v a r i e t y of s t imula t ion and p a t i e n t - d i r e c t e d behaviour ( e . g . , contingency responses). Outside the pa t i ent space, the s o c i a l dimensions included v a r i e t y , o ther-d irected behaviour and act ions d i rec ted at the p h y s i c a l environment. The f i n a l dimension of s o c i a l s t i m u l a t i o n , which cut across space, was complexity ( i . e . , s t imula t ion of d i f f e r e n t m o d a l i t i e s ) . Imagery. Hypothesis 3(a) predicted that r e s t r i c t i o n of environmental s t imula t ion would lead to increased imagery scores on the MIPI . The most potent predic tor of the MIPI (Table 4 ) was o ther-d i rec ted s o c i a l s t imula t ion (ODII). This va r i ab le accounted for TABLE 4 UNIVERSITY HOSPITAL STUDY STEPWISE REGRESSION ANALYSIS: DIMENSIONS OF STIMULATION AS PREDICTORS OF IMAGERY (MIPI) PREDICTOR STANDARDIZED REGRESSION COEFFICIENT INCREMENT I N MULTIPLE R F-TO-ENTER CTHER-DIRECTED SOCIAL (ODII) +.40 .16 8.79 SOCIAL VARIETY - O u t s i d e Space (SVII) - . 5 4 .10 5.99 SOCIAL VARIETY - I n s i d e Space (SVI) +.29 .08 5.24 NONSOCIAL RESPONSIVENESS (NSR) - . 2 5 .06 4.35 PREDICTORS COMBINED .40 Note . I = I n s i d e p a t i e n t ' s space ( w i t h i n beds ide c u r t a i n s ) I I = O u t s i d e p a t i e n t ' s space Multiple R: S tep 1 = . 40 ; S tep 2 = . 5 1 ; S tep 3 = . 5 8 ; S tep 4 = . 6 3 . TABLE 4 (Continued) STEPWISE REGRESSION RERUN: SVI I FORCED INTO THE EQUATION AT THE OUTSET PREDICTOR STANDARDIZED REGRESSION COEFFICIENT INCREMENT IN MULTIPLE R F-TO-ENTER SOCIAL VARIETY - Out s ide space (SVII) OTHER-DIRECTED SOCIAL (ODII) SOCIAL VARIETY - I n s i d e space (SVI) NONSOCIAL RESPONSIVENESS (NSR) +.14 +.84 +.29 - . 2 5 .02 .24 .08 .06 .93 14.54 5.24 4.35 PREDICTORS COMBINED .40 Note . The o t h e r s i x p r e d i c t o r s d i d not reach the F v a l u e o f 4.00 r e q u i r e d t o e n t e r the e q u a t i o n i n the BMDP2R program: n o n s o c i a l ( v a r i e t y , c o m p l e x i t y and noise) and s o c i a l ( p a t i e n t - d i r e c t e d , d i r e c t e d a t the p h y s i c a l environment and complex i ty ) d imens ions . M u l t i p l e R: S tep 1 = .14 ; S tep 2 = . 5 1 ; S tep 3 = . 5 8 ; S tep 4 = . 63 . 82 16% o f the v a r i a n c e on the M I P I . E x a m i n a t i o n o f the p o l a r i t y o f the s t a n d a r d i z e d r e g r e s s i o n c o e f f i c i e n t s (beta weights ) shows t h a t , c o n t r a r y t o e x p e c t a t i o n , the r e l a t i o n s h i p was d i r e c t r a t h e r i n v e r s e . T h i s suggested t h a t w h i l e n o n o p t i m a l s t i m u l a t i o n p r e d i c t e d i n c r e a s e d imagery , the e f f e c t stemmed from e x c e s s i v e r a t h e r than r e s t r i c t e d s t i m u l a t i o n . O t h e r - d i r e c t e d s t i m u l a t i o n o c c u r r e d when two p e o p l e engaged i n a c o n v e r s a t i o n w h i c h e x c l u d e d the p a t i e n t b e i n g observed and was o u t s i d e the observed p a t i e n t ' s space . Thus , the v e r b a l i z a t i o n was h i g h on s o c i a l s t i m u l a t i o n b u t r e l a t i v e l y low on meaning f o r the observed p a t i e n t . The second v a r i a b l e t o e n t e r the e q u a t i o n was v a r i e t y o f s o c i a l s t i m u l a t i o n o u t s i d e the p a t i e n t * s space ( S V I I ) , which accounted f o r 10% o f the v a r i a n c e . U n e x p e c t e d l y , the r e l a t i o n s h i p appeared t o be n e g a t i v e i n d i r e c t i o n . T h i s f i n d i n g was unexpected because the i n i t i a l p a r t i a l c o r r e l a t i o n between S V I I and M I P I was p o s i t i v e and the p a t t e r n o f o t h e r s o c i a l s t i m u l a t i o n r e s u l t s was p o s i t i v e l y r e l a t e d t o imagery f o r b o t h the i n i t i a l p a r t i a l c o r r e l a t i o n s and the r e g r e s s i o n c o e f f i c i e n t s . I n some c a s e s , due t o a p a r t i c u l a r c o n s t e l l a t i o n o f p a r t i a l c o r r e l a t i o n s o f two v a r i a b l e s w i t h a t h i r d v a r i a b l e , t h e r e w i l l be a suppres sor e f f e c t (Edwards, 1976, p . 6 4 ) . F o r t h i s r e a s o n , the a n a l y s i s was r e r u n w i t h S V I I f o r c e d i n t o the e q u a t i o n a t the o u t s e t . The r e s u l t s on the second page o f T a b l e 4 show a c o n s i s t e n t p a t t e r n i n which s o c i a l s t i m u l a t i o n has a p o s i t i v e r e l a t i o n s h i p t o imagery on a l l t h r e e d imens ions which reached s i g n i f i c a n c e . I n the second a n a l y s i s , the v a r i a n c e accounted f o r by S V I I has dropped from 10% t o 2%, whereas ODII accounts f o r an 83 increase of variance from 16% to 24%. In the i n i t i a l a n a l y s i s , when ODII enters the equation f i r s t , i t appeared to enhance SVII g i v i n g an e f f e c t opposite to a suppressor v a r i a b l e . The t h i r d pred ic tor o f the MIPI was v a r i e t y of s o c i a l s t imula t ion in s ide the p a t i e n t ' s space (SVT), which accounted for 8% of the variance c o n s i s t e n t l y i n both analyses. Again the r e l a t i o n s h i p was p o s i t i v e , lending a d d i t i o n a l support to a st imulus overload argument. F i n a l l y , a further 6% of the variance on the MIPI could be a t t r i b u t e d to responsiveness of nonsocia l s t imula t ion (NSR). This v a r i a b l e measured the opt ion o f c o n t r o l over s t imula t ion as opposed to the quant i ty of nonsocia l s t imula t ion per se. Hypothesis 5, which re l a ted to personal c o n t r o l , d i d not make any pred ic t ions regarding imagery. However, the inverse r e l a t i o n s h i p of NSR to imagery shows that when pat ients have few nonsocia l s t i m u l i which have the opt ion for c o n t r o l , the incidence of imagery increases . For example, there may be exposure to nonsocia l s t imula t ion from a rad io which i s out of reach so that there i s no opt ion to change the volume or turn i t o f f . S t res s . No s p e c i f i c hypothesis was made concerning the e f f ec t o f s t imula t ion l e v e l s on s t re s s , because previous research suggested that i n d i v i d u a l d i f ferences are such that a given s t imula t ion l e v e l might evoke a p o s i t i v e response i n one person and a negative response i n another. As an exploratory approach, however, the stepwise regress ion ana lys i s of s t imula t ion dimensions was repeated for the dependent measures o f s tress used i n t h i s study. S i g n i f i c a n t pred ic tor s emerged for two subscales of the ESS and for the SSS. The ESS subscale I , which 84 measured s tress re l a ted to personal space and p r i v a c y , was predic ted by the v a r i e t y of nonsocia l s t imula t ion (NSV), which accounted for 10% of the variance (Appendix G . 5 ) . The NSV score included nonsocia l s t imula t ion ( e . g . , r a d i o , t e l ev i s ion ) which belonged t o , and was c o n t r o l l e d by, other pat ients as w e l l as that c o n t r o l l e d by the observed p a t i e n t . High l e v e l s of NSV l e d to increased s tress re l a ted to personal space and p r i v a c y , again supporting an overload argument. S i m i l a r l y , high l e v e l s of s o c i a l s t imula t ion d i rec ted at the p h y s i c a l environment (Appendix G.5) such as housekeeping, l e d to increased s tress re l a ted to imagery and dreams (ESS-subscale I V ) . None of the s t imula t ion pred ic tor s entered the equation for subscales I I , I I I , or the t o t a l ESS because they f a i l e d to reach the de fau l t value of F = 4.00 for the BMDP2R s t a t i s t i c a l program. The SSS had two s i g n i f i c a n t pred ic tor s i n the regress ion ana lys i s (Appendix G . 4 ) . Twenty-one percent o f the o v e r a l l variance on the SSS was accounted for by the combination o f nonsocial noise (NSN) and other-d i rec ted s o c i a l s t imula t ion (CDII), wi th t h e i r respect ive contr ibut ions being 14% and 7%. Both e f fects were i n the p o s i t i v e d i r e c t i o n , demonstrating that high l e v e l s o f both s o c i a l and nonsocia l s t imula t ion predic ted high s tress l e v e l s . Nonsocial noise and o ther-d i rec ted s o c i a l s t imula t ion ( soc i a l noise) were not pa t i e n t -d i rec ted and, therefore , were r e l a t i v e l y low i n meaning and informat ional value for the observed pa t ient as compared to pa t i en t -d i rec ted s t imula t ion such as contingency responses. 85 Noncompliance» The p r e d i c t i o n from hypothesis 3(b) that low l e v e l s o f s t imula t ion would lead to increased noncompliant behaviour received support on the noncompliance measure from the interv iew (ESS). As shown on Table 5 f v a r i e t y of nonsocia l s t imula t ion (NSV) accounted for 9% o f the var iance , wi th the expected inverse r e l a t i o n s h i p between NSV and noncompliance. No other pred ic tor s achieved a s u f f i c i e n t value of F to enter the equation. On the noncompliance measure from the chart (patient record) , nonsocia l noise (NSN) accounted for 9% o f the var iance . The r e l a t i o n s h i p was p o s i t i v e i n d i c a t i n g that high noise l e v e l s predicted increased, noncompliance. This f i n d i n g , whi le contrary to the s p e c i f i c hypothesis , was cons i s tent wi th the t h e o r e t i c a l framework o f an opt imal l e v e l of s t i m u l a t i o n . Summary: Stimulation Regression Results for Study 1 The f i r s t stepwise regress ion ana lys i s tested hypotheses r e l a ted to the environment (category 3 ) . The r e s u l t s , whi le sometimes contrary to the s p e c i f i c hypotheses, are cons i s tent wi th the t h e o r e t i c a l framework of opt imal l e v e l s o f s t imula t ion and c o n t r o l . However, some f indings are a t the opposite end o f the t h e o r e t i c a l inverted-U curve than pred ic ted . Hypothesis 3(a) was unsupported. Low l e v e l s o f environmental s t imula t ion d i d not p r e d i c t imagery (MIPI). However, imagery was predic ted by high l e v e l s o f s o c i a l s t imula t ion on three dimensions: o ther -d i rec ted , v a r i e t y outside the observed p a t i e n t ' s space, and 8 6 TABLE 5 UNIVERSITY HOSPITAL STUDY STEPWISE REGRESSION ANALYSIS: DIMENSIONS OF STIMULATION AS PREDICTORS OF NONXMPLIANCE NCNCCMPLIANT BEHAVIOUR (INTERVIEW - ESS) STANDARDIZED REGRESSION INCREMENT I N PREDICTOR COEFFICIENT MULTIPLE R F-TO-ENTER NONSOCIAL VARIETY (NSV) - . 2 9 .09 4 .36 ^ l t i p l e R = .30 NONCOMPLIANT BEHAVIOUR (PATIENT RECORD) STANDARDIZED REGRESSION INCREMENT IN PREDICTOR COEFFICIENT MULTIPLE R F-TO-ENTER NONSOCIAL NOISE (NSN) +.29 .09 4.37 N o t e . None o f the s t i m u l a t i o n p r e d i c t o r s e n t e r e d the e q u a t i o n f o r the measure o f noncompliance from the nurse q u e s t i o n n a i r e . k M u l t i p l e R = .30 87 variety inside the patient space. Imagery was also predicted by low it control options over nonsocial stimuli as measured by the responsiveness (NSR) dimension. Hypothesis 3(b) was partly supported. As hypothesized, low levels of variety of nonsocial stimulation predicted self-reported noncompliance. In a direction opposite to hypothesis 3(b), high levels of nonsocial noise predicted noncompliance recorded in the patient charts. These two findings are consistent with the two theoretical extremes of nonoptimal stimulation. Although no hypotheses were made concerning the effects of stimulation dimensions on stress, an exploratory regression analysis was done. A l l significant findings were in the direction of high social and nonsocial stimulation predicting self-reported stress on interview (ESS) and questionnaire (SSS). Variety of nonsocial stimulation predicted stress related to personal space and privacy (ESS - subscale I). Social stimulation directed at the physical environment predicted stress related to imagery and dreams (ESS - subscale IV). The questionnaire measure of subjective stress (SSS) was predicted by nonsocial noise and other-directed social stimulation. The latter variable could also be described as social noise. Stepwise Regression Results - General The third analysis for Study 1 was a stepwise regression analysis used to test hypotheses related to l i f e stress (category 4 ) and personal control (category 5 ) . Predictions were made for two of the dependent variables: imagery and stress. Demographic and situational variables 88 were a l s o i n c l u d e d as p o s s i b l e p r e d i c t o r s i n t h i s a n a l y s i s . The 10 p r e d i c t o r s were the L i f e E x p e r i e n c e s S u r v e y , the S u b j e c t i v e H e l p l e s s n e s s S c a l e , Dependence and Independence s u b s c a l e s o f the nurse q u e s t i o n n a i r e , age, s ex , p r i v a t e room, a c c i d e n t , s u r g e r y , and t r a c t i o n . Imagery. H y p o t h e s i s 4(a) p r e d i c t e d t h a t h i g h n e g a t i v e change s c o r e s on the L i f e E x p e r i e n c e s Survey (LES) over the year p r i o r t o h o s p i t a l i z a t i o n would be p r e d i c t i v e o f i n c r e a s e d imagery as measured by the M I P I . T h i s h y p o t h e s i s was suppor ted by the f i n d i n g s r e p o r t e d i n T a b l e 6 . Of the t e n p o s s i b l e p r e d i c t o r s o f M I P I s c o r e s , o n l y two reached the m i n i m a l a c c e p t a b l e F v a l u e o f 4 .00 t o e n t e r the e q u a t i o n i n the BMDP2R program. The LES p r e d i c t o r accounted f o r 32% o f the v a r i a n c e . The second p r e d i c t o r t o emerge i n the a n a l y s i s was age , w h i c h accounted f o r 9% o f the v a r i a n c e . Young p a t i e n t s w i t h h i g h n e g a t i v e impact s c o r e s ( l i f e s t r e s s ) on the LES tended t o have h i g h s c o r e s on the imagery q u e s t i o n n a i r e . S t r e s s . H y p o t h e s i s 4(b) s t a t e d t h a t p r e v i o u s l i f e s t r e s s would be p r e d i c t i v e o f s t r e s s d u r i n g h o s p i t a l i z a t i o n and two months a f t e r d i s c h a r g e . T h i s h y p o t h e s i s r e c e i v e d suppor t on the p o s t - d i s c h a r g e measure b u t n o t on the measures t a k e n w h i l e i n h o s p i t a l . T a b l e 7 shows the p o s t - d i s c h a r g e r e s u l t s on the p s y c h o l o g i c a l ad justment s u b s c a l e o f the P s y c h o s o c i a l Adjus tment t o I l l n e s s S c a l e ( P A I S ) . The LES v a r i a b l e was the o n l y p r e d i c t o r t o e n t e r the e q u a t i o n and i t accounted f o r 21% o f the v a r i a n c e . The r e l a t i o n s h i p between LES and the PAIS measure was p o s i t i v e as p r e d i c t e d . That i s , h i g h n e g a t i v e impact s c o r e s on the LES p r e d i c t e d h i g h s c o r e s on the p s y c h o l o g i c a l ad justment s u b s c a l e ( i . e . , decreased a d j u s t m e n t ) . TABLE 6 UNIVERSITY HOSPITAL STUDY STEPWISE REGRESSION ANALYSIS: GENERAL PREDICTORS OF IMAGERY (MIPI) STANDARDIZED REGRESSION INCREMENT , PREDICTOR COEFFICIENT OF MULTIPLE R F-TO-ENTER L i f e E x p e r i e n c e s Survey + .56 .32 15.73 Age - .31 .09 4.97 P r e d i c t o r s Combined .41 N o t e . The o t h e r e i g h t p r e d i c t o r s d i d not reach the F v a l u e o f 4 .00 r e q u i r e d t o e n t e r the e q u a t i o n i n the BMDP2R program: h e l p l e s s n e s s , dependence, independence, a c c i d e n t , s ex , p r i v a t e room, s u r g e r y , and t r a c t i o n . Multiple R: S tep 1 = .56 ; S tep 2 = . 6 4 . TABLE 7 UNIVERSITY HOSPITAL STUDY STEPWISE REGRESSION ANALYSIS: GENERAL PREDICTORS OF THE PSYCHOLOGICAL SUBSCALE OF THE PSYCHOSOCIAL ADJUSTMENT TO ILLNESS SCALE (PAIS) STANDARDIZED REGRESSION INCREMENT „ PREDICTOR COEFFICIENT MULTIPLE R F-TO-ENTER L i f e E x p e r i e n c e s Survey + .46 .21 8 .89 N o t e . The d e f a u l t va lue o f F = 4.00 necessary f o r the BMDP2R program was n o t reached by the o t h e r n i n e p r e d i c t o r s : h e l p l e s s n e s s , dependence, independence, age, s ex , p r i v a t e room,, a c c i d e n t , surgery and t r a c t i o n . 91 The r e s u l t s i n Table 7 do not support hypothesis 5, which predic ted an inverse r e l a t i o n s h i p between personal c o n t r o l and post-discharge s t r e s s . I t was expected that high personal c o n t r o l would be re la ted to decreased s tress on the PAIS measure. However, none of the measures of personal c o n t r o l were pred ic tor s of post-discharge adjustment. The measures of s t ress during h o s p i t a l i z a t i o n were from pa t i ent interv iew (ESS), pa t i en t quest ionnaire (SSS) and s t a f f records i n pa t i en t charts (Distress Record). Hypothesis 4 (b) predic ted a d i r e c t r e l a t i o n s h i p between l i f e s t ress (LES) and the h o s p i t a l s t ress measures, whereas hypothesis 5 predic ted an inverse r e l a t i o n s h i p between personal c o n t r o l and the three s t ress measures. On the environmental s t ress measure (ESS), the stepwise regress ion ana lys i s was done for each of the subscales as w e l l as for the t o t a l sca le (Table 8 ) . Contrary to hypothesis 4 (b), LES d i d not emerge as a pred ic tor for any of these analyses. The ESS f indings provided support for hypothesis 5, which predic ted that personal c o n t r o l would be inver se ly re l a ted to environmental s t r e s s . On the t o t a l ESS (second page of Table 8 ) , accident and helplessness emerged as pred ic tor s accounting for 27% and 13% of the variance r e s p e c t i v e l y . Accident v i c t i m s wi th high scores on the Subject ive Helplessness Scale ( i . e . , low personal control ) had greater environmental s t ress o v e r a l l . Data from the subscales of the ESS provide a d d i t i o n a l support for hypothesis 5 . On subscale I I , which examined s t ress re l a ted to environmental s t imula t ion l e v e l s , high helplessness ( i . e . , low personal UNIVERSITY HOSPITAL STUDY STEPWISE REGRESSION ANALYSIS: GENERAL PREDICTORS OF ENVIRONMENTAL STRESS (ESS) PREDICTORS SUBSCALE I : PERSONAL SPACE AND PRIVACY STANDARDIZED REGRESSION COEFFICIENT INCREMENT IN MULTIPLE R F-TO-ENTER ACCIDENT +.40 .16 6 .62 [ultiple R = .40 PREDICTORS SUBSCALE I I : ENVIRONMENTAL STIMULATION LEVELS STANDARDIZED REGRESSION COEFFICIENT INCREMENT I N MULTIPLE R F-TO-ENTER AGE - . 4 5 .21 8 .79 HELPLESSNESS +.34 .11 5.17 SEX +.34 .10 5 .51 PREDICTORS COMBINED .42 Multiple R: S tep 1 = . 45 ; S tep 2 = . 56 ; S tep 3 = . 6 4 . TABLE 8 (Continued) UNIVERSITY HOSPITAL STUDY STEPWISE REGRESSION ANALYSIS: ENVIRONMENTAL STRESS SCALE (ESS) SUBSCALE I I I : PERSONAL CONTROL AND RESPONSE RESTRICTION PREDICTORS STANDARDIZED REGRESSION COEFFICIENT INCREMENT IN MULTIPLE R F-TO-ENTER ACCIDENT INDEPENDENCE PREDICTORS COMBINED +.61 - . 2 8 .37 .08 .45 20 .32 4 .75 Multiple R: S tep 1 = . 4 6 ; S t e p 2 = . 5 5 . TOTAL: ENVIRONMENTAL STRESS SCALE PREDICTORS STANDARDIZED REGRESSION COEFFICIENT INCREMENT IN MULTIPLE R F-TO-ENTER ACCIDENT HELPLESSNESS PREDICTORS COMBINED +.52 +.37 .27 .13 .40 12.56 6 .95 Note . None of the 10 predictors reached the default value of F Imagery and Dreams. Multiple R: step 1 = . 5 2 ; S t e p 2 = . 3 7 . = 4 to enter the equation for subscale I V : 94 c o n t r o l ) accounted f o r 11% o f the v a r i a n c e i n the p r e d i c t e d d i r e c t i o n . As w e l l , age and sex p r e d i c t e d 21% and 10% r e s p e c t i v e l y t o the v a r i a n c e . Young, female p a t i e n t s who r a t e d themselves as h i g h on h e l p l e s s n e s s p r i o r t o a d m i s s i o n , r e p o r t e d g r e a t e r e n v i r o n m e n t a l s t i m u l a t i o n s t r e s s on i n t e r v i e w . F u r t h e r suppor t f o r h y p o t h e s i s 5 was found on ESS s u b s c a l e I I I w h i c h measured s t r e s s r e l a t e d t o p e r s o n a l c o n t r o l and response r e s t r i c t i o n . An a c c i d e n t accounted f o r 37% o f the v a r i a n c e , w h i l e low independence ( i . e . , low p e r s o n a l c o n t r o l ) c o n t r i b u t e d another 8% i n the p r e d i c t e d d i r e c t i o n . Subsca le I ( s t r e s s r e l a t e d t o p e r s o n a l space and p r i v a c y ) was a l s o p r e d i c t e d by an a c c i d e n t , w h i c h accounted f o r 16% o f the v a r i a n c e . There were two o t h e r measures o f s t r e s s i n t h i s s t u d y : the S u b j e c t i v e S t r e s s S c a l e (SSS) and the D i s t r e s s Record o b t a i n e d from the c h a r t . On the SSS, none o f the t e n v a r i a b l e s reached a s u f f i c i e n t F v a l u e t o emerge as p r e d i c t o r s i n the r e g r e s s i o n a n a l y s i s . Thus , n e i t h e r h y p o t h e s i s 4 ( b ) , w h i c h p r e d i c t e d a d i r e c t r e l a t i o n s h i p between LES and SSS, nor h y p o t h e s i s 5 , w h i c h p r e d i c t e d an i n v e r s e r e l a t i o n s h i p between p e r s o n a l c o n t r o l and SSS, i s suppor ted on t h i s measure. Support f o r h y p o t h e s i s 5 was found on on the D i s t r e s s Record (Table 9 ) . Low independence accounted f o r 24% o f the v a r i a n c e i n the p r e d i c t e d i n v e r s e r e l a t i o n s h i p t o d i s t r e s s . TABLE 9 UNIVERSITY HOSPITAL STUDY STEPWISE REGRESSION ANALYSIS: GENERAL PREDICTORS OF THE DISTRESS RECORD STANDARDIZED REGRESSION INCREMENT IN PREDICTORS COEFFICIENT MULTIPLE R F-TO-ENTER INDEPENDENCE -.49 .24 10.60 Multiple R = .49. 9 6 Summary: General Regression Results for Study 1 The second stepwise regression analysis tested hypotheses related to l i f e stress (category 4) and personal control (category 5). Predictions were made from l i f e stress to measures of imagery and stress. Personal control predictions related exclusively to measures of stress. In neither category were there predictions regarding noncompliance, the third dependent variable in this project. Hypothesis 4(a) was supported. High l i f e stress over the year prior to hospitalization measured by negative impact scores on the Life Experiences Survey, predicted increased imagery on the MIPI questionnaire. Young patients reported greater imagery than older patients. Hypothesis 4(b) was supported on the post-discharge measure but not on the measures taken while in hospital. High previous l i f e stress predicted high stress (i.e., decreased adjustment) two months after discharge. By contrast, hypothesis 4(b) was unsupported on a l l three stress measures taken during hospitalization: patient interview (ESS), patient questionnaire (SSS), and staff records in the patient charts (Distress Record). Hypothesis 5 was not supported on the post-discharge measure but did receive support from the in-hospital measures. Personal control was not inversely related to stress two months after discharge. On the other hand, during hospitalization the predicted inverse relationship between control (helplessness) and stress was found on the interview measure of environmental stress (total ESS) and on the ESS subscale 97 which measured s t ress re la ted to environmental s t imula t ion l e v e l s . Further support for hypothesis 5 was provided by subscale I I I (stress re l a ted to personal c o n t r o l and response r e s t r i c t i o n ) which was inver se ly re l a ted to c o n t r o l as measured by low independence scores on the nurse quest ionnaire . The other two measures of s t ress were from pa t i ent quest ionnaire (SSS) and the s t a f f record i n pa t ient charts (Distress Record). In t h i s a n a l y s i s , there were no s i g n i f i c a n t pred ic tor s on the SSS, contrary to p r e d i c t i o n . As pred ic ted , d i s t r e s s was inver se ly re la ted to personal c o n t r o l ( i . e . , low independence). Shaughnessy Hospital Study Analysis of Variance Results Study 2, conducted at Shaughnessy H o s p i t a l , tested hypotheses r e l a ted to immobil i ty (category 1) and the environment (category 3 ) . A l l pa t ients i n t h i s study had some degree of p a r a l y s i s or i n t e r n a l immobil i ty as w e l l as ex terna l immobil i ty (Appendix F . 2 ) . With respect to the h o s p i t a l environment, each pa t ient was admitted to the intens ive care u n i t and l a t e r t rans ferred to the ward. The ana lys i s of variance r e s u l t s i n t h i s sec t ion r e l a t e to i n t e r n a l immobi l i ty , whereas the stepwise regress ion r e s u l t s ( in the sec t ion to follow) examine the e f fec t s of ex te rna l immobi l i ty . Imagery. Hypothesis 1(a) predic ted that immobil i ty would lead to increased imagery. This hypothesis received support from two main e f fect s i n the 2 x 2 x 2 ana lys i s o f variance and covariance wi th 98 repea ted measures (Table 1 0 ) . Mean s c o r e s f o r t h i s a n a l y s i s a re p r e s e n t e d i n T a b l e 1 1 . The f i r s t main e f f e c t was f o r l e v e l , w h i c h r e p r e s e n t e d the l e v e l o f i n j u r y t o the s p i n a l c o r d ( q u a d r i p l e g i a v s . p a r a p l e g i a ) , F ( 1 , 45) = 9 . 7 3 , £ < . 0 1 . These r e s u l t s o f f e r e d suppor t t o H y p o t h e s i s 1(a) because q u a d r i p l e g i c s , who had a h i g h l e v e l ( i . e . , c e r v i c a l ) i n j u r y and c o n s e q u e n t l y e x p e r i e n c e d the g r e a t e s t r e s t r i c t i o n i n movement due t o p a r a l y s i s from the neck o r upper t r u n k down had g r e a t e r imagery than p a r a p l e g i c s w i t h a low l e v e l i n j u r y . The second main e f f e c t was f o r degree o f i n j u r y (complete v s . i n c o m p l e t e ) , F ( 1 , 45) = 1 0 . 0 5 , £ < . 0 1 . P a t i e n t s w i t h complete i n j u r i e s had t o t a l l o s s o f n e u r o l o g i c a l f u n c t i o n below the l e v e l o f i n j u r y and hence e x p e r i e n c e d g r e a t e r i m m o b i l i t y than p a t i e n t s w i t h incomple te i n j u r i e s who, i n some c a s e s , wa lked o u t o f the h o s p i t a l . A g a i n , the g r e a t e r the i m m o b i l i t y , t h e g r e a t e r the imagery . There was a l s o a L e v e l x Degree i n t e r a c t i o n , F (1,45) = 7 . 9 1 , £ < . 0 1 . E x a m i n a t i o n o f the means (Table 11) r e v e a l s t h a t t h i s i n t e r a c t i o n e f f e c t c a n be accounted f o r by the group o f complete q u a d r i p l e g i c s i n i n t e n s i v e c a r e , who have a mean imagery s c o r e a t l e a s t seven t imes g r e a t e r t h a n each o f the o t h e r group means. The c o v a r i a t e a n a l y s i s f o r i n j e c t a b l e a n a l g e s i c s was n o n s i g n i f i c a n t throughout t h i s a n a l y s i s , F < 1. T h e r e f o r e , imagery e f f e c t s c o u l d not be a t t r i b u t e d t o h a l l u c i n a t o r y s i d e e f f e c t s o f n a r c o t i c s and o t h e r i n j e c t a b l e a n a l g e s i c s ( e . g . , T a l w i n ) . H y p o t h e s i s 3(a) s t a t e d t h a t r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n would p r e d i c t i n c r e a s e d imagery . The d a t a from the repea ted measures v a r i a b l e , environment ( i n t e n s i v e c a r e v s . w a r d ) , r e v e a l e d a main e f f e c t TABLE 10 SHAUGHNESSY HOSPITAL STUDY ANALYSIS OF VARIANCE AND COVARIANCE: IMAGERY Source d f MS LEVEL (L) DEGREE (D) L x D COVARIATE ERROR 1 1 1 1 45 ENVIRONMENT (E) E x L. E x D E x L x D COVARIATE ERROR 1 1 1 1 1 45 90.10 93.10 73.24 3.77 9.26 9 . 73 * * 10 .05 * * 7 . 91 * * < 1 47.01 78.85 76.02 45.91 .01 6.88 6 . 83 * * 11 .46* * 11 .05 * * 6 .67 * * < 1 * * < .01 Note. Covariate = i n j e c t a b l e narcot ic s reduced to a common u n i t on an equianalgesic t a b l e . 100 TABLE 11 SHAUGHNESSY HOSPITAL STUDY MEAN RECORDED IMAGERY OVER TIME ENVIRONMENT Group INTENSIVE CARE WARD L e v e l / D e g r e e n IMAGERY COVARIATE IMAGERY COVARIATE Q u a d r i p l e g i c s / Complete 12 M 8 .25 5 .90 0 .75 0.24 SD 6 .93 5 .40 1.77 0.68 Q u a d r i p l e g i c s / Incomplete 12 M 1.00 3.54 0.17 0 .28 SD 2 .26 3 .53 0 .39 0 .65 P a r a p l e g i c s / Complete 18 M 1.17 8 .78 0.28 0 .47 SD 2 .33 4 .44 0.58 0 .66 P a r a p l e g i c s / Incomplete 8 M 0 .38 6 .54 0.50 1.80 SD 0.74 5 .37 1.07 2.37 N o t e . C o v a r i a t e = i n j e c t a b l e a n a l g e s i c s reduced t o a common u n i t a c c o r d i n g t o an e g u i a n a l g e s i c t a b l e . The i n t e n s i v e c a r e environment preceded the ward environment i n a l l c a s e s . 101 f o r env i ronment , F ( 1 , 45) = 6 . 8 3 , p_ < . 0 1 , as shown i n T a b l e 10 . A l l o f the i n t e r a c t i o n s were a l s o s i g n i f i c a n t a t the .01 l e v e l : environment x l e v e l , F ( 1 , 45) = 1 1 . 4 6 ; environment x degree , F ( 1 , 45) = 1 1 . 0 5 ; and environment x l e v e l x degree , F ( 1 , 45) = 6 . 6 7 . The e f f e c t s f o r env i ronment , however, do not d i r e c t l y address the i s s u e o f whether the ICU e f f e c t i s due t o r e s t r i c t e d o r e x c e s s i v e e n v i r o n m e n t a l s t i m u l a t i o n . The p a t t e r n o f r e s u l t s f o r the A n a l y s i s o f V a r i a n c e w i t h o u t the c o v a r i a t e (Appendix G . l l ) a re s i m i l a r t o those w i t h t h e c o v a r i a t e (Table 1 0 ) . However, i n the former a n a l y s i s the e f f e c t o f environment i s enhanced. W i t h o u t the c o v a r i a t e , the main e f f e c t f o r environment i s s i g n i f i c a n t a t the .0001 l e v e l , as compared t o the .01 l e v e l o f s i g n i f i c a n c e w i t h the c o v a r i a t e . Because o f the unequa l n i n t h i s s t u d y , a s u b s i d i a r y a n a l y s i s was done t o a r r i v e a t an unweighted means s o l u t i o n f o r compar i son w i t h the o r i g i n a l r e s u l t s (see method, p . 5 8 ) . The F v a l u e s o b t a i n e d from the unweighted means s o l u t i o n (Appendix G.10) c l o s e l y resembled the o r i g i n a l F v a l u e s (Table 10) w i t h a n e g l i g i b l e range o f 0.09 t o 0 .03 d i f f e r e n c e i n the e f f e c t s . T h i s d i f f e r e n c e was o b t a i n e d by s u b t r a c t i n g c o r r e s p o n d i n g F v a l u e s f o r the two a n a l y s e s . T a b l e 11 shows the change i n mean imagery s c o r e s over t ime from the i n t e n s i v e c a r e u n i t (ICU) t o the w a r d . The complete q u a d r i p l e g i c s had by f a r the g r e a t e s t change i n imagery s c o r e s w i t h the change o f env i ronment . The o n l y group w h i c h had lower mean imagery i n t h e ICU than the ward was the incomple te p a r a p l e g i c g r o u p , w i t h a n e g l i g i b l e d i f f e r e n c e s c o r e o f . 1 2 . 102 Subsequent a n a l y s i s o f s i m p l e e f f e c t s (Appendix G.9) r e v e a l e d t h a t degree o f i n j u r y i n f l u e n c e d t h e f requency o f imagery recorded f o r the 24 q u a d r i p l e g i c p a t i e n t s but n o t the 26 p a r a p l e g i c p a t i e n t s . Q u a d r i p l e g i c s w i t h complete l e s i o n s had g r e a t e r r ecorded imagery t h a n d i d q u a d r i p l e g i c s w i t h incomple te l e s i o n s , F ( 1 , 45) = 1 8 . 6 0 , £ < . 0 1 , but t h e r e was no c o r r e s p o n d i n g d i f f e r e n c e between p a r a p l e g i c s w i t h complete and incomple te l e s i o n s , F < 1. A n a l y s i s o f s i m p l e e f f e c t s f o r l e v e l o f i n j u r y w i t h i n each degree c a t e g o r y y i e l d e d complementary r e s u l t s ; namely among q u a d r i p l e g i c s , p a t i e n t s w i t h complete l e s i o n s had g r e a t e r r e c o r d e d imagery t h a n d i d p a t i e n t s w i t h incomple te l e s i o n s , F ( 1 , 45) = 1 8 . 3 6 , £ < . 0 1 ; b u t , among p a r a p l e g i c s , completeness o f l e s i o n had no s i g n i f i c a n t e f f e c t on the f requency o f imagery , F < 1 . The s i m p l e e f f e c t s a n a l y s i s f o r env i ronment , the repeated measures v a r i a b l e , f o l l o w e d the same p a t t e r n . F u r t h e r s i m p l e e f f e c t s a n a l y s e s w i t h i n the repeated measures v a r i a b l e (environment) showed t h a t the l e v e l o f i n j u r y o n l y i n f l u e n c e d imagery i n i n t e n s i v e c a r e , F ( 1 , 45) = 2 2 . 5 8 , £ < . 