UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The development of an evaluation tool to measure the adaptation of spinal injury patients to disability Kao, Jack J. H 1974

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1974_A5_7 K35_9.pdf [ 4.19MB ]
Metadata
JSON: 831-1.0099911.json
JSON-LD: 831-1.0099911-ld.json
RDF/XML (Pretty): 831-1.0099911-rdf.xml
RDF/JSON: 831-1.0099911-rdf.json
Turtle: 831-1.0099911-turtle.txt
N-Triples: 831-1.0099911-rdf-ntriples.txt
Original Record: 831-1.0099911-source.json
Full Text
831-1.0099911-fulltext.txt
Citation
831-1.0099911.ris

Full Text

THE DEVELOPMENT OF AN EVALUATION TOOL TO MEASURE THE ADAPTATION OF SPINAL INJURY PATIENTS TO DISABILITY by JACK J . H. KAO M.A., U n i v e r s i t y of Chengchi, Taiwan Republic of China, 1964 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n the School of Nursing We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1974 In present ing t h i s thes is in p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the Un ivers i ty of B r i t i s h Columbia, I agree that the L ib ra ry sha l l make it f ree l y a v a i l a b l e for reference and study. I fu r ther agree that permission for extensive copying of th i s thes is for s c h o l a r l y purposes may be granted by the Head of my Department or by h i s . r e p r e s e n t a t i v e s . It is understood that copying or p u b l i c a t i o n of th i s thes is f o r f i n a n c i a l gain sha l l not be allowed without my wr i t ten permiss ion . Department of The Un ivers i t y of B r i t i s h Columbia Vancouver 8, Canada Date /h)rU 10 . / 9 7ft ABSTRACT The purpose of the study was to develop an evaluation tool to measure adaptation of spinal cord injury patients to disability. The Q-Sort technique was used to develop the tool. This tool is intended to enable health professionals, especially nurses, to measure a patient's current status in adaptation to disability, to assess progress in adaptation, and to provide guidelines for intervention. Literature relevant to Q-Methodology and to conceptual frameworks of d i s a b i l i t y and adaptation to disability was reviewed. In the process of tool development, Q-Sort statements were collected from patients' own descriptions of their current status following injury. Six graduate students in nursing served as panel judges: Vo examine the relevance and importance of the statements which were provided by the patients. Fifty-six statements were selected to be used as the Q-Sort statements. Then, following Crate's adaptation model, the f i f t y -six statements were distributed into four categories in terms of her four stages of adaptation: (1) denial and disbelief, (2) developing awareness, (3) re-organization and (.4) adaptation. i v To t e s t the v a l i d i t y of statements i n the four c a t e g o r i e s , twenty h e a l t h p r o f e s s i o n a l s {nurses, p h y s i o t h e r a p i s t s , v o c a t i o n a l c o u n s e l l o r s and s o c i a l workers) were asked to s o r t the f i f t y - s i x items i n t o these same f o u r categories of ad a p t a t i o n . There was high agreement (61-81%) on the d i s t r i b u t i o n of s t a t e -ments i n t o the f o u r c a t e g o r i e s . The e v a l u a t i o n Q-Sort was t e s t e d out on two groups of ten p a t i e n t s each. This t e s t measured the degree of adaptation of each of the twenty p a t i e n t s . Scores showed d i f f e r e n t l e v e l s of adaptation i n the two groups of p a t i e n t s . Relevant v a r i a b l e s were se l e c t e d f o r a n a l y s i s . Several v a r i a b l e s were found to be s i g n i f i c a n t at the 0 . 0 5 l e v e l . 91 pages ACKNOWLEDGEMENTS The writer wishes to express his sincere appreciation to Professors Miss Mary Cruise, Mrs. Helen Elfert, and Miss Rose Murakami, who gave guidance and encouragement during the course of this study. Grateful acknowledgement i s also made of the cooperation and encouragement of the staff and patients of two rehabilitation settings. The writer also wishes to thank Miss Kay Gilchrist for her expert typing of the thesis. v DEDICATION To my wife Audrey and our children, Elizabeth, Paul and Grace v i TABLE OF CONTENTS Page ABSTRACT i i i ACKNOWLEDGEMENTS v DEDICATION v i LIST OF TABLES ix CHAPTER I. THE RESEARCH PROBLEM 1 Introduction 1 The Significance of the Problem 4 The Statement of the Problem 8 The Purpose of the Study 9 II. A CONCEPTUAL FRAMEWORK 10 The Uniqueness of the Disabled Person . . 10 Adaptation;; Initiating the Rehabilitation Process 11 Adaptation is an Important Factor Leading to Successful Rehabilitation. . 13 Adaptation Models 15 III. A METHODOLOGICAL FRAMEWORK 24 The Q-Technique 24 Forced Choice 26 Advantages and Disadvantages 27 Literature Regarding the Use of Q-Sort in Health Science 28 v i i v i i i CHAPTER Page IV. ASSUMPTIONS, LIMITATIONS AND DEFINITIONS . . 31 Underlying Assumptions 31 Limitations 31 Definitions 32 V. DEVELOPMENT OF THE EVALUATION Q-SORT . . . . 34 The Development of the Q-Sort 34 Setting 39 Testing 39 Method of Scoring 41 Pre-Testing 41 VI. TESTING OF THE PATIENTS 43 Analysis of Items 44 Analysis of Findings from Testing of Patients 53 VII. SUMMARY, CONCLUSION AND RECOMMENDATION . . . 68 BIBLIOGRAPHY $1 APPENDICES 78 A. Q-Sort Items Arranged by Categories. . 79 B. Data Sheets 83 C. Agreement of Items in Stages 87 LIST OF TABLES TABLE Page 1. The D i s t r i b u t i o n , sex and p r o f e s s i o n s of judges 38 2. Q - S o r t , Scores and Frequency 40 3 . The D i s t r i b u t i o n of P a r t i c i p a n t s by Age, Sex, D i a g n o s i s , Durat ion of D i s a b i l i t y , Degree of Independence, M o t i v a t i o n Scores 45 4 . The Most S i g n i f i c a n t Items Between Group A and Group B 46 5 . The Least S i g n i f i c a n t Items Between Group A and Group B 47 6. The Twelve Most S i g n i f i c a n t Items of i Group A P a t i e n t s i n Rank Order 49 7. The Twelve Least S i g n i f i c a n t Items of Group A P a t i e n t s i n Rank Order 50 8. The Twelve Most S i g n i f i c a n t Items of Group B. P a t i e n t s i n Rank Order 51 9. The Twelve Least S i g n i f i c a n t Items of Group B P a t i e n t s i n Rank Order 52 10. The Scores of Adapta t ion to D i s a b i l i t y Between Group A and B 54 11. •'Scores of P a t i e n t s by Age 56 12. Scores of P a t i e n t s by D iagnos is 57 13. Durat ion of D i s a b i l i t y 58 14. Durat ion from I n j u r y to S t a r t of : R e h a b i l i t a t i o n Program 60 15. Future P lans and Scores on Adaptat ion Sca le 63 16 M o t i v a t i o n and Scores on Adaptat ion S c a l e . . 64 i x X TABLE Page 17. Scores of Help from Patients' Family During Rehabilitation Period 65 18. Scores and Degrees of Independency 67 CHAPTER I THE RESEARCH PROBLEM I. INTRODUCTION The disabled constitute a significant proportion of the population of North America. Although there are various estimates of the extent of dis a b i l i t y , the precise dimensions of the problem are unknown. In 1969 1 the U.S. National Health Survey reported that 53 million persons were injured in 1967 and estimated an average of about 26 d i s a b i l i t y days for each occurrence of an illness, impairment, or injury. The National Center for Health Statistics reported that in 1967 about 22 million persons, or about one out of every four civilians liv i n g outside of institutions, had some activity limitation, and that close to 9 per cent of this group were restricted in their major activities (working, keeping house, school or pre-school a c t i v i t i e s . The 2 National Center estimated that 5 million of.the IS mil-lion disabled adults between the ages of eighteen and sixty four could benefit from vocational rehabilitation and 1 National Center for Health Statistics, U.S. Department of Health, Education and Welfare, 1969. Current  Estimates for Health Interview Survey. U.S. 1967. Washington, D.C., U.S. Department of Health, Education and Welfare. 2 IBID 1 2 go back i n t o the community o r to t h e i r jobs. In Canada, s t a t i s t i c s p u b l i s h e d by the Department o f N a t i o n a l Health and Welfare i n d i c a t e t h at t h e r e were about 1,295,000 permanent p h y s i c a l l y d i s a b l e d i n I960. A f a r b e t t e r u n d e r s t a n d i n g of the number and needs of t h i s p o p u l a t i o n i s r e q u i r e d . P h y s i c a l d i s a b i l i t y , a h e a l t h care problem, can a l s o be viewed i n the broader c o n t e x t as a s o c i a l problem. It a f f e c t s the l i v e s of m i l l i o n s of people d i r e c t l y or i n d i r e c t l y . The p e r s o n a l and economic c r i s e s i t p r e c i p i t a t e s o f t e n cause severe d i s r u p t i o n o f f a m i l y r e l a t i o n s and o t h e r primary t i e s . Absenteeism, l o s s of v o c a t i o n a l s k i l l s , and withdrawal from the l a b o r mar-ket are a l s o among the important e f f e c t s of d i s a b i l i t y . 5 As one r e s e a r c h e r p o i n t s out, "manifested not o n l y i n p e r s o n a l expense and l o s t p r o d u c t i o n , the e f f e c t of 3 N a t i o n a l Healt,h and Welfare and the Dominion Bureau o f S t a t i s t i c s , I l l n e s s and Health Care i n Canada, Canada S i c k n e s s Survey, 1950-51, Ottawa: Queen's P r i n t e r , 1963. 4 Dominion Bureau of S t a t i s t i c s , Census 1961, Ottawa: Queen's P r i n t e r , 1963. 