0 1 , and not on the w a r d , F < 1 . When degree o f i n j u r y was c o n s i d e r e d i n c o m b i n a t i o n w i t h env i ronment , l e v e l o f i n j u r y o n l y a f f e c t e d imagery s c o r e s f o r p a t i e n t s w i t h complete i n j u r i e s i n I C U , F ( 1 , 45) = 3 7 . 0 3 , £ < . 0 1 , and not f o r the o t h e r t h r e e g r o u p s , F < 1 . L i k e w i s e , the e f f e c t f o r degree was o n l y i n i n t e n s i v e c a r e , F ( 1 , 45) = 2 2 . 0 1 , £ < . 0 1 , and n o t on the ward ; F < 1. Degree o f i n j u r y i n f l u e n c e d imagery s c o r e s f o r q u a d r i p l e g i c s i n I C U , F ( 1 , 45) = 3 6 . 5 2 , £ < . 0 1 , and n o t f o r the o t h e r t h r e e combina t ions o f l e v e l and env i ronment , F < 1 f o r e a c h . F i n a l l y , the 103 i n t e r a c t i o n o f l e v e l and degree a f f e c t s r ecorded imagery i n I C U , F ( 1 , 45) = 1 4 . 8 6 , £ < . 0 1 , and n o t on the w a r d , F < 1. S t r e s s . H y p o t h e s i s 1(c) a l s o p r e d i c t e d t h a t i m m o b i l i t y would l e a d t o i n c r e a s e d s t r e s s . T h i s p r e d i c t i o n was not suppor ted by the d a t a from t h e c h a r t s o f s p i n a l c o r d i n j u r y p a t i e n t s (Table 1 2 ) . There were no main e f f e c t s f o r l e v e l , degree o r env i ronment , F < 1 i n each c a s e , and the c o v a r i a t e a n a l y s i s f o r i n j e c t a b l e n a r c o t i c s was n o n s i g n i f i c a n t as w e l l , F < 1. Mean s t r e s s s c o r e s over t ime a re p r e s e n t e d i n T a b l e 13 . The subsequent a n a l y s i s w i t h o u t the c o v a r i a t e (Appendix G.12) r e v e a l e d the same p a t t e r n o f n o n s i g n i f i c a n t f i n d i n g s . There were no s i g n i f i c a n t i n t e r a c t i o n s f o r e i t h e r a n a l y s i s . A l t h o u g h t h e r e were no s i g n i f i c a n t d i f f e r e n c e s , the mean s t r e s s s c o r e s (Table 13) show a p a t t e r n o f g r e a t e r s t r e s s i n ICU t h a n the ward f o r a l l groups excep t the incomple te p a r a p l e g i c s , who had a s l i g h t i n c r e a s e i n s t r e s s over t i m e . The h i g h e s t s c o r e f o r ICU s t r e s s was found i n the incomple te q u a d r i p l e g i c g r o u p . On the w a r d , t h e g r e a t e s t s t r e s s was e v i d e n t f o r complete p a r a p l e g i c s . H y p o t h e s i s 1 ( b ) , w h i c h p r e d i c t e d t h a t i m m o b i l i t y would l e a d t o i n c r e a s e d s t r e s s r e l a t e d t o imagery , was n o t examined i n S tudy 2 because t h e r e were t o o few n o t a t i o n s r ecorded i n the c h a r t t o m e r i t a n a l y s i s . Much o f the r e c o r d o f s t r e s s , w h i c h was o b t a i n e d from the c h a r t s , d i d n o t r e f e r t o a s p e c i f i c source o f s t r e s s . Noncompl iance . N e i t h e r H y p o t h e s i s 1(d) nor H y p o t h e s i s 3(b) r e c e i v e d suppor t on the noncompliance v a r i a b l e . As shown i n T a b l e 14 , t h e r e were no s i g n i f i c a n t main e f f e c t s f o r l e v e l o r degree o f i n j u r y 104 TABLE 12 SHAUGHNESSY HOSPITAL STUDY ANALYSIS OF VARIANCE AND COv7\RIANCE: STRESS SOURCE d f - MS F LEVEL (L) 1 DEGREE (D) 1 L x D 1 COVARIATE 1 ERROR 45 38.17 < 1 8 .61 < 1 354.51 2 .41 41 .91 < 1 147.13 ENVIRONMENT (E) E X L E X D E X L X D COVARIATE ERROR 1 1 1 1. . 1 45 39.39 245.87 .00 7.94 .42 135.82 < 1 1.81 < 1 < 1 < 1 N o t e . C o v a r i a t e = i n j e c t a b l e n a r c o t i c s . 105 TABLE 13 SHAUGHNESSY HOSPITAL STUDY MEAN RECORDED STRESS OVER TIME Group ENVIRONMENT L e v e l / D e g r e e o f I n j u r y n INTENSIVE CARE WARD Q u a d r i p l e g i c s / Complete 12 M 11 .92 6 .92 SD 10.79 5.78 Quadr i p l e g i e s / Incomplete 12 M 16.08 10 .00 SD 19 .13 14.38 P a r a p l e g i c s / Complete 18 M 11.33 11.78 SD 9.84 11 .10 P a r a p l e g i c s / Incomplete 8 M 6 .25 8 .00 SD 9.77 7 .73 N o t e . Means a d j u s t e d f o r c o v a r i a t e ( i n j e c t a b l e a n a l g e s i c s ) . TABLE 14 SHAUGHNESSY HOSPITAL STUDY ANALYSIS OF VARIANCE AND COVARIANCE: NO^CMPLIANCE 106 SOURCE d f MS LEVEL (L) DEGREE (D) L X D COVARIATE ERROR 1 1 1 1 45 1.71 .71 25.76 2 .52 18 .59 < 1 < 1 1.39 < 1 ENVIRONMENT (E) 1 E x L 1 E x D 1 E X L x D 1 COVARIATE 1 ERROR 45 7 .89 1.44 2 .79 < 1 2 .77 < 1 .58 < 1 2 .41 < 1 5.47 N o t e . C o v a r i a t e = i n j e c t a b l e n a r c o t i c s . 107 ( v a r i a b l e s w h i c h r e p r e s e n t i n t e r n a l i m m o b i l i t y ) , F < 1 i n each c a s e . T h i s f i n d i n g was c o n t r a r y t o H y p o t h e s i s 1(d) w h i c h p r e d i c t e d t h a t i m m o b i l i t y would l e a d t o i n c r e a s e d noncompl iance . The L e v e l x Degree i n t e r a c t i o n (L x D) was a l s o n o n s i g n i f i c a n t , F ( 1 , 45) = 1 .39 . H y p o t h e s i s 3(b) p r e d i c t e d t h a t r e s t r i c t e d s t i m u l a t i o n would l e a d t o i n c r e a s e d noncompl iance . However, t h e r e was no main e f f e c t f o r e n v i r o n m e n t , the v a r i a b l e w h i c h r e p r e s e n t e d s t i m u l a t i o n l e v e l s , F ( 1 , 45) = 1 .44 , NS. A l l o f t h e o t h e r i n t e r a c t i o n s and the a n a l y s i s had an F < 1 . The a n a l y s i s w i t h o u t the c o v a r i a t e (Appendix G.13) was a lmost i d e n t i c a l t o t h e a n a l y s i s w i t h the c o v a r i a t e . The a d j u s t e d means f o r noncompliance (Table 15) resembled the p a t t e r n f o r s t r e s s (Table 13) more c l o s e l y than the p a t t e r n f o r imagery (Table 1 1 ) . I n the ICU e n v i r o n m e n t , the incomple te q u a d r i p l e g i c group had the h i g h e s t i n c i d e n c e o f noncompl iant behav iour and s t r e s s o f the f o u r g r o u p s , whereas complete q u a d r i p l e g i c s had the h i g h e s t i n c i d e n c e o f imagery . The complete p a r a p l e g i c group had a s l i g h t increment o f b o t h noncompl iant behav iour and s t r e s s on the ward as compared t o the ICU env i ronment , w h i l e a decrement o f imagery was r e c o r d e d . By c o n t r a s t , the incomple te p a r a p l e g i c s showed an increment o f imagery and s t r e s s f rom ICU t o the w a r d , and a c o r r e s p o n d i n g decrement o f noncompl iant b e h a v i o u r . 108 TABLE 15 SHAUGHNESSY HOSPITAL STUDY MEAN RECORDED NONCOMPLIANT BEHAVIOUR OVER TIME Group ENVIRONMENT L e v e l / D e g r e e o f I n j u r y n INTENSIVE CARE WARD Q u a d r i p l e g i c s / Complete 12 M 2 .00 1.33 SD 2 .83 2 .31 Q u a d r i p l e g i c s / Incomplete 12 M 3.25 2 .00 SD 5 .03 2.70 P a r a p l e g i c s / Complete 18 M 2.06 2 .61 SD 3.67 4 .00 P a r a p l e g i c s / Incomplete 8 M 1.50 0 .75 SD 3 .12 1.39 N o t e . Means a d j u s t e d f o r c o v a r i a t e ( i n j e c t a b l e a n a l g e s i c s ) . 109 Summary; Analysis of Variance Results for Study 2 The a n a l y s i s o f v a r i a n c e f o r S tudy 2 t e s t e d hypotheses r e l a t e d t o i m m o b i l i t y ( ca tegory 1) and the environment (ca tegory 3 ) . T h i s a n a l y s i s examined the e f f e c t s o f i n t e r n a l i m m o b i l i t y , o r p a r a l y s i s , through the v a r i a b l e s o f l e v e l ( q u a d r i p l e g i a v s . p a r a p l e g i a ) and degree (complete v s . incomplete) o f i n j u r y . The e n v i r o n m e n t a l v a r i a b l e was the change from i n t e n s i v e c a r e t o ward env i ronment , w h i c h o c c u r r e d over t i m e . H y p o t h e s i s 1(a) was s u p p o r t e d . P a t i e n t s w i t h the g r e a t e s t i n t e r n a l i m m o b i l i t y (h igh l e v e l and complete degree) had i n c r e a s e d imagery recorded by s t a f f i n the c h a r t s . H y p o t h e s i s 1(b) was n o t examined because c h a r t i n g on s t r e s s r e l a t e d t o imagery was t o o r a r e t o conduct an a n a l y s i s . H y p o t h e s i s 1(c) was n o t s u p p o r t e d . N e i t h e r l e v e l nor degree o f i n j u r y , w h i c h r e p r e s e n t e d i n t e r n a l i m m o b i l i t y , l e d t o i n c r e a s e d r e c o r d e d s t r e s s . H y p o t h e s i s 1(d) was n o t s u p p o r t e d . I m m o b i l i t y ( l e v e l and degree) d i d not l e a d t o i n c r e a s e d noncompl iant behav iour r e c o r d e d i n the c h a r t s . H y p o t h e s i s 3(a) was n o t c l e a r l y s u p p o r t e d . P a t i e n t s i n the i n t e n s i v e c a r e environment had g r e a t e r r ecorded imagery t h a n p a t i e n t s on t h e w a r d . However , the d a t a do n o t address whether t h i s f i n d i n g was due t o r e s t r i c t e d o r e x c e s s i v e e n v i r o n m e n t a l s t i m u l a t i o n . H y p o t h e s i s 3(b) was not s u p p o r t e d . There was no d i f f e r e n c e i n r e c o r d e d noncompl iant behav iour f o r p a t i e n t s i n the i n t e n s i v e c a r e environment as opposed t o the ward env i ronment . 110 S t e p w i s e R e g r e s s i o n A n a l y s i s The s t epwi se r e g r e s s i o n a n a l y s i s f o r S tudy 2 t e s t e d t h e same hypotheses as d i d the a n a l y s i s o f v a r i a n c e . However, the i m m o b i l i t y v a r i a b l e i n t h i s i n s t a n c e was the e x t e r n a l type ( i m m o b i l i z i n g a p p a r a t u s ) . To the e x t e n t p o s s i b l e , v a r i a b l e s were d e f i n e d so as t o p a r a l l e l those used f o r S tudy 1. F o r the r e g r e s s i o n a n a l y s i s i n S tudy 2 , the p r e d i c t o r s were s e x , age , employment s t a t u s , c o n c u s s i o n , s u r g e r y , days i n i n t e n s i v e c a r e , s l e e p d e p r i v a t i o n , days i m m o b i l i z e d i n a h o r i z o n t a l p o s i t i o n , and i m m o b i l i z i n g a p p a r a t u s . Imagery and Temperature R e g u l a t i o n . I n suppor t o f H y p o t h e s i s 1(a) w h i c h p r e d i c t e d a d i r e c t r e l a t i o n s h i p between i m m o b i l i t y and imagery , the o n l y v a r i a b l e w h i c h e n t e r e d the e q u a t i o n f o r imagery was appara tus (Table 1 6 ) . P a t i e n t s w i t h the g r e a t e s t r e s t r i c t i o n o f m o b i l i t y ( i . e . , those i n c e r v i c a l tongs o r h a l o r i n g apparatus) had the g r e a t e s t f requency o f imagery r e p o r t e d i n the c h a r t s . The number o f days i m m o b i l i z e d i n a h o r i z o n t a l p o s i t i o n d i d n o t p r e d i c t imagery f r e q u e n c y . H y p o t h e s i s 3(a) p r e d i c t e d t h a t r e s t r i c t e d s t i m u l a t i o n would l e a d t o i n c r e a s e d imagery . Two o f the v a r i a b l e s were i n d i c a t o r s o f e n v i r o n m e n t a l s t i m u l a t i o n l e v e l s : days i n i n t e n s i v e c a r e and s l e e p d e p r i v a t i o n . C o n t r a r y t o h y p o t h e s i s , the e n v i r o n m e n t a l s t i m u l a t i o n v a r i a b l e s d i d n o t p r e d i c t imagery s c o r e s . However, s l e e p d e p r i v a t i o n d i d p r e d i c t 10% o f the v a r i a n c e on a v a r i a b l e r e l a t e d t o imagery : temperature r e g u l a t i o n anomaly (Table 1 6 ) . T h i s p e r c e p t u a l a l t e r a t i o n , w h i c h was f r e q u e n t l y noted i n the c h a r t s , resembled t h e u n u s u a l body s e n s a t i o n s d e s c r i b e d i n the l i t e r a t u r e . I l l TABLE 16 Shaughnessy H o s p i t a l S tudy S tepwise R e g r e s s i o n A n a l y s i s : G e n e r a l P r e d i c t o r s IMAGERY (PATIENT CHARTS) STANDARDIZED REGRESSION INCREMENT I N PREDICTOR COEFFICIENT MULTIPLE R F-TO-ENTER Appara tus +.38 .14 8 .00 * C e r v i c a l t o n g s / h a l o r i n g v e r s u s o t h e r b M u l t i p l e R = .38 TEMPERATURE REGULATION ANOMALY STANDARDIZED REGRESSION INCREMENT I N PREDICTOR COEFFICIENT MULTIPLE R F-TO-ENTER S l e e p D e p r i v a t i o n +.31 .10 5.16 / N o t e . V a r i a b l e s w h i c h d i d n o t e n t e r the e q u a t i o n f o r e i t h e r a n a l y s i s above were : s e x , age, c o n c u s s i o n , s u r g e r y , days i n I C U , days i m m o b i l e , and employment s t a t u s . Multiple R = .31 112 S t r e s s and Noncompl iance , C o n t r a r y t o H y p o t h e s i s 1 ( c ) , t h e r e were no s i g n i f i c a n t p r e d i c t o r s o f the s t r e s s r ecorded i n the p a t i e n t c h a r t s . On r e c o r d e d noncompl iance , the o n l y v a r i a b l e t o e n t e r the e q u a t i o n was c o n c u s s i o n , a c c o u n t i n g f o r 26% o f the v a r i a n c e (Table 1 7 ) . Thus , p a t i e n t s who had a m i l d c o n c u s s i o n demonstrated g r e a t e r noncompliance than those w i t h no c o n c u s s i o n . C o n c u s s i o n r e f e r s t o a b low t o the head r e s u l t i n g i n l o s s o f c o n s c i o u s n e s s . O n l y p a t i e n t s w i t h m i l d c o n c u s s i o n (unconscious f o r no more t h a n a few minutes) were i n c l u d e d i n t h e s t u d y . The c o n c u s s i o n v a r i a b l e may be i m p o r t a n t on i t s own m e r i t o r because o f i t s r e l a t i o n s h i p t o the s e r i o u s n e s s o f an a c c i d e n t and consequent i n c r e a s e d i m m o b i l i t y . The i n t e r c o r r e l a t i o n m a t r i x (Appendix G.14) o f the 11 o r i g i n a l v a r i a b l e s (see method, p . 58) s e l e c t e d f o r t h i s a n a l y s i s shows t h a t c o n c u s s i o n was d i r e c t l y r e l a t e d t o the number o f f r a c t u r e s o t h e r than the s p i n a l i n j u r y , r_ = . 4 0 , £ < . 0 1 . Because e x t e r n a l i m m o b i l i t y i s used t o t r e a t f r a c t u r e s , the g r e a t e r the number o f o t h e r f r a c t u r e s , the g r e a t e r the i m m o b i l i t y . C o n c u s s i o n was a l s o c o r r e l a t e d w i t h b o t h type o f a c c i d e n t (r = - . 2 5 , £ < .05) and age (r = . 2 9 , £ < . 0 5 ) . The i n c i d e n c e o f c o n c u s s i o n was g r e a t e r f o r young p a t i e n t s who had nonwork-type a c c i d e n t s , o f w h i c h the m a j o r i t y were motor v e h i c l e a c c i d e n t s . H y p o t h e s i s 1(d) s t a t e d t h a t i m m o b i l i t y would l e a d t o i n c r e a s e d noncompl iant b e h a v i o u r . N e i t h e r days i m m o b i l i z e d i n a h o r i z o n t a l p o s i t i o n nor i m m o b i l i z i n g apparatus p r e d i c t e d noncompl iance . The f i n d i n g t h a t c o n c u s s i o n p r e d i c t e d noncompliance appears c o n s i s t e n t w i t h the h y p o t h e s i s , g i v e n t h a t c o n c u s s i o n c o r r e l a t e d w i t h the number o f TABLE 17 Shaughnessy Hosp i t a l Study Stepwise Regression A n a l y s i s : General Predic tors o f Noncompliance STANDARDIZED REGRESSION INCREMENT 2 PREDICTOR COEFFICIENT OF MULTIPLE R F-TO-ENTER Concussion +.51 .26 16.40 Note. None of the predictors entered the equation for the measure of stress from the charts. Multiple R = .51 114 f r a c t u r e s . In genera l , the more fractures a pa t i ent has, the greater the degree o f immobi l i ty . Hypothesis 3(b) predic ted that r e s t r i c t e d s t imula t ion would lead to increased noncompliant behaviour as recorded i n the pa t ient char t s . Neither of the environmental s t imula t ion var i ab le s were s i g n i f i c a n t pred ic tor s o f noncompliant behaviour i n t h i s a n a l y s i s . Summary: Stepwise Regression Results for Study 2 The regress ion ana lys i s provided further examination o f hypotheses re la ted to immobil i ty and the environment. Whereas the ana lys i s of variance examined i n t e r n a l immobi l i ty , the regress ion ana lys i s included two measures o f ex terna l immobi l i ty : number of days immobilized i n a h o r i z o n t a l p o s i t i o n and type o f immobil iz ing apparatus. Environmental va r i ab le s were the number of days i n intens ive care and sleep d e p r i v a t i o n . Hypothesis 1(a) was supported for the apparatus pred ic tor but was not supported by the number of days immobilized i n a h o r i z o n t a l p o s i t i o n . Pat ient s who were immobilized by c e r v i c a l t r a c t i o n (tongs or halo ring) had greater recorded imagery than pat ient s wi th another type o f ex terna l immobil i ty ( e . g . , Stryker frame). Hypothesis 1(c) was not supported. Neither of the immobil i ty va r i ab le s predicted s t ress scores . Hypothesis 1(d) was not supported. Neither measure o f ex terna l immobil i ty predicted noncompliant behaviour. However, the f ind ing that concussion predicted noncompliant behaviour could be interpreted as 115 c o n s i s t e n t w i t h h y p o t h e s i s 1 ( d ) . C o n c u s s i o n was c o r r e l a t e d w i t h the number o f f r a c t u r e s o t h e r t h a n the s p i n a l i n j u r y . S i n c e f r a c t u r e s a re t r e a t e d by i m m o b i l i z a t i o n , the g r e a t e r the number o f f r a c t u r e s , the g r e a t e r the i m m o b i l i t y . Thus , c o n c u s s i o n i s r e l a t e d t o b o t h i m m o b i l i t y and noncompl iance . H y p o t h e s i s 3(a) was n o t s u p p o r t e d . N e i t h e r days i n i n t e n s i v e c a r e nor s l e e p d e p r i v a t i o n p r e d i c t e d recorded imagery . However, s l e e p d e p r i v a t i o n d i d p r e d i c t temperature r e g u l a t i o n anomaly, a v a r i a b l e r e l a t e d t o imagery . H y p o t h e s i s 3(b) was a l s o unsuppor ted . The e n v i r o n m e n t a l s t i m u l a t i o n v a r i a b l e s - days i n i n t e n s i v e c a r e and s l e e p d e p r i v a t i o n -d i d n o t p r e d i c t noncompl iant b e h a v i o u r . M u l t i v a r i a t e A n a l y s i s o f V a r i a n c e The MANOVA was used t o examine the e f f e c t s o f i m m o b i l i t y a c r o s s t h r e e p a t i e n t groups ( g e n e r a l s u r g e r y , o r t h o p e d i c and s p i n a l c o r d i n j u r y ) on the d imens ions o f imagery a t the s u b s c a l e l e v e l o f the M o d i f i e d I m a g i n a l P r o c e s s e s I n v e n t o r y ( M I P I ) . The s i x s u b s c a l e s were : v i s u a l , a u d i t o r y , h a l l u c i n a t o r y v i v i d n e s s , k i n e s t h e t i c , hypnagogic and change i n dreams/daydreams i n h o s p i t a l . The f i r s t t h r e e s u b s c a l e s were t aken d i r e c t l y from S i n g e r and A n t r o b u s (1972) , w h i l e the l a t t e r s u b s c a l e s were deve loped f o r t h i s s t u d y . The t o t a l sample o f 67 p a t i e n t s f rom the two h o s p i t a l s i n c l u d e d 24 g e n e r a l s u r g e r y p a t i e n t s , 24 o r t h o p e d i c s u r g e r y p a t i e n t s and 19 s p i n a l c o r d i n j u r y p a t i e n t s . The d e c i s i o n t o conduct t h i s MANOVA was prompted by an i n i t i a l d e s c r i p t i v e e x a m i n a t i o n o f means (Table 18) w h i c h showed a 116 TABLE 18 MEAN IMAGERY SCORES ON SUBSCALES OF THE MIPI AS A FUNCTION OF IMMOBILITY LEVEL OF IMMOBILITY Imagery Dimensions I " T V i s u a l M 3.88 5 .54 7.00 SD 3 .28 3 .11 3.83 Auditory M 3.17 4 .63 5 .37 SD 2 .48 3.10 3.52 H a l l u c i n a t o r y Viv idness M 1.38 2 .58 4 .11 SD 2 .53 3.28 3.62 K i n e s t h e t i c M 2 .46 2 .75 3.16 SD 2 .00 1.42 2.29 Hypnagogic M 0 .50 0 .63 1.11 SD 0 .59 0 .79 1.10 Dreams/Daydreams M 0 .25 0.67 1.11 SD 0 .44 0.82 0 .81 Note. The MIPI has 50 items w i t h the followiwng component i tems/subscale: v i s u a l = 12; auditory - 12; h a l l u c i n a t o r y v iv idness = 12 ; k i n e s t h e t i c = 9 ; hypnagogic = 3 ; and change i n dreams/daydreams s ince h o s p i t a l i z a t i o n = 2 . Maximum t o t a l score = 50 . a M o b i l e surgery p a t i e n t s , U n i v e r s i t y H o s p i t a l , n = 24 . Immobile orthopedic p a t i e n t s , U n i v e r s i t y H o s p i t a l , n = 24 . cImmobile s p i n a l cord i n j u r y p a t i e n t s , Shaughnessy H o s p i t a l , n = 19 . 117 c o n s i s t e n t increment i n the mean s c o r e f o r each o f the s u b s c a l e s as i m m o b i l i t y i n c r e a s e d f rom the g e n e r a l s u r g e r y group through the o r t h o p e d i c group t o the s p i n a l c o r d i n j u r y g roup . The MANOVA f o r the two extreme groups on the i m m o b i l i t y cont inuum, g e n e r a l s u r g e r y v e r s u s s p i n a l c o r d i n j u r y p a t i e n t s , r e v e a l e d an i m m o b i l i t y e f f e c t w i t h H o t e l l i n g s F = 3 .34 , £ < . 0 1 . U n i v a r i a t e a n a l y s e s o f s i m p l e e f f e c t s f o r each o f the s u b s c a l e s appear on T a b l e 19 . W i t h the e x c e p t i o n o f the k i n e s t h e t i c s u b s c a l e , t h e r e were s i g n i f i c a n t d i f f e r e n c e s between groups f o r each s u b s c a l e so t h a t s p i n a l c o r d i n j u r y p a t i e n t s ( i . e . , h i g h i m m o b i l i t y ) had g r e a t e r imagery than g e n e r a l s u r g e r y p a t i e n t s on f i v e o f s i x d imens ions on the imagery q u e s t i o n n a i r e . The r e s u l t s were as f o l l o w s : v i s u a l imagery - F (1 , 41) = 8 . 3 2 , £ < . 0 1 ; a u d i t o r y imagery - F ( 1 , 41) = 5 . 7 9 , £ < . 0 5 ; h a l l u c i n a t o r y v i v i d n e s s - F ( 1 , 41) = 8 . 4 5 , £ < . 0 1 ; k i n e s t h e t i c imagery - F (1 , 41) = 1 .14 , NS; hypnagogic imagery - F ( 1 , 41) = 5 . 3 5 , £ < . 0 5 ; dreams and daydreams - F ( 1 , 41) = 1 9 . 5 2 , £ < . 0 0 1 . N e i t h e r MANOVA f o r the o t h e r two p a i r s o f the t h r e e i m m o b i l i t y groups was s i g n i f i c a n t on the imagery q u e s t i o n n a i r e . The d i f f e r e n c e i n i m m o b i l i t y d i d n o t a f f e c t the i n c i d e n c e o f imagery f o r e i t h e r the g e n e r a l s u r g e r y v e r s u s o r t h o p e d i c a n a l y s i s , H o t e l l i n g s F = 1 .23 , NS; o r the o r t h o p e d i c v e r s u s s p i n a l c o r d i n j u r y a n a l y s i s , H o t e l l i n g s F < 1. Because no i n i t i a l d i f f e r e n c e s emerged, no s i m p l e e f f e c t s were computed f o r the s u b s c a l e s . TABLE 19 Shaughnessy H o s p i t a l S tudy S imple E f f e c t s : Dimensions o f Imagery (MIPI) - Surgery v s S p i n a l C o r d I n j u r y P a t i e n t s V a r i a b l e MS (Hypoth.) MS ( E r r o r ) F V i s u a l imagery 103.56 12.45 8 . 3 2 * * A u d i t o r y imagery 51.41 8.87 5 . 7 9 * H a l l u c i n a t o r y v i v i d n e s s 79.05 9.35 8 . 4 5 * * K i n e s t h e t i c imagery 5.19 4 .55 1.14 Hypnagogic imagery 3.89 .73 5 . 3 5 * Dreams and daydreams 7.76 .40 1 9 . 5 2 * * * N o t e . The above u n i v a r i a t e ana lyse s (df = 1, 41) were conducted a f t e r a s i g n i f i c a n t i m m o b i l i t y e f f e c t was found on the MANOVA: H o t e l l i n g s F = 3 .34 , p_ = . 0 1 . * < .05 * * < .01 * * * < .001 119 I n summary, t h e m u l t i v a r i a t e a n a l y s i s o f v a r i a n c e p r o v i d e d f u r t h e r s u p p o r t f o r h y p o t h e s i s 1 ( a ) . E x a m i n a t i o n o f imagery s u b s c a l e s (MIPI) f o r t h r e e p a t i e n t samples , who d i f f e r e d i n degree o f i m m o b i l i t y , r e v e a l e d a c o n s i s t e n t increment i n means as i m m o b i l i t y i n c r e a s e d . The s p i n a l c o r d i n j u r y g r o u p , w h i c h had the g r e a t e s t i m m o b i l i t y , r e p o r t e d s i g n i f i c a n t l y more imagery than the m o b i l e , s u r g e r y group on f i v e o f s i x s u b s c a l e s . Correlation Analyses I n an at tempt t o e x p l o r e the c o n t r i b u t i o n o f r e s t r i c t e d v e r s u s e x c e s s i v e s t i m u l a t i o n , s l e e p d e p r i v a t i o n was examined i n b o t h s t u d i e s . T h i s v a r i a b l e emerged as i m p o r t a n t f rom b o t h p a t i e n t i n t e r v i e w s and r e c o r d s i n c h a r t s . S l e e p d e p r i v a t i o n , w h i c h presumably l e a d s t o s t i m u l u s o v e r l o a d ( S u e d f e l d , 1980) , c an be s t u d i e d as e i t h e r an independent o r dependent v a r i a b l e . I n the p r e s e n t i n s t a n c e , i t i s a n a l y z e d as a dependent v a r i a b l e . However, the assumed r e l a t i o n s h i p w i t h o v e r l o a d , based on the i n c r e a s e d a t t e n t i o n a l demands i n a 24-hour p e r i o d , a l s o acknowledges t h a t s l e e p d e p r i v a t i o n has an independent e f f e c t . S l e e p D e p r i v a t i o n . F o r Study 1, s l e e p d e p r i v a t i o n d a t a were o b t a i n e d from the change i n s l e e p s e c t i o n o f the i n t e r v i e w (ESS) . S l e e p d e p r i v a t i o n was examined as a dependent v a r i a b l e i n t h e s tepwise r e g r e s s i o n a n a l y s i s w i t h 10 g e n e r a l p r e d i c t o r s . T a b l e 20 shows t h a t independence c o n t r i b u t e d t o 19% o f the v a r i a n c e , w h i l e a p r i v a t e room c o n t r i b u t e d 9%. That i s , p a t i e n t s who were r a t e d as independent by nurses and who were i n a p r i v a t e room tended t o have i n c r e a s e d s l e e p d i s t u r b a n c e . T A B L E 20 UNIVERSITY HOSPITAL STUDY STEPWISE REGRESSION ANALYSIS: GENERAL PREDICTORS OF SLEEP DEPRIVATION (ESS) STANDARDIZED REGRESSION INCREMENT IN PREDICTOR CQEFFIECIENT MULTIPLE R F-TO-ENTER INDEPENDENCE + .44 .19 8.01 PRIVATE ROOM - .32 .10 4.66 PREDICTORS COMBINED .29 Multiple R: Step 1 = .44; Step 2 = .54. 121 Study 2 i n c l u d e d a t ime span o f the f i r s t e i g h t weeks o f h o s p i t a l i z a t i o n . I n t e r c o r r e l a t i o n m a t r i c e s were deve loped week ly and as a compos i te e ight-week m a t r i x (Table 21) t o show the r e l a t i o n s h i p over t i m e o f s l e e p d e p r i v a t i o n and the dependent v a r i a b l e s : imagery , s t r e s s and noncompl iant b e h a v i o u r . On the compos i te m a t r i x , s l e e p d e p r i v a t i o n was d i r e c t l y r e l a t e d t o each o f the dependent v a r i a b l e s : imagery , £ = . 3 0 , £ < . 0 5 ; s t r e s s , £ = . 2 9 , £ < . 0 5 ; and noncompl iance , £ = . 2 3 , £ < . 0 5 . The p a t t e r n o f i n t e r c o r r e l a t i o n s over t ime was g e n e r a l l y p o s i t i v e up t o week s i x and then moved i n a n e g a t i v e d i r e c t i o n , a l b e i t n o n s i g n i f i c a n t , through week e i g h t . Imagery was d i r e c t l y r e l a t e d t o s l e e p d e p r i v a t i o n on week o n e , £ = . 2 8 , £ < . 0 5 ; week t h r e e , r_ = . 5 2 , £ < . 0 0 1 ; week f o u r , £ = . 4 6 , £ < . 0 0 1 ; and week s i x , £ = . 4 9 , £ < . 0 0 1 . T h i s suggests t h a t s l e e p d e p r i v a t i o n and a s s o c i a t e d s t i m u l u s o v e r l o a d may be an e x p l a n a t o r y f a c t o r i n the a n a l y s i s o f v a r i a n c e f i n d i n g s on imagery . S t r e s s a l s o c o r r e l a t e d w i t h s l e e p d e p r i v a t i o n on week one , r_ = . 4 2 , £ < . 0 0 1 ; week f o u r , £ = . 4 5 , £ < . 0 0 1 ; week s i x , £ = . 4 1 , £ < . 0 1 ; and week seven , £ = . 4 4 , £ < . 0 0 1 . F i n a l l y , noncompliance had a p o s i t i v e c o r r e l a t i o n w i t h s l e e p d e p r i v a t i o n on week t h r e e , £ = . 5 4 , £ < . 0 0 1 . Imagery, S t r e s s and Noncompl iance . The o r i g i n a l t h r e e dependent v a r i a b l e s i n t h i s p r o j e c t were h y p o t h e s i z e d as e f f e c t s o f i m m o b i l i t y . As concomi tan t e f f e c t s , these v a r i a b l e s c o u l d be expected t o be i n t e r c o r r e l a t e d . 122 T A B L E 21 SHAUGHNESSY HOSPITAL STUDY INTERCORRELATION MATRIX: DEPENDENT VARIABLES AND SLEEP DEPRIVATION VARIABLE 2 3 4 WEEK ONE OF HOSPITALIZATION (N = 50) 1. IMAGERY .17 .27* .28* 2. STRESS . 4 4 * * * .42*** 3. NONCOMPLIANCE .20 4 . SLEEP DEPRIVATION WEEK TWO CF HOSPITALIZATION (N = 50) 1. IMAGERY .23 -.06 -.04 2. STRESS . 4 4 * * * .22 3. NO^CMPLIANCE .10 4 . SLEEP DEPRIVATION WEEK THREE OF HOSPITALIZATION (N = 50) 1. IMAGERY .01 .17 .52*** 2. STRESS .57*** .19 3. NONCC^LIANCE .54*** 4 . SLEEP DEPRIVATION * £ < .05 ** £ < .01 *** £ < .001 TABLE 21 (GONnNDED) VARIABLE 2 3 4 WEEK FOUR OF HOSPITALIZATION (N = 50) 1. IMAGERY . 3 9 * * . 2 8 * . 4 6 * * * 2 . STRESS . 5 4 * * * . 4 5 * * * 3 . NCMZOMPLIANCE . 5 3 * * * 4 . SLEEP DEPRIVATION WEEK F I V E OF HOSPITALIZATION (N = 50) 1. IMAGERY .01 _ . 0 1 .10 2 . STRESS . 2 7 * .16 3 . NONCOMPLIANCE .04 4 . SLEEP DEPRIVATION WEEK SIX OF HOSPITALIZATION (N = 50) 1. IMAGERY .13 .11 . 4 9 * * * 2 . STRESS . 6 2 * * * . 4 1 * * 3 . NONCOMPLIANCE .01 4 . SLEEP DEPRIVATION * £ < .05 * * £ < .01 * * * £ < .001 TABLE 21 (CONTINUED) VARIABLE WEEK SEVEN CF HCSPITALIZATION (N = 50) 1. IMAGERY . 3 6 * * - . 0 6 - . 0 8 2 . STRESS - . 0 3 . 4 4 * * * 3 . NONCOMPLIANCE _ . U 4 . SLEEP DEPRIVATION WEEK EIGHT OF HOSPITALIZATION (N = 50) 1. IMAGERY .00 2 . STRESS 3 . NONCOMPLIANCE 4 . SLEEP DEPRIVATION - . 0 6 - . 0 7 .20 - . 1 5 - . 0 7 TOTAL: FIRST EIGHT WEEKS IN HOSPITAL (N = 50) 1. IMAGERY .17 .16 . 3 0 * 2 . STRESS . 6 6 * * * . 2 9 * 3 . NONCOMPLIANCE . 2 3 * 4 . SLEEP DEPRIVATION * £ < .05 * * £ < .01 * * * £ < .001 125 Imagery and s t r e s s were p o s i t i v e l y c o r r e l a t e d i n week f o u r , £ = . 3 9 , p < . 0 5 ; and week seven ( £ = . 3 6 , £ < . 0 1 ) , b u t n o t i n any o f the o t h e r weeks o r i n the compos i te m a t r i x . An i r r e g u l a r d i r e c t r e l a t i o n s h i p a l s o was e v i d e n t between imagery and noncompl iance , w i t h s i g n i f i c a n t c o r r e l a t i o n s o n l y on week one , £ = . 2 7 , £ < . 0 5 ; and week f o u r , £ = . 2 8 , £ < . 0 5 . There was no r e l a t i o n s h i p on the compos i te m a t r i x . A more s t r i k i n g p o s i t i v e r e l a t i o n s h i p was demonstrated between s t r e s s and noncompl iance , w i t h s i g n i f i c a n t c o r r e l a t i o n s i n each o f the f i r s t s i x weeks o f h o s p i t a l i z a t i o n . These c o r r e l a t i o n s ranged from £ = . 2 7 , £ < .05 (week 5) t o £ = . 6 2 , £ < .001 (week 6) w i t h 5 o f 6 c o r r e l a t i o n s b e i n g s i g n i f i c a n t a t the .001 l e v e l . O v e r a l l , t h e compos i te r e l a t i o n s h i p , w h i c h was based on t h e t o t a l s c o r e s f o r the f i r s t e i g h t weeks i n h o s p i t a l , was £ = . 6 6 , £ < . 0 0 1 . I n summary, the c o r r e l a t i o n a l a n a l y s e s showed t h a t independence and a p r i v a t e room c o n t r i b u t e d t o s l e e p d e p r i v a t i o n i n Study 1; and t h a t s l e e p d e p r i v a t i o n was c o r r e l a t e d w i t h a l l t h r e e dependent v a r i a b l e s (Study 2) over an 8-week p e r i o d . O v e r a l l , imagery i n S tudy 2 was n o t s i g n i f i c a n t l y c o r r e l a t e d w i t h e i t h e r s t r e s s o r noncompl iance , bu t the l a t t e r two v a r i a b l e s were h i g h l y c o r r e l a t e d w i t h each o t h e r . 126 Summary: Results frcm 2 Studies The r e s u l t s from analyses of Study 1 (Univers i ty Hospita l ) and Study 2 (Shaughnessy Hospita l ) w i l l be summarized according to the hypotheses o f t h i s p r o j e c t . Study 1 examined ex terna l immobil i ty (bedrest, t rac t ion) and Study 2 inves t igated both ex terna l and i n t e r n a l (paralysis) immobi l i ty . Category 1: Hypotheses Related to Immobility Hypothesis 1(a) predic ted that immobil i ty would lead to increased imagery. This hypothesis received support frcm both studies on analyses of ex terna l and i n t e r n a l immobi l i ty . In the ana lys i s of variance for Study 1 , there was a main e f fec t for immobi l i ty . That i s , pa t ient s who were immobilized for f i v e days or more had greater se l f - repor ted imagery on the Modif ied Imaginal Processes Inventory (MIPI) than d i d pa t ient s who were mobi l ized w i t h i n two days. A subs id iary ana lys i s o f imagery dimensions, as measured by MIPI subscales, included three pa t i en t groups which d i f f e r e d i n degree o f immobi l i ty : the two groups from Study 1 and a t h i r d group from Study 2 . As immobil i ty increased, there were cons i s tent increments i n mean imagery scores on each o f the s i x dimensions. M u l t i v a r i a t e ana lys i s of variance revealed that the s p i n a l cord i n j u r y p a t i e n t s , who had the greatest immobi l i ty , reported s i g n i f i c a n t l y more imagery on 5 o f 6 subscales than d i d mobile p a t i e n t s . The general regress ion ana lys i s for Study 1 d i d not lend further support to hypothesis 1 ( a ) . Of the ten poss ib le p r e d i c t o r s , t r a c t i o n (the ind ica tor o f externa l immobility) d i d not emerge as a s i g n i f i c a n t 127 p r e d i c t o r o f imagery on the M I P I . F i f t e e n o f the 24 immobi le p a t i e n t s (63%) were i m m o b i l i z e d i n t r a c t i o n . The a n a l y s i s o f v a r i a n c e f o r S tudy 2 p r o v i d e d f u r t h e r suppor t f o r h y p o t h e s i s 1 ( a ) . There were main e f f e c t s f o r l e v e l and degree o f i n j u r y (which r e p r e s e n t e d i n t e r n a l i m m o b i l i t y ) on imagery recorded i n the c h a r t s . P a t i e n t s w i t h a h i g h l e v e l ( q u a d r i p l e g i a ) and complete degree o f i n j u r y had the g r e a t e s t r ecorded imagery . On the r e g r e s s i o n a n a l y s i s f o r S tudy 2 , h y p o t h e s i s 1(a) was suppor ted on one e x t e r n a l i m m o b i l i t y v a r i a b l e , type o f a p p a r a t u s , b u t n o t on the second v a r i a b l e , number o f days i m m o b i l i z e d i n h o r i z o n t a l p o s i t i o n . The appara tus v a r i a b l e had a b i n a r y c a t e g o r i z a t i o n : c e r v i c a l t r a c t i o n (tongs o r h a l o r i n g ) v e r s u s o t h e r . P a t i e n t s i m m o b i l i z e d i n c e r v i c a l tongs o r a h a l o r i n g had g r e a t e r imagery than those who had o t h e r types o f e x t e r n a l i m m o b i l i t y , such as a S t r y k e r f rame. T h i s f i n d i n g does not c o n t r a d i c t the r e g r e s s i o n r e s u l t s from S tudy 1, i n w h i c h t r a c t i o n f a i l e d t o p r e d i c t imagery . I n S tudy 1, o f the 15 p a t i e n t s i n t r a c t i o n , o n l y f o u r were i m m o b i l i z e d i n h a l o c e r v i c a l t r a c t i o n . These r e s u l t s suggest t h a t t r a c t i o n i n g e n e r a l does n o t p r e d i c t imagery , b u t c e r v i c a l t r a c t i o n i n p a r t i c u l a r i s p r e d i c t i v e o f imagery . H y p o t h e s i s 1(b) p r e d i c t e d t h a t i m m o b i l i t y would l e a d t o i n c r e a s e d s t r e s s r e l a t e d t o imagery . T h i s h y p o t h e s i s was n o t s u p p o r t e d . I n Study 1, c o n t r a r y t o h y p o t h e s i s , immobile p a t i e n t s d i d not r e p o r t g r e a t e r s t r e s s r e l a t e d t o imagery than d i d m o b i l e p a t i e n t s on i n t e r v i e w ( subsca le IV o f the E n v i r o n m e n t a l S t r e s s S c a l e ) . However, 128 immobil i ty d i d lead to increased environmental s t ress re la ted to personal c o n t r o l and response r e s t r i c t i o n (subscale I I I ) . Study 2, which r e l i e d on data from the c h a r t s , d i d not provide s u f f i c i e n t notat ions on s t ress re l a ted to imagery to meri t a n a l y s i s . Chart ing tended to i d e n t i f y d i s t r e s s without i n d i c a t i n g the s p e c i f i c source. Hypothesis 1(c) predic ted that immobil i ty would lead to increased s t r e s s . This hypothesis was not supported on ana lys i s of variance or regress ion analyses from e i t h e r Study 1 or Study 2. Neither externa l immobil izing devices nor extent of p a r a l y s i s predic ted s t r e s s . Hypothesis 1(d) pred ic ted that immobil i ty would lead to increased noncompliant behaviour. This hypothesis was not supported on the ana lys i s of variance for Study 1 or Study 2. However, i n the regress ion ana lys i s for Study 2, concussion predicted noncompliance. This f ind ing was cons i s tent w i t h the hypothesis i n that concussion was a l so cor re l a ted wi th an ind ica tor o f degree of immobi l i ty : the number of f ractures other than the s p i n a l i n j u r y . The l a t t e r v a r i a b l e was not included i n the regress ion ana lys i s because i t cor re la ted wi th severa l of the p r e d i c t o r s . Category 2: Hypothesis Related to the Intervention (Study 1) Hypothesis 2 (a) predic ted that the cogn i t ive in te rvent ion would lead to decreased s t ress re l a ted to imagery. Contrary to hypothesis , *" the in te rvent ion group d i d not report decreased s t ress r e l a ted to imagery on interview (subscale IV of the ESS). 129 Hypothesis 2 (b ) , which predic ted that the in te rvent ion would lead to decreased s t re s s , was supported on the measure of Subject ive Stress (SSS), but not on Environmental Stress Scale (ESS - to t a l ) nor on the nurse record i n the pa t ient charts (Distress Record). The in te rvent ion was based on laboratory studies i n which expectations for imagery i n r e s t r i c t e d s t imula t ion environments neut ra l i zed negative reac t ions . To examine the r e l a t i o n s h i p between expectations and react ions i n Study 1, the interv iew (ESS) included questions on expectations and previous h o s p i t a l i z a t i o n s . An i n t e r c o r r e l a t i o n matr ix showed that pa t ient s who had not been prev ious ly h o s p i t a l i z e d had higher reac t ion (stress) scores than those w i t h h o s p i t a l i z a t i o n experience. However, t h i s measure d i d not c o r r e l a t e w i t h the expectation scores . Neither were expectations cor re l a ted wi th occupation or rura l-urban residence. On the other hand, the t o t a l expectat ion score was d i r e c t l y re l a ted to the t o t a l react ion score . That i s , pa t ient s w i t h high environmental s t ress tended to have unmet expectat ions . The expectat ion-react ion c o r r e l a t i o n was a l so found w i t h i n subscale I (personal space and privacy) and subscale I I I (personal c o n t r o l and response r e s t r i c t i o n ) of the ESS. Category 3 : Hypotheses Related t o the Environment Hypothesis 3 (a) s tated that r e s t r i c t e d environmental s t imula t ion would be p r e d i c t i v e of increased imagery. In Study 1, the regress ion ana lys i s for dimensions of s o c i a l and nonsocia l s t imula t ion provided support for the converse of t h i s hypothesis . That i s , high rather than low l e v e l s of s o c i a l s t imula t ion predicted imagery (MIPI). The 130 dimens ions o f s t i m u l a t i o n w h i c h p r e d i c t e d imagery were : o t h e r - d i r e c t e d s o c i a l s t i m u l a t i o n , v a r i e t y o u t s i d e the observed p a t i e n t ' s space and v a r i e t y i n s i d e the p a t i e n t space . E i t h e r the h y p o t h e s i s as s t a t e d o r t h e converse h y p o t h e s i s a re c o n s i s t e n t w i t h the t h e o r y o f an o p t i m a l l e v e l o f s t i m u l a t i o n . A f u r t h e r p r e d i c t o r o f imagery was low c o n t r o l o p t i o n s over n o n s o c i a l s t i m u l i , as measured by the re spons ivenes s (NSR) d i m e n s i o n . The l a t t e r f i n d i n g was c o n s i s t e n t w i t h the t h e o r y o f an o p t i m a l l e v e l o f p e r s o n a l c o n t r o l . S tudy 2 d i d n o t suppor t h y p o t h e s i s 3 ( a ) . The a n a l y s i s o f v a r i a n c e r e v e a l e d a main e f f e c t f o r environment on the imagery v a r i a b l e . I n t e n s i v e c a r e p a t i e n t s had g r e a t e r r ecorded imagery than p a t i e n t s i n the ward env i ronment . However, t h e r e was no d i r e c t ev idence p r o v i d e d on whether the i n t e n s i v e c a r e environment r e p r e s e n t e d r e s t r i c t e d o r e x c e s s i v e s t i m u l a t i o n . The r e g r e s s i o n a n a l y s i s d i d n o t suppor t h y p o t h e s i s 3 ( a ) . N e i t h e r o f the i n d i c a t o r s o f e n v i r o n m e n t a l s t i m u l a t i o n l e v e l s (days i n i n t e n s i v e c a r e o r s l e e p d e p r i v a t i o n ) p r e d i c t e d the imagery r e c o r d i n the c h a r t s . S l e e p d e p r i v a t i o n , on the o t h e r hand , p r e d i c t e d a v a r i a b l e w h i c h appeared r e l a t e d t o imagery : temperature r e g u l a t i o n anomaly. H y p o t h e s i s 3(b) p r e d i c t e d t h a t r e s t r i c t e d e n v i r o n m e n t a l s t i m u l a t i o n would l e a d t o i n c r e a s e d noncompl iant b e h a v i o u r . T h i s h y p o t h e s i s r e c e i v e d p a r t i a l suppor t from S tudy 1, b u t was unsupported i n S tudy 2 . I n suppor t o f h y p o t h e s i s 3 ( b ) , the s t i m u l a t i o n r e g r e s s i o n a n a l y s i s i n S tudy 1 showed t h a t low v a r i e t y o f n o n s o c i a l s t i m u l a t i o n was p r e d i c t i v e o f s e l f - r e p o r t e d noncompliance (ESS) . The conver se o f 131 h y p o t h e s i s 3 ( b ) , r e l a t i n g h i g h r a t h e r than low l e v e l s o f s t i m u l a t i o n t o noncompl iance , would a l s o be c o n s i s t e n t w i t h the o p t i m a l l e v e l o f s t i m u l a t i o n framework. I n l i n e w i t h the converse o f h y p o t h e s i s 3 ( b ) , h i g h l e v e l s o f n o n s o c i a l n o i s e p r e d i c t e d roncompl iance r ecorded i n the p a t i e n t c h a r t s . S tudy 2 d i d n o t suppor t h y p o t h e s i s 3(b) on e i t h e r the a n a l y s i s o f v a r i a n c e o r r e g r e s s i o n a n a l y s i s . I n the former a n a l y s i s , t h e r e was no environment e f f e c t ( i n t e n s i v e c a r e v s . ward) on noncompl iant b e h a v i o u r . I n the l a t t e r a n a l y s i s , n e i t h e r days o f i n t e n s i v e c a r e nor s l e e p d e p r i v a t i o n p r e d i c t e d noncompl iant b e h a v i o u r . The i n t e n s i v e c a r e v a r i a b l e d i f f e r e d i n these two a n a l y s e s because the former a n a l y s i s reduced s c o r e s t o a common m e t r i c by c o r r e c t i o n f o r t i m e , whereas the second a n a l y s i s examined the t ime d u r a t i o n s p e c i f i c a l l y . R e s t r i c t e d S t i m u l a t i o n v e r s u s O v e r l o a d T o ' f u r t h e r e x p l o r e the r e l a t i v e c o n t r i b u t i o n o f s ensory r e s t r i c t i o n v e r s u s o v e r l o a d , the v a r i a b l e s l e e p d e p r i v a t i o n was examined. S l e e p d e p r i v a t i o n c o n t r i b u t e s t o o v e r l o a d because o f the i n c r e a s e d a t t e n t i o n a l demands r e q u i r e d over t ime when one would o t h e r w i s e be a s l e e p . I n S tudy 1, s l e e p d e p r i v a t i o n was more p r e v a l e n t f o r h i g h l y independent p a t i e n t s i n a p r i v a t e room. I n t h i s i n s t a n c e , i t appears t h a t the low s t i m u l a t i o n o f a p r i v a t e room c o n t r i b u t e s t o s l e e p d e p r i v a t i o n . Over the f i r s t e i g h t weeks o f h o s p i t a l i z a t i o n i n Study 2 , each o f the t h r e e dependent v a r i a b l e s was d i r e c t l y c o r r e l a t e d w i t h s l e e p d e p r i v a t i o n . I n t e r c o r r e l a t i o n s between the dependent v a r i a b l e s showed t h a t s t r e s s and noncompl iant behav iour were h i g h l y c o r r e l a t e d , b u t imagery was not 132 re l a ted to e i ther s t ress or noncompliant behaviour on the composite c o r r e l a t i o n matr ix for e ight weeks. On the weekly c o r r e l a t i o n matr ices , imagery corre la ted w i t h s t ress and noncompliance on two of e ight weeks, whereas a d i r e c t r e l a t i o n s h i p between imagery and sleep depr iva t ion was found on four weeks. During the f i r s t week of h o s p i t a l i z a t i o n , when pat ients were i n the intens ive care u n i t , a s i g n i f i c a n t c o r r e l a t i o n between imagery and sleep depr iva t ion was found. This suggests that st imulus overload may contr ibute to imagery e f fect s i n intens ive care more than st imulus r e s t r i c t i o n . Imagery during week one was a l so d i r e c t l y re l a ted to noncompliance but not to s t re s s . In an attempt to determine the s tress p o t e n t i a l of st imulus r e s t r i c t i o n versus over load, an exploratory s t imula t ion regress ion ana lys i s was done on s tress measures for Study 1. The f indings c o n s i s t e n t l y pointed to high l e v e l s of s t imula t ion as p red ic tor s of se l f - repor ted s tress (ESS, SSS), which suggests that overload i s a s tressor i n the h o s p i t a l environment. On in terv iew, s t res s r e l a t e d to personal space and pr ivacy was predicted by high v a r i e t y of nonsocia l s t i m u l a t i o n . High l e v e l s of s o c i a l s t imula t ion d i rec ted at the p h y s i c a l environment predic ted s tress re la ted to imagery and dreams. Nonsocial noise and other-d i rec ted s o c i a l s t imula t ion ( soc i a l "noise") predicted subject ive s tress on the quest ionnaire . Category 4; Hypotheses Related t o L i f e Stress (Study 1) Hypothesis 4(a) predic ted that previous l i f e s t ress would lead to increased imagery. Consistent wi th the hypothesis , high negative change scores ( l i f e stress) on the LES predicted imagery (MIPI). Age a l so 133 predic ted imagery, w i t h young pat ient s having higher imagery scores . Hypothesis 4(b), which predicted that previous l i f e s t ress would be re l a ted to s tress during and a f ter h o s p i t a l i z a t i o n , was supported on the post-discharge measure but not on the measures taken i n h o s p i t a l . Pa t ient s who had high l i f e s t ress during the year p r i o r to h o s p i t a l i z a t i o n tended to have lower adjustment scores ( i . e . , high stress) two months a f ter discharge from h o s p i t a l . Previous l i f e s t ress d i d not p r e d i c t any o f the three measures taken whi le i n h o s p i t a l (ESS, SSS, D i s t r e s s Record). Category 5: Hypothesis Related to Personal Control (Study 1) Hypothesis 5 pred ic ted that high personal c o n t r o l would lead to decreased s t r e s s . Consistent wi th the hypothesized inverse r e l a t i o n s h i p , helplessness (low control ) predicted environmental s t res s i n general (ESS - to t a l ) and s t res s re l a ted to environmental s t i m u l a t i o n l e v e l s (ESS - subscale I I ) . Further support for hypothesis 5 was found i n that low independence (low control ) predic ted s t ress r e l a ted to personal c o n t r o l and response r e s t r i c t i o n (subscale I I I of the ESS). There was no r e l a t i o n s h i p between c o n t r o l and the other s t ress measures i n h o s p i t a l (SSS, D i s t re s s Record) or post-discharge (PAIS). 134 DISCUSSION The r e s u l t s from the two studies i n t h i s research pro jec t provide some support for hypotheses w i t h i n each of the f i v e categories of independent var i ab le s examined. In genera l , these f indings suggest that the model of p h y s i c a l i l l n e s s as c r i s i s (Moos & Tsu, 1977) has a p p l i c a b i l i t y to emergency-admitted pat ients who d i f f e r i n degree of immobi l i ty . The in te rvent ion tested here, which encouraged cogn i t ive r eappra i s a l , was e f f e c t i v e i n reducing subject ive s tress i n p a t i e n t s . The c r i s i s model of Moos and Tsu w i l l form the o rgan iza t iona l framework for the d i scuss ion of r e s u l t s . T i i r e ^ ^ R e i a r e d F a c t o r s Immobil i ty, which was the major v a r i a b l e i n t h i s s e c t i o n , does not neces sar i ly r e s u l t from an i l l n e s s per se. Many of the pa t ient s i n the present research pro jec t were trauma cases (see Appendix F ) . The " i l l n e s s - r e l a t e d " f a c to r s , as defined here, included var i ab le s which re l a ted to some aspect of treatment during h o s p i t a l i z a t i o n for the i l l n e s s or i n j u r y which p r e c i p i t a t e d admission. Immobility (Study 1) was defined as f i v e or more days o f complete bedrest which may or may not involve an externa l immobil iz ing device . For s p i n a l cord i n j u r y pat ient s i n Study 2, the immobil i ty v a r i a b l e included the l e v e l of i n j u r y to the s p i n a l cord ( c e r v i c a l v s . lumbar) and the degree of neuro log ica l d e f i c i t (complete v s . incomplete) at that l e v e l . Other var i ab le s were: t r a c t i o n , type of apparatus, number of days immobil ized, and surgery. The r a t i o n a l e for examining severa l 135 immobi l i ty-re la ted var iab le s was to a s s i s t i n the explanation of whether an immobil i ty e f f ec t was due to the type or durat ion o f immobi l i ty . The surgery v a r i a b l e was included to c o n t r o l for extraneous variance because i t was impossible to obta in a homogenous sample i n r e l a t i o n to surgery. E x t e r n a l and I n t e r n a l Immobility Examination of immobil i ty as both externa l ( tract ion) and i n t e r n a l (paralysis) r e s t r i c t i o n , revealed a s i m i l a r pat tern of imagery f indings i n the two types of immobi l i ty , but a d i f ference i n degree (incidence and vividness) of e f f e c t . The gradient of means (Table 18) for the three pa t i en t groups on the s i x subscales of the imagery quest ionnaire i l l u s t r a t e s t h i s p o i n t . Of the three groups, two were e x c l u s i v e l y e x t e r n a l l y r e s t r i c t e d , whereas the t h i r d had both externa l and i n t e r n a l r e s t r i c t i o n . However, the pa t tern of an increment i n mean imagery scores across modality i s s i m i l a r between the two e x t e r n a l l y r e s t r i c t e d groups as i t i s between the ex terna l and i n t e r n a l / e x t e r n a l r e s t r i c t i o n groups. Previous research has not made the comparison between the e f fec t s o f i n t e r n a l and ex terna l immobi l i ty . The exploratory f indings presented here suggest that t h i s conceptua l iza t ion and comparison may be use fu l for future research. The imagery e f fect s of the two types of immobil i ty f a l l on a continuum i n which the greater the immobil i ty (regardless of whether ex terna l or i n t e r n a l ) , the greater the incidence and viv idness of v i s u a l , aud i tory , k i n e s t h e t i c and hypnagogic imagery. This d i f ference was s t a t i s t i c a l l y s i g n i f i c a n t for f i v e of s i x subscales when the extreme groups (surgery v s . s p i n a l cord in jury) were compared. 136 As shown i n Table 19, the k i n e s t h e t i c subscale was the only nons ign i f i cant d i f ference between surgery and s p i n a l cord i n j u r y p a t i e n t s . This was su rpr i s ing because i t might be expected that movement i l l u s i o n s would have a stronger r e l a t i o n s h i p to immobil i ty than, for example, audi tory imagery. However, the basel ine o f k i n e s t h e t i c imagery i n the mobile , c o n t r o l group was higher than expected. For example, one mobile p a t i e n t , who had s u r g i c a l removal of a ruptured spleen fo l lowing an acc ident , experienced k i n e s t h e t i c imagery i n which she f e l t that she was f l o a t i n g up toward the c e i l i n g from her bed. A s p i n a l cord i n j u r y p a t i e n t , who had no movement below the neck, reported an i d e n t i c a l experience. In a search for a l t e r n a t i v e explanations for t h i s phenomenon, i t seemed f ea s ib l e that b i z a r r e k i n e s t h e t i c imagery could r e s u l t from anaesthetic used for surgery. Both of the above pa t i ent s had had a general anaesthet ic . However, on regress ion a n a l y s i s , surgery was not a s i g n i f i c a n t pred ic tor of imagery i n e i ther study. In future research, i t would be i n t e r e s t i n g to study k i n e s t h e t i c imagery across a broader range of pa t i en t groups, such as short-term and long-term care , and to develop normative data for persons who are not h o s p i t a l i z e d and who are ages which sample the l i f e span. Immobility and Imagery Hypothesis 1 (a ) , which predic ted that immobil i ty would lead to increased imagery, was supported by both s tud ie s . This f i n d i n g , which corroborates previous research, does not provide an explanation of why the imagery e f fec t occurs . For t h i s reason, severa l var i ab le s which were subsets of immobi l i ty , such as t r a c t i o n , were examined through regression a n a l y s i s . 137 T r a c t i o n i n genera l • . d i d n o t p r e d i c t imagery i n S tudy 1, b u t c e r v i c a l t r a c t i o n i n p a r t i c u l a r (tongs o r ha lo ) was p r e d i c t i v e o f imagery i n S tudy 2 . These r e s u l t s must be v iewed w i t h c a u t i o n because i t was i m p o s s i b l e t o s epara te the e f f e c t s o f i n t e r n a l and e x t e r n a l i m m o b i l i t y i n Study 2 . However, i t appears t h a t p a t i e n t s w i t h r e s t r i c t i o n o f head movement, as i s the case w i t h c e r v i c a l t r a c t i o n , a re a t g r e a t e r r i s k f o r imagery e f f e c t s t h a n are p a t i e n t s w i t h r e s t r i c t i o n o f movement t o a l i m b . Of the 15 p a t i e n t s i n t r a c t i o n from S tudy 1, o n l y f i v e had tongs o r h a l o t r a c t i o n . The o t h e r t e n had t r a c t i o n t o the lower body ( l e g , p e l v i s ) . The imagery r i s k f a c t o r a p p a r e n t l y a s s o c i a t e d w i t h c e r v i c a l t r a c t i o n may have a p h y s i o l o g i c a l e x p l a n a t i o n . I t i s p o s s i b l e t h a t r e s t r i c t i o n o f head movement i n c r e a s e s t h e i n c i d e n c e o f v i s u a l and k i n e s t h e t i c changes due t o the r e l a t i o n s h i p o f the v i s u a l and v e s t i b u l a r sys tems . V e s t i b u l a r v e r t i g o (Kornhuber , 1974) i s a s e n s a t i o n o f b e i n g t u r n e d o r t i l t e d t o the s i d e , w h i c h i s o f t e n a s s o c i a t e d w i t h apparent m o t i o n i n the env i ronment . T h i s d e s c r i p t i o n o f v e r t i g o matches some o f the r e p o r t s o f " k i n e s t h e t i c imagery" from b o t h o r t h o p e d i c and s p i n a l c o r d i n j u r y p a t i e n t s i n c e r v i c a l t r a c t i o n . To de termine t h e p o s s i b l e e f f e c t o f i m m o b i l i t y d u r a t i o n , the number o f days immobile i n a h o r i z o n t a l p o s i t i o n was e n t e r e d i n t o the r e g r e s s i o n a n a l y s i s f o r S tudy 2 . D u r a t i o n had no e f f e c t . P a t i e n t s who were immobi le f o r the l o n g e s t t ime d i d n o t r e p o r t g r e a t e r imagery . Indeed , imagery r e p o r t s i n the c h a r t s tended t o o c c u r d u r i n g the e a r l y h o s p i t a l i z a t i o n and t o t aper o f f a f t e r the f i r s t week i n h o s p i t a l . T h i s 138 suggests t h a t an a d a p t a t i o n e f f e c t has o c c u r r e d w h i c h has a t ime frame independent from the d u r a t i o n o f i m m o b i l i t y . I n Study 2 , i n t e r n a l i m m o b i l i t y p r e d i c t e d imagery i n t h a t complete q u a d r i p l e g i c s (h igh l e v e l i n j u r y , complete degree) had g r e a t e r imagery r e p o r t s than any o f the o t h e r t h r e e p a t i e n t g r o u p s . Most q u a d r i p l e g i c s were m o b i l i z e d i n a h a l o t h o r a c i c brace a t an e a r l i e r t ime than p a r a p l e g i c s . Incomplete p a r a p l e g i c s , who had the l e a s t n e u r o l o g i c a l d e f i c i t o f the f o u r g r o u p s , were sometimes i m m o b i l i z e d f o r the l o n g e s t d u r a t i o n . E x a m i n a t i o n o f mean imagery s c o r e s i n T a b l e 11 shows t h a t i n c o m p l e t e p a r a p l e g i c s had a low i n c i d e n c e o f imagery i n s p i t e o f the l o n g d u r a t i o n i m m o b i l i t y . T h e r e f o r e , degree o f n e u r o l o g i c a l d e f i c i t i s a more p o t e n t p r e d i c t o r o f imagery than d u r a t i o n o f i m m o b i l i t y . I t i s i m p o r t a n t t o underscore the f a c t t h a t a l l p a t i e n t s i n S tudy 2 were i n the acu te phase o f ad jus tment immedia te ly f o l l o w i n g a t rauma. Conomy (1973) found t h a t trauma p a t i e n t s had g r e a t e r imagery than p a t i e n t s w i t h s i m i l a r n e u r o l o g i c a l d e f i c i t f rom c o n g e n i t a l o r d e g e n e r a t i v e p r o b l e m s . The p h y s i o l o g i c a l e x p l a n a t i o n o f imagery e f f e c t s a f t e r s p i n a l c o r d i n j u r y may be t h a t spontaneous c e n t r a l n e u r a l a c t i v i t y r e s u l t s from l o s s o f the i n h i b i t o r y e f f e c t w h i c h was p r o v i d e d by sensory i n p u t p r i o r t o the i n j u r y , i n a p r o c e s s analogous t o t h a t p o s t u l a t e d f o r phantom l i m b p a i n (Melzack , 1974) . H i s t o r i c a l l y , the n e u r o l o g i c a l l i t e r a t u r e has examined u n u s u a l s e n s a t i o n s i n s p i n a l c o r d i n j u r y from t h e p e r s p e c t i v e o f "phantom l i m b " (R iddoch , 1917; R i d d o c h , 1941; B o r s , 1951) . . More r e c e n t l y , t h i s ana logy has been c h a l l e n g e d ( P o l l o c k e t a l , 1957) and these f i n d i n g s have been r e c o n c e p t u a l i z e d as d i s t u r b a n c e s o f body image 139 ( K o l b , 1959; E v a n s , 1962) . As Conomy (1973, p . 849) n o t e d , the term "phantom" may be " a n i n a p p r o p r i a t e term t o d e s c r i b e the s i t u a t i o n o c c u r r i n g a f t e r s p i n a l c o r d i n j u r y . The l i m b s a re a c t u a l l y p r e s e n t , and t h e q u a l i t i e s o f p a i n , c o n t r a c t u r e , s h r i n k a g e and f o r e s h o r t e n i n g so o f t e n p r e s e n t i n p o s t a m p u t a t i o n phantom l i m b s a re n o t a b l y a b s e n t . " I n the p r e s e n t r e s e a r c h the d e f i n i t i o n o f imagery i n c l u d e d u n u s u a l body e x p e r i e n c e s ( c a l l e d t a c t i l e and k i n e s t h e t i c imagery here) as r e p o r t e d i n the n e u r o l o g i c a l l i t e r a t u r e , b u t a l s o i n c l u d e d u n u s u a l v i s u a l and a u d i t o r y e x p e r i e n c e s w h i c h have not been emphasized i n n e u r o l o g i c a l r e s e a r c h . N o n e t h e l e s s , l e a v i n g d e f i n i t i o n a s i d e , i t i s p o s s i b l e t h a t M e l z a c k ' s t h e o r y may have e x p l a n a t o r y v a l u e f o r a t l e a s t some imagery e x p e r i e n c e s i n the p r e s e n t p r o j e c t ( i . e . , those d i r e c t l y r e l a t e d t o l o s s o f s ensory i n p u t i n the s p i n a l c o r d i n j u r y s a m p l e ) . Melzack and L o s e r (1978) , who examined "phantom body p a i n " i n p a r a p l e g i c s , proposed a c e n t r a l " p a t t e r n g e n e r a t i n g mechanism" e x p l a n a t i o n , c o n s i s t e n t w i t h the ga te c o n t r o l t h e o r y o f p a i n , whereby " l o s s o f i n p u t t o c e n t r a l s t r u c t u r e s by d e a f f e r a t i o n " ( e . g . , a m p u t a t i o n , c o r d t r a n s e c t i o n ) . . . " c a n t r i g g e r abnormal , p r o l o n g e d f i r i n g and produce s e v e r e , p e r s i s t e n t p a i n s w h i c h are f e l t i n d i s c r e t e areas o f the denerva ted l i m b s o r o t h e r body p a r t s (p. 2 0 8 ) . " A l t h o u g h t h i s e x p l a n a t i o n r e l a t e s t o p a i n e x p e r i e n c e , one c o u l d argue t h a t a s i m i l a r e x p l a n a t i o n might be r e l e v a n t f o r o t h e r u n u s u a l s e n s a t i o n s . I n a s tudy o f 7 p a r a p l e g i c s , Evans (1962) found t h a t w h i l e p a t i e n t s d e s c r i b e d s e n s a t i o n s w h i c h the i n v e s t i g a t o r c o u l d c a t e g o r i z e as p a i n , " i n f a c t no p a t i e n t ever spontaneous ly compla ined o f p a i n o r behaved as though he was s u f f e r i n g i n p a i n " (p. 692 ) . 140 In the present research, the f a c t that imagery e f f e c t s tended to occur predominantly i n the f i r s t week of h o s p i t a l i z a t i o n could be explained as a p h y s i o l o g i c a l adaptation e f f e c t . I t i s p o s s i b l e that imagery accompanies a process of hab i t u a t i o n t o e x t e r n a l o r i n t e r n a l immobility. Because a l l of the p a t i e n t s with i n t e r n a l immobility i n Study 2 a l s o had some type of ext e r n a l immobilizing apparatus, the e f f e c t s of i n t e r n a l . and e x t e r n a l immobility could not be completely separated. Future research might examine p h y s i o l o g i c a l i n d i c a t o r s i n matched p a i r s of p a t i e n t s with and without n e u r o l o g i c a l d e f i c i t , keeping type of immobilizing apparatus constant. For example, one might examine the r e l a t i o n s h i p of nystagmus and k i n e s t h e t i c imagery f o r orthopedic and s p i n a l cord i n j u r y p a t i e n t s i n c e r v i c a l t r a c t i o n . In sum, p a t i e n t s with e x t e r n a l immobility (bedrest with or without immobilizing apparatus) f o r f i v e days or more (Study 1) had grea t e r imagery on day e i g h t of h o s p i t a l i z a t i o n than d i d p a t i e n t s who were mobile w i t h i n two days of admission. Although the i n t e r a c t i o n e f f e c t (Immobility x Intervention) was n o n s i g n i f i c a n t , t h i s study should be r e p l i c a t e d , given the discrepant mean f o r the mobile - i n t e r v e n t i o n group (Table 2) as compared t o the other three groups. T r a c t i o n alone d i d not p r e d i c t imagery e f f e c t s i n t h i s sample. In Study 2, which had an e i g h t week time frame, p a t i e n t s who had a high l e v e l i n j u r y (quadriplegics) of complete degree, with l o s s of a l l n e u r o l o g i c a l f u n c t i o n below the l e v e l of the i n j u r y , had greater imagery than q u a d r i p l e g i c s with incomplete i n j u r i e s or pa r a p l e g i c s with e i t h e r complete or incomplete i n j u r i e s . Thus, f o r i n t e r n a l immobility, the 141 degree o f neuro log ica l d e f i c i t predic ted imagery. Since much of t h i s imagery occurred during the f i r s t week o f h o s p i t a l i z a t i o n , i t i s pos s ib le that a process of p h y s i o l o g i c a l adaptation has occurred. I n i t i a l l y , l o s s of sensory input could t r igger spontaneous f i r i n g i n the sensory p r o j e c t i o n area of the cortex leading to imagery e f f e c t s . Over t ime, hab i tuat ion might occur so that imagery experiences would decrease. The type of immobil iz ing apparatus a l so had an imagery e f fec t i n Study 2. Pa t ient s i n c e r v i c a l t r a c t i o n (halo or tongs) had greater imagery recorded i n the c h a r t . As compared to Study 1, where most of the t r a c t i o n was attached to the lower body, i t appears that r e s t r i c t e d head movement may be a component of imagery i n d u c t i o n . A p h y s i o l o g i c a l explanat ion here could be that interference to normal ex terna l inputs to the v i s u a l , and/or ve s t ibu l a r systems leads to imagery. The r o l e of sensory inputs i n imagery induct ion w i l l be discussed further i n the sec t ion on environmental s t imula t ion l e v e l s . While degree of neuro log ica l d e f i c i t and type of apparatus predicted imagery, the durat ion o f immobil i ty (as ind ica ted by the number of days hor izonta l ) had no e f f ec t on imagery recorded i n the c h a r t . Surgery had no imagery e f f ec t i n e i t h e r study. Immobility and Stress Hypothesis 1(b), which predicted that immobil i ty would lead to increased s t ress re l a ted to imagery was not supported. Nevertheless, anecdotal data suggest that there may be mer i t i n further exp lora t ion of t h i s hypothesis i n future research. For example, to re turn to the 142 di scus s ion o f the two pat ient s (mobile versus s p i n a l cord in jury) who reported i d e n t i c a l sensations o f f l o a t i n g to the c e i l i n g , t h e i r react ions to the experience were extremely d i f f e r e n t because of the d i f ference i n degree o f immobi l i ty . The mobile pa t i en t was able to get out of bed and go for a walk, which ended the f l o a t i n g sensat ion. For her , the experience was "weird" but only m i l d l y d i s t r e s s i n g . By contra s t , the s p i n a l cord i n j u r y pa t i en t endured the f l o a t i n g sensation for approximately f i v e minutes, which was extremely d i s t r e s s i n g because o f the helplessness of quadr ip leg ia and c e r v i c a l t r a c t i o n . Although the l a t t e r pa t i en t knew that the experience was not r e a l , and t h i s was confirmed by r e a l i t y t e s t ing w i t h another person i n the room, the apparent movement p e r s i s t e d . F i n a l l y , the sensation ended abrupt ly when he was turned onto h i s s i d e . The above two cases d i f f e r e d i n t h e i r a v a i l a b l e options for c o n t r o l . In Baron and Rodin ' s (1978) terms, the mobile pa t ient had the opt ion for o f f s e t c o n t r o l to end contact w i t h , or o f f s e t , the s t r e s s f u l s i t u a t i o n , whereas the immobile pa t i en t d i d not . I t i s i n t e r e s t i n g to note from Study 1, that immobil i ty l e d to s tress re l a ted to personal c o n t r o l and response r e s t r i c t i o n . Immobility had a potent e f f ec t (p_ < .001) which suggests that immobil i ty leads to nonoptimal l e v e l s of personal c o n t r o l which produces s t re s s . Hypothesis 1(c) predic ted that immobil i ty would lead to increased s t r e s s . Contrary to hypothesis , r e s u l t s from the two studies d i d not show a r e l a t i o n s h i p between immobil i ty and s t re s s . There was no s t a t i s t i c a l d i f ference i n s tress reports from immobile pat ients as 143 compared t o m o b i l e p a t i e n t s . L i k e w i s e , i n t e r n a l i m m o b i l i t y was u n r e l a t e d t o s t r e s s . These r e s u l t s were i n sharp c o n t r a s t t o the imagery f i n d i n g s and suggest t h a t a d i f f e r e n t u n d e r l y i n g p r o c e s s has o c c u r r e d . Whereas degree o f n e u r o l o g i c a l d e f i c i t p r e d i c t e d imagery , t h e r e was no d i f f e r e n c e i n s t r e s s l e v e l s o f d i f f e r e n t l e v e l s and degree o f s p i n a l c o r d i n j u r y . The p h y s i o l o g i c a l e x p l a n a t i o n s o f imagery suggested e a r l i e r a re n o t r e l e v a n t t o the s t r e s s r e s u l t s . R a t h e r , i t appears t h a t the s e l e c t i o n o f emergency admis s ions f o r the samples o f b o t h s t u d i e s meant t h a t a l l p a t i e n t s s t u d i e d were i n the s t r e s s o f a c r i s i s s i t u a t i o n . T h i s i n t e r p r e t a t i o n concur s w i t h the Moos and Tsu model o f the c r i s i s o f p h y s i c a l i l l n e s s (or i n j u r y , i n the p r e s e n t e x t e n s i o n o f the m o d e l ) . I n the i n i t i a l e i g h t weeks o f h o s p i t a l i z a t i o n , the c r i s i s e x p e r i e n c e d by the complete q u a d r i p l e g i c f a c i n g a l i f e t i m e o f p a r a l y s i s from the neck down was no g r e a t e r than the c r i s i s o f the incomple te p a r a p l e g i c who may walk o u t o f the h o s p i t a l . T h i s f i n d i n g may be e x p l a i n e d i n terms o f a d a p t a t i o n l e v e l t h e o r y i n which c o n t r a s t and h a b i t u a t i o n l e s s e n the extremes o f a f f e c t i v e r e a c t i o n s t o event s (Br ickman, Coates & J a n o f f - B u l m a n , 1978) . The l i t e r a t u r e on s p i n a l c o r d i n j u r i e s i s c o n t r a d i c t o r y i n r e g a r d t o the i s s u e o f phases o f p s y c h o l o g i c a l a d a p t a t i o n i n the r e h a b i l i t a t i o n p e r i o d . Stages o f p s y c h o l o g i c a l r e a c t i o n have been d e s c r i b e d (Guttmann, 1976; R i g o n i , 1977) and have come t o be accepted as g i v e n i n much o f the l i t e r a t u r e , bu t r e c e n t s t u d i e s ( e . g . , S h a d i s h , Hickman, & A r r i c k , 1981) have n o t found e m p i r i c a l ev idence f o r a s i m p l e s tage t h e o r y . Tr ieschmann (1980) emphasized t h a t t h i s i s s u e must be r e s o l v e d by f u t u r e l o n g i t u d i n a l s t u d i e s . 