5 Saad Nagi, D i s a b i l i t y and R e h a b i l i t a t i o n , L e g a l , C l i n i c a 1 , and S e l f - C o n c e p t s and Measurement, Ohio State U n i v e r s i t y Press, 1969. p. 3« 3 disability upon the general economy can also be seen in the increasing cost of welfare payments, extended health care, compensation, and insurance benefits for the disabled." Though the presence of physical defects may imply limitation of capacity to work in some cases, this premise is false in the majority of instances. Even in the presence of serious physical defect, suf-ficient function may remain to carry out industrial activity. One study of 4404 physically handicapped persons engaged in 653 different types of work shows the versatility and adaptability of the physically handicapped. If a man accepts his d i s a b i l i t i e s , 6 Dr. Kessler pointed out, that acceptance may over-compensate the internal body function. While drive or motivation pushes a man to an ordinary level of achieve-ment, an increase in the intensity of that drive propels him far beyond what he thought he could do, and helps him to approach the limits of his capabilities. 7 Adler developed a psychological system based 6 Henry Kessler, "Rehabilitation of the Physically Handicapped", Columbia University Press, New York, 1947. p. 4. 7 A. Adler, Understanding Human Nature. New York, 1928, p. 286. 4 on the idea of organ inf e r i o r i t y . He notes that we are equipped with resources that are not f u l l y developed. Yet with this imperfect development good performances are turned out, just as our ancestors produced great works with imperfect tools. It is possible that a man equipped with defective organs, that i s , with inadequate tools, w i l l actually develop a better technique to combat the rigors of his environment. Either from an individual or a social system point of view, disability i s a worthy problem to study. Study of this problem should include identifying those factors which might influence the process of rehabilit-ation for the disabled. II. THE SIGNIFICANCE OF THE PROBLEM Adaptation to a di s a b i l i t y is correlated with the progress of rehabilitation. Prolongation of the process of adaptation may delay the process of rehab-8 i l i t a t i o n . If nurses could use some tool to measure a patient's present status in adaptation to his disability and give suitable intervention to the patient, i t may assist the patient to move forward in 8 M. Crate, "Nursing Function in Adaptation for Chronic Illness", American Journal of Nursing. Oct. 1965, p. 72. 5 his adaptation process. With these possibilities in mind the researcher felt i t worth while to develop a tool which can measure adaptation to disa b i l i t y . Q-Sort is a technique which gives direction for the development of a tool which in turn can measure the 9 adaptation to a disability. 10 Dr. Whiting pointed out that: In general, there are two major problems that the Q-Sort is designed to solve: (l)i The problem of correlation, or degree of similarity, between different individuals' or different groups' attitudes, expectations or opinions at a given time; and (2) The degree of change in individuals' or groups' attitudes or opinions from one time to another. The Q-Sort in this research was designed to explore the attitudes of spinal injury individuals toward disability and to i n i t i a t e the preliminary steps toward standardizing an instrument which measures adaptation to disa b i l i t y . 9 F. Whiting, "Q-Sort, A Technique for Evaluating Perceptions of Interpersonal Relationship", Nursing  Research. Oct., 1955, p. 70. 10 IBID, p. 72. 6 The underlying assumption is that everyone, disabled or not, must deal with dependency-need 11 12 gratification. For example, Homey states that, "affection i s needed by both 'normal' and 'neurotic' 13 people". Sullivan also points out that people strive for satisfaction and security. It i s further assumed 14 by Bell that for the physically disabled the problem of having to cope with the satisfaction of certain dependency needs i s exacerbated, or brought into focus, by the nature and extent of the dis a b i l i t y . Therefore, the manner and extent of adaptation to disability is closely related to the way disabled persons handle gratification of dependency needs. 11 H. Bell, "Measure for Adjustment of the Physically Disabled" tf : Psychological Reports, Southern University Press, 1967, p. 773. 12 K. Horney, The Neurotic Personality of Our  Time. New York. Norton, 1937. 13 H. S. Sullivan, "A Note on the Implications of Psychiatry, The Study of Interpersonal Relations for Investigation in the Social Sciences", American Journal of Sociology. 1937-42, p. 34$. 14 H. Bell, "Measure for Adjustment of the Physically Disabled". Psychological Reports. Southern University Press, 19o7. p. 774. 7 15 Bell in his study indicates there are three levels of adaptation. These levels he describes as follows: 1. Does the disabled person become excessively depen-dent by displaying extreme acceptance of the disability? 2. Does he become overly independent by exhibiting non-acceptance or denial of the disability? 3. Does he develop a "healthy" attitude toward his disability whichlisrreTlected in his behavior by an optimal amount of acceptance of his dependency needs? In a sense, we can recategorize Bell's three levels into two levels; a person becomes either adapted to his disability and therefore accepts his dependency needs, or maladapted to his disability, and therefore exhibits excessive dependent or independent need behavi ors. Adaptation to a di s a b i l i t y would involve both: 1. Acceptance of the di s a b i l i t y , not only in terms of conscious recognition but also in terms of an accept-ing attitude toward self, and 2. Living successfully as a disabled person wit-hcan 15 A. H. Bell, "Attitudes of Selected Rehabilitation Workers and other Hospital Employees Toward the Physically Disabled", Psychological Report 10. 1962, p. 183. 8 optimal amount of acceptance of dependency-need gratif i c a t i on. On the other hand, maladaptation or non-adaptation would involve either extreme dependency or extreme independency need behaviors.- The most obvious behaviors are denial, frustration, and lack of motivation toward rehabilitation. Nurses are dealing with patients' dependency behaviors every day without the aid of a tool to measure patients' behaviors which either become excessively dependent or overly independent. Since attitudes are usually related to other 16 behaviors, measurement of these attitudes in the disabled person might well provide information about the manner in which the disabled person adapts to his disability. Therefore a tool which measures adaptation is urgently needed. III. THE STATEMENT OF THE PROBLEM Psychological adaptation to a d i s a b i l i t y influences the individual's physical course of rehab-i l i t a t i o n . It i s significant for health professionals 16 R. G. Barker; Wright, Meyerson and Gorick, "Adjustment to Physical Handicap and Illness: A Survey of the Social Psychology of Physique and Disability." Bull.- Social Sciences. Research_;Council 1953* 9 to understand individuals who are disabled and how they adapt to their d i s a b i l i t i e s . Members of the health profession need to know the process of adaptation, and especially how to identify the stage in which a disabled person is at any given time. Health professionals also need a tool to measure the degree of adaptation. Once the degree and stage of adaptation is established the nurse's role then becomes that of f a c i l i t a t i n g the patient's adaptation to a permanent and profoundly changed, different l i f e situation. IV. THE PURPOSE OF THE STUDY The purpose of this study i s to: 1. Develop a tool which w i l l ; (a) measure the patient's current status of adaptation to a d i s a b i l i t y . (b) assess a patient's progress in his adaptation process. 2. Test the validity and r e l i a b i l i t y of the tool. CHAPTER II CONCEPTUAL FRAMEWORKS The following review of literature reflects ways in which various authors have viewed "disabi l i t y " and "adaptation to di s a b i l i t y " . I. THE UNIQUENESS OF THE DISABLED PERSON Serious injury or illness, resulting in per-manent disability, often forces an individual to change his whole way of l i f e . It may become necessary for him to make major adjustments in the mechanics of his daily living, in his social l i f e , and in his productive l i f e . Disability i s not an entity in i t s e l f , in that i t cannot be separated from the total person and his general problems of l i v i n g . Every disabled person undergoes a personal struggle before he is able to adjust to forced changes in his body image, or in his domestic and social l i f e . Adaptation to a disa b i l i t y i s a psychological factor of rehabilitation that cannot be separated 1 from physical rehabilitation. Kessler points 1 H. Kessler, Principles and Practices of  Rehabilitation. Philadelphia. Lea and Febiger, I960. 10 11 out that the individual must be evaluated as a whole. The individual does not act as a series of separate structural units or funct: ons, but rather as a psycho-physical entity. Mind and body cannot be divorced from the need of meeting each problem in an integrated way. II. ADAPTATION: INITIATING THE REHABILITATION PROCESS The rehabilitation process includes the four 2 following phases: i n i t i a t i n g the process; vocational evaluation; treatment; adjustment to the community. The importance of recognizing a l l phases of adaptation to a disability i s the main task of the f i r s t phase — that i s , i n i t i a t i n g the process. Psychologically, the rehabilitation process becomes possible with the acceptance of loss. This 3 process i s analyzed by Wright as the recognition that the effect of the impairment i s limiting rather than total and that values are based upon a b i l i t i e s rather than d i s a b i l i t i e s . Acceptance implies also recognition by the 2 W. Gellman, Fundamentals of Rehabilitation in Rehabilitation Practices With the Physically Disabled. edited by J. Garrett and S. Levine, New York Columbia Uaiversity Press, 1973, p. 19. 