144 Most o f the s tage t h e o r i e s appear t o be d e r i v e d from l i t e r a t u r e on g r i e f o r d y i n g ( K u b l e r - R o s s , 1971) . Stages such as shock , d e n i a l , anger , and acceptance have been i d e n t i f i e d . T h i s suggests t h a t t h e r e would be a change i n s t r e s s over t i m e . From S tudy 2 , the mean s t r e s s s c o r e s (Table 15) show t h a t s t r e s s may d e c r e a s e , i n c r e a s e o r remain c o n s t a n t over t ime f o r groups o f p a t i e n t s , bu t the o v e r a l l change was n o n s i g n i f i c a n t . These f i n d i n g s o f f e r suppor t t o the r e s e a r c h o f S h a d i s h e t a l . , i n c o n t r a d i c t i o n t o a s i m p l e s tage t h e o r y . However, the e i g h t week t ime frame o f t h i s s tudy may be t o o s h o r t t o adequa te ly e v a l u a t e the s tage t h e o r y approach . I n sum, i m m o b i l i t y d i d n o t l e a d t o i n c r e a s e d s t r e s s r e l a t e d t o imagery , a l t h o u g h a n e c d o t a l ev idence sugges t s t h a t t h i s h y p o t h e s i s c o u l d be f u r t h e r s t u d i e d . C o n t r a r y t o h y p o t h e s i s , immobi le p a t i e n t s d i d n o t have g r e a t e r s t r e s s t h a n m o b i l e p a t i e n t s i n S tudy 1. However, immobi le p a t i e n t s d i d r e p o r t g r e a t e r s t r e s s r e l a t e d t o p e r s o n a l c o n t r o l and response r e s t r i c t i o n than d i d the m o b i l e g r o u p . A c c o r d i n g t o Baron and R o d i n (1978) t h i s e f f e c t c o u l d be e x p l a i n e d by d i f f e r e n c e s i n o f f s e t c o n t r o l . F o r i n t e r n a l i m m o b i l i t y i n S tudy 2 , t h e r e was no d i f f e r e n c e i n s t r e s s a c c o r d i n g t o l e v e l o r degree o f i n j u r y , nor was t h e r e a p a t t e r n o f change o r phases over t i m e . The p a t t e r n o f s t r e s s r e s u l t s d i f f e r e d from the imagery f i n d i n g s , w h i c h were e x p l a i n e d p h y s i o l o g i c a l l y . The l a c k o f main e f f e c t s f o r s t r e s s was i n t e r p r e t e d w i t h i n the Moos and Tsu (1977) framework o f p h y s i c a l i l l n e s s as c r i s i s , because a l l p a t i e n t s i n t h i s p r o j e c t were emergency a d m i s s i o n s . 145 Immobility and Noncompliance H y p o t h e s i s 1 ( d ) , w h i c h p r e d i c t e d t h a t i m m o b i l i t y would l e a d t o i n c r e a s e d noncompl iant b e h a v i o u r , d i d n o t r e c e i v e d i r e c t suppor t from e i t h e r s t u d y . However, c o r r e l a t i o n a l ev idence suggests t h a t t h i s h y p o t h e s i s m e r i t s f u r t h e r i n v e s t i g a t i o n . I n S tudy 2 , c o n c u s s i o n , w h i c h p r e d i c t e d noncompl iance , was a l s o c o r r e l a t e d w i t h the number o f f r a c t u r e s o t h e r than the s p i n a l c o r d i n j u r y . S i n c e the g r e a t e r the number o f f r a c t u r e s , the g r e a t e r the i m m o b i l i t y , as a consequence o f t r e a t i n g the f r a c t u r e s , t h i s f i n d i n g i s c o n s i s t e n t w i t h h y p o t h e s i s 1 ( d ) . The o r i g i n a l c o n c e p t u a l i z a t i o n o f noncompliance i n t h i s p r o j e c t was based on e a r l i e r r e s e a r c h (S tewar t , 1977; Z i s k i n d e t a l , 1960) w h i c h suggested t h a t imagery and noncompliance were r e l a t e d v a r i a b l e s ( e . g . , noncompliance as a r e s u l t o f v i v i d hypnagogic i m a g e r y ) . A l t h o u g h some i n d i v i d u a l ca se s i n b o t h s t u d i e s suppor t t h i s r e l a t i o n s h i p , the d a t a as a whole do n o t . I n S tudy 1, imagery tended t o o c c u r i n the f i r s t week o f h o s p i t a l i z a t i o n w h i l e noncompliance o c c u r r e d l a t e r . I n S tudy 2 , noncompliance over the t o t a l o f the f i r s t e i g h t weeks o f h o s p i t a l i z a t i o n (Table 21) was c o r r e l a t e d w i t h s t r e s s , £ = +.66 ( £ < . 0 0 1 ) , bu t n o t w i t h imagery , r = +.16 (NS) . There was a s i g n i f i c a n t c o r r e l a t i o n between noncompliance and imagery on two o f t h e e i g h t weeks; week one : £ = +.27 ( £ < .05) and week f o u r : £ = +.28 ( £ < . 0 5 ) . By c o n t r a s t , the c o r r e l a t i o n between noncompliance and s t r e s s was a t the .001 l e v e l f o r f i v e o f the e i g h t weeks . Noncompliance a s s o c i a t e d w i t h imagery tends t o be i n v o l u n t a r y . The d a t a f rom the p r e s e n t s t u d i e s suggest t h a t v o l u n t a r y noncompl iance , 146 a s s o c i a t e d w i t h s t r e s s , i s more p r e v a l e n t than i n v o l u n t a r y noncompliance i n immobi le p a t i e n t s . One p o s s i b l e e x p l a n a t i o n o f t h i s i s a r e a c t a n c e e f f e c t due t o t h e l o s s o f p e r s o n a l c o n t r o l a s s o c i a t e d w i t h i m m o b i l i t y . Wortman and Brehm (1975) proposed a change i n response t o l o s s o f c o n t r o l from r e a c t a n c e t o h e l p l e s s n e s s over t i m e . I f one d e f i n e s the noncompliance i n t h i s p r o j e c t as r e a c t a n c e , the p r e s e n t f i n d i n g s do n o t s u p p o r t the t empora l p h a s i n g suggested by Wortman and Brehm. From Study 2 , the mean noncompliance s c o r e s (Table 15) e i t h e r s l i g h t l y decrease o r i n c r e a s e a c r o s s p a t i e n t groups b u t t h e r e i s no s i g n i f i c a n t change over t i m e . I n S tudy 1, the most extreme case o f noncompl iance , i n w h i c h a p a t i e n t w i t h a f r a c t u r e d femur r e p e a t e d l y removed h i s t r a c t i o n and went f o r a w a l k , o c c u r r e d a f t e r 18 days o f i m m o b i l i t y and c o m p l i a n c e . A c c o r d i n g t o Wortman and Brehm, one would expec t the noncompliance t o o c c u r i n t h e e a r l y h o s p i t a l i z a t i o n phase , r a t h e r than 18 days a f t e r a d m i s s i o n . I n sum, the p r e d i c t i o n t h a t i m m o b i l i t y would l e a d t o noncompliance was n o t d i r e c t l y suppor ted by e i t h e r s t u d y . C o r r e l a t i o n a l and a n e c d o t a l ev idence suggest t h a t f u r t h e r r e s e a r c h needs t o be done on t h i s h y p o t h e s i s . C o n c u s s i o n , w h i c h p r e d i c t e d noncompl iance , a l s o c o r r e l a t e d w i t h an i m m o b i l i t y i n d e x (number o f f r a c t u r e s ) . The ev idence p r e s e n t e d here suppor t a v o l u n t a r y , r eac tance (Brehm, 1966) e x p l a n a t i o n o f noncompl iance , as opposed t o i n v o l u n t a r y noncompliance a s s o c i a t e d w i t h hypnagogic imagery . S i m i l a r t o the s t r e s s r e s u l t s , t h e r e was no ev idence f o r t empora l p h a s i n g o f r e a c t a n c e and h e l p l e s s n e s s (Wortman & Brehm, 1975) . 147 Cognitive Appraisal According to the Moos and Tsu model, the in te rvent ion tested i n Study 1 was aimed at the l e v e l o f cogn i t ive appra i sa l or the perceived meaning o f the i l l n e s s experience. This in te rvent ion was designed to counteract s t ress by provid ing information (expectancy for imagery, a p o s i t i v e set and an environmental explanation) on which to base reappra i sa l o f imagery e f fect s as a normal reac t ion to an emergency admission to h o s p i t a l , i n the event that the imagery could be perceived as a s ign o f mental i l l n e s s . Cognitive Reappraisal and Stress Reduction Hypothesis 2(a) predicted that the in te rvent ion (cognit ive reappraisal) would lead to reduced s t ress re l a ted to imagery. This p r e d i c t i o n was unsupported by the interv iew data (subscale IV o f the Environmental Stress Sca l e ) . The in terv iew, which was conducted on day e i g h t , focused on the e n t i r e e ight day span of h o s p i t a l i z a t i o n . Most of the reported imagery had occurred during the f i r s t few days o f h o s p i t a l i z a t i o n . The retrospect ive report ing may have minimized the stress involved w i t h the passage o f time. Support for t h i s p o s s i b i l i t y came from the p i l o t interviews conducted wi th long term pat ient s from the Acute S p i n a l Cord In jury U n i t a t Shaughnessy H o s p i t a l . In one case, a pat ient described b i z a r r e imagery from severa l months e a r l i e r and reported that he found these experiences m i l d l y s t r e s s f u l . He had a t t r i b u t e d the imagery e f f ec t to val ium and refused to take the medication afterwards. The content o f the inc ident was recorded i n the char t i n a s i m i l a r manner to the p a t i e n t ' s repor t , but the s t r i k i n g 148 d i f f e r e n c e was the c h a r t r e c o r d o f extreme a n x i e t y a s s o c i a t e d w i t h the imagery . T h i s suggests t h a t the memory o f n e g a t i v e a f f e c t r e l a t i v e t o imagery may be a t t e n u a t e d once a d a p t a t i o n has o c c u r r e d . A second example o f t h i s phenomenon o c c u r r e d one morning when a p a t i e n t r e p o r t e d on b i z a r r e , m u l t i m o d a l i t y imagery e x p e r i e n c e s w h i c h had happened d u r i n g the n i g h t . Comparison o f her r e p o r t w i t h nurse r e p o r t s ( v e r b a l and w r i t t e n ) o f the same event s were v e r y s i m i l a r i n c o n t e n t except f o r the d e s c r i p t i o n o f a s s o c i a t e d s t r e s s . A c c o r d i n g t o the n u r s e s , the p a t i e n t had been e x t r e m e l y upse t as ev idenced by her a f f e c t , v e r b a l i z a t i o n and b e h a v i o u r , such as c o n s t a n t use o f the c a l l l i g h t . The p a t i e n t , by c o n t r a s t , d e s c r i b e d h e r s e l f as m i l d l y u p s e t . A l t h o u g h t h i s c o u l d a l s o be i n t e r p r e t e d as a - s o c i a l d e s i r a b i l i t y e f f e c t , i t seemed more p r o b a b l e t h a t the e x p e r i e n c e was p e r c e i v e d d i f f e r e n t l y by the p a t i e n t once the b i z z a r e imagery had ended and d a y l i g h t had r e t u r n e d . G i v e n the p o s s i b i l i t y t h a t r e t r o s p e c t i v e r e p o r t s o f n e g a t i v e a f f e c t may be m i n i m i z e d once a d a p t a t i o n o c c u r s over t i m e , a c o n c u r r e n t measure o f s t r e s s may be p r e f e r a b l e t o the r e t r o s p e c t i v e approach . H y p o t h e s i s 2 ( b ) , w h i c h p r e d i c t e d t h a t the i n t e r v e n t i o n would l e a d t o decreased s t r e s s , was suppor ted on the c o n c u r r e n t measure o f s u b j e c t i v e s t r e s s . The S u b j e c t i v e S t r e s s S c a l e , w h i c h was a l s o a d m i n i s t e r e d on day e i g h t , p r o v i d e d i n s t r u c t i o n s f o r p a t i e n t s t o i n d i c a t e how they f e l t on t h a t d a y , r a t h e r t h a n r e t r o s p e c t i v e l y over the p r e v i o u s week. P a t i e n t s who heard the i n t e r v e n t i o n r e p o r t e d l e s s s u b j e c t i v e s t r e s s than those who were n o t exposed t o t h i s i n f o r m a t i o n . 149 Neither measures of environmental s tress (ESS - to ta l ) nor the Di s t re s s Record from the pa t ient charts supported hypothesis 2(b) . As mentioned p r e v i o u s l y , the Environmental Stress Scale involves re t rospect ive report ing on in te rv iew. On the other hand, the Di s t re s s Record i s taken from the s t a f f ' s concurrent record i n the p a t i e n t ' s c h a r t . . However, i t i s qu i te f ea s ib le tha t : (1) The p a t i e n t ' s subject ive experience of s t ress may not be transmitted to the nurse, or (2) The nurse may observe the s tress but not make a notat ion i n the c h a r t . The method o f problem-oriented char t ing used at the U n i v e r s i t y H o s p i t a l , as compared to the ongoing progress notes at Shaughnessy H o s p i t a l , appears t o have resu l ted i n reduced psycholog ica l notat ions i n the c h a r t . Many heal th profess ionals w i l l argue that expectat ions, such as provided i n t h i s i n t e r v e n t i o n , should be avoided because they could increase the p r o b a b i l i t y of imagery occurrence. No basis for t h i s avoidance was provided by the comparison of imagery scores i n the in tervent ion group wi th the group who d i d not hear the i n t e r v e n t i o n . The in tervent ion d i d not "produce" the imagery e f f e c t . A c r i t i c i s m which may be ra i sed concerning the present study i s the lack of more ob jec t ive ind ices of s t ress to measure the ef fect iveness of the i n t e r v e n t i o n . However, Langer, J an i s and Wolfer (1975), i n a study o f the e f f e c t of cogn i t ive reappra i sa l on s tress i n s u r g i c a l pa t i en t s , d i d not f i n d p h y s i o l o g i c a l measures ( i . e . , pulse , blood pressure) to be use fu l as dependent v a r i a b l e s . The above study d i d f i n d value i n an ob jec t ive measure of the "number of pa in r e l i e v e r s and sedatives the 150 pa t i en t requested" (p. 160). Previous research (c i ted i n Stone, Cohen & A d l e r , 1979, p . 236) had shown that study of postoperative analgesic use cannot separate pa in from anxie ty . For t h i s reason, numerous s tudies o f s t ress i n h o s p i t a l i z e d pat ients have used analgesic admini s t ra t ion as a s t ress i n d i c a t o r . The present research d i d not include t h i s ind ica tor for two reasons: (1) The sample was not homogeneous r e l a t i v e to the presence or absence of surgery, and (2) No v a l i d method e x i s t s for the measurement o f "requests" for analgesia using data from the char t s . Analges ics are only given a f ter a s p e c i f i e d time regardless o f the number of requests that are made by the p a t i e n t . To be sure, they are ordered to be given "as needed", but of ten the s t a f f have a good dea l o f c o n t r o l over t h e i r t iming . Sometimes a pa t i en t who frequently requests analgesia w i l l cause annoyance for the nursing s t a f f and the "request" w i l l be met more s lowly than that of a l e s s loquacious su f f e re r . However, the only information appearing i n the char t , w i t h the exception of the occas ional behavioural entry i n the progress notes, w i l l be the time of admini s t ra t ion of the medication. Because the in te rvent ion had severa l components, which made i t more r e a l i s t i c for a p p l i c a t i o n i n a c l i n i c a l s e t t i n g , i t i s impossible to s tate d e f i n i t e l y which component(s) was instrumental i n reducing the subject ive s tress scores for the in tervent ion group. Expectancy for sensory experiences enhances p r e d i c t a b i l i t y (Johnson, 1975), whereas a t t r i b u t i o n s to a l e s s threatening cause should increase c o n t r o l (Pittman & Pit tman, 1980). For example, the cogn i t ive reappaisa l may involve a transfer of a t t r i b u t i o n for the cause of imagery from a 151 s t a b l e , i n t e r n a l cause ( e . g . , m e n t a l i l l n e s s ) t o an u n s t a b l e , e x t e r n a l cause ( e . g . , change i n e n v i r o n m e n t ) . P r e d i c t a b i l i t y and c o n t r o l have been shown t o have s t r e s s - r e d u c i n g p r o p e r t i e s i n l a b o r a t o r y r e s e a r c h (Glas s & S i n g e r , 1972) . Another u s e f u l component may be t h e n o r m a l i z a t i o n p r o c e s s i n v o l v e d when p a t i e n t s hear t h a t o t h e r s have had e x p e r i e n c e s s i m i l a r t o t h e i r own. Such consensus i n f o r m a t i o n has n o t reduced n e g a t i v e a f f e c t i n some r e s e a r c h , such as a s t u d y o f the e f f e c t o f consensus i n f o r m a t i o n on s t r e s s and d e p r e s s i o n i n f i r s t - y e a r f a c u l t y members ( N i s b e t t , B o r g i d a , C r a n d a l l & Reed , 1976 ) . However, the p o s s i b i l i t y remains t h a t i t might have p o t e n t i a l i n a s i t u a t i o n where some s t i g m a o r taboo i s i n v o l v e d e . g . , m e n t a l i l l n e s s , s e x u a l i t y . The S e x u a l H e a l t h C o u n s e l l o r s on the A c u t e S p i n a l C o r d I n j u r y U n i t a t Shaughnessy H o s p i t a l (Anderson, 1980) have found t h a t a l a r g e p o r t i o n o f t h e i r t a sk i s t o h e l p n o r m a l i z e s e x u a l concerns i n the p a r a l y z e d p o p u l a t i o n . A method th ey used t o do t h i s i s t o p r o v i d e consensus i n f o r m a t i o n ( i . e . , t h a t o t h e r peop le w i t h s p i n a l c o r d i n j u r i e s have these concerns as w e l l ) . The consensus i n f o r m a t i o n a p p a r e n t l y reduces a n x i e t i e s about s e x u a l i t y . S i m i l a r l y , the i n t e r v e n t i o n t e s t e d here c o u l d l e s s e n a n x i e t y r e g a r d i n g m e n t a l s t a t u s . A l l the components o f the i n t e r v e n t i o n c o u l d a f f e c t p r e d i c t a b i l i t y o r c o n t r o l . A c c o r d i n g t o Baron and R o d i n (1978, p . 148) p r e d i c t a b i l i t y i s nece s sa ry b u t not s u f f i c i e n t as a p r e - c o n d i t i o n f o r outcome c o n t r o l . T h e r e f o r e , p r e d i c t a b i l i t y w i l l be v iewed here as s e r v i n g outcome c o n t r o l . 152 The type of outcome c o n t r o l that the in te rvent ion aimed to induce was predominantly o f f s e t c o n t r o l rather than onset c o n t r o l . The pa t i ent could use the information ( e . g . , environmental a t t r i b u t i o n ) to end contact w i t h the s tressor (threatening thoughts regarding the meaning of imagery experiences) and hence c o n t r o l or o f f se t the negative outcome. A l l o f the 24 pat ient s who heard the tape (the in te rvent ion group) responded p o s i t i v e l y or n e u t r a l l y ; none were negative. Some had already had imagery experiences, which they had not discussed wi th anyone, and they were both anxious to t a l k about the imagery and r e l i e v e d to hear that these experiences were normal. For pat ients who had not experienced imagery p r i o r to the i n t e r v e n t i o n , the expectation for imagery could reduce u n p r e d i c t a b i l i t y and therefore increase onset c o n t r o l (Baron & Rodin, p . 162). In future r e p l i c a t i o n s tud ie s , i t would be use fu l to administer the in te rvent ion e a r l i e r than day f i v e because by t h i s time much o f the onset c o n t r o l p o t e n t i a l was l o s t . The data on psycholog ica l recovery i n the two month fol low-up quest ionnaire (PAIS) were not included i n the ana lys i s of variance because the sample was reduced by 25% leaving an n of seven i n one c e l l . However, the pat tern o f r e s u l t s was cons i s tent wi th hypotheses. The mean psycholog ica l d i s t r e s s scores for the immobile versus mobile groups were 5.07 and 3.10 r e s p e c t i v e l y . This may be explained by the f ac t that many orthopedic pa t ient s would have a slower return to normal a c t i v i t i e s than pat ients who had general surgery. The c o r r e l a t i o n a l matrix for s t imula t ion l e v e l s and dependent var iab le s (Appendix G.6) showed a d i r e c t r e l a t i o n s h i p between psycholog ica l d i s t r e s s on the PAIS and 153 imagery on the M o d i f i e d I m a g i n a l Proces se s I n v e n t o r y : r_ = .34 (£ < . 0 5 ) . The PAIS was a l s o c o r r e l a t e d w i t h the p e r s o n a l c o n t r o l and response r e s t r i c t i o n s u b s c a l e o f the E n v i r o n m e n t a l S t r e s s S c a l e : r_ = .38 ( £ = . 0 1 ) . Of i n t e r e s t t o the p r e s e n t argument was the f a c t t h a t t h e mean d i s t r e s s s c o r e f o r the i n t e r v e n t i o n group was 3.80 as compared t o 4.37 f o r the group who were n o t exposed t o the i n t e r v e n t i o n . T h i s suggests suppor t f o r p r e v i o u s r e s e a r c h w h i c h r e l a t e s c o n t r o l t o l o n g - t e r m decreased s t r e s s ( A v e r i l l , 1973) . However, i n the p r e s e n t case t h e r e appears t o be s h o r t - t e r m and l o n g - t e r m b e n e f i t , whereas A v e r i l l r e p o r t e d s h o r t - t e r m i n c r e a s e and l o n g - t e r m decrease i n s t r e s s . I n summary, m a n i p u l a t i o n o f c o g n i t i v e a p p r a i s a l l e d t o reduced s u b j e c t i v e s t r e s s , r a t h e r than reduced i m a g e r y - s p e c i f i c s t r e s s , w i t h no i n c r e a s e i n imagery e f f e c t s . There was no i n t e r v e n t i o n e f f e c t f o r e n v i r o n m e n t a l s t r e s s o r c h a r t e d d i s t r e s s . Some ev idence was p r o v i d e d f o r b o t h s h o r t - t e r m and l o n g - t e r m b e n e f i t from t h i s i n t e r v e n t i o n . W h i l e t h i s e f f e c t c o u l d have been mediated by e x p e c t a n c y , a t t r i b u t i o n a l , consensus o r sensory i n f o r m a t i o n a l p r o c e s s e s , the e x p l a n a t i o n o f f e r e d here i s t h a t a l l o f these mechanisms i n c r e a s e outcome c o n t r o l . Physical (Nonsocial) and Social Environmental Factors The e n v i r o n m e n t a l f a c t o r s o f i n t e r e s t i n t h i s p r o j e c t were d imens ions o f s o c i a l and n o n s o c i a l s t i m u l a t i o n . I n S tudy 1, these d imens ions were examined by d i r e c t o b s e r v a t i o n o f the environment i n p a t i e n t rooms. Much o f p r e v i o u s r e s e a r c h has tended t o make assumptions about a spec t s o f the h o s p i t a l environment as " s e n s o r y d e p r i v a t i o n " o r 154 overload. While either extreme can theoretically predict the same effect, such as imagery, the lack of precision about the polarity of this relationship does not provide the necessary guidance for intervention in the cl i n i c a l setting. Stimulation Dimensions and Imagery Hypothesis 3(a) stated that restricted environmental stimulation levels would lead to increased imagery. It was interesting to find that, in general, there was a direct relationship between stimulation dimensions and imagery, rather than the predicted inverse relationship. Most of the predictors were from the social environment, as opposed to the nonsocial environment. High imagery, as measured by the imagery questionnaire (MIPI), was associated with high levels of social interaction which was directed at someone else in the room and outside the observed patient's space (area within bedside curtains). Imagery was also directly related to the variety of social stimulation. The most potent predictor was variety outside the patient space. These predictors a l l suggest an overload explanation. However, i t is overload of a particular type of stimulation. The f i r s t two predictors represent the background noise of people talking in the room and the traffic of different people entering the room. These variables are similar in that the observed patient does not directly interact with the stimulus persons. It is possible that the social noise and traffic created by these two variables leads to increased imagery because of the arousal created by the noise or the ambiguity of partially heard dialogue. Zuckerman's theory of an optimal 155 l e v e l o f s t i m u l a t i o n (1969, p . 431) suggests t h a t v i s u a l , a u d i t o r y , k i n e s t h e t i c , and s o m e s t h e t i c (body i l l u s i o n ) s e n s a t i o n s may r e s u l t from h i g h o r low c o r t i c a l a r o u s a l r e l a t i v e t o the o p t i m a l l e v e l o f s t i m u l a t i o n f o r the i n d i v i d u a l . When someone i s r e c o v e r i n g f rom i n j u r y o r i l l n e s s , i t i s f e a s i b l e t h a t the o p t i m a l l e v e l o f s t i m u l a t i o n i s lower than n o r m a l . T h e r e f o r e , h i g h s t i m u l a t i o n c o u l d have more d e l e t e r i o u s e f f e c t s t h a n i t would under o r d i n a r y c i r c u m s t a n c e s . The t h i r d p r e d i c t o r o f imagery , v a r i e t y i n s i d e the p a t i e n t ' s space , i s more l i k e l y t o be s t i m u l a t i o n w h i c h i s r e l e v a n t t o the p a t i e n t . However, h i g h v a r i e t y , w i t h a number o f d i f f e r e n t p e o p l e p a s s i n g by the p a t i e n t ' s bed , c o u l d l e a d t o a r o u s a l i n the p a t i e n t because o f i n c o n s i s t e n c y o f c o n t a c t s and l a c k o f meaning i n the s o c i a l w o r l d . T h a t i s , t h i s v a r i e t y would l e a d t o a l a r g e r number o f s u p e r f i c i a l c o n t a c t s r a t h e r t h a n f e w e r , more m e a n i n g f u l i n t e r a c t i o n s . One c o u l d argue from these d a t a t h a t t h e r e s h o u l d be l e s s d i v i s i o n o f l a b o u r i n h o s p i t a l s and more emphasis on p r i m a r y n u r s i n g c a r e , i n w h i c h one nurse has t o t a l r e s p o n s i b i l i t y f o r a p a t i e n t . I n a d d i t i o n t o the t h r e e p r e d i c t o r s d i s c u s s e d above, the d i m e n s i o n o f r e spons ivenes s o f n o n s o c i a l s t i m u l a t i o n (NSR) p r e d i c t e d imagery s c o r e s on the MIPI i n Study 1. Low re spons ivenes s (which p r e d i c t e d h i g h imagery) i s r e l e v a n t t o p e r s o n a l c o n t r o l . P a t i e n t s who were exposed t o few n o n s o c i a l s t i m u l i w h i c h had the d imens ion r e s p o n s i v e n e s s , d i d not have the o p t i o n o f c o n t r o l l i n g the o n s e t , o f f s e t o r i n t e n s i t y o f s t i m u l a t i o n . F o r example, a r a d i o w h i c h was o u t o f r e a c h , such as one b e l o n g i n g t o the p a t i e n t i n the nex t bed , would l a c k r e s p o n s i v e n e s s . 156 Again, an arousal explanation could account for the imagery induction. In this case, both nonoptimal stimulation and nonoptimal control would contribute to the arousal. The arousal may be related to anxiety or frustration with low control of the stimulation. However, no direct physiological measure of arousal was obtained in this study. The use of patient self-report, nurse report and observational data were considered i \ preferable from an ethical viewpoint because a l l of the patients had endured the crisis of an emergency admission. Hypothesis 3(a) was supported by Study 2 in that the environment variable predicted imagery. Patients in the intensive care environment, as opposed to the ward, had greater imagery recorded in the chart. This effect, however, was confounded by time because a l l patients were in the intensive care unit immediately after admission and then transferred to the ward at a later date. To the extent that the imagery effect can be attributed to the intensive care environment (which replicates previous research on intensive care syndrome), i t is s t i l l not possible to ascertain from these data whether restricted or excessive stimulation contributed to the effect. The observational tool which was developed for Study 1 could be used in future research to obtain direct observational data on dimensions of social and nonsocial stimulation in intensive care as opposed to ward environments. The possible imagery-inducing effect of injectable analgesics, such as morphine and demerol, was ruled out here in the covariate analysis. However, future research should also examine the potential effect of a broader range of medications, including sedatives and oral analgesics. 