3 B. Wright, Physical Disability: A Psychological  Approach, Harper & Row, I960. 12 physically disabled person that he is handicapped and w i l l need assistance to reach his goals. The transition from the role of a patient to the role of a rehabilitant occurs when he views rehabilitation as a means for overcoming barriers to achievement. A report of a detailed follow-up survey of 4 200 patients found out that the rehabilitation of the severely disabled must be based on a detailed assessment of the patient ' s physical disability coupled with a reali s t i c approach to his practical competence. The unrealistic or mal-adapted patient is hardly able to reach his rehabilitation goal. 5 Fordyce said that he sees rehabilitation as a behavior and behavior change. Rehabilitation approaches success when the desired behaviors occur at the appro-6 priate rate in the appropriate places. Nichols also points out that concentrated and continuous physical exercise is the basis of much rehabilitation for the 4 R. E. Goble & P. J. R. Nichols, Rehabilitation of the Severely Disabled. I-Evaluation of a Disabled  Living Unit. Butterworths, London, 1971 5 W. E. Fordyce, "Behavioral Methods in Rehabilitation in W. Neff (ed.) Rehabilitation Psychology. 6 P. J. R. Nichols, Rehabilitation of the Severely  Disabled; Aspects of Rehabilitation. National Fund for Research into Crippling Disease, London, 1963. 13 p e r i o d of time when d e f i n i t i v e improvement can be obtained. I t may be j u s t i f i a b l e f o r long periods of time a f t e r , f o r example, m u l t i p l e i n j u r i e s . However, i t i s o f t e n easy to continue such treatment f o r too long and there comes a stage when i t i s more appropriate f o r the p a t i e n t t o d i r e d t h i s e f f o r t s towards f u n c t i o n a l independence. I I I . ADAPTATION IS AN IMPORTANT FACTOR LEADING TO SUCCESSFUL REHABILITATION There i s a deep-seated mechanism i n every person who wants to pursue h i s adaptation to a d i s -a b i l i t y . A d i s a b l e d person undergoes emotional t u r m o i l , bewilderment, a n x i e t y , doubt, i n d e c i s i o n , f e a r and o f t e n panic, i n w i s h f u l l y t h i n k i n g that some miracle w i l l r e s t o r e him t o h i s o l d s e l f with i n t a c t body and body image and f a m i l i a r plans and hopes f o r the f u t u r e . Before he can move forward t o a new way of l i f e , however, he must adapt t o h i s new, a l t e r e d s e l f . I t i s on t h i s point t h a t hinges the success or f a i l u r e of r e h a b i l i t a t i o n f o r many a d i s a b l e d person. Some never adapt t o the r e a l i t y of d i s a b i l i t y and continue w i s h i n g f o r a m i r a c l e that w i l l e v e n t u a l l y r e s t o r e them t o t h e i r o l d s e l v e s again. The p o t e n t i a l i t y t h a t might be t h e i r s i f they were t o adapt t o t h e i r new image never comes to f r u i t i o n . 14 Most disabled persons, after a struggle, do adapt to their new image and upon i t build a new future. Adaptation to a disability, to the investigator, emphasizes the acceptance of one's disa b i l i t y as non-devaluating. The d i s a b i l i t y may s t i l l be seen as inconveniencing and limiting. The person may s t i l l strive to "improve the improvable" where improvement w i l l f a c i l i t a t e certain aspects of his l i f e , but he wi l l not feel debased as a person and suffer the strain and shame of hiding and pretense. On the other hand he takes the disability as a fact and tries to overcome and adjust to i t . 7 Dembo and co-workers have made a careful beginning in tracing the process of what they have called "acceptance of loss". By loss is meant the absence of something valuable; loss i s f e l t as a personal misfor-tune, According to Dembo, the fact is what the patient has to accept, is the loss i t s e l f . The following dis-cussion is a development of their analysis of the changes within the value system of the person that are instrumental in overcoming the feelings of shame and inferiority resulting from di s a b i l i t y as a value loss. 7 T. Dembo, G. L. Leviton and B. H. Wright, "Adjustment to Misfortune—A Problem of Social Psychological Rehabilitation", A r t i f i c i a l Limbs 2> 1956. pp. 4-62. 15 These changes may be designated as: (a) enlarging the scope of values, (b) containing disability effects, (c) subordinating physique, and (d) transforming com-parative values into asset values. If a patient takes these results as a measurement of the value placed on adaptation to his disability, according to Dembo, he w i l l turn into a well-adapted patient and wi l l have a successful rehabilitation. IV. ADAPTATION MODELS A broad concern was with the way in which the person with a disability copes with social and personal connotations, these being aroused by the fact that the disability imposes certain limitations and i s fe l t as a loss or denial of something valuable. Nurses are specifically concerned with f a c i l i t -ating adaptation to one's disa b i l i t y as non-devaluating. The d i s a b i l i t y may s t i l l be seen as inconveniencing and limiting. The person may s t i l l strive to "improve the improvable", where improvement w i l l f a c i l i t a t e certain aspects of his l i f e . He may exercise daily to graduate from crutch walking to cane walking, but he w i l l not abandon his drutches prematurely in order to be as much like a normal person as possible. He w i l l not feel debased as a person and suffer the strain and shame of 16 hiding and pretense. Existing literature related to adaptation models is extensive. The following review reflects specific views of adaptation. Adjustment to Misfortune For adaptation, the classic study of Dembo, 8 Levi ton, and Wright, "Adjustment to Misfortune" has provided valuable information. The subjects were 177 visibly injured persons—121 hospitalized military service personnel, 21 veterans of World War II, and 18 civi l i a n s . In addition, there were 65 noninjured subjects (wives, relatives, staff and others). The subjects were told that the purpose of the study was "to determine d i f f i c u l t i e s existing in the relation-9 ships between injured and non-injured people". The authors derived the concept that the difference between those who are and those who are not injured is that of misfortune. The non-injured they contended, tend to feel that the injured victim "ought to" suffer, that he should "mourn his loss", that devaluation of the person w i l l occur i f he does not mourn the loss to the extent that the loss is regarded as an "asset value"' 8 I. Dembo, G. L. Leviton & B. H. Wright, "Adjustment to Misfortune—A Problem of Social Psychological Rehabilitation?, A r t i f i c i a l Limbs, 1956. 3. pp. 4-62. 9 IBID, p. 17. 17 rather than a "possession value". Mourning f u l f i l l s one's fondest hopes for exploratory conceptualization. Thus, acceptance of loss "does not mean becoming reconciled to one's unfortunate 10 situation. Instead, i t is a process of value change". Acceptance of loss helps the individual to view re a l i s t -i c a l l y the social rejection of others without devaluating himself. Ad jus tment to Crisis 11 Cohn described the process of adjustment to disability as consisting of five stages: Shock, expect-ancy of recovery, mourning, defense, and f i n a l adjustment. 12 Fink specified only four stages: Shock, defensive retreat, acknowledgement and adaptation. Fink tied his analysis to motivation theory by specifying that the f i r s t three stages primarily involve safety or 10 I. Dembo, G. L. Leviton & B. H. Wright, "Adjustment to Misfortune—A Problem of Social Psychological Rehabilitation". A r t i f i c i a l Limbs. 1956, 3 . p . 20. 11 N. Cohn, "Understanding the Process of Adjust-ment of Disability". Journal of Rehabilitation. 1961, 27. 12 S. L. Fink, "Crisis and Motivation: A Theoretical Model". Archives of Physical Medicine and  Rehabilitation . 1967, 4 3 . pT 592. IB security needs, while the last stage is growth oriented 13 and can result in increased self-actualization. Shontz described the adjustment process as a succession of approach-avoidance cycles. In the early stages of reaction, these cycles recur rapidly and reach high levels of emotional intensity. With time, a dampening process reduces both their frequency and amplitude un t i l , in adjustment, the cyc l i c a l nature of the process becomes virtually unnoticeable. Comparison Level 14 Kelley, Hastorf, Jones, Thibault and Usdane 15 suggested that the concept of comparison level might be useful in explaining "adaptation to a d i s a b i l i t y " . Comparison level (CL) is the level of payoff or rein-forcement a person experiences as neutral in value. Outcomes that exceed the CL are experienced as good and satisfying. Outcomes below the CL are experienced F. C. Shontz, "Reactions to C r i s i s " . Volta Review. 1965, 67. pp. 364-370. 14 H. H. Kelley, A. H. Hastorf, E. E. Jones, J. W'. Thibault, and W. Usdane, "Some Implications of Social Psychological Theory for Research of the Handicapped". In L. H. Lofquist (ed.) Psychological Research and  Rehabilitation. Washington, D.C. American Psychological Association, I 9 6 0 . 