157 Recent r e s e a r c h suggests t h a t e x c e s s i v e s t i m u l a t i o n i s a problem i n i n t e n s i v e c a r e u n i t s . M a c K i n n o n - K e s l e r (1983) found t h a t n o i s e l e v e l s c o n t r i b u t e t o o v e r l o a d i n i n t e n s i v e c a r e s e t t i n g s . I n a s t u d y o f the d e c i b e l l e v e l s a t the p a t i e n t ' s head i n ICU (Redding & M i n s k y , 1977) , the f i n d i n g s were comparable t o the n o i s e l e v e l s i n an o f f i c e s e t t i n g w i t h t y p e w r i t e r s and te l ephones i n c o n s t a n t u s e . I f these f i n d i n g s can be g e n e r a l i z e d t o the i n t e n s i v e c a r e u n i t o f the p r e s e n t s t u d y , the d a t a , w h i c h demonstrate an imagery e f f e c t i n the i n t e n s i v e c a r e env i ronment , may b e s t be e x p l a i n e d i n terms o f e x c e s s i v e s t i m u l a t i o n r a t h e r than r e s t r i c t e d s t i m u l a t i o n . I n S tudy 2 , the r e g r e s s i o n a n a l y s i s d i d n o t suppor t h y p o t h e s i s 3(a) on e i t h e r i n d i c a t o r o f e n v i r o n m e n t a l s t i m u l a t i o n : number o f days i n t h e i n t e n s i v e c a r e u n i t o r s l e e p d e p r i v a t i o n . The l a t t e r v a r i a b l e was used as an i n d i c a t o r o f e n v i r o n m e n t a l s t i m u l a t i o n because the g r e a t e r the s l e e p d e p r i v a t i o n , the more t ime the p a t i e n t w i l l be awake and exposed t o e n v i r o n m e n t a l s t i m u l a t i o n . S l e e p d e p r i v a t i o n d i d p r e d i c t temperature r e g u l a t i o n anomaly, a v a r i a b l e w h i c h may r e l a t e t o imagery . T h i s anomaly, w h i c h i s an u n u s u a l somat ic e x p e r i e n c e j u s t as v i s u a l imagery i s an u n u s u a l sensory e x p e r i e n c e , o c c u r r e d when p a t i e n t s f e l t e i t h e r h o t o r c o l d , independent o f e n v i r o n m e n t a l t empera ture . The r e g r e s s i o n t e c h n i q u e , w h i c h o n l y p r o v i d e s c o r r e l a t i o n a l r e s u l t s , may e r r o n e o u s l y c r e a t e the i m p r e s s i o n t h a t the p r e d i c t o r causes the outcome. I n f a c t , i t i s more l i k e l y here t h a t the temperature r e g u l a t i o n anomaly, which i s v e r y a g g r a v a t i n g f o r p a t i e n t s , i n t e r f e r e s w i t h s l e e p , r a t h e r than the o t h e r way a round . T h e r e f o r e , these d a t a p r o b a b l y c o u l d b e t t e r be 158 explained by p h y s i o l o g i c a l mechanisms ( e . g . , adaptation to damage of the autonomic nervous system) rather than environmental s t i m u l a t i o n . Coding of the temperature regula t ion anomaly from the charts was prompted by d i scus s ion w i t h a nurse who had observed, i n her experience w i t h acute s p i n a l cord i n j u r y p a t i e n t s , that there seemed to be a two-stage process over t ime: (1) v i v i d dreams and b i z a r r e imagery ( " h a l l u c i n a t i o n s " ) , fol lowed by (2) temperature regu la t ion anomaly. Graphs were made for each of the 50 s p i n a l cord i n j u r y pat ient s to show the changes i n dependent var i ab le s over the e n t i r e length of h o s p i t a l i z a t i o n . Although the above temporal phasing was evident for some i n d i v i d u a l p a t i e n t s , there was no c l e a r pa t tern of stages when the data were examined as a whole. In sum, environmental s t imula t ion was d i r e c t l y re l a ted to imagery i n Study 1, contrary to the predic ted inverse r e l a t i o n s h i p . High l e v e l s o f dimensions o f s o c i a l s t imula t ion ( i . e . , overload) and low l e v e l s o f nonsocia l s t i m u l a t i o n over which the pa t i ent had c o n t r o l , predic ted imagery i n Study 1. These f ind ings were interpreted as cons i s tent w i t h theories of opt imal l e v e l s o f s t imula t ion and c o n t r o l . In Study 2, pa t ient s had greater imagery i n intens ive care than on the ward. This f ind ing was a l so interpreted as most l i k e l y r e s u l t i n g from stimulus over load, i n support of Study 1 and contrary to hypothesis 3(a) . E i t h e r excessive or r e s t r i c t e d s t i m u l a t i o n , remain a l t e r n a t i v e explanations u n t i l more observat ional data of s p i n a l cord i n j u r y pa t ient s i n in tens ive care u n i t s are a v a i l a b l e . 159 Other environmental var i ab le s ( i . e . , number of days i n intens ive care and sleep deprivat ion) d i d not p r e d i c t imagery. Sleep depr iva t ion predic ted ( i . e . , cor re l a ted with) temperature regu la t ion anomaly, although the most probable causative l i n k i s that the temperature anomaly causes lo s s of s leep. The data on imagery and temperature regu la t ion anomaly d i d not provide support for temporal phasing of these phenomena. The temperature regu la t ion problem can be a t t r i b u t e d to a d e f i c i t o f the autonomic nervous system (Burke & Murray, 1975). S t imula t ion Dimensions and Stress The previous f ind ings of imagery pred ic tor s frcm Study 1 l e d the inves t iga tor to examine the r e l a t i o n s h i p between s t i m u l a t i o n dimensions and s t re s s , even though no p r i o r hypotheses were developed. The imagery pred ic tor s included high l e v e l s o f s o c i a l s t imula t ion dimensions (other-directed and var ie ty ) and low c o n t r o l options over nonsocia l s t imula t ion (responsiveness). Baron and Rodin (1978) i n t h e i r concept of "numerosity s t r e s s " , o u t l i n e features of s o c i a l over load , u n p r e d i c t a b i l i t y and lack of onset c o n t r o l . A l l four imagery pred ic tor s from Study 1 are cons i s tent w i t h these features . Therefore, the Baron and Rodin model suggests that these pred ic tor s would c o r r e l a t e wi th s t r e s s . The above f indings form a pa t tern of high s t imula t ion and low c o n t r o l which, i n Cohen's (1978) terms, takes greater a t t e n t i o n a l e f f o r t than overload w i t h c o n t r o l . Baron and Rodin (p. 154) suggest that crowding s t r e s s , of which numerosity s tress i s one type, a r i se s when the s t imula t ion i s seen as a " threa t to personal c o n t r o l " . A l l four of the above pred ic tor s could be 160 seen by the p a t i e n t as such a t h r e a t . Cohen f u r t h e r m a i n t a i n s t h a t p r o l o n g e d demands ( e . g . , o v e r l o a d w i t h o u t c o n t r o l ) c a n l e a d t o c o g n i t i v e f a t i g u e i n w h i c h the a t t e n t i o n a l c a p a c i t y " s h r i n k s " (p. 18) and fewer i n p u t s c a n be p roce s sed t h a n a t r e s t . The r e l a t i o n s h i p between s t i m u l a t i o n d imens ions and s t r e s s i n Study 1 was examined through an e x p l o r a t o r y r e g r e s s i o n a n a l y s i s . The p a t t e r n o f r e s u l t s suggested t h a t o v e r l o a d was a s t r e s s o r i n the h o s p i t a l env i ronment . P r e d i c t o r s o f s u b j e c t i v e s t r e s s ( q u e s t i o n n a i r e ) were n o n s o c i a l n o i s e and o t h e r - d i r e c t e d s o c i a l s t i m u l a t i o n ( s o c i a l " n o i s e " ) . On i n t e r v i e w , two sources o f e n v i r o n m e n t a l s t r e s s ( i . e . , two s u b s c a l e s o f the ESS) were p r e d i c t e d by h i g h s t i m u l a t i o n . H i g h v a r i e t y o f n o n s o c i a l s t i m u l a t i o n p r e d i c t e d s t r e s s r e l a t e d t o p e r s o n a l space and p r i v a c y ( subsca le I ) . I n a d d i t i o n , h i g h l e v e l s o f s o c i a l s t i m u l a t i o n d i r e c t e d a t the p h y s i c a l environment ( e . g . , housekeeping) p r e d i c t e d s t r e s s r e l a t e d t o imagery and dreams ( subsca le I V ) . The d a t a on n o i s e as an i n d u c e r o f s t r e s s suppor t s a numeros i ty s t r e s s e x p l a n a t i o n i n accordance w i t h Baron and R o d i n . The o b s e r v a t i o n s i n S tudy 1 were done on a g i v e n day f o r each p a t i e n t and so i t i s n o t p o s s i b l e t o s a y , whether " p r o l o n g e d exposure" t o n o i s e e x i s t e d , c o n s i s t e n t w i t h Cohen (1978) . However, i t i s p r o b a b l e t h a t the d a y - t o - d a y s t i m u l a t i o n l e v e l s were more s i m i l a r t h a n d i f f e r e n t . M o r e o v e r , the f i n d i n g t h a t n o n s o c i a l n o i s e and o t h e r - d i r e c t e d s o c i a l s t i m u l a t i o n were the o n l y two v a r i a b l e s t h a t p r e d i c t e d s u b j e c t i v e s t r e s s (SSS) l e n d s suppor t t o the p o s s i b i l i t y t h a t a p r o l o n g e d e f f e c t was e x p e r i e n c e d . I n a s t u d y o f n o i s e from highway t r a f f i c , Ward and 161 S u e d f e l d (1973) found t h a t p o s i t i v e a f f e c t decreased over t i m e . A l t h o u g h the d e c i b e l l e v e l o f ward t r a f f i c undoubted ly d i f f e r s from highway t r a f f i c , the g e n e r a l e f f e c t may be s i m i l a r . I n f u t u r e r e s e a r c h , i t would be u s e f u l t o i n c l u d e d e c i b e l r a t i n g s o f the n o i s e l e v e l on o r t h o p e d i c and s u r g e r y wards i n the h o s p i t a l . Another p o s s i b l e e x p l a n a t i o n f o r s t r e s s r e s u l t i n g from o t h e r - d i r e c t e d s o c i a l s t i m u l a t i o n c o u l d be due t o p a t i e n t c o n c e r n about whether d i s c u s s i o n s ( e . g . , two s t a f f t a l k i n g a t the doorway) a re r e l e v a n t t o the p a t i e n t but n o t under h i s o r her c o n t r o l . On i n t e r v i e w , t h i s c o n c e r n was r a r e l y r a i s e d , whereas t h e annoyance o f ward n o i s e l e v e l s ( s o c i a l and n o n s o c i a l ) was much more f r e q u e n t l y e x p r e s s e d . Baron and R o d i n i d e n t i f y two types o f c rowding s t r e s s i n t h e i r framework: numeros i ty s t r e s s ( d i s c u s s e d above) and p r i v a c y s t r e s s (p. 178) i n w h i c h t h e r e i s " o v e r s t i m u l a t i o n due t o l a c k o f t e r m i n a t i o n c o n t r o l " ( i . e . , o f f s e t c o n t r o l ) . B o t h o f the i n t e r v i e w f i n d i n g s o f s t i m u l a t i o n d imens ions as p r e d i c t o r s o f e n v i r o n m e n t a l s t r e s s c o u l d be i n t e r p r e t e d as p r i v a c y s t r e s s . V a r i e t y o f n o n s o c i a l s t i m u l a t i o n i n c l u d e s b o t h r e s p o n s i v e ( w i t h c o n t r o l o p t i o n s ) and nonrespons ive s t i m u l i . H i g h n o n s o c i a l v a r i e t y c o u l d be v iewed as i n t r u s i v e ( e . g . , s e v e r a l r a d i o s and t e l e v i s i o n s on w i t h i n ear shot ) a n d , t h e r e f o r e , c o u l d c o n t r i b u t e t o p r i v a c y s t r e s s , as ev idenced by the p r e d i c t i o n on p e r s o n a l space and p r i v a c y (ESS - s u b s c a l e I ) . L i k e w i s e , h i g h s o c i a l s t i m u l a t i o n d i r e c t e d a t the p h y s i c a l environment c o u l d a l s o be v iewed as i n t r u s i v e , w h i c h c o u l d c o n t r i b u t e t o s t r e s s r e l a t e d t o imagery and dreams (ESS -s u b s c a l e I V ) . B o t h o f the above e n v i r o n m e n t a l f a c t o r s i n t e r f e r e d w i t h o f f s e t c o n t r o l . 162 In sum, the observat ional data from Study 1 show that high s t i m u l a t i o n (overload) and low c o n t r o l options are p r e d i c t i v e of s t re s s . These e f fect s are explained i n terms o f the Baron and Rodin model o f crowding s t re s s , which includes numerosity s t ress and pr ivacy s t re s s . Stimulation Dimensions and Noraxnpliance Hypothesis 3(b) , which predic ted that r e s t r i c t e d environmental s t imula t ion would lead to greater noncompliant behaviour, was p a r t l y supported i n Study 1 but unsupported by both analyses i n Study 2. In Study 1, as pred ic ted , low v a r i e t y o f nonsocia l s t imula t ion predicted noncompliance reports on in terv iew. However, contrary to hypothesis , high l e v e l s of nonsocia l noise predic ted noncompliance recorded i n the c h a r t . Both o f these f indings could be predic ted from Zuckerman's opt imal l e v e l o f s t i m u l a t i o n theory. Nonoptimal l e v e l s o f high and low s t i m u l a t i o n dimensions predicted noncompliance. The d i r e c t r e l a t i o n s h i p between noise and noncompliance, as evidenced above, can be further examined w i t h i n Baron and Rodin's framework o f crowding s t r e s s . In t h i s framework, coping methods are predicted i n r e l a t i o n to the type of crowding s t re s s . Numerosity s t r e s s , such as that produced by no i se , may p r e d i c t "withdrawal from unpredictable s e t t i n g " i n order to "decrease environmental complexity" (Baron & Rodin, 1978, p . 179). Other suggested coping methods are de ind iv idua t ion o f s e l f and others , and group formation. Reactance i s not included as a probable r e s u l t because "when overs t imulat ion occurs , freedom of choice may even increase as outcome c o n t r o l decreases" (p. 179). According to Baron and Rodin, pr ivacy s t r e s s , by contras t to 163 numerosity s t r e s s , may arouse reactance and pos s ib ly helplessness , w i t h coping through s e l e c t i v e i n a t t e n t i o n , withdrawal or t e r r i t o r i a l buf fer s . I f the noncompliance data are viewed as i n d i c a t i v e of reactance, the present data do not support the Baron and Rodin assessment of coping techniques. Noise , which produces numerosity s t r e s s , was p r e d i c t i v e of noncompliance (reactance), contrary to the model. The Baron and Rodin framework i s d e f i c i e n t at the l e v e l of coping techniques because i t does not a l low for e i t h e r the range o f p o s s i b i l i t i e s w i t h i n an i n d i v i d u a l ' s reper to i re or the d i f ferences i n coping s t y l e s between people. In sum, both low and high s t imula t ion l e v e l s may be p r e d i c t i v e o f noncompliance. Low nonsocia l v a r i e t y and high noi se , which predicted noncompliant behaviour, are both cons i s tent w i t h Zuckerman's opt imal l e v e l o f s t imula t ion theory. The r e l a t i o n s h i p of noise to noncompliance i s incons i s tent w i t h Baron and Rodin ' s ana lys i s of coping s t y l e s . The Baron and Rodin framework of crowding s tress f i t s the present data r e l a t i v e to types of s t r e s s , but not r e l a t i v e to coping techniques. Sleep Depr iva t ion In order to further explore the r e s t r i c t e d versus excessive s t i m u l a t i o n explanations o f the environmental e f f ec t i n Study 2, s leep depr iva t ion was cor re l a ted w i t h the three dependent va r i ab le s over t ime. The assumption here was that s leep depr iva t ion contr ibuted to over load, as prev ious ly discussed. Over the i n i t i a l e ight weeks of h o s p i t a l i z a t i o n , s leep depr iva t ion was d i r e c t l y re la ted to each o f the dependent v a r i a b l e s . These data strengthen the case for an overload i n t e r p r e t a t i o n of the e f f ec t of environment i n Study 2. 164 On t h e o t h e r hand , t h e r e a re o b v i o u s l y m u l t i f a c t o r i a l d e t e r m i n a n t s o f imagery , s t r e s s and noncompl iance , i n accordance w i t h the Moos and Tsu mode l . I n the case o f imagery r e s u l t s i n S tudy 2 , f o r example, t h e r e a re s e v e r a l p o s s i b l e c o n t r i b u t o r s t o imagery e f f e c t s , such as i n t e r n a l i m m o b i l i t y ( n e u r o l o g i c a l d e f i c i t ) , e x t e r n a l i m m o b i l i t y (apparatus) and sensory i n p u t s (environment , s l e e p d e p r i v a t i o n ) . I t may be the ca se t h a t a c r i t i c a l c o m b i n a t i o n o f these v a r i a b l e s i s neces sa ry t o r e a c h a t h r e s h o l d o f imagery e f f e c t . Complete q u a d r i p l e g i c s i n i n t e n s i v e c a r e r e a c h t h i s t h r e s h o l d w i t h c o n s i d e r a b l y g r e a t e r f requency than do incomple te q u a d r i p l e g i c s , complete p a r a p l e g i c s o r incomple te p a r a p l e g i c s . One o f the problems w i t h o v e r l o a d mode l s , a c c o r d i n g t o Ba r on and R o d i n (1978, p . 1 8 2 ) , i s t h e i r l a c k o f a b i l i t y t o make a p r i o r i p r e d i c t i o n s about t h e o c c u r r e n c e o f o v e r l o a d e f f e c t s . There i s a g r e a t d e a l o f v a r i a b i l i t y w i t h i n and between i n d i v i d u a l s , w i t h r e g a r d t o t o l e r a n c e f o r h i g h s t i m u l a t i o n l e v e l s . They a s s e r t t h a t t h e i r model o f p e r s o n a l c o n t r o l w i l l improve p r e d i c t a b i l i t y because i t can be used t o d e f i n e d imens ions o f o v e r l o a d , w h i c h i n c l u d e b o t h s t i m u l u s ( s t i m u l a t i o n ) and response ( a t t e n t i o n ) components. The p r e s e n t d a t a suggest t h a t the n o t i o n o f m u l t i p l e d e t e r m i n a n t s r e a c h i n g a c r i t i c a l t h r e s h o l d w i l l a l s o i n c r e a s e p r e d i c t a b i l i t y , even though i t i s n o t p o s s i b l e a t t h i s t ime t o make a d e f i n i t i v e s ta tement on the r e l a t i v e c o n t r i b u t i o n o f r e s t r i c t e d o r e x c e s s i v e s t i m u l a t i o n . I n S tudy 1, a p e r s o n a l and an e n v i r o n m e n t a l v a r i a b l e ( i n Moos & Tsu terms) were p r e d i c t o r s o f s l e e p d e p r i v a t i o n . P a t i e n t s who were a s ses sed 165 as independent (high personal control ) by nurses had greater sleep d e p r i v a t i o n . A second pred ic tor of s leep depr iva t ion was a p r iva te room, which presumably has r e s t r i c t e d s t imula t ion r e l a t i v e to a nonprivate room. These data suggest that a number of combinations of nonoptimal s t imula t ion and c o n t r o l may p r e d i c t psycholog ica l e f fec t s i n h o s p i t a l . Although s leep depr iva t ion was not included as a v a r i a b l e i n t h i s research, the data suggest that i t i s an important v a r i a b l e to include i n further research on h o s p i t a l environmental determinants o f psycholog ica l e f f e c t s . A bas ic tenet o f the present research i s that imagery, environmental s t res s and noncompliant behaviour are normal responses to nonoptimal l e v e l s o f s t i m u l a t i o n and c o n t r o l , rather than pa tho log i ca l s i gns . In genera l , the data presented here appear supportive of t h i s v iew. The type of in te rvent ion which fo l lows from t h i s perspective i s one which a l t e r s the s o c i a l or nonsocia l environment, rather than psychotropic medicat ion. Suedfeld (1974, p . 11) suggests that when a person confronts a novel environment there i s a need " t o i d e n t i f y informat ional anchor po int s and develop a set of adaptive responses". The more unfami l iar and p o t e n t i a l l y dangerous the environment, the greater the information need which may lead to a t t e n t i o n , d i rec ted at i n t e r n a l s t i m u l i ( e . g . , imagery) when externa l information flow i s l a c k i n g . The in te rvent ion tested i n Study 1 could be viewed as an anchor po in t of informat ion. The overload argument presented here appears to cont rad i c t e a r l i e r data concerning "sensory depr iva t ion" i n c e r v i c a l s p i n a l cord i n j u r y 166 p a t i e n t s ( Johnson, 1976) . Tr ieschmann (1980) r a i s e d the p o s s i b i l i t y o f " s e n s o r y d e p r i v a t i o n " as a c o n t r i b u t o r t o b e h a v i o u r a l changes i n the acu te s p i n a l c o r d i n j u r y p a t i e n t , b u t noted the absence o f d a t a on the t o p i c . The d a t a p r o v i d e d by Johnson (1976, p . 21) assumed t h a t o b s e r v a t i o n s such as n i g h t m a r e s , " s e e i n g t h i n g s " , and c o n f u s i o n were i n d i c a t i v e o f s ensory d e p r i v a t i o n . T h i s as sumption was backed by the r e s u l t s o f the s t u d y w h i c h showed a marked decrease i n the above o b s e r v a t i o n s f o r p a t i e n t s i n the i n t e r v e n t i o n g r o u p . The i n t e r v e n t i o n , w h i c h was d e r i v e d from the sensory d e p r i v a t i o n l i t e r a t u r e , i n c l u d e d i n c r e a s e d s o c i a l c o n t a c t , i n f o r m a t i o n , group c o u n s e l l i n g , acce s s t o t ime p i e c e s , m i r r o r s , g l a s s e s and h e a r i n g a i d s as needed. V o l u n t e e r s spent t i m e w i t h p a t i e n t s and a l l s t a f f addressed p a t i e n t s by name and reques ted p e r m i s s i o n b e f o r e p r o v i d i n g s e r v i c e s . I n terms o f the B a r o n and R o d i n framework, t h i s i n t e r v e n t i o n c o u n t e r a c t e d problems o f onse t c o n t r o l ( i n f o r m a t i o n , o r i e n t i n g d e v i c e s ) and problems o f o f f s e t c o n t r o l ( reques t p e r m i s s i o n b e f o r e s e r v i c e ) and thus c o u l d be b e n e f i c i a l from an o v e r l o a d p e r s p e c t i v e as w e l l . The i n c r e a s e i n s o c i a l c o n t a c t , as d i s t i n c t from the o t h e r - d i r e c t e d s o c i a l s t i m u l a t i o n i n S tudy 1, was d e s i g n e d t o be m e a n i n g f u l ( t r a i n e d v o l u n t e e r s , c o u n s e l l i n g ) and p r o v i s i o n was made f o r the p a t i e n t t o t e r m i n a t e o r r e fu se c o n t a c t and thus use c o n t r o l t o a c h i e v e h i s o r her own o p t i m a l l e v e l o f s t i m u l a t i o n . I n o t h e r words , t h i s g l o b a l i n t e r v e n t i o n a l l o w e d f o r enough c o n t r o l o p t i o n s t o be u s e f u l f o r e i t h e r u n d e r l o a d o r o v e r l o a d . I n the Johnson s t u d y , t h e r e was no d i r e c t check o f the " s e n s o r y d e p r i v a t i o n " h y p o t h e s i s through e n v i r o n m e n t a l 167 o b s e r v a t i o n , so i t would be more a c c u r a t e t o suggest t h a t a l t e r e d s t i m u l a t i o n and low c o n t r o l l e d t o c o g n i t i v e f a t i g u e (Cohen, 1978) , w i t h s e n s o r y and c o g n i t i v e e f f e c t s . I n sum, s l e e p d e p r i v a t i o n - was c o r r e l a t e d w i t h a l l t h r e e dependent v a r i a b l e s i n S t u d y . 1 . P r e d i c t o r s o f s l e e p d e p r i v a t i o n f rom Study 2 were independence and a p r i v a t e room. F i n d i n g s were d i s c u s s e d i n r e l a t i o n t o n o n o p t i m a l s t i m u l a t i o n and c o n t r o l , t h r e s h o l d e f f e c t s and i m p l i c a t i o n s f o r i n t e r v e n t i o n . I n g e n e r a l , the d a t a p r o v i d e more suppor t f o r an o v e r l o a d argument t h a n u n d e r l o a d , a l t h o u g h m u l t i p l e d e t e r m i n a n t s a re e v i d e n t i n h o s p i t a l s e t t i n g s . Background and P e r s o n a l F a c t o r s The c r i t e r i o n o f an emergency a d m i s s i o n f o r b o t h s t u d i e s p r e c l u d e d d a t a c o l l e c t i o n b e f o r e a d m i s s i o n . However, i n Study 1, p a t i e n t s e l f - r e p o r t s were o b t a i n e d d u r i n g h o s p i t a l i z a t i o n on l i f e e x p e r i e n c e s f o r the p r e v i o u s year and h e l p l e s s n e s s p r i o r t o a d m i s s i o n . Nurse r a t i n g s o f p a t i e n t behav iour i n h o s p i t a l were o b t a i n e d on independence and dependence. Other f a c t o r s r e l e v a n t t o Moos and T s u ' s background and p e r s o n a l c a t e g o r y were age , s ex , employment s t a t u s and an a c c i d e n t as the reason f o r a d m i s s i o n . L i f e S t r e s s H y p o t h e s i s 4 ( a ) , which p r e d i c t e d t h a t l i f e s t r e s s would l e a d t o i n c r e a s e d imagery , was suppor ted i n Study 1. P a t i e n t s w i t h h i g h n e g a t i v e impact s c o r e s , measured by the degree o f impact o f n e g a t i v e events ( L i f e E x p e r i e n c e s Survey) d u r i n g the year p r i o r t o 168 h o s p i t a l i z a t i o n , had h i g h e r imagery s c o r e s on the M o d i f i e d I m a g i n a l P r o c e s s e s I n v e n t o r y . The r e g r e s s i o n c o e f f i c i e n t f o r t h i s r e l a t i o n s h i p was +.46, which i s a r e l a t i v e l y s t r o n g c o r r e l a t i o n as compared t o much o f the l i f e s t r e s s l i t e r a t u r e i n w h i c h c o r r e l a t i o n s w i t h dependent v a r i a b l e s t end t o be i n the +.20 t o +.30 range (Johnson & S a r a s o n , 1979) . T h i s sugges t s t h a t the use o f n e g a t i v e change s c o r e s , as opposed t o u s i n g bo th p o s i t i v e and n e g a t i v e changes s c o r e s (Holmes & Masuda, 1974) , may i n c r e a s e the p r e d i c t i v e p o t e n t i a l f o r h o s p i t a l i z e d p a t i e n t s . On the o t h e r hand , because the r e l a t i o n s h i p between l i f e s t r e s s and imagery has had l i t t l e p r e v i o u s e x p l o r a t i o n , t h e r e a re no compara t ive d a t a u s i n g the Holmes and Masuda approach on w h i c h t o base t h i s c o n c l u s i o n . H o r o w i t z (1969, 1976) has examined the response t o s t r e s s f u l e v e n t s , as opposed t o t h e l i f e s t r e s s r e s e a r c h emphasis on the p r e c i p i t a t i n g event s themse lve s . The " s t r e s s response syndrome" w h i c h H o r o w i t z o u t l i n e s (1976, p . 56) has the f o l l o w i n g t empora l p h a s i n g : o u t c r y , d e n i a l , i n t r u s i v e n e s s , w o r k i n g through and c o m p l e t i o n . H o r o w i t z observed t h a t i l l u s i o n s , p s e u d o h a l l u c i n a t i o n s (see F i s h , 1967, p . 17) and nightmares o c c u r r e d i n the " i n t r u s i v e - r e p e t i t i v e phase" w h i c h f o l l o w e d the i n i t i a l d e n i a l a f t e r a s t r e s s f u l e v e n t . Repeated i n t r u s i o n s o f thoughts i n t e r r u p t the numbing d e n i a l w i t h re-enactments and r u m i n a t i o n s o f the event i t s e l f . H o r o w i t z has d e s c r i b e d the r e c u r r e n c e o f t r a u m a t i c p e r c e p t i o n s as "unb idden images" (1970, p . 215) . T h i s suggests t h a t these images a re o u t s i d e the p e r s o n ' s c o n t r o l . 169 I n t e r v i e w d a t a from Study 1 p r o v i d e some suppor t f o r H o r o w i t z 1 " i n t r u s i v e - r e p e t i t i v e p h a s e " . A number o f p a t i e n t s i n Study 1 r e p o r t e d t h a t t h e i r a c c i d e n t r e c u r r e d t o them i n dreams o r as v i v i d images on the w a l l o f t h e i r rooms. F o r some, these e x p e r i e n c e s were a u d i t o r y , t a c t i l e o r k i n e s t h e t i c as w e l l . They l a s t e d d u r i n g the i n i t i a l ad justment p e r i o d , and some p a t i e n t s r e l a t e d the d u r a t i o n o f the e x p e r i e n c e s t o w o r k i n g through some a s p e c t o f the a c c i d e n t t h a t was b o t h e r i n g them ( e . g . , the d r i v e r i n a motor v e h i c l e a c c i d e n t wonder ing how he c o u l d have done t h i n g s d i f f e r e n t l y ) . I n these c a s e s , the p a t i e n t s d i d n o t f e e l i n c o n t r o l o f the imagery and the imagery i t s e l f was sometimes u p s e t t i n g . However, i n one i n s t a n c e , a p a t i e n t had c o n t r o l over the imagery i n t h i s i n i t i a l p e r i o d and used h i s a b i l i t y t o image v i v i d l y t o "go back" t o the s e t t i n g j u s t b e f o r e the a c c i d e n t " t o l o o k around and see what I d i d w r o n g " . I n h i s d e t a i l e d d e s c r i p t i o n o f t h i s p r o c e s s , i t was c l e a r t h a t he was a b l e t o " l o o k " a t the scene c r i t i c a l l y , f rom many vantage p o i n t s , u n t i l he was s a t i s f i e d t h a t he had l e a r n e d what was nece s s a ry t o p r e v e n t a s i m i l a r work a c c i d e n t i n the f u t u r e . These a n e c d o t a l d a t a suggest t h a t the degree t o w h i c h images a re " u n b i d d e n " o r o u t o f the p e r s o n ' s c o n t r o l w i l l v a r y a c r o s s i n d i v i d u a l s a c c o r d i n g t o c o p i n g s t y l e s . The e x p l a n a t i o n o f imagery i n H o r o w i t z ' framework does n o t n e c e s s a r i l y c o n t r a d i c t the e a r l i e r p h y s i o l o g i c a l e x p l a n a t i o n o f imagery as spontaneous f i r i n g i n the sensory p r o j e c t i o n a r e a o f the c o r t e x . Trauma c o u l d l e a d t o c o r t i c a l a c t i v a t i o n , j u s t as e n v i r o n m e n t a l s t i m u l a t i o n c o u l d enhance such a c t i v a t i o n (Zuckerman, 1969) . However, these e x p l a n a t i o n s a re a t d i f f e r e n t l e v e l s o f p r o c e s s i n g . 170 The c o n t e n t o f the dreams and imagery r e p o r t e d by the n i n e s p i n a l c o r d i n j u r y p a t i e n t s i n the p i l o t s t u d y can a l s o be examined w i t h i n the f o r m u l a t i o n by H o r o w i t z . B o t h memory images ( t rauma-re la ted) and b i z a r r e imagery (see R i c h a r d s o n , 1969, f o r c l a s s i f i c a t i o n ) , were r e p o r t e d by t h i s group". Dreams o f t e n tended t o be s i m i l a r t o memory imagery i n t h a t they were f a m i l i a r i n c o n t e n t , v i v i d , e x t r e m e l y r e a l i s t i c and the p a t i e n t was r a r e l y ( i . e . , o n l y one case) p a r a l y z e d i n the dream. T h i s f i n d i n g was s i m i l a r t o o t h e r d a t a from p a r a p l e g i c s , the b l i n d and amputees ( c i t e d i n B o r s , 1951) . B o r s found t h a t the d i s a b i l i t y does e n t e r the dream f o r p a r a p l e g i c s over t i m e . One c o u l d i n t e r p r e t t h i s absence o f d i s a b i l i t y i n the dream as d e n i a l a c c o r d i n g t o H o r o w i t z . On the o t h e r hand, the i d e a o f i n j u r y - t r i g g e r e d memory imagery removes t h e i m p l i c a t i o n o f a m a l a d a p t i v e defense mechanism. Tr ieschmann (1980) has suggested, t h a t p r o f e s s i o n a l s may o v e r - e s t i m a t e the degree o f p a t h o l o g y a f t e r s p i n a l c o r d i n j u r y and thereby s e t up a " C a t c h 22" s i t u a t i o n : " I f you have a d i s a b i l i t y , you must have p s y c h o l o g i c a l p rob lems ; i f you s t a t e t h a t you have no p s y c h o l o g i c a l p r o b l e m s , then t h i s i s d e n i a l and t h a t i s a p s y c h o l o g i c a l p r o b l e m " . P a r a l y z e d p a t i e n t s i n the p i l o t s t u d y , who were not d i s a b l e d i n t h e i r dreams, were o f t e n v e r y upset when they awoke. Any d e n i a l i n dreams, t h e r e f o r e , tended t o be o f f s e t by he ightened awareness on w a k i n g . H y p o t h e s i s 4(b) p r e d i c t e d t h a t p r e v i o u s l i f e s t r e s s would be p r e d i c t i v e o f the degree o f s t r e s s e x p e r i e n c e d b o t h d u r i n g and a f t e r h o s p i t a l i z a t i o n . I n t h i s c a s e , s t r e s s appears t o be b o t h an independent and dependent v a r i a b l e . The r a t i o n a l e f o r t h i s approach comes from 171 c r i s i s t h e o r y ( A g u i l e r a & M e s s i c k , 1982) w h i c h p r e d i c t s t h a t p r e v i o u s s t r e s s has an impact on l a t e r p s y c h o l o g i c a l outcomes i n the s t r e s s o f a c r i s i s s i t u a t i o n . I t was found t h a t , c o n t r a r y t o h y p o t h e s i s , p r e v i o u s l i f e s t r e s s d i d n o t p r e d i c t any o f the measures o f s t r e s s t a k e n w h i l e the p a t i e n t was i n h o s p i t a l . The h o s p i t a l i z a t i o n may indeed have p r o v i d e d a r e s p i t e f o r p a t i e n t s w i t h p r i o r s t r e s s . On the o t h e r hand, h y p o t h e s i s 4(b) was suppor ted on the measure o f p s y c h o l o g i c a l s t r e s s ( subsca le o f the PAIS) t a k e n two months a f t e r d i s c h a r g e . That i s , p a t i e n t s who had h i g h l i f e s t r e s s i n the year p r i o r t o a d m i s s i o n a l s o tended t o have h i g h s t r e s s , o r reduced ad jus tment , a f t e r d i s c h a r g e . T h i s suggests t h a t p r i o r l i f e event s w i t h a n e g a t i v e impact t end t o decrease the e f f e c t i v e n e s s o f l o n g t e r m c o p i n g a f t e r an emergency a d m i s s i o n t o h o s p i t a l , even though s h o r t t e r m adjustment i s u n a f f e c t e d . An a l t e r n a t i v e e x p l a n a t i o n i s t h a t the h o s p i t a l p r o v i d e d re fuge f rom an o t h e r w i s e s t r e s s - p r o d u c i n g environment o u t s i d e the h o s p i t a l . The f i n d i n g o f reduced l o n g t e r m adjustment ( i . e , i n c r e a s e d s t r e s s ) may be e x p l a i n e d i n terms o f p e r s o n a l c o n t r o l . H i g h p e r s o n a l c o n t r o l has been found t o be p r e d i c t i v e o f reduced l o n g t e r m s t r e s s , even though s h o r t t e r m s t r e s s may be i n c r e a s e d ( A v e r i l l , 1973) . Here we have the r e v e r s e l o n g - t e r m f i n d i n g s . Low p e r s o n a l c o n t r o l , e v i d e n c e d by p r i o r t r a u m a t i c l i f e events (negat ive i m p a c t ) , p r e d i c t s i n c r e a s e d long te rm s t r e s s , w i t h no e f f e c t on s h o r t t e r m s t r e s s . I n sum, as h y p o t h e s i z e d , p r e v i o u s l i f e s t r e s s p r e d i c t e d imagery d u r i n g the f i r s t e i g h t days o f h o s p i t a l i z a t i o n i n Study 1. The use o f 172 n e g a t i v e impact as an i n d i c a t o r o f l i f e s t r e s s , as opposed t o the c o m b i n a t i o n o f p o s i t i v e and n e g a t i v e change, was found t o be b e n e f i c i a l . R e s u l t s were examined i n r e l a t i o n t o H o r o w i t z * f o r m u l a t i o n o f a s t r e s s response syndrome, i n w h i c h t r a u m a t i c p e r c e p t i o n s t e n d t o r e c u r as "unb idden images" d u r i n g the " i n t r u s i v e - r e p e t i t i v e phase" p r i o r t o w o r k i n g through f e e l i n g s r e l a t e d t o a s t r e s s f u l e v e n t . H o r o w i t z , who w r i t e s from a p s y c h o a n a l y t i c a l p e r s p e c t i v e , v i e w s trauma as e x c e s s i v e s t i m u l a t i o n ( H o r o w i t z , 1970) . A s p r e d i c t e d , p r i o r l i f e s t r e s s l e a d s t o reduced p o s t - d i s c h a r g e ad jus tment , i n t h a t p a t i e n t s who had a h i g h i n c i d e n c e o f n e g a t i v e impact event s i n the year b e f o r e h o s p i t a l i z a t i o n tended t o r e p o r t g r e a t e r d i s t r e s s two months a f t e r d i s c h a r g e . C o n t r a r y t o h y p o t h e s i s , t h e r e was no change i n s t r e s s d u r i n g h o s p i t a l i z a t i o n i n r e l a t i o n t o p r e v i o u s l i f e s t r e s s . These r e s u l t s were i n t e r p r e t e d i n terms o f an i n v e r s e r e l a t i o n s h i p between p e r s o n a l c o n t r o l and s t r e s s . O t h e r Background F a c t o r s R e g r e s s i o n a n a l y s i s was used t o de termine the p r e d i c t i v e e f f e c t o f a number o f background f a c t o r s . T h i s approach was i n c l u d e d b o t h t o p r o v i d e a d d i t i o n a l suppor t f o r hypotheses and e x p l o r e the p o s s i b i l i t i e s o f a l t e r n a t i v e e x p l a n a t i o n s f o r d a t a , g i v e n the c o m p l e x i t y o f v a r i a b l e s w h i c h e x i s t i n a h o s p i t a l c o n t e x t . Where p o s s i b l e confounding v a r i a b l e s c o u l d not be c o n t r o l l e d i n the c l i n i c a l s i t u a t i o n , the r e g r e s s i o n a n a l y s i s p r o v i d e d a degree o f s t a t i s t i c a l c o n t r o l . The f a c t o r s examined here were : age and sex (Study 1 and Study 2 ) , a c c i d e n t (Study 1) and employment s t a t u s (Study 2 ) . 