15 J. W. Thibault & H. H. Kellog, The Social  Psychology of Groups. Wiley, New York, 1959. 19 as bad and dissatisfying. Mourning occurs when outcomes drop below the CL, but the CL f a i l s to drop to accommodate change. If the CL changes appropriately, adaptation takes place at a "lower level of functioning" and mourning ceases. If outcomes return to their previous level (the patient finds that he can do things that he thought he could no longer do)., adaptation takes place at or near the previous level and again mourning ceases. If outcomes are not affected by disability, mourning does not occur at a l l . Similarly, mourning does not occur i f the CL is chronically below actual outcome level (if the person always underestimates his own potential). The Significance of Motivation 16~ Shontz indicated that disability poses two groups of problems. The f i r s t requires neutralizing 17 the' problem by loss of valued capacities and functions. The second requires discovering new and positive reasons for l i v i n g . This group of problems cannot be solved until the f i r s t have been satisfactorily settled. Shontz's point of view i s consistent with motivational theories that propose a distinction between "lower level" 16 F. C. Shontz, "Severe Chronic Illness", in J. F. Starrett & E. S. Levine (eds.)1 Psychological  Practices with the Physically Disabled, Columbia University Press, New Y 0rk, 1962. 17 F. C. Shontz, S. L. Fink & C. E. Hollenbeck, "Chronic Physical Illness as Threat", Archives of  Physical Medicine and Rehabilitation, I960, 41. p. 143. 20 needs for physiological gratifications and personal safety and "higher level" needs for interpersonal 13 satisfaction and self-esteem. Integrative Approach 19 The "adjustment" is multipfaceted, not a unitary concept. There are many adjustments in various areas of l i f e , and the level of success or failure in each area i s usually uneven. For example, a person ma$-be high in knowledge, low in s k i l l , make a good father but an unsatisfactory husband, do l i t t l e in the community, yet be a good immediate neighbor, and so on. 20 Dr. Michael Saratoreg proposed four stages of a daptation: The f i r s t stage is "regression", in which some people are overly dependent and emotionally defensive and use their d i s a b i l i t y as a self-centered lever in interpersonal relations. The second stage i s "accommodation" in which some people use their d i s a b i l i t y to play the role of 13 A. H. Maslow, Motivation and Personality Rev. ed.) Harper and Row, 1970. 19 Dr. Michael Saratoreg, The Current Scene in Vocational Rehabilitation of the Disabled: An Overview. Edited by D. Malikin & H. Rusalem, New York University Press, New York 1969. p. 2 3 . 20 IBID, pp. 5-27. 21 martyr. They regard l i f e as barely tolerable; the role gives them a partial crutch on which tomaintain self-dependence. The third stage is a kind of "practical compromise" with their handicap. They manifest their feelings in self-perceptions of moderate i n f e r i o r i t i e s with the non-disabled. They have self-esteem and self-worth, but i t is tinged more or less by competitive feelings with people on the basis of disa b i l i t y . The highest stage is integration of disability, in which the person has developed a deeper, more lofty set of values; the disability has served to draw out of him great inner strength, unusual personal courage, and maturity. He now sees himself as a m'uch^better human being than he might have been i f he had not learned to cope with his disa b i l i t y . He i s not glad that he has the disabil i t y , but he cherishes the great values of l i f e that he struggled for and found. Few people go so far. Sociological Perspective In viewing .adaptation to a disability, * * sociologists looked' at the patients' as a <.grotip",".-trying to relate the individual to a group, and par-21 ticu l a r l y the consequences for him of membership. 21 L. J. Xamir, Expanding Dimensions in Rehabilitation. Charles C. Thomas, Pub., Springfield U.S.A., 1967. p. 135. 