173 I n s tudy 2 , none o f the demographic v a r i a b l e s (sex, age , employment) were s i g n i f i c a n t p r e d i c t o r s o f dependent v a r i a b l e s . However, i n Study 1, s e v e r a l p r e d i c t o r s emerged. Age p r e d i c t e d one measure on each o f the dependent v a r i a b l e s i n S tudy 1. Young p a t i e n t s had h i g h e r imagery s c o r e s ( M I P I ) , g r e a t e r s t r e s s r e l a t e d t o e n v i r o n m e n t a l s t i m u l a t i o n l e v e l s (ESS — s u b s c a l e I I ) and had more noncompliance r e c o r d e d i n the c h a r t , as opposed t o o l d e r p a t i e n t s . These f i n d i n g s l e n d suppor t t o Putnam and Y a g e r ' s (1978) o b s e r v a t i o n s t h a t e m o t i o n a l and b e h a v i o u r a l r e a c t i o n s i n n i n e o r t h o p e d i c p a t i e n t s , o r " t r a c t i o n i n t o l e r a n c e syndrome" i n t h e i r t e rms , o c c u r r e d e x c l u s i v e l y i n the 16 - 26 year age range , r a t h e r than i n the 27 - 45 year r ange . The p r e s e n t d a t a were coded t o match the Putnam and Yager c a t e g o r i e s , b u t a l s o i n c l u d e d a 46 - 65 year r ange . These f i n d i n g s show t h a t age p r e d i c t s imagery , e n v i r o n m e n t a l s t r e s s and noncompl iant behav iour i n a l a r g e r sample o f b o t h o r t h o p e d i c and s u r g e r y p a t i e n t s , r a t h e r than t r a c t i o n p a t i e n t s a l o n e . Sex was a l s o a p r e d i c t o r o f s t r e s s r e l a t e d t o e n v i r o n m e n t a l s t i m u l a t i o n l e v e l s i n S tudy 1. On i n t e r v i e w , female p a t i e n t s r e p o r t e d g r e a t e r e n v i r o n m e n t a l s t r e s s on s u b s c a l e I I . T h i s f i n d i n g has n o t appeared i n p r e v i o u s l i t e r a t u r e . No o t h e r f i n d i n g s r e l a t e d t o sex emerged. I n Study 1, an a c c i d e n t as the reason f o r h o s p i t a l i z a t i o n p r e d i c t e d e n v i r o n m e n t a l s t r e s s (ESS - t o t a l ) and two s e c t i o n s w i t h i n the ESS: s u b s c a l e I , which r e l a t e d t o p e r s o n a l space and p r i v a c y ; and s u b s c a l e I I I , w h i c h measured r e a c t i o n t o p e r s o n a l c o n t r o l and response r e s t r i c t i o n . J u s t as l i f e s t r e s s c o u l d be c o n c e p t u a l i z e d as decreased 174 personal c o n t r o l , so could an accident be seen as yet another l i f e event w i t h a negative impact. Therefore, these f indings a l l provide support for hypothesis 5 (to follow) which predicted an inverse r e l a t i o n s h i p between personal c o n t r o l and s t re s s . An accident and l i f e s t ress events are a l so unpredictable . Both p r e d i c t a b i l i t y and c o n t r o l have been re l a ted to s tress e f fec t s (Glass & Singer , 1972). Personal C o n t r o l Hypotheses 5 predic ted that high personal c o n t r o l would lead to decreased s t re s s . This inverse r e l a t i o n s h i p was supported on measures of environmental s t r e s s , but not on other s tress measures taken during or a f ter h o s p i t a l i z a t i o n . In support of t h i s hypothesis , pa t i en t reports of subject ive helplessness p r i o r to h o s p i t a l i z a t i o n (low control ) predic ted environmental s t ress scores from the interv iew (ESS - to ta l ) and from subscale I I on s t ress r e l a t i v e to environmental s t imula t ion l e v e l s . Confirmation of t h i s f ind ing was provided by the nurse quest ionnaire assessment of pa t i en t behaviour, i n which independent pat ients (high contro l ) reported l e s s environmental s t ress r e l a t i v e to personal c o n t r o l and response r e s t r i c t i o n (subscale I I I ) . The f ind ing of an inverse r e l a t i o n s h i p between personal c o n t r o l and environmental s t r e s s , coupled w i t h the previous f i n d i n g that high l e v e l s o f s o c i a l s t imula t ion predicted s t re s s , gives support to the not ion that personal c o n t r o l mediates crowding e f fect s (Baron & Rodin, 1978). Insofar as a s o c i a l l y s t imula t ing environment can be seen as crowding the f ac t that personal c o n t r o l does not p r e d i c t any of the measures of 175 general s t ress suggests that c o n t r o l , whi le relevant to environmental s t r e s s , does not a f f ec t general s t ress i n h o s p i t a l . Conclusion and Clinical Implications In conc lus ion , t h i s i n v e s t i g a t i o n examined factors re la ted to the psycholog ica l outcome af ter the c r i s i s of an emergency admission to h o s p i t a l . The independent var i ab le s for study included immobi l i ty , cogn i t ive reappra i s a l , environmental s t imula t ion dimensions, l i f e s t ress and personal c o n t r o l . Outcome var iab le s for both s tudies o f h o s p i t a l i z e d pa t ient s were imagery, s t ress and noncompliant behaviour. The model of Moos and Tsu (1977), which proposed fac tors cont r ibu t ing to the c r i s i s o f p h y s i c a l i l l n e s s , provided a useful framework for the var i ab le s o f i n t e r e s t here. The data supported the model insofar as s i g n i f i c a n t f ind ings were reported under each o f the f i v e categories of hypotheses, which could be adapted to sect ions of the model. From a c l i n i c a l perspect ive , the f indings from the two studies i n the present pro jec t have impl ica t ions for pa t i ent care on surgery, orthopedic and s p i n a l cord i n j u r y u n i t s i n acute care h o s p i t a l s e t t i n g s . Although immobil i ty was hypothesized to lead to increased imagery, s t ress and noncompliant behaviour; both studies supported the r e l a t i o n s h i p w i t h imagery, but not genera l ly w i t h s tress or noncompliance. One exception to the l a t t e r r e s u l t s was found i n Study 1, i n which immobile pa t ient s d i d have increased s tress re la ted to lack of c o n t r o l opt ions . Otherwise, s t ress e f fects were comparable across pa t i en t groups i n both s tud ie s . Pat ient s wi th extensive p a r a l y s i s d i d 176 not have s i g n i f i c a n t l y more s tress than d i d those who were s l i g h t l y para lyzed . However, imagery increased w i t h greater immobil i ty regardless of whether t h i s immobil i ty was ex terna l (apparatus) or i n t e r n a l (paralysis) i n o r i g i n . Most imagery e f fects occurred during the e a r l y h o s p i t a l i z a t i o n p e r i o d , u sua l ly during the f i r s t week of h o s p i t a l s tay , whereas noncompliance occurred l a t e r . Noncompliance and s t ress were cor re l a ted w i t h each other , whi le unrelated to immobi l i ty . However, noncompliant behaviour was more frequent i n pa t ient s wi th mi ld concussion. These pat ient s a l so tended to have more fractures and, hence, greater immobi l i ty . Sleep depr iva t ion was found to c o r r e l a t e w i t h a l l three outcome v a r i a b l e s : imagery, s t ress and noncompliant behaviour. These data can a s s i s t h o s p i t a l s t a f f i n the p r e d i c t i o n of psycholog ica l react ions of pa t ient s admitted under emergency c o n d i t i o n s . In r e l a t i o n to ex terna l immobi l i ty , the type o f immobil iz ing apparatus ( e . g . , c e r v i c a l t rac t ion) i s more l i k e l y to determine imagery e f fec t s than durat ion o f immobi l i ty . The cogn i t ive reappra i sa l in te rvent ion tested here would be e s p e c i a l l y important for pat ients who are most l i k e l y to have imagery e f f e c t s , such as those wi th c e r v i c a l f ractures w i t h or without accompanying p a r a l y s i s . A l l pat ients i n t h i s category could p o t e n t i a l l y benef i t from exposure to t h i s informat ional in te rvent ion as a preventat ive measure. Even though r e p l i c a t i o n of the in te rvent ion e f fec t would be des i rab le i n future research, the present data suggest that provid ing an expectancy for imagery, a p o s i t i v e set and an environmental explanation can reduce s tress without increas ing 177 the incidence o f imagery. This information could be provided v e r b a l l y (the tape was for research c o n t r o l only) to pat ients by nurses during careg iv ing a c t i v i t i e s i n the ea r ly days of h o s p i t a l i z a t i o n . Other intervent ions could be geared to monitor and improve sleep-wake patterns of pa t ient s i n genera l , and to increase c o n t r o l options for immobilized pa t ient s i n p a r t i c u l a r . For example, provid ing choice i n matters r e l a ted to personal care (such as time of bath) would be one way to increase c o n t r o l opt ions . C o r r e l a t i o n a l data a l so showed that pa t ient s w i t h no previous h o s p i t a l experience had greater environmental s t r e s s . This f ind ing suggests the importance of provid ing a ward o r i e n t a t i o n to emergency pa t ient s i n h o s p i t a l for the f i r s t time so that they have some idea of what to expect during t h e i r h o s p i t a l s tay . Aga in , personal c o n t r o l could be increased through expectancy informat ion. With regard to environmental s t i m u l a t i o n , the data show that imagery was predicted by high l e v e l s of s o c i a l s t imula t ion and of nonsocia l s t imula t ion over which the pa t ient has l i t t l e c o n t r o l , such as a rad io which belongs to (and i s c o n t r o l l e d by) the pa t i en t i n the next bed or across the h a l l . The high s o c i a l s t imula t ion was of two types: (1) o ther-d i rec ted which re ferred to v e r b a l i z a t i o n by two or more people who are i n the p a t i e n t ' s room, outside the space surrounding the p a t i e n t , and who do not include the pa t ient i n the d i scuss ion ( s o c i a l " n o i s e " ) , and (2) v a r i e t y which r e f l ec ted the frequency that d i f f e r e n t people entered the room. 178 These data suggest that h o s p i t a l s t a f f need to monitor and reduce the t r a f f i c of people i n t o pa t ient rooms. Secondly, a greater proport ion of e x i s t i n g s o c i a l communication i n rooms should be d i rec ted persona l ly at each pa t i ent i n a g iven room. One way that both o f these ob ject ives might be achieved would be through primary nursing i n which one nurse i s t o t a l l y responsible for the care of a pa t i en t throughout the h o s p i t a l s tay . This would improve the degree of per sona l i za t ion of care and would reduce the number of caretakers . Instead of d i f f e r e n t nurses administering medications, taking v i t a l s igns and a s s i s t i n g wi th the bath, the same nurse would be responsible for a l l aspects of care . Johnson (1976) produced a s t r i k i n g reduction of imagery i n s p i n a l cord i n j u r y pa t ient s through a se r ie s o f intervent ions which a l t e red the s o c i a l and nonsocia l h o s p i t a l environment. The present research supports Johnson's approach to in te rvent ion but does not concur wi th h i s explanation of the mechanism for the change. Johnson suggests that h i s approach reduces "sensory depr iva t ion" e f f e c t s ; the present i n t e r p r e t a t i o n would be that he has provided more personal ized and i n d i v i d u a l i z e d care which increases c o n t r o l opt ions . For example, Johnson increased the amount of s o c i a l s t imula t ion through increased contact w i t h other p a t i e n t s , volunteers and s t a f f . Pa t ient s were addressed by name and the s t a f f asked for pa t i en t permission before provid ing care . The s t a f f a l so provided information to pat ients on s p i n a l cord i n j u r i e s i n general and t h e i r own p a r t i c u l a r c o n d i t i o n , treatment and prognosis . Group meetings were organized for pat ients to d i scuss t h e i r i n j u r i e s and to support each other . This study, which was 179 conducted i n a C a l i f o r n i a h o s p i t a l , included intervent ions which were already being done i n the two Canadian hosp i t a l s where the present p ro j ec t was conducted. For example, pat ients i n both the U n i v e r s i t y H o s p i t a l (UH) and Shaughnessy H o s p i t a l (SH) were addressed by name. However, other intervent ions ( e . g . , the use of volunteers , p r o v i s i o n of d e t a i l e d information and pa t ient support groups) were e i ther done i n c o n s i s t e n t l y or not at a l l . Johnson further a l t e red the nonsocia l environment by the p r o v i s i o n of c l o c k s , watches, eyeglasses, hearing a ids and m i r r o r s . With the exception of m i r r o r s , nursing s t a f f at UH and SH genera l ly took steps (pr ior to the present project) to assure that pa t ient s had access to t imepieces, sensory aids and other nonsocia l s t imula t ion such as p i c t u r e s on the w a l l and b u l l e t i n boards for personal cards and mementos. The intens ive care u n i t at SH had a mul t i -co lored design on the c e i l i n g . A t i n d i v i d u a l pa t i ent s ' suggestions, nursing s t a f f provided ass istance w i t h attaching p i c ture s to leg t r a c t i o n (SH) or to the c e i l i n g (UH). In the l a t t e r case, a woman i n c e r v i c a l t r a c t i o n could gaze at a blow-up photograph of her young c h i l d rather than the blank c e i l i n g . These inc idents were pra i sed by the pa t ient s i n quest ion and suggest that a p p l i c a t i o n of t h i s approach could be increased i n fu ture . The quest ion of mirrors i s one that merits further i n v e s t i g a t i o n by h o s p i t a l s t a f f who work wi th immobile p a t i e n t s . In the ea r ly days of the Acute S p i n a l Cord In jury U n i t (ASCIU) at SH, mirrors were attached to pa t ient beds i n order to increase the v i s u a l s t imula t ion for 180 p a t i e n t s . This p r a c t i c e was discontinued at the request of pat ients who found that the mirrors accentuated t h e i r l i m i t e d pr ivacy at times such as catheter change or being turned from side to s i d e . Even without m i r r o r s , the issue of pr ivacy i s a d i f f i c u l t one for s p i n a l cord i n j u r y p a t i e n t s . One pa t i ent on the ASCIU suggested that the word pr ivacy had l o s t a l l meaning: "pr ivacy no longer e x i s t s " . I t i s poss ib le that mirrors could counteract k i n e s t h e t i c imagery for immobile pat ients i n a manner s i m i l a r to the e f f ec t o f going for a walk i n the case of mobile p a t i e n t s . In both cases v i s u a l and p o s i t i o n a l inputs would be increased which could counter k i n e s t h e t i c imagery due to the r e l a t i o n s h i p between v i s u a l and ve s t ibu l a r systems. One way that the p o t e n t i a l benef i t of mirrors could be achieved without interference w i t h pr ivacy could be to design a mirror which had an opaque v i z o r attached to a device which the pa t i ent could c o n t r o l . In t h i s manner, when the pa t ient wanted to see through the mirror v i z o r could be l i f t e d for v i s i o n and when there was a need to avoid i n t r u s i v e eyes the v i z o r could be lowered to obstruct the m i r r o r . This device could be adapted for use by quadr ip leg ics who lack hand c o n t r o l by using a c o n t r o l operated by head movement. In the experience of nurses at the ASCIU, some pat ients are interested i n c o n t r o l devices ( e . g . , head c o n t r o l of t e l ev i s ion ) during the e a r l y h o s p i t a l i z a t i o n per iod and others are not . However, the opt ion for a mirror wi th a v i z o r could be useful for at l ea s t some of the p a t i e n t s . In the present research, imagery was greater i n the presence of nonsocia l s t imula t ion over which the pa t ient had low c o n t r o l opt ions . 181 Both nonsocia l noise and s o c i a l "noise" (other-directed verba l iza t ion) a l so predicted s t re s s . C l i n i c i a n s could attempt to reduce these e f fec t s by such measures as the encouragement of pat ients to use earphones for t h e i r radios and t e l e v i s i o n s so that other pa t ient s w i l l not have the f r u s t r a t i o n of l i s t e n i n g to programs without c o n t r o l over volume/ content or time of day for l i s t e n i n g . To some degree t h i s approach i s already i n e f fec t but i t i s by no means u n i v e r s a l . The imagery-inducing e f fec t of the intens ive care environment was found, on subs id iary a n a l y s i s , to be s p e c i f i c to the complete quadr ip leg ic p a t i e n t s . I t was suggested e a r l i e r that environmental factors may i n t e r a c t and when s u f f i c i e n t number of factors e x i s t ( e . g . , complete quadr ip leg ia i n intens ive care environment) a threshold may be reached so that most, i f not a l l , pa t ients i n t h i s group could be expected to have imagery e f f e c t s . A l i m i t a t i o n of t h i s data was that i t came e x c l u s i v e l y from pa t ient charts which tend to under-represent psycholog ica l e f fec t s such as imagery. Nevertheless , the intervent ions suggested i n t h i s sec t ion could be p a r t i c u l a r l y important for complete, quadr ip leg ics i n intens ive care who appear to reach t h i s threshold for imagery e f f e c t . Prom Study 2, the f ind ing that sleep depr iva t ion corre la ted wi th imagery ( cor re l a t ion matrices) but d i d not p r e d i c t imagery (other than the temperature regula t ion anomaly) on the stepwise regress ion analys i s suggests that other uncontrol led factors may be operating here. Data were obtained on psycholog ica l ind ices such as hypoxia , in fec t ions and other complications but no c l ea r pat tern of r e l a t i o n s h i p to imagery 182 emerged. However, again i t i s pos s ib le that p h y s i o l o g i c a l complications i n t e r a c t w i t h environmental factors to reach a threshold of imagery e f f e c t . Confusion associated wi th imagery was n e g l i g i b l e for the surgery and orthopedic pa t i en t groups, whereas i t was more frequently noted for s p i n a l cord i n j u r y p a t i e n t s . To the extent that these f indings could be c l a s s i f i e d as the e a r l y stage of d e l i r i u m , the data suggest that perceptual changes (imagery) precede cogn i t ive e f fect s such as d i s o r i e n t a t i o n . This f ind ing does not f i t the c l a s s i c a l p s y c h i a t r i c p i c t u r e of d e l i r i u m w i t h cogn i t ive changes (clouding of consciousness, d i s o r i e n t a t i o n and memory impairment) which may or may not be accompanied by perceptual disturbance such as i l l u s i o n s or h a l l u c i n a t i o n s . Regardless of d e f i n i t i o n , graphs of these data do not support the ef fect iveness of psychotropic medication i n reducing imagery when i t occurs . Noncompliance was unrelated to environmental var iab les i n Study 2 but was re la ted to low v a r i e t y of nonsocia l s t imula t ion and to high noise l e v e l s i n Study 1. This suggests that intervent ions which provide nonsocia l s t imula t ion wi th relevance to the pa t ient (as opposed to noise) may be useful to reduce noncompliance. Occupational therapy could be b e n e f i c i a l i n t h i s instance. The hosp i t a l s included i n the present pro jec t d i d provide occupational therapy for immobile p a t i e n t s . However, t h i s p r a c t i c e could be increased and nursing s t a f f could a l so provide a c t i v i t i e s for pat ients when occupational therapis t s are not a v a i l a b l e . Reduction of noise by whatever means poss ib le needs to be a p r i o r i t y as w e l l . 183 During the f i r s t week of h o s p i t a l i z a t i o n i n Study 2, imagery was d i r e c t l y re l a ted to s leep depr iva t ion and to noncompliance. Most of these pa t ient s were i n the intens ive care u n i t at t h i s t ime. Further research needs to be done on intervent ions to promote s leep , e s p e c i a l l y during the e a r l y h o s p i t a l i z a t i o n p e r i o d . Nonoptimal environmental s t imula t ion may be e i ther low s t imula t ion (independent pat ients i n p r iva te rooms had greater s leep deprivation) or high s t imula t ion (high l e v e l s of noise predicted subject ive s t r e s s ) . Other overload factors were p r e d i c t i v e of environmental s t r e s s : a high degree of v a r i e t y of nonsocia l s t imula t ion and the presence of people who were involved wi th the environment ( e . g . , housekeeping) but d i d not i n t e r a c t wi th the p a t i e n t . In genera l , these r e s u l t s suggest that st imulus overload i s more problematic for the pa t i en t groups studied than i s r e s t r i c t e d s t i m u l a t i o n . C l i n i c a l a p p l i c a t i o n of these f indings should take i n t o account both st imulus (overload) factors and response f ac to r s , such as the p a t i e n t ' s options for c o n t r o l . Personal c o n t r o l measures were inver se ly re la ted to environmental s tress i n general as w e l l as to subscales I I and I I I of the Environmental Stress Sca le . Subscale I I , which measures s t ress re l a ted to environmental s t imula t ion l e v e l s , has p a r t i c u l a r relevance here. The i m p l i c a t i o n of these f indings are that intervent ions which increase personal c o n t r o l should reduce s tress t r iggered by environmental f a c to r s . L i f e events wi th a negative impact on the pa t ient during the year p r i o r to admission l e d to greater imagery during h o s p i t a l i z a t i o n and 184 reduced adjustment ( i . e . , high stress) two months a f ter discharge. This suggests that the i n i t i a l assessment of emergency pat ient s on admission should include a notat ion of events i n the previous year ( e . g . , death of a family member) which could complicate adjustment to the current emergency. In both hosp i t a l s these events were sometimes brought to the a t t en t ion of a s o c i a l worker or other counsel lor a f ter a pa t i en t became upset. However, the i n c l u s i o n of " l i f e s t ress i n the previous year" as a heading on the admission form might serve a prevention funct ion to a l e r t s t a f f to p o t e n t i a l areas of concern which may impede the recovery process . The f i n d i n g that younger pa t ient s had greater imagery provides an a d d i t i o n a l cue for s t a f f to p r e d i c t psycholog ica l e f fec t s a f ter admission. In summary, t h i s p ro j ec t has provided data on the e f fect s o f immobi l i ty , environmental s t i m u l a t i o n , previous l i f e s t ress and personal c o n t r o l on imagery, s t ress and noncompliant behaviour i n emergency-admitted p a t i e n t s . An in tervent ion was tested to demonstrate that cogni t ive reappra i sa l of imagery e f fect s had stress-reducing p o t e n t i a l . 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Perceptual and  Motor S k i l l s , 27, 319-334 [b] . 200 Code APPENDIX A Date U n i t CONSENT FORM I, the undersigned, hereby agree to p a r t i c i p a t e i n a research pro jec t inves t i ga t ing the psycholog ica l e f fec t s of h o s p i t a l i z a t i o n under emergency cond i t ions . The pro jec t i s conducted by Norma Stewart, a doc tora l student i n psychology, under the supervi s ion of Dr . P . Suedfeld, Head o f the Psychology Department at the U n i v e r s i t y o f B r i t i s h Columbia. This research has been approved by the h o s p i t a l medical and adminis t ra t ive s t a f f . I understand that I w i l l be asked to answer questions and to f i l l out forms concerning my recent experiences before h o s p i t a l i z a t i o n and my react ions whi le i n h o s p i t a l . This procedure w i l l take a t o t a l of about two hours of my time over three sessions and w i l l involve no r i s k . I understand that the researcher w i l l a l so s i t i n my room and make observations of the environment over four 15-minute periods on one day. During these observation per iods , I understand that I can ca r ry on my a c t i v i t i e s (e.g. s l eep ing , ea t ing , t a l k i n g to others) as i f the researcher were not present . I a l so understand that I may be asked to l i s t e n to some tape-recorded mate r i a l concerning the e f fec t s of h o s p i t a l i z a t i o n . I understand further that the researcher w i l l review my medical record whi le I am i n h o s p i t a l . Three months a f ter I am discharged, I understand that I w i l l receive by m a i l a quest ionnaire concerning my react ions at that t ime. This f i n a l quest ionnaire w i l l take about an hour of my time to complete and m a i l to the i n v e s t i g a t o r . I understand that my responses w i l l remain c o n f i d e n t i a l and anonymous and that no i n d i v i d u a l s w i l l be i d e n t i f i a b l e i n the r e s u l t s of t h i s research. I a l so understand that I am free to discontinue my p a r t i c i p a t i o n i n the study at any time and for any reason. I understand that withdrawal from the study w i l l have no e f fec t whatsoever on my further treatment and care by h o s p i t a l s t a f f . F i n a l l y , I appreciate that the r e s u l t s of t h i s p ro jec t may benef i t future pa t ient s i n circumstances s i m i l a r to mine. To ensure the accuracy of r e s u l t s , I agree not to discuss the research wi th anyone e l s e whi le I am i n h o s p i t a l . 201 APPENDIX A (continued) Name (print) Signed • . '  On behalf of the pro jec t I do hereby agree to abide by the e t h i c a l p r i n c i p l e s i n the conduct of research of the American Psycholog ica l A s s o c i a t i o n . Norma Stewart, R . N . , B . S . N . , M . S . , M.A. / 202 CODE APPENDIX B . l DATE UNIT L I F E EXPERIENCES SURVEY The purpose of t h i s research pro jec t i s to inves t iga te the psycholog ica l e f fec t s of h o s p i t a l i z a t i o n under emergency cond i t ions . The quest ionnaire below w i l l provide background information on events you may have experienced during the year before t h i s admission to h o s p i t a l . These events may br ing about changes i n the l i v e s of those who experience them. Ins t ruc t ions ; Rate each event that occurred i n your l i f e during the  past year as Good or Bad ( c i r c l e which one a p p l i e s ) . Show how much the event affected your l i f e by c i r c l i n g the appropriate statement (no effect - some effect -moderate effect - great effect). I f you have not experienced a p a r t i c u l a r event i n the  past year , leave i t blank. Please go through the e n t i r e l i s t before you begin to get an idea of the type of events you w i l l be asked to r a t e . I t w i l l probably take you 10-15 minutes to complete the e n t i r e form. As I mentioned e a r l i e r , you are free to refuse to answer any questions or to withdraw from the pro jec t at any time without pre judice to your h o s p i t a l care . I f the quest ionnaire i s completed, i t w i l l be assumed that consent has been g i v e n . TYPE OF EVENT EVENT EFFECT OF EVENT ON YOUR LIFE 1. Marriage Good Bad no some moderate great e f f ec t e f f ec t e f f ec t e f fec t 2. Detention i n j a i l or Good Bad no some moderate great comparable i n s t i t u t i o n e f fec t e f f ec t e f f ec t e f f ec t 3. Death of spouse Good Bad no some moderate great e f fec t e f f ec t e f f ec t e f f ec t 203 TYPE OF EVENT EVENT EFFECT OF EVENT ON YOUR LIFE Major change i n s leep habi t s (much more or much l e s s sleep) Good Bad no e f f ec t some e f f ec t moderate e f f ec t great e f f ec t Death of c lose fami ly a. mother Good Bad no e f f ec t some e f f ec t moderate e f f ec t great e f f ec t b. father Good Bad no e f f ec t some e f fec t moderate e f fec t great e f f ec t c . brother Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t d. s i s t e r Good Bad no e f f ec t some e f fec t moderate e f fec t great e f f ec t e. grandmother Good Bad no e f fec t some e f fec t moderate e f fec t great e f f ec t f . grandfather Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t g. other (specify) Good Bad no e f f ec t some e f fec t moderate e f fec t great e f f ec t Major change i n eat ing habi t s (much more or much l e s s food in take) . Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t Foreclosure on mortgage or loan Good Bad no e f fec t some e f fec t moderate e f f ec t great e f f ec t Death of c lose f r i e n d Good Bad no e f fec t some e f fec t moderate e f f ec t great e f fec t 204 TYPE CF EVENT EVENT EFFECT CF EVENT CN YOUR L I F E 9 . O u t s t a n d i n g p e r s o n a l achievement Good Bad no e f f e c t some e f f e c t moderate e f f e c t g r e a t e f f e c t 10 . M i n o r l aw v i o l a t i o n s ( t r a f f i c t i c k e t s , d i s t u r b i n g t h e peace , e t c . ) Good Bad no e f f e c t some e f f e c t moderate e f f e c t g r e a t e f f e c t 1 1 . M a l e W i f e ' s / g i r l -f r i e n d ' s pregnancy Good Bad no e f f e c t some e f f e c t moderate e f f e c t g r e a t e f f e c t 1 2 . Female Pregnancy Good Bad no e f f e c t some e f f e c t moderate e f f e c t g r e a t e f f e c t 1 3 . Changed work s i t u a t i o n ( d i f f e r e n t work r e s p o n -s i b i l i t y , major change i n w o r k i n g c o n d i t i o n s , w o r k i n g h o u r s , e t c . ) Good Bad no e f f e c t some e f f e c t moderate e f f e c t g r e a t e f f e c t 14 . New j o b Good Bad no e f f e c t some e f f e c t moderate e f f e c t g r e a t e f f e c t 1 5 . S e r i o u s i l l n e s s o r i n j u r y o f c l o s e f a m i l y member a . mother Good Bad no e f f e c t some e f f e c t moderate e f f e c t g r e a t e f f e c t b . f a t h e r Good Bad no e f f e c t some e f f e c t moderate e f f e c t g r e a t e f f e c t c . b r o t h e r Good Bad no e f f e c t some e f f e c t moderate e f f e c t g r e a t e f f e c t d . s i s t e r Good Bad no e f f e c t some e f f e c t moderate e f f e c t g r e a t e f f e c t 205 TYPE CF EVENT EVENT EFFECT CF EVENT ON YOUR LIFE e. grandmother Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t f . grandfather Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t g . other (specify) Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t 16. Sexual d i f f i c u l t i e s Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t 17. Trouble wi th employer ( in danger of l o s i n g job , being suspended, demoted, e tc . ) Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t 18. Trouble w i t h in-laws Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t 19. Major change i n f i n a n c i a l s t a t u s (a l o t bet ter o f f or a l o t worse off) Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t 20. Major change i n closeness of family members Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t 21. Gaining a new family member (through b i r t h , adoption, fami ly member moving i n , e tc . ) Good Bad no e f f ec t some e f fec t moderate e f f ec t great e f f ec t 22. Change of residence Good Bad no e f fec t some e f fec t moderate e f f ec t great e f f ec t 206 TYPE CF EVENT EVENT EFFECT CF EVENT ON YOUR LIFE 2 3 . M a r i t a l s e p a r a t i o n Good Bad no some moderate g r e a t from mate (due t o e f f e c t e f f e c t e f f e c t e f f e c t c o n f l i c t ) 24 . M a j o r change i n Good Bad no some moderate g r e a t a c t i v i t i e s e f f e c t e f f e c t e f f e c t e f f e c t ( i n c r e a s e d o r decreased attendance) 25 . M a r i t a l r e c o n c i l i - Good Bad no some moderate g r e a t a t i o n w i t h mate e f f e c t e f f e c t e f f e c t e f f e c t 26 . Ma jor change i n Good Bad no some moderate g r e a t number o f arguments e f f e c t e f f e c t e f f e c t e f f e c t w i t h spouse (a l o t more o r a l o t l e s s ) 27 . M a r r i e d m a l e . Change i n w i f e ' s work o u t s i d e the home (beg inn ing w o r k , chang ing t o new j o b , e t c . ) 28 . M a r r i e d f ema le . Change Good Bad no some moderate g r e a t i n husband ' s work ( l o s s e f f e c t e f f e c t e f f e c t e f f e c t o f j o b , b e g i n n i n g new j o b , r e t i r e m e n t , e t c . ) 29 . M a j o r change i n u s u a l Good Bad no some moderate g r e a t t y p e and /or amount o f e f f e c t e f f e c t e f f e c t e f f e c t r e c r e a t i o n Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 30 . B o r r o w i n g more than $10,000 (buying home, b u s i n e s s , e t c . ) Good Bad no e f f e c t some moderate g r e a t e f f e c t e f f e c t e f f e c t 207 TYPE CF EVENT EVENT EFFECT CF EVENT ON YOUR LIFE 3 1 . Borrowing l e s s t h a n $10,000 (buying c a r , T V , g e t t i n g s c h o o l l o a n , e t c . ) Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 32 . B e i n g f i r e d from j o b Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 3 3 . M a l e W i f e / g i r l f r i e n d Good Bad no some moderate g r e a t h a v i n g a b o r t i o n e f f e c t e f f e c t e f f e c t e f f e c t 34 . Female Hav ing a b o r t i o n Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 3 5 . Ma jor p e r s o n a l i l l n e s s o r i n j u r y Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 36 . Ma jor change i n s o c i a l a c t i v i t i e s , e . g . , par t i e s , m o v i e s , v i s i t i n g Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 37 . Major change i n l i v i n g c o n d i t i o n s o f f a m i l y ( b u i l d i n g new home, r e m o d e l i n g , d e t e r i -o r a t i o n o f home, ne ighborhood , e t c . ) Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 38 . D i v o r c e Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 39 . S e r i o u s i n j u r y o r i l l n e s s o f c l o s e f r i e n d Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 2 0 8 EVENT TYPE CF EVENT EFFECT OF EVENT ON YOUR L I F E 40 . R e t i r e m e n t f rom work Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 4 1 . Son o r daughter l e a v i n g Good Bad no some moderate g r e a t home (due t o m a r r i a g e , e f f e c t e f f e c t e f f e c t e f f e c t c o l l e g e , e t c . ) 42 . End ing o f f o r m a l s c h o o l i n g Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 43 . S e p a r a t i o n from spouse Good Bad no some moderate g r e a t (due t o work , t r a v e l , e f f e c t e f f e c t e f f e c t e f f e c t e t c . ) 44 . Engagement Good Bad no some moderate g r e a t e f f e c t . e f f e c t e f f e c t e f f e c t 45 . B r e a k i n g up w i t h b o y f r i e n d / g i r l f r i e n d Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 46 . L e a v i n g home f o r t h e f i r s t t ime Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 47 . R e c o n c i l i a t i o n w i t h g i r I f r i e n d / b o y f r i e n d Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 48 . B e g i n n i n g a new s c h o o l i n g e x p e r i e n c e a t a h i g h e r academic l e v e l ( c o l l e g e , graduate s c h o o l , p r o f e s s i o n a l s c h o o l , e t c . ) Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t EVENT TYPE CF EVENT EFFECT CF EVENT ON YOUR L I F E 49. Changing to a new school a t the same l e v e l (undergraduate, graduate, e tc . ) 50. Academic probat ion 51. Being dismissed from dormitory or other residence 52. F a i l i n g an important exam 53. Changing a major 54. F a i l i n g a course 55. Dropping a course 56. J o i n i n g a f r a t e r n i t y / s o r o r i t y 57. F i n a n c i a l problems concerning school ( in danger of not having s u f f i c i e n t money to continue) Good Bad no some moderate great e f f ec t e f f ec t e f f ec t e f f ec t Good Bad no some moderate great e f fec t e f f ec t e f f ec t e f fec t Good Bad no some moderate great e f fec t e f f ec t e f f ec t e f f ec t Good Bad no some moderate great e f f ec t e f f ec t e f f ec t e f f ec t Good Bad no some moderate great e f f ec t e f fec t e f f ec t e f f ec t Good Bad no some moderate great e f f ec t e f fec t e f fec t e f f ec t Good Bad no some moderate great e f f ec t e f f ec t e f f ec t e f f ec t Good Bad no some moderate great e f fec t e f fec t e f fec t e f f ec t Good Bad no some moderate great e f f ec t e f f ec t e f f ec t e f f ec t 210 Other recent experiences which have had an iippact on your l i f e . L i st and Rate. 58. • Good Bad no some moderate great e f f ec t e f fec t e f f ec t e f f ec t 59. Good Bad no some moderate great e f f ec t e f f ec t e f f ec t e f f ec t 60 . Good Bad no some moderate g r e a t e f f e c t e f f e c t e f f e c t e f f e c t 211 Code: APPENDIX B.2 (a) Date: Unit: BEBAVTOUR ASSESSMENT The purpose of this study i s to investigate the reactions that patients have to hospitalization after an emergency admission. We hope that this research may be useful to improve the hospital experience of future patients. We are interested i n your assessment of 's behaviour today. Your responses w i l l remain confidential and anonymous. If this questionnaire i s completed, we w i l l assume that consent has been given. You are free to withdraw from the study or to refuse to answer any questions without prejudice. Completion of this form should only take a couple of minutes of your time. Instructions: On each of the 7-point scales below, place a check (y/) i n the space which represents your assessment of this patient today. For example, i f you found the patient moderately aggressive today, you would place a check as follows: Nonaggressive : : Aggressive Friendly : : : : : : : : Hostile Authoritarian : : : : : : : : Obedient Cooperative : : : : : : : : Complies resentfully C r i t i c a l : : : : : : : : F u l l of praise (gregarious) A f f i l i a t i v e : : : : : : : : D i s a f f i l i a t i v e (aloof) Submissive : : : : : : : : Dominant APPENDIX B.2 (a) - continued Seeks information Attacking Warm Noncompliant Passive Trusting Does not seek information Supportive Cold Compliant (obeys instructions) Active Distrusting 213 Code: APPENDIX B.2 (a) - continued Date: Unit: BEHAVIOUR ASSESSMENT (continued) The following questionnaire is also concerned with your assessment of this patient's behaviour today. Completion of this form should only take an additional few minutes of your time. Instructions: Below are ten descriptions of patient behavior. On each of the 5-point scales below the descriptions, rate how well this patient f i t s the description based on your observation today. For example, i f the description stated "seeks information" and the patient has asked many questions today, you would place a check (\/) as follows: seeks information Not at a l l : : :_^ /: : : A great deal (a moderate amount) 1. Seeks recognition, praise and approval Not at a l l : : : : : : A great deal 2. Seeks activity; gets satisfaction frcm work Not at a l l : : : : : : A great deal 3 . Seeks physical contact Not at a l l : : : : : : A great deal 4. Takes initiatives Not at a l l : : : : : : A great deal 214 5. Seeks help (physica l and psychological) Not at a l l : : : : : : A great dea l 6. Pers i s tence ; t r y s to ca r ry a c t i v i t i e s to completion i n accordance wi th p h y s i c a l l i m i t a t i o n s and a b i l i t y Not at a l l : : : : : : A great dea l 7. Seeks proximity (nearness) Not a t a l l : : : : : : A great dea l 8. Wants to do things by oneself even when these things are beyond p h y s i c a l l i m i t a t i o n or a b i l i t y (tends to ignore or turn down help offered) Not at a l l : : : : : : A great dea l 9. Overcomes obstacles Not at a l l : : : : : : A great deal 1 0 . Seeks a t t en t ion Not at a l l A great dea l 215 the f o l l o w i n g q u e s t i o n u s i n g the s c a l e p r o v i d e d . Code : U n i t : TTRT.PT jy^NESS SCALE F o r each o f the f o l l o w i n g b e h a v i o r s o r a c t i v i t i e s , p l e a s e answer f o l l g B e f o r e you came t o h o s p i t a l , t o what e x t e n t d i d you f e e l a b l e t o i n f l u e n c e o r c o n t r o l the i n i t a t i o n and outcome o f t h i s a c t i v i t y , o r t o succeed a t t h i s a c t i v i t y ? 1 2 3 4 5 6 7 P l e a s e w r i t e the number o f your response i n the space i n f r o n t o f the a c t i v i t y . 1. M e e t i n g p e o p l e o f t h e same sex 2 . M e e t i n g p e o p l e o f the o p p o s i t e sex 3 . T a l k i n g t o p e o p l e i n one- to-one s i t u a t i o n s ; making s m a l l t a l k 4 . D a t i n g o r s o c i a l i z i n g w i t h p e o p l e 5 . T a l k i n g o r m i x i n g a t p a r t i e s o r g a t h e r i n g s 6 . E x p r e s s i n g m y s e l f ( s e r i o u s t a l k o r i m p o r t a n t f e e l i n g s ) 7 . C o m p l e t i n g work e f f e c t i v e l y , adequa te ly o r s a t i s f a c t o r i l y 8 . G e t t i n g p e o p l e t o l i k e me, need me o r a p p r e c i a t e me 9 . G e t t i n g s i g n s o f a f f e c t i o n (hugging , k i s s i n g ) 10 . G e t t i n g s e x u a l s a t i s f a c t i o n ( n e c k i n g , p e t t i n g , i n t e r c o u r s e ) 1 1 . Do ing w e l l i n s c h o o l 12 . G o i n g o u t t o a r e s t a u r a n t , bar o r c l u b , e t c . 1 3 . S t a r t i n g o r m a i n t a i n i n g a s e r i o u s l o v e r e l a t i o n s h i p 14 . R e l a x i n g o r g e t t i n g peace o f mind 1 5 . Doing hobbie s o r r e c r e a t i o n a l a c t i v i t i e s 16 . B u y i n g t h i n g s f o r m y s e l f 17 . T a k i n g c a r e o f o r d o i n g t h i n g s f o r m y s e l f (shower, d r e s s , f i x h a i r ) 18 . F i x i n g , g e t t i n g o r b u y i n g good meals 1 9 . G e t t i n g a good j o b 20 . Hav ing a good r e l a t i o n s h i p w i t h p a r e n t s o r f a m i l y 2 1 . A v o i d i n g c r i t i c i s m from o t h e r s o r from s e l f 22 . H a v i n g company o r companionship 23 . Hav ing enough energy , i n t e r e s t o r e x c i t e m e n t t o do t h i n g s 24 . S t a r t i n g o r m a i n t a i n i n g c l o s e f r i e n d s h i p s 25 . A v o i d i n g money w o r r i e s 216 Cede: APPENDIX B.3 Date: U n i t : MODIFIED IMAGINAL PROCESSES INVENTORY This research pro jec t i s concerned wi th the psycholog ica l e f fec t s of h o s p i t a l i z a t i o n a f ter an emergency admission. On the form below, we are interes ted i n your inner experiences, your images and your daydreams whi le i n h o s p i t a l . Your reports w i l l help us both to understand the experience o f future pa t ient s and to provide better care during t h e i r h o s p i t a l i z a t i o n . You are free to withdraw from the study at any time or to refuse to answer questions without pre judice to your h o s p i t a l care . I f the quest ionnaire i s completed we w i l l assume that consent has been g iven . In s t ruc t ions : For each of the 50 statements below, decide whether i t i s true or f a l s e as i t appl ies t o your experience s ince t h i s  admission to h o s p i t a l . I f a statement i s TRUE or MOSTLY TRUE, c i r c l e the T next to the statement. I f a statement i s FALSE or MOSTLY FALSE, c i r c l e the F . I t w i l l take about 10-15 minutes to complete t h i s form. T F 1. I sometimes seem to be able to hear the characters i n my fantas ies t a l k i n g to one another. T F 2. In my daydreams, the voices of people i n my fami ly are c r i t i c i z i n g me. T F 3. I do not r e a l l y "see" the objects i n a daydream. T F 4. In my daydreams, both v i s u a l scenes and sounds are so c l e a r and d i s t i n c t that I almost have to pinch myself to make sure they are not r e a l . T F 5. I sometimes dream that I am doing something and then wake to f i n d that I am t r y i n g to act out the dream. T F 6. The people i n my daydreams are so true to l i f e , I often be l ieve they are i n the same room wi th me. T F 7. I can often "see" a large number of things or people i n my fantas ie s . T F 8 . I sometimes f e e l l i k e my e n t i r e bed i s t i l t i n g to the s i d e . 217 T F 9 . The scenes of my daydreams are never longer than b r i e f f l a shes . T F 10 . I never f e e l d i z z y as I l i e i n my bed. T F 1 1 . The v i s u a l images i n my daydreams are so v i v i d I be l ieve that they are a c t u a l l y happening. T F 1 2 . A piece of music sometimes runs through my head as c l e a r l y as i f I were l i s t e n i n g to i t on a t r a n s i s t o r r a d i o . T F 13 . I have never experienced a sense of motion sickness whi le l y i n g i n my h o s p i t a l bed. T F 14 . Voices i n my daydreams seem so d i s t i n c t and c l e a r that I'm almost tempted to answer them. T F 1 5 . I can hear conversations between myself and other people very c l e a r l y i n my mind during a daydream. T I F 16 . I have found that when I "see" objects i n a daydream, they vanish i f I move my head. T F 17 . My fantas ies of ten cons i s t of black-and-white or co lo r images. T F 18 . The "scenes" i n my daydreams are so v i v i d and c l e a r to me that my eyes seem a c t u a l l y to fo l low them. T F 19 . When I do hear voices i n my thoughts, they are not r e a l l y very c l e a r or recognizable . T F 20 . Since my admission to h o s p i t a l , I have had no more dreams than usual i n the " t w i l i g h t " per iod between wakefulness and s leep. T F 2 1 . Some of the voices i n my thoughts are threatening or f r i g h t e n i n g . T F 22 . I can hear music w i t h shades of both softness and loudness i n my daydreams. T F 2 3 . I t i s hard for me to d i s t i n g u i s h my daydreams from what i s a c t u a l l y happening i n r e a l l i f e . T F 24 . The voices and sounds i n my daydreams seem r e a l . T F 2 5 . I be l ieve I a c t u a l l y see v i s i o n s of people I know even though i t seems impossible for them to be there at the t ime. 218 T F 26 . My daydreams are u s u a l l y accompanied by the sounds o f the s u b j e c t s o f my daydreams. T F 27 . My daydreams have become more v i v i d s i n c e I have been i n h o s p i t a l . T F 28 . I c a n s t i l l remember scenes from r e c e n t daydreams. T F 29 . Sometimes sounds I ' v e heard i n the p a s t come i n t o my mind d u r i n g a daydream as i f I c o u l d a lmos t hear them a g a i n . T F 30 . I n a daydream, I c a n hear a tune a lmos t as c l e a r l y as i f I were a c t u a l l y l i s t e n i n g t o i t . T F 3 1 . My daydreams a r e so c l e a r t h a t I o f t e n b e l i e v e the p e o p l e i n them a re i n the room. T F 3 2 . The " s cenes " i n my daydreams a re s o r t o f f u z z y and u n c l e a r . T F 3 3 . As I am f a l l i n g a s l e e p , my i m a g i n a t i o n becomes so v i v i d t h a t i t sometimes wakes me u p . T F 34 . I sometimes have a v e r y c l e a r , l i f e l i k e p i c t u r e o f what I am i m a g i n i n g . T F 3 5 . I n my f a n t a s i e s , v o i c e s o f p e o p l e i m p o r t a n t i n my l i f e a re t e l l i n g me what t o d o . T F 36 . My daydreams a re m o s t l y made up o f thoughts and f e e l i n g s r a t h e r than v i s u a l images. T F 37 . I have never had the s e n s a t i o n t h a t I am s t a n d i n g on my head i n b e d . T F 38 . There has been no change i n my dreams s i n c e I have been i n h o s p i t a l . T F 39 . The v o i c e s o f p e o p l e who are i m p o r t a n t t o me sound v e r y c l e a r when I daydream about them. T F 40 . When I f e e l a s e n s a t i o n o f movement w h i l e l y i n g i n bed , I f i n d t h a t I c a n " r i g h t m y s e l f " by l o o k i n g o u t the window. T F 4 1 . I c a n see the p e o p l e o r t h i n g s i n my daydreams as i f they were moving a round . T F 4 2 . D u r i n g a daydream, v o i c e s seem t o come i n l o u d l y and c l e a r l y and then fade away. 219 T F 4 3 . I have e x p e r i e n c e d a p u l l o f mot ion so s t r o n g t h a t I wondered whether I was g o i n g t o f a l l over the f o o t o f my b e d . T F 44 . The sounds I hear i n my daydreams a re c l e a r and d i s t i n c t . T F 4 5 . V i s u a l scenes a r e an i m p o r t a n t p a r t o f my daydreams. T F 46 . I have n o t e x p e r i e n c e d a s e n s a t i o n o f movement as I l i e i n bed . T F 47 . The " p i c t u r e s i n my mind" seem as c l e a r as photographs . T F 4 8 . I o f t e n wake up w i t h a sudden movement o f my e n t i r e body. T F 4 9 . When peop le speak i n my daydreams, I cannot r e a l l y hear t h e i r v o i c e s . T F 50 . My thoughts seem as r e a l as a c t u a l event s i n my l i f e . / APPENDIX B.4 Code: Date: U n i t : SUBJECTIVE STRESS SCALE This research i s concerned wi th the psycholog ica l e f fec t s o f h o s p i t a l i z a t i o n , p a r t i c u l a r l y a f ter an emergency admission. We are interes ted i n how you f e e l about t h i s experience i n h o s p i t a l . Below you w i l l f i n d a l i s t o f words that describe moods or f e e l i n g s . In s t ruc t ions : P lace a check (^/) next to the one word which best describes your f ee l ings today. Nervous Comfortable F ine Panicky Scared s t i f f Wonderful Steady Unsafe Doesn't bother me Ind i f fe rent Frightened Timid Worried Unsteady 221 APPENDIX B.5 Letter mailed with Psychosocial Adjustment to TITness Scale Dear Thank you so much for agreeing to be par t of my research pro jec t whi le you were i n h o s p i t a l . I appreciated our discuss ions and hope that the r e s u l t s of t h i s study w i l l be b e n e f i c i a l for future p a t i e n t s . Enclosed i s the f i n a l quest ionnaire that I would l i k e you to f i l l out . I t contains questions about the e f fec t that your recent medical problem has had on you. We are interes ted i n knowing what e f fec t s i t has had on your performance around the house, on your job , as w e l l as on family and personal r e l a t i o n s h i p s . Other questions dea l w i t h i t s e f fec t s on your s o c i a l and l e i s u r e time a c t i v i t i e s , and how you have f e l t p s y c h o l o g i c a l l y . In answering each quest ion, please put a check mark i n the smal l box alongside the answer that best describes what your experience has been. Please answer a l l the questions and t r y not to s k i p any. I f none of the answers to a question match your experience e x a c t l y , please choose the answer that comes c l o s e s t to what your experience has been. The time we would l i k e you to report on i s the l a s t 30 days,  inc lud ing today. Answer each quest ion i n terms of what your experience has been during t h i s time unless the question s p e c i f i c a l l y re fers to the time s ince h o s p i t a l i z a t i o n . We appreciate the time you have given us i n doing t h i s form. Please check again to make sure you have completed a l l the items. I f you have any questions about the form, please w r i t e them on the back of t h i s l e t t e r and send i t back wi th the completed quest ionnaire i n the enclosed re turn envelope. Aga in , thank you for your time and i n t e r e s t . I hope t h i s f inds you i n good h e a l t h . When my thes i s i s f i n i s h e d I w i l l send you a summary of the r e s u l t s of the study. A l l the best , Norma J . Stewart 2 2 2 APPENDIX B.5 (b) PSYCHOSOCIAL ADJUSTMENT TO ILLNESS SCALE (PAIS) SECTION I. Health Care Orientation ( 1 ) Which o f the fo l lowing statements best describes your usual a t t i tude about taking care of your health? [ ] a) I am very concerned and pay c lose a t t en t ion to my personal h e a l t h . [ ] b) Most o f the time I pay a t t ent ion to my hea l th care needs. [ ] c) U s u a l l y , I t r y to take care o f heal th matters but sometimes I j u s t don ' t get around to i t . [ ] d) Heal th care i s something that I j u s t don ' t worry too much about. (2) Your present medical cond i t ion probably requires some s p e c i a l a t t ent ion and care on your p a r t . Would you please s e l ec t the statement below that best describes your r e a c t i o n . [ ] a) I do things p r e t t y much the way I always have done them and I don ' t worry or take any s p e c i a l considerat ions for my medical c o n d i t i o n . [ ] b) I t r y to do a l l the things I am supposed to do to take care o f myself , but l o t s o f times I forget or I am too t i r e d or busy. [ ] c) I do a p r e t t y good job taking care o f my present medical c o n d i t i o n . [ ] d) I pay c lose a t t ent ion to a l l the needs o f my present medical cond i t ion and do everything I can to take care of myself . (3) In genera l , how do you f e e l about the q u a l i t y o f medical care ava i l ab le today and the doctors who provide i t . [ ] a) Medica l care has never been b e t t e r , and the doctors who g ive i t are doing an exce l l en t job . [ ] b) The q u a l i t y o f medical care a v a i l a b l e i s very good, but there are some areas that could stand improvement. [ ] c) Medical care and doctors are ju s t not o f the same q u a l i t y they once were. [ ] d) I don ' t have much f a i t h i n doctors and medical care today. 223 (4) During your recent h o s p i t a l i z a t i o n you have received treatment from both doctors and medical s t a f f . How do you f e e l about them and the treatment you have received from them? [ ] a) I am very unhappy wi th the treatment I have received and don ' t think the s t a f f has done a l l they could have for me. [ ] b) I have not been impressed wi th the treatment I have rece ived , but I think i t i s probably the best they can do. [ ] c) The treatment has been p r e t t y good on the whole, although there have been a few problems. [ ] d) The treatment and the treatment s t a f f have been e x c e l l e n t . (5) During your recent h o s p i t a l i z a t i o n you have received care from nursing s t a f f . How do you f e e l about the nurses and the care that you have received from them? [ ] a) I am very unhappy wi th the care I have received and don ' t think the nursing s t a f f has done a l l they could have for me. [ ] b) I have not been impressed w i t h the care I have rece ived , but I think i t i s probably the best they can do. [ - ] c) The nursing care has been p r e t t y good on the whole, although there have been a few problems. [ ] d) The care and the nursing s t a f f have been e x c e l l e n t . (6) When they have a medical problem, d i f f e r e n t people expect d i f f e r e n t things and have d i f f e r e n t a t t i t u d e s . Could you please check the statement below which cones c lo se s t to descr ib ing your f e e l i n g s . [ ] a) I am sure that I am going to overcome t h i s medical problem q u i c k l y and get back to being my o l d s e l f . [ ] b) My medical cond i t ion has caused some problems for me, but I f e e l I w i l l overcome them f a i r l y soon, and get back to the way I was before. [ ] c) My medical cond i t ion has r e a l l y put a great s t r a i n on me, both p h y s i c a l l y and menta l ly , but I am t r y i n g very hard to overcome i t , and f e e l sure that I w i l l be back to my o l d s e l f one of these days. t ] d) I f e e l worn out and very weak from my medical c o n d i t i o n and there are times when I don ' t know i f I am r e a l l y ever going to be able to overcome i t . 224 (7) Being a pa t ient can be a confusing experience, and some pat ients f e e l that they do not receive enough information and d e t a i l from t h e i r doctors and the medical s t a f f about t h e i r i l l n e s s e s . Please s e l ec t a statement below which best describes your f ee l ings about t h i s matter. [ ] a) My doctor and the medical s t a f f have t o l d me very l i t t l e about my medical c o n d i t i o n even though I have asked more than one. [ ] b) I do have some information about my medical cond i t ion but I f e e l I would l i k e to know more. [ ] c) I have a p r e t t y f a i r understanding about my medical c o n d i t i o n and f e e l that i f I want to know more I can always get the informat ion. [ ] d) I have been given a very complete p i c t u r e o f my medical c o n d i t i o n and my doctor and the medical s t a f f have given me a l l the d e t a i l s I wish to have. (8) In circumstances such as yours , people have d i f f e r e n t ideas about t h e i r treatment and what to expect from i t . Please s e l ec t one of the statements below which best describes what you expect about your treatment. [ ] a) I be l ieve my doctors and medical s t a f f are qu i t e able to d i r e c t my treatment and f e e l i t i s the best treatment I could rece ive . [ ] b) I have t r u s t i n my doctor ' s d i r e c t i o n of my treatment; however, sometimes I have doubts about i t . [ ] c) I don ' t l i k e c e r t a i n par t s of my treatment which are very unpleasant but my doctors t e l l me I should go through i t anyway. [ ] d) In many ways I th ink my treatment i s worse than the i l l n e s s and I am not sure i t i s worth going through i t . (9) Pat ients w i t h a medical c o n d i t i o n such as yours are g iven d i f f e r e n t amounts of information about t h e i r treatment. Please s e l ec t a statement from those below which best describes information you have been give^i about your treatment. [ ] a) I have been t o l d almost nothing about my treatment and f e e l l e f t out about i t . [ ] b) I have some information about my treatment but not as much as I would l i k e to have. [ ] c) My information concerning treatment i s p r e t t y complete, but there are one or two things I s t i l l want to know. [ . ] d) I f e e l my information concerning treatment i s very complete and up-to-date. 225 (10) I n s o f a r as you were g i v e n i n s t r u c t i o n s t o f o l l o w a t home a f t e r you were d i s c h a r g e d from h o s p i t a l , how w e l l have you f o l l o w e d these i n s t r u c t i o n s ? [ ] a) I was g i v e n no i n s t r u c t i o n s . [ ] b) I cannot remember t h e i n s t r u c t i o n s I was g i v e n . [ ] c) I have n o t f o l l o w e d the i n s t r u c t i o n s g i v e n me. [ ] d) I have f o l l o w e d the i n s t r u c t i o n s as w e l l as p o s s i b l e . SECTION II. Vocational Environment (11) Has your m e d i c a l c o n d i t i o n i n t e r f e r e d w i t h your a b i l i t y t o do your j o b ( schco lwork)? [ ] a) No problems w i t h my j o b . [ ] b) Some p r o b l e m s , b u t o n l y minor ones . [ ] c) Some s e r i o u s p r o b l e m s . [ ] d) I l l n e s s has t o t a l l y p revented me from d o i n g my j o b . (12) How w e l l do you p h y s i c a l l y p e r f o r m your j o b ( s tud ie s ) now? [ ] a) P o o r l y . [ ] b) Not t o o w e l l . [ ] c) A d e q u a t e l y . [ ] d) V e r y w e l l . (13) D u r i n g t h e p a s t 30 d a y s , have you l o s t any t ime a t work ( school) due t o your m e d i c a l c o n d i t i o n ? [ ] a) 3 days o r l e s s . [ ] b) 1 week. [ ] c) 2 weeks . [ ] d) More than 2 weeks. (14) I s your j o b ( school) as i m p o r t a n t t o you now as i t was b e f o r e your h o s p i t a l i z a t i o n ? [ ] a) L i t t l e o r no importance t o me now. [ ] b) A l o t l e s s i m p o r t a n t . [ ] c) S l i g h t l y l e s s i m p o r t a n t . [ ] d) E q u a l o r g r e a t e r importance than b e f o r e . (15) Have you had t o change your g o a l s c o n c e r n i n g your j o b (educat ion) as a r e s u l t o f your m e d i c a l c o n d i t i o n ? [ ] a) My g o a l s a r e unchanged. [ ] b) There has been a s l i g h t change i n my g o a l s . [ ] c) My g o a l s have changed q u i t e a b i t . [ ] d) I have changed my g o a l s c o m p l e t e l y . 226 (16) Have you n o t i c e d any i n c r e a s e i n arguments o r problems i n g e t t i n g a l o n g w i t h your co-worker s s i n c e your h o s p i t a l i z a t i o n ? [ ] a) A g r e a t i n c r e a s e i n p r o b l e m s . [ ] b) A moderate i n c r e a s e i n p rob lems . [ j c) A s l i g h t i n c r e a s e i n p r o b l e m s . [ ] d) None. SUCTION I I I . Domest ic Env i ronment (17) How would you d e s c r i b e your r e l a t i o n s h i p w i t h your husband o r w i f e ( p a r t n e r , i f n o t marr ied) s i n c e your h o s p i t a l i z a t i o n ? [ ] a) Good . [ ] b) F a i r . [ ] c) P o o r . [ ] d) V e r y p o o r . (18) How would you d e s c r i b e your g e n e r a l r e l a t i o n s h i p s w i t h the o t h e r peop le you l i v e w i t h ( e . g . c h i l d r e n , p a r e n t s , a u n t s , e t c . ) ? [ ] aj G o o d . [ ] b) F a i r . [ ] c) P o o r . [ ] d) V e r y p o o r . (19) How much has your m e d i c a l p rob lem i n t e r f e r e d w i t h your work and d u t i e s around the house? [ ] a) Not a t a l l . [ • •] b) S l i g h t p r o b l e m s , e a s i l y overcome. [ ] c) Moderate p r o b l e m s , n o t a l l o f w h i c h can be overcome. [ ] d) Severe d i f f i c u l t i e s w i t h household d u t i e s . (20) I n those areas where your m e d i c a l c o n d i t i o n has caused problems w i t h your household work how has the f a m i l y s h i f t e d d u t i e s t o h e l p you out ? [ ] a) The f a m i l y has n o t been a b l e t o h e l p o u t a t a l l . [ ] b) The f a m i l y has t r i e d t o h e l p b u t many t h i n g s a r e l e f t undone. [ ] c) The f a m i l y has done w e l l except f o r a few minor t h i n g s . [ ] d) No p r o b l e m s . 227 (21) Has your medical c o n d i t i o n resu l ted i n a decrease i n communication between you and members of your family? [ ] a) No decrease i n communication. [ ] b) A s l i g h t decrease i n communication. [ j c) Communication has decreased and I f e e l somewhat withdrawn from them. [ ] d) Communication has decreased a l o t and I f e e l very alone. (22) Some people wi th a medical c o n d i t i o n l i k e yours f e e l they need help from other people ( f r i ends , neighbors, f ami ly , e tc . ) to get things done from day-to-day. Do you f e e l you need such help and i s there anyone to provide i t ? [ ] a) I r e a l l y need help but seldom i s anyone around to he lp . [ ] b) I get some h e l p , but I c a n 1 t count on i t a l l the t ime. [ ] c) I don ' t get a l l the help I need a l l o f the t ime, but most of the time help i s there when I need i t . [ ] d) I don ' t f e e l I need such h e l p , or the help I need i s a v a i l a b l e from my family or f r i e n d s . (23) How much p h y s i c a l d i s a b i l i t y have you experienced? [ ] a) No p h y s i c a l d i s a b i l i t y . [ j b) A s l i g h t p h y s i c a l d i s a b i l i t y . [ ] c) A moderate p h y s i c a l d i s a b i l i t y . [ ] d) A severe p h y s i c a l d i s a b i l i t y . (24) A medical problem such as yours can sometimes cause a d r a i n on the f a m i l y ' s f inances ; are you having any d i f f i c u l t i e s meeting the f i n a n c i a l demands of your condit ion? [ ] a) Severe f i n a n c i a l hardship. [ ] b) Moderate f i n a n c i a l problems. [ ] c) A s l i g h t f i n a n c i a l s t r a i n . [ ] d) No money problems. 228 SECTION IV. Sexual Relationships (25) Sometimes having a medical problem can cause problems i n a r e l a t i o n s h i p . Has your i l l n e s s l e d to any problems w i t h your husband or wife (partner, i f not married)? [ ] a) There has been no change i n our r e l a t i o n s h i p . [ ] b) We are a l i t t l e l e s s c lose s ince my i l l n e s s . [ ] c) We are d e f i n i t e l y l e s s c lose s ince my i l l n e s s . [ j d) We have had ser ious problems or a break i n our r e l a t i o n s h i p s ince my i l l n e s s . (26) Sometimes when people have a medical cond i t ion they report a loss of i n t e r e s t i n sexual a c t i v i t i e s . Have you experienced l e s s sexual i n t e r e s t s ince your i l l n e s s ? [ ] a) Abso lute ly no sexual i n t e r e s t s ince i l l n e s s . [ j b) A marked lo s s of sexual i n t e r e s t . [ ] c) A s l i g h t lo s s of sexual i n t e r e s t . [ ] d) No lo s s of sexual i n t e r e s t . (27) A medical c o n d i t i o n sometimes causes a decrease i n sexual a c t i v i t y . Have you experienced any decrease i n the frequency o f your sexual a c t i v i t i e s ? [ ] a) No decrease i n sexual a c t i v i t i e s . [ ] b) S l i g h t decrease i n sexual a c t i v i t i e s . [ ] c) Marked decrease i n sexual a c t i v i t i e s . [ ] d) Sexual a c t i v i t i e s have stopped. (28) Has there been any change i n the pleasure or s a t i s f a c t i o n you normally experience from sex? [ ] a) Sexual pleasure and s a t i s f a c t i o n have stopped. [ ] b) A marked lo s s o f sexual pleasure or s a t i s f a c t i o n . [ ] c) A s l i g h t lo s s of sexual pleasure or s a t i s f a c t i o n . [ ] d) No change i n sexual s a t i s f a c t i o n . (29) Sometimes a medical c o n d i t i o n w i l l cause an interference i n a person's a b i l i t y to perform sexual a c t i v i t i e s even though they are s t i l l interes ted i n sex. Has t h i s happened to you, and i f so, to what degree? [ ] a) No change i n my a b i l i t y to have sex. [ ] b) S l i g h t problems wi th sexual performance. [ ] c) Constant sexual performance problems. [ j d) T o t a l l y unable to perform sexua l ly . (30) Sometimes a m e d i c a l p rob lem w i l l i n t e r f e r e w i t h a c o u p l e ' s normal s e x u a l r e l a t i o n s h i p and cause arguments o r problems between them. Have you and your p a r t n e r had any arguments l i k e t h i s , and i f s o , t o what degree? [ ] a) C o n s t a n t arguments . [ ] b) F r e q u e n t arguments . [ ] c) Some arguments , t ] d) No arguments . SECTION V. Extended Family Relationships (31) Have you had as much c o n t a c t ( e i t h e r p e r s o n a l l y o r by telephone) w i t h members o f your f a m i l y o u t s i d e your household s i n c e your h o s p i t a l i z a t i o n ? [ ] a) C o n t a c t i s the same o r g r e a t e r s i n c e i l l n e s s . [ ] b) C o n t a c t i s s l i g h t l y l e s s . [ ] c) C o n t a c t i s markedly l e s s . [ ] d) No c o n t a c t s i n c e i l l n e s s . (32) Have you remained as i n t e r e s t e d i n g e t t i n g t o g e t h e r w i t h these members o f your f a m i l y s i n c e your h o s p i t a l i z a t i o n ? [ ] a) L i t t l e o r no i n t e r e s t i n g e t t i n g t o g e t h e r w i t h them. [ ] b) I n t e r e s t i s a l o t l e s s t h a n b e f o r e . [ ] c) I n t e r e s t i s s l i g h t l y l e s s t h a n b e f o r e . [ ] d) I n t e r e s t i s t h e same as b e f o r e . (33) Sometimes, when peop le have a m e d i c a l c o n d i t i o n they are f o r c e d t o depend on those members o f the f a m i l y o u t s i d e t h e i r household f o r h e l p . Do you need h e l p from them, and do th ey s u p p l y the h e l p you need? [ ] a) . I need no h e l p o r th ey g i v e me a l l the h e l p I need . [ ] b) T h e i r h e l p i s enough, excep t f o r some minor t h i n g s . [ ] c) They g i v e me some h e l p , but n o t n e a r l y enough. [ ] d) They g i v e me l i t t l e o r no h e l p even though I need a g r e a t d e a l . (34) I n g e n e r a l , how have you been g e t t i n g a l o n g w i t h these members o f your f a m i l y r e c e n t l y ? [ ] a) Good . [ ] b) F a i r . [ ] c) P o o r . [ ] d) V e r y p o o r . 230 SECTION V T . S o c i a l Envi ronment (35) A r e you s t i l l as i n t e r e s t e d i n your l e i s u r e t ime a c t i v i t i e s and hobbie s as you were p r i o r t o your h o s p i t a l i z a t i o n ? ( e . g . / w a t c h i n g T . V . , s e w i n g , b i c y c l i n g , e t c . ) [ ] a) Same l e v e l o f i n t e r e s t as p r e v i o u s l y . [ j b) S l i g h t l y l e s s i n t e r e s t than b e f o r e . [ ] c) S i g n i f i c a n t l y l e s s i n t e r e s t than b e f o r e . [ ] d) L i t t l e o r no i n t e r e s t r e m a i n i n g . (36) How about a c t u a l p a r t i c i p a t i o n ? A r e you s t i l l a c t i v e l y i n v o l v e d i n d o i n g those a c t i v i t i e s ? [ ] a) L i t t l e o r no p a r t i c i p a t i o n a t p r e s e n t . [ ] b) P a r t i c i p a t i o n reduced s i g n i f i c a n t l y . [ ] c) P a r t i c i p a t i o n reduced s l i g h t l y . [ ] d) P a r t i c i p a t i o n remains unchanged. (37) A r e you as i n t e r e s t e d i n l e i s u r e t ime a c t i v i t i e s w i t h your f a m i l y ( e . g . , p l a y i n g c a r d s and games, t a k i n g t r i p s , g o i n g swimming, e t c . ) as you were p r i o r t o your h o s p i t a l i z a t i o n ? [ ] a) Same l e v e l o f i n t e r e s t as p r e v i o u s l y . [ ] b) S l i g h t l y l e s s i n t e r e s t than b e f o r e . [ ] c) S i g n i f i c a n t l y l e s s i n t e r e s t t h a n b e f o r e . [ ] d) L i t t l e o r no i n t e r e s t r e m a i n i n g . (38) Do you s t i l l p a r t i c i p a t e i n those a c t i v i t i e s t o the same degree you once d i d ? [ ] a) L i t t l e o r no p a r t i c i p a t i o n a t p r e s e n t . [ ] b) P a r t i c i p a t i o n reduced s i g n i f i c a n t l y . [ ] c) P a r t i c i p a t i o n reduced s l i g h t l y . [ ] d) P a r t i c i p a t i o n remains unchanged. (39) Have you m a i n t a i n e d your i n t e r e s t i n s o c i a l a c t i v i t i e s s i n c e your h o s p i t a l i z a t i o n ? ( e . g . , s o c i a l c l u b s , c h u r c h g r o u p s , g o i n g t o the m o v i e s , e t c . ) . [ ] a) Same l e v e l o f i n t e r e s t as p r e v i o u s l y . [ ] b) S l i g h t l y l e s s i n t e r e s t t h a n b e f o r e . [ ] c) S i g n i f i c a n t l y l e s s i n t e r e s t than b e f o r e . [ ] d) L i t t l e o r no i n t e r e s t r e m a i n i n g . 231 (40) How about p a r t i c i p a t i o n ? Do you s t i l l go out w i t h your f r i ends and do those things? [ ] a) L i t t l e or no p a r t i c i p a t i o n at present. [ j b) P a r t i c i p a t i o n reduced s i g n i f i c a n t l y . [ ] c) P a r t i c i p a t i o n reduced s l i g h t l y . [ ] d) P a r t i c i p a t i o n remains unchanged. SECTION VII. Psychological Distress (41) Recently , have you f e l t a f r a i d , tense, nervous, or anxious? [ ] a) Not at a l l . [ ] b) A l i t t l e b i t . [ ] c) Quite a b i t . [ ] d) Extremely. (42) Recently , have you f e l t sad, depressed, l o s t i n t e r e s t i n th ings , or f e l t hopeless? [ ] a) Extremely. [ ] b) Quite a b i t . [ ] c) A l i t t l e b i t . [ ] d) Not a t a l l . (43) Recently , have you f e l t angry, i r r i t a b l e , or had d i f f i c u l t y c o n t r o l l i n g your temper? [ ] a) Not at a l l . [ ] b) A l i t t l e b i t . [ ] c) Quite a b i t . [ ] d) Extremely. (44) Recently , have you blamed your se l f for th ings , f e l t g u i l t y , or f e l t l i k e you have l e t people down? [ ] a) Extremely. [ ] b) Quite a b i t . [ ] c) A l i t t l e b i t . [ ] d) Not at a l l . (45) Recent ly , have you worried much about your medical cond i t ion or other matters? [ ] a) Not at a l l . [ ] b) A l i t t l e b i t . [ ] c) Quite a b i t . [ ] d) Extremely. 232 (46) R e c e n t l y , have been f e e l i n g down on y o u r s e l f o r l e s s v a l u a b l e as a person? [ ] a) E x t r e m e l y . [ ] b) Qui te a b i t . [ ] c) A l i t t l e b i t . [ ] d) Not a t a l l . (47) R e c e n t l y , have you been concerned t h a t your m e d i c a l c o n d i t i o n has caused changes i n your appearance t h a t make you l e s s a t t r a c t i v e ? [ ] a) Not a t a l l . [ ] b) A l i t t l e b i t . [ ] c) Q u i t e a b i t . [ ] d) E x t r e m e l y . 233 CODE APPENDIX C l DATE TIME UNIT NCNPARTICIPANT OBSERVATION OF SOCIAL AND NONSOCIAL ENVIRONMENT IN PATIENT'S ROOM - 15 minute o b s e r v a t i o n s a t f o u r t ime p e r i o d s throughout one day o f h o s p i t a l s t a y . - Check i f type o f s t i m u l a t i o n o c c u r r e d once (or more) d u r i n g each one-minute i n t e r v a l . M i n u t e s 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 PATIENT AWARENESS P e o p l e i n room - o t h e r - s t a f f , p a t i e n t s v i s i t o r s NONSOCIAL STIMULATION 1. V a r i e t y 2 . Respons iveness 3 . C o m p l e x i t y a) V i s u a l b) A u d i t o r y c) T a c t i l e d) O l f a c t o r y e) G u s t a t o r y f ) K i n e s t h e t i c 4 . N o i s e a) i n s i d e room b) o u t s i d e room M i n u t e s CO 8 3 234 APPENDIX C l (cont inued) SOCIAL STIMULATION M i n u t e s 6 7 8 9 10 11 12 13 14 15 1. Frequency and V a r i e t y a) I n s i d e p a t i e n t space b) O u t s i d e space 2 . Type o f c a r e t a k e r / o t h e r b e h a v i o r a) V e r b a l i z a t i o n t o p a t i e n t b) N o n v e r b a l ( s i t by p a t i e n t ) c) T r e a t m e n t / c a r e t o p a t i e n t d) Other - d i r e c t e d e) D i r e c t e d a t p h y s i c a l environment 3 . C o n t i n g e n c y responses a) Eye c o n t a c t b) V e r b a l i z a t i o n c) A s s i s t a n c e 4 . M o d a l i t y o f s t i m u l a t i o n a) V i s u a l b) A u d i t o r y c) T a c t i l e d) K i n e s t h e t i c APPENDIX C . 2 (a) [ i ] U n i v e r s i t y H o s p i t a l Reg. # Code # Ward Doctor DEMOGRAPHIC DATA Age -Sex -Address -Occupation -Date of emergency -Type -Days i n h o s p i t a l -Diagnosis -M a r i t a l s tatus -Family -Education -Locat ion of emergency Date of admission -Days f l a t i n bed -Surgery -Complications -Apparatus (days for each) -Moves w i t h i n h o s p i t a l -Relevant h i s t o r y -Prognosis at discharge -Data incomplete at discharge -2 3 6 Reg. # APPENDIX C.2 (a) Code # [ i i ] Shaughnessy H o s p i t a l Age - Sex -Home -Occupation -Date of emergency -Date o f admission -Diagnosis - Para ( level) Other Complications -DEMOGRAPHIC DATA M a r i t a l s tatus -Family -Education -Type -Days i n h o s p i t a l -Quad (high/lew) - Complete Incomplete f r a c t u r e s / i n j u r i e s Surgery -Apparatus -Leve l of funct ion at discharge -Discharge p lan 237 APPENDIX C . 2 (b) CODE # MEDICATIONS DATES NAME DOSE & MODE FREQUENCY FROM TO REACTIONS RATIONALE FOR ADMIN. OR DISCONTINUTION APPENDIX C.2 (c) [i] University Hospital CODE # DATE DAY IN HOSPITAL SHIFT 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 * PRN MEDS MOBILITY PROCEDURES NOTES: * PRN medications (e.g., analgesics) are given within specified time periods as the patient needs them. APPENDIX C.2 (c) [i i ] Shaughnessy Hospital CODE # DATE DAY IN HOSPITAL SHIFT 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 DREAMS Visual Auditory Kinesthetic Imagery Tactile Temperature Anomaly Stress Reaction to imagery General Non- Anger Compliance Interference with care Room Changes Mobility Procedures Cognition (e.g., confusion, sleep deprivation) Complications (e.g., below 60; elevated temperature) PRN MEDICATIONS (given as needed) 240 APPENDIX D CODE DATE ENvTROMENTAL STRESS SCALE SECTION I o f ESS - P e r s o n a l Space and P r i v a c y 1 . Do you p r e f e r a p r i v a t e room, a room w i t h one room-mate, o r a room w i t h more t h a n one room-mate? [ ] 0 = p r i v a t e [ ] 1 = one room-mate [ j 2 = 2-3 room-mates ( e . g . , 4-bed ward) [ ] 3 = more than 3 room-mates ( e . g . , 20-bed ward) 2 . I n your p r e s e n t room, how much p r i v a c y do you have? [ ] 0 = a g r e a t d e a l [ ] 1 = a moderate amount [ ] 2 = a s m a l l amount [ j 3 = none 3 . How do you f e e l about t h i s ? [ ] 0 = p o s i t i v e [ j 1 = n e u t r a l [ ] 2 = somewhat n e g a t i v e [ ] 3 = e x t r e m e l y n e g a t i v e 4 . Do you expec t e i t h e r more o r l e s s p r i v a c y i n h o s p i t a l ? [ ] 0 = more [ ] 1 = l e s s [ j 2 = no e x p e c t a t i o n s [ ] 3 = e x p e c t a t i o n s met 5 . A r e t h e r e p l a c e s i n t h i s room t h a t you c o n s i d e r "your space?" [ ] 0 = none [ ] 1 = the bed [ ] 2 = bed and immediate s u r r o u n d i n g s ( e . g . , l o c k e r , overbed t a b l e ) [ ] 3 = e n t i r e room 241 6. Do other people consider t h i s "your space" as we l l ? [ ] 0 = a l l o f the time [ ] 1 = most of the time [ j 2 = some of the time [ j 3 = none of the time 7 . Do the s t a f f and other pa t ient s ask your permission to enter your bed area (or room) when the cur ta ins (or door) are closed? [ ] 0 = a l l o f the time [ ] 1 = most of the time [ ] 2 = some of the time [ ] 3 = none of the time 8. I f not , how do you react to t h i s ? [ ] 0 = p o s i t i v e [ ] 1 = neut ra l [ ] 2 = somewhat negative [ ] 3 = extremely negative 9 . Do people ever move your belongings around here i n your h o s p i t a l room? [ ] 0 = a l l o f the time [ ] 1 = most of the time [ ] 2 = some of the time [ ] 3 = none of the time 10. How do you f e e l about t h i s ? [ ] 0 = p o s i t i v e [ ] 1 = neutra l [ j 2 = somewhat negative [ j 3 = extremely negative 1 1 . Would you expect e i ther more or l e s s space to c a l l your own i n hosp i ta l ? [ ] 0 = more [ ] 1 = l e s s [ ] 2 = no expectations [ ] 3 = expectations met 242 1 2 . Do you ever f e e l crowded here? [ ] 0 = a l l o f the t ime [ ] 1 = most o f the t ime [ ] 2 = some o f t h e t ime [ ] 3 = none o f the t ime 1 3 . I f s o , i s t h i s because o f the number o f peop le o r the p h y s i c a l a spec t s o f the room ( e . g . s i z e , f u r n i t u r e , equipment)? [ ] 0 = p e o p l e [ ] 1 = p h y s i c a l a spec t s (e laborate ) Section II of ESS - Environmental stimulation levels 14 . How many v i s i t o r s from o u t s i d e the h o s p i t a l do you have on an average day? [ ] 0 = none [ ] 1 = one [ ] 2 = two t o f o u r [ j 3 = f i v e o r more 15 . Do you f i n d t h i s number o f v i s i t o r s s a t i s f a c t o r y ? [ ] 0 = t o o many [ j 1 = j u s t about r i g h t [ ] 2 = would l i k e a few more [ j 3 = would l i k e many more 16 . Does the amount o f t ime you spend w i t h v i s i t o r s meet your e x p e c t a t i o n s ? [ ] 0 = yes [ ] 1 = no , I expected l e s s [ ] 2 = n o , I expec ted somewhat more [ ] 3 = n o , I expected much more 1 7 . How do you pass,/your t ime o t h e r w i s e here? [ ] 0 = T . V . , r a d i o , t a p e s , read ( v i s u a l / a u d i t o r y ) [ ] 1 = w r i t e , handiwork , c r a f t s (manual) [ ] 2 = t h o u g h t , r e f l e c t i o n [ ] 3 = t a l k w i t h o t h e r p a t i e n t s , s t a f f , v i s i t o r s 243 18 . How much t ime d i d you spend y e s t e r d a y w i t h these a c t i v i t i e s o v e r a l l ? [ ] 0 = under 2 hours [ ] 1 = two t o f i v e hours [ ] 2 = f i v e t o t e n hours [ ] 3 = over t e n hours 19 . Do you have enough t o do i n h o s p i t a l ? [ ] 0 = yes [ ] 1 = no ( e l a b o r a t e : not enough/too much) 20 . Do you ever f e e l bored here i n h o s p i t a l ? [ ] 0 = a l l the t ime [ ] 1 = o f t e n [ ] 2 = o c c a s i o n a l l y [ ] 3 = n o t a t a l l 2 1 . The r o u t i n e s o r procedures on t h i s ward may r e q u i r e movement o f peop le and equipment i n and o u t o f your room. I n g e n e r a l , how much a c t i v i t y o f t h i s s o r t happens i n your room d u r i n g the day? [ ] 0 = a g r e a t d e a l [ ] 1 = a moderate amount [ ] 2 = v e r y l i t t l e [ ] 3 = e x t r e m e l y v a r i a b l e 22 . How do you f e e l about t h i s ? [ ] 0 = p o s i t i v e [ ] 1 = n e u t r a l [ ] 2 = somewhat n e g a t i v e [ j 3 = e x t r e m e l y n e g a t i v e 23 . Does t h i s d i f f e r , i n any way, from what you expected t o happen here? [ ] 0 = no [ ] 1 = y e s , I expected more a c t i v i t y [ ] 2 = y e s , I expected l e s s a c t i v i t y [ ] 3 — no e x p e c t a t i o n s Do you ever f e e l i s o l a t e d here? [ ] 0 — a l l o f the t ime [ ] 1 = most o f the t ime [ ] 2 = some o f the t ime [ ] 3 = none o f the t ime 244 25 . I f s o , do you f e e l t h i s way because you a re s epara te from your f a m i l y and f r i e n d s o r because o f the h o s p i t a l s i t u a t i o n i t s e l f ( e . g . , nobody t o t a l k t o h e r e ) ? [ ] 0 = s e p a r a t i o n [ ] 1 = h o s p i t a l s i t u a t i o n [ ] 2 = o t h e r (e labora te ) 26. How many t imes have you been i n h o s p i t a l b e f o r e t h i s admiss ion? [ ] 0 = none [ ] 1 = one o r two [ ] 2 = t h r e e o r f o u r [ ] 3 = f i v e o r more 27 . Have you ever been a d m i t t e d as an emergency be fore? [ ] 0 = yes [ 3 1 = no Section III of ESS - Personal Control and Response Restriction 28 . Do the s t a f f on t h i s ward i d e n t i f y themselves t o you? [ ] 0 = a l l o f the t ime [ 3 1 = most o f the t ime [ 3 2 = some o f t h e t ime [ j 3 = none o f the t ime 29 . Do t he y e x p l a i n t h e i r r o l e i n your c a r e ? [ 3 0 = a l l o f the t ime [ ] 1 = most o f the t ime [ 3 2 = some o f the t ime [ ] 3 = none o f the t ime 30 . How much do you know about the n a t u r e o f your i n j u r y (or i l l n e s s ) and i t s t rea tment? [ 3 0 = a s u b s t a n t i a l amount [ ] 1 = a moderate amount [ ] 2 = a s m a l l amount (Rate a m b i g u i t y , i f p o s s i b l e ) [ ] 3 = no knowledge a t a l l 245 3 1 . Do you ask many q u e s t i o n s o f your d o c t o r d u r i n g a v i s i t ? [ ] 0 = asks many (5 o r more) q u e s t i o n s [ j 1 = a sks s e v e r a l (3-4) q u e s t i o n s [ ] 2 = a sks one o r two q u e s t i o n s [ ] 3 = none a t a l l 32 . D u r i n g t h e d a y , do you ask many q u e s t i o n s o f the nurses about your c o n d i t i o n o r your ca re? [ ] 0 = a sks many (5 o r more) q u e s t i o n s [ ] 1 = asks s e v e r a l (3-4) q u e s t i o n s [ ] 2 = asks one o r two q u e s t i o n s [ j 3 = none a t a l l 3 3 . A r e you s a t i s f i e d w i t h the answers t h a t you g e t ? [ ] 0 = e x t r e m e l y s a t i s f i e d [ ] 1 = modera te ly s a t i s f i e d [ j 2 = s l i g h t l y s a t i s f i e d [ ] 3 = n o t a t a l l s a t i s f i e d 34. I f n o t , w i t h whom a r e you d i s s a t i s f i e d ? [ ] 0 = s e l f [ ] 1 = d o c t o r s o n l y [ j 2 = nurse s o n l y [ j 3 = d o c t o r s and nurses 35 . Do t h e s t a f f seem t o be w i l l i n g t o spend as much t ime speak ing t o you as you t h i n k i s neces sary? [ ] 0 = yes [ ] 1 = n o , f e e l s somewhat n e g l e c t e d [ ] 2 = n o , f e e l s modera te ly n e g l e c t e d [ ] 3 = n o , f e e l s e x t r e m e l y n e g l e c t e d 36 . Do t h e s t a f f speak i n language you can understand? [ ] 0 = a l l o f the t ime [ ] 1 = most o f the t ime [ ] 2 = some o f the t ime ( I f n o t , g i v e examples) [ ] 3 = none o f the t ime 37 . What caused your a c c i d e n t ( i l l n e s s ) ? [ ] 0 = sees s e l f as cause [ j 1 = sees o t h e r peop le as cause [ ] 2 = sees p h y s i c a l environment as cause [ ] 3 = sees l u c k o r chance as cause 246 38 . When somebody becomes i l l o r has an a c c i d e n t he/she o f t e n t h i n k s , " I f o n l y I h a d n ' t done such and such I would have avo ided t h i s . " Have you had any thoughts l i k e t h i s ? [ ] 0 = y e s [ ] 1 = no 39 . Do you t h i n k you c o u l d have a v o i d e d becoming i l l ( the a c c i d e n t ) ? [ ] 0 = c o u l d e a s i l y have a v o i d e d [ j 1 = p r o b a b l y c o u l d have avo ided [ ] 2 = l i t t l e c o u l d have been done t o a v o i d [ ] 3 = n o t h i n g c o u l d have been done t o a v o i d 40 . How do you f e e l about b e i n g i n bed i n h o s p i t a l ? [ ] 0 = p o s i t i v e ( e . g . , chance f o r a r e s t ) [ ] 1 = n e u t r a l [ ] 2 = somewhat n e g a t i v e ( e . g . , t i e d down) [ ] 3 = e x t r e m e l y n e g a t i v e 4 1 . Have any p o s i t i v e consequences r e s u l t e d from your h o s p i t a l i z a t i o n ? [ ] 0 = many t h i n g s have changed f o r the b e t t e r [ ] 1 = a few t h i n g s have improved somewhat [ ] 2 = one o r two minor t h i n g s have improved [ j 3 = none a t a l l 42 . How do you wake up i n the morning here i n h o s p i t a l ? [ ] 0 = nurse s wake me up ( v i t a l s i g n s , b r e a k f a s t ) [ ] 1 = o t h e r p a t i e n t s wake me up [ ] 2 = wake up due t o d i s c o m f o r t [ j 3 = wake up as I do a t home 4 3 . I n g e n e r a l , do you see y o u r s e l f o r o t h e r peop le i n c o n t r o l o f when you do t h i n g s here ( e . g . , b a t h , go t o s l e e p , have v i s i t o r s ) ? [ ] 0 = s e l f [ ] 1 = o t h e r peop le 44 . A r e you s a t i s f i e d o r u n s a t i s f i e d w i t h t h i s ? [ ] 0 = s a t i s f i e d [ ] 1 = u n s a t i s f i e d 247 45 . Do you see y o u r s e l f o r o t h e r peop le i n c o n t r o l o f what you do here ( e . g . , what you wear , what you do t o pass the t ime) ? [ ] 0 = s e l f [ ] 1 = o t h e r peop le 46 . How do you f e e l about t h i s ? [ ] 0 = p o s i t i v e [ ] 1 = n e u t r a l (as expected) [ ] 2 = somewhat n e g a t i v e [ ] 3 = e x t r e m e l y n e g a t i v e 47 . I n g e n e r a l , when you use your c a l l l i g h t ( b e l l ) , how q u i c k l y do you g e t h e l p ? [ ] 0 = a lmos t immedia te ly (under 5 minutes) [ ] 1 = 5-10 minutes [ ] 2 = 10-15 minutes [ ] 3 = t o o l o n g , so t h a t I have t o use o t h e r means t o g e t h e l p ( e . g . c a l l o u t , c o n t a c t o t h e r p a t i e n t ) 48 . How do you [ ] 0 = ] [ ] 1 = [ ] 2 = [ ] 3 = Do you ever [ ] 0 = : [ ] 1 = [ ] 2 = • [ ] 3 = 49 . expec t a s s i s t a n c e more q u i c k l y than you r e c e i v e i t ? 50 . Some m e d i c a t i o n s , such as s l e e p i n g p i l l s and p a i n k i l l e r s , may be g i v e n on reques t as you need them. When you ask f o r m e d i c a t i o n , do you r e c e i v e i t ? [ ] 0 = never r e q u e s t s m e d i c a t i o n [ ] 1 = a lways r e c e i v e s i t when the proper t ime has passed [ ] 2 = a lways r e c e i v e s i t b u t may be much d e l a y e d [ ] 3 = sometimes does not r e c e i v e i t a t a l l 248 5 1 . How do you f e e l about t h i s ? [ ] 0 = p o s i t i v e [ ] 1 = n e u t r a l [ ] 2 = somewhat n e g a t i v e [ ] 3 = e x t r e m e l y n e g a t i v e 52 . Have you ever r e c e i v e d m e d i c a t i o n t h a t you d i d n ' t want s i n c e your a d m i s s i o n t o t h i s U n i t ? [ ] 0 = yes [ ] 1 = no 53 . I f y e s , d i d you t e l l the nurses t h a t you d i d n ' t want the m e d i c a t i o n ? [ ] 0 = yes [ ] 1 = no 54 . Have the nurses ever w i t h h e l d m e d i c a t i o n on your reques t ? [ ] 0 = y e s [ ] 1 = no 55 . Do you d i s c u s s your m e d i c a t i o n s w i t h your d o c t o r o r o t h e r s t a f f ? [ ] 0 = y e s , d o c t o r s and nurses [ ] 1 = y e s , d o c t o r s o n l y [ ] 2 = y e s , nurses o n l y [ ] 3 = no 56 . A r e m e d i c a t i o n s d e a l t w i t h on t h i s ward as you would expect? [ ] 0 = yes [ ] 1 = no 57 . I n g e n e r a l , how do you f e e l about the r o u t i n e s and procedures on t h i s U n i t ? [ ] 0 = p o s i t i v e [ ] 1 = n e u t r a l [ ] 2 = somewhat n e g a t i v e [ j 3 = e x t r e m e l y n e g a t i v e 58 . Have you ever broken any o f the r e g u l a t i o n s on t h i s U n i t ? [ ] 0 = yes [ ] 1 = p r o b a b l y [ ] 2 = n o t t o my knowledge [ ] 3 = no 249 Section IV of ESS - Imagery and Dreams 5 9 . S i n c e you have been i n h o s p i t a l , do you s l e e p as w e l l as you u s u a l l y do? [ ] 0 = b e t t e r t h a n u s u a l [ ] 1 = no change [ ] 2 = somewhat worse [ ] 3 = much worse 60 . Have your dreams changed i n any way? [ ] 0 = yes [ ] 1 = no 6 1 . I f y e s , i n what way have they changed? [ ] 0 = l e s s f r e q u e n t [ ] 1 = more f r e q u e n t [ j 2 = more v i v i d [ ] 3 = dreams about d i f f e r e n t t h i n g s than a t home ( e . g . , a c c i d e n t ) 62 . I f y e s , how do you account f o r any change i n your s l e e p o r dreams? [ ] 0 = no e x p l a n a t i o n [ ] 1 = c o n c e r n w i t h i n j u r y / i l l n e s s ( s e l f - c o n c e r n ) [ ] 2 = h o s p i t a l environment [ j 3 = e x t e r n a l concerns ( e . g . , f a m i l y , job) 6 3 . I f y e s , how do you f e e l about t h i s change? [ ] 0 = p o s i t i v e [ ] 1 = n e u t r a l [ ] 2 = somewhat n e g a t i v e [ ] 3 = e x t r e m e l y n e g a t i v e 64 . Have your daydreams changed i n any way? [ ] 0 = yes [ ] 1 = no 6 5 . I f y e s , i n what way have they changed? [ ] 0 = l e s s f r e q u e n t [ ] 1 = more f r e q u e n t [ ] 2 = more v i v i d [ ] 3 = daydream about d i f f e r e n t t h i n g s than a t home 250 66 . I f y e s , how do you account f o r t h i s change?   r 1 [ ] 0 [ ] 1 [ ] 2 t ] 3 [ ] 4 I f yes , 1 [ ] 0 [ ] 1 [ ] 2 [ ] 3 67 .  , how do you f e e l about t h i s change? 68 . S i n c e you have been here i n h o s p i t a l , have you had any u n u s u a l o r p e c u l i a r s e n s a t i o n s o r e x p e r i e n c e s o f any k i n d ? [ ] 0 = yes [ ] 1 = no 69 . I f y e s , would you t e l l me about t h i s ? [ ] 0 = v i v i d dreams [ ] 1 = v i s u a l imagery [ ] 2 = a u d i t o r y imagery [ ] 3 = k i n e s t h e t i c imagery 70 . What t ime o f day d i d i t happen? [ ] 0 = morning [ ] 1 = a f t e r n o o n [ ] 2 - even ing [ ] 3 = n i g h t 7 1 . How l o n g d i d i t l a s t ? [ ] 0 = seconds [ ] 1 = minutes [ ] 2 = hours [ ] 3 = days 7 2 . D i d t h i s happen more t h a n once? [ ] 0 = no [ ] 1 = y e s , 2-3 t imes [ ] 2 = y e s , 3-10 t imes [ j 3 = y e s , over 10 t imes 251 7 3 . Do you remember how many days you had been i n h o s p i t a l when you Had t h i s e x p e r i e n c e (these e x p e r i e n c e s ) ? [ ] 0 = f i r s t 48 hours [ ] 1 = day 3 o r 4 [ ] 2 = day 5 t o 7 [ ] 3 = more t h a n a week a f t e r a d m i s s i o n 74 . D i d you t e l l anyone about the exper ienced? [ ] 0 [ ] 1 [ ] 2 [ ] 3 7 5 . I f n o t , why d i d n ' t you t e l l anyone about i t ? [ ] 0 = s t a f f busy [ ] 1 = f e a r o r a n x i e t y [ ] 2 = d e a l t w i t h i t m y s e l f , thought i t would pass [ ] 3 = o t h e r = y e s , the d o c t o r s = y e s , the nurses = y e s , my f a m i l y o r f r i e n d s = no 7 6 . I f y e s , what was done about i t ? [ ] 0 = n o t h i n g [ ] 1 = someone t a l k e d w i t h me [ ] 2 = e x p l a n a t i o n g i v e n [ ] 3 = m e d i c a t i o n g i v e n 7 7 . How d i d you f e e l about t h i s e x p e r i e n c e ? [ ] 0 = p o s i t i v e [ ] 1 = n e u t r a l [ ] 2 = somewhat n e g a t i v e [ ] 3 = e x t r e m e l y n e g a t i v e 78 . How d i d you e x p l a i n t h i s e x p e r i e n c e t o y o u r s e l f a t the t ime? [ ] 0 = no e x p l a n a t i o n [ ] 1 = e x t e r n a l a t t r i b u t i o n [ ] 2 = i n t e r n a l a t t r i b u t i o n 79 . The reason I have been a s k i n g you these q u e s t i o n s i s t h a t sometimes p e o p l e who have t o spend t ime i n bed i n the h o s p i t a l do have t h o u g h t s , f e e l i n g s , and e x p e r i e n c e s w h i c h they wonder about ; f o r example, they see t h i n g s , such as o b j e c t s o r p a t t e r n s , and wonder i f they are r e a l . Has a n y t h i n g l i k e t h i s happened t o you (other t h a n what you have a l r e a d y t o l d me)? 252 80 . Sometimes peop le who have t o spend t ime i n bed i n h o s p i t a l hear sounds and wonder i f they a re r e a l . Has a n y t h i n g l i k e t h i s happened t o you? 8 1 . Some peop le t e l l u s , a f t e r they have spent t ime i n bed i n h o s p i t a l , t h a t they f e e l a s e n s a t i o n o f movement o f themselves o r o f some p a r t o f t h e i r room. Have you had any s e n s a t i o n s l i k e t h i s ? 8 2 . Have you ever wakened t o f i n d t h a t , w h i l e h a l f a s l e e p , you were d o i n g something t h a t was a g a i n s t the i n s t r u c t i o n s g i v e n t o you by the m e d i c a l o r n u r s i n g s t a f f ? 8 3 . Do you have any o t h e r comments about your e x p e r i e n c e s i n c e y o u ' v e been here i n h o s p i t a l ? 253 APPENDIX E C O G N I T I V E INTERVENTION The in tervent ion used for Study I w i l l be a 3-minute cassette recording of information aimed to provide : ( 1 ) An expectancy for imagery and v i v i d dreams whi le i n h o s p i t a l . (2) A p o s i t i v e se t . (3) An environmental explanation for these e f f e c t s . Verba l i n s t r u c t i o n s to p a t i e n t : This cassette recording was made by a nurse who has had experience w i t h many pat ient s i n circumstances s i m i l a r to your own. She t e l l s of some of the poss ib le e f fect s of h o s p i t a l i z a t i o n , p a r t i c u l a r l y wi th the sudden changes of environment fo l lowing an emergency admission to h o s p i t a l . (Places cassette i n recorder ) . A l l I want you to do i s to l i s t e n and think about your own experiences i n h o s p i t a l . The tape w i l l only take a few minutes and then I w i l l be ava i l ab le to answer any questions you might have. (Play recorded m a t e r i a l ) . Do you have any questions or comments? Transcr ip t of tape: Because you were admitted to h o s p i t a l on an emergency bas i s , you have probably had very l i t t l e time to prepare yourse l f for becoming a pa t i en t i n h o s p i t a l . The purpose of t h i s recording i s to t e l l you about 254 c e r t a i n experiences that you may have whi le you are here. We have found that i t i s of ten h e l p f u l to know i n advance what to expect whi le i n h o s p i t a l . That i s not to say that the experiences discussed here w i l l neces sar i ly happen to you. On the other hand, you may have already had such experiences s ince your admission to h o s p i t a l and t h i s w i l l g ive you an opportunity to t a l k about them, i f you wish , a f ter you have l i s t e n e d to t h i s tape. The experiences I am r e f e r r i n g to are sensations such as v i v i d dreams, daydreams, and changes i n perception of one's immediate environment. Some people f i n d that they do not s leep as w e l l i n h o s p i t a l as they do at home. This i s qu i te understandable g iven the change from f a m i l i a r home surroundings to the r e l a t i v e u n f a m i l i a r i t y of h o s p i t a l . People who must stay i n bed for a time i n h o s p i t a l of ten t e l l us they they not ice a change i n t h e i r dreams. For some t h i s means that t h e i r dreams are more frequent or that they experience the same dream over and over again, such as a dream about the accident which l ed to h o s p i t a l i z a t i o n . Other pa t ient s t e l l us that occa s iona l ly t h e i r dreams become so v i v i d that i t i s hard to t e l l them from r e a l i t y . These v i v i d dreams may occur at n ight , whi le ha l f -a s leep , or during the day as par t of daydreams. For example, some people w i l l think that they hear sounds, such as music p l a y i n g , but r e a l i z e that the sounds are not r e a l . Other people have v i s u