22 Persons who experience crises often feel a need to restructure their common situation in a manner which provides meaning and c l a r i t y not only for the present, but for the future as well. Consistent with what is known about the processes of personal adjustment general-ly, that i s often done collectively, rather than in isola-tion, group solutions to common problems are often arrived at through interaction over periods of time. As individ-uals interact, there are also certain group or system problems that must be solved. Thus, in answer to the common problems, needs, interests and frustrations and in response to the problems of group interaction in a particular environment or setting, a group structure and a system of norms emerge. A status hierarchy is created and role differentiation occurs. Norms develop that regulate behavior consequential to the group. Adaptation as a Grief Process Engel states that successful grief and grieving follow certain more or less predictable steps which 22 permit a judgment that healing i s taking place. He points out that the grief process involves four events; (a) shock and disbelief; (b) developing awareness; 22 G. L. Ehgel, "Grief and Grieving", American  Journal of Nursing, Sept., 196/+.. p. 72. 23 (c) restitution and (d) resolving.-the loss, and . identification. 23 M. Crate has developed a model of adaptation to chronic illness according to Engel's grieving process. She says "Adaptation to chronic illness w i l l be considered as following a similar pattern of grief and grieving." They are: (a) disbelief; (b) developing awareness; (c) reorganization and (d) resolution and identity change or adaptation. Adaptation to a disability viewed in this paper, is considered to follow a pattern similar to Crate's model. It is the patient's d i s a b i l i t y and his adaptation; but i t is the nurse's function to observe, understand, and adjust her care to his specific needs at different stages of the adaptation process. The Development of an Evaluation Q-Sort to Measure  Adaptation to Disability The development of an evaluation Q-Sort as a tool has followed Crate's Adaptation |o Chronic Illness Model in this study to categorize the 56 Q-Sort state-ments into four stages. The 56 Q-Sort statements were collected from patients and were categorized into the 4 stages of adaptation proposed by Crate: disbelief, developing awareness, reorganization and adaptation. 23 M. Crate, "Nursing Function in Adaptation to Chronic Illness", American Journal of Nursing. Oct., 1963• p. 72 . CHAPTER III A METHODOLOGICAL FRAMEWORK I. THE Q-TECHNIQUE ©-Methodology was a name assigned by William 1 Stephenson to a group of psychometric and s t a t i s t i c a l procedures which he developed. Q-Technique related to the procedures employed in carrying out Q-Methodology. Essentially this involved the sorting out of packs of cards called Q-Sorts and the correlating of the response of different individuals or different groups of individuals or factors. As a psychological measurement tool, Q-Sort has been used by Carl Rogers and his colleagues and students as a means of allowing clients to reveal their percept-ions of themselves and others. From the results of these studies inferences could be drawn about personality and 2 the results of therapy. The worth of the Q-Sort in nursing has been stated 1 William Stephenson, The Study of Behavior: Q-Techniques and i t s Methodology, Chicago, University of Chicago Press, 1961. 2 Fred N. Kerlinger, Foundations of Behavioral  Research, New York. Holt, Rinehart and Winston line. 1964. p. 586. 24 3 by Dr. Whiting and has been used as an evaluation of 4 attitudes towards psychiatric nursing care and the 5 varying images of the professional nurse. The Q-Sort can be considered essentially as an inventory, consisting of a number (usually between 50 to 150) of descriptive statements. This is called Q-Sort, and the person describing himself i s said to be sorting. Typically, the procedure begins with devising or selection of a t r a i t universe. In the Butler-Haigh Study 100 statements were taken from recordings of clients in different stages of therapy. The items may be phrased positively, "people always like me" or negatively, "I am no damned good to anyone." They may consist of long sentences or single adjectives such ass"cheerful". The subject is asked to distribute these items on a continuum of "like me" to "not like me". 3 Frank Whiting, "Q-Sort: A* Technique for Evaluating Perceptions of Interpersonal Relationships". Nursing Research, Oct., 1955. 4 MacAndrew and E l l i o t t , "Varying Images of the Professional Nurse, A Case Study"., Nursing Research, Winter, 1959. p. 33-5 D. Gerham, "An Evaluation of Attitudes Toward Psychiatric Nursing Care"', Nursing Research. June 1958. p. 71. 26 Instructions under which he sorts vary widely, according to the researcher's interests. One may describe himself in the present, the past, the future; as he wishes he were, as his friends see him, as he sees himself in relation to them; or he may describe others withithe same items 6 in equally varying ways. II. FORCED CHOICE The forced choice requires every person to put himself on the measuring scale in much the same manner. Since more statements are placed in the middle pile, the subject is freed from many d i f f i c u l t and rather un-important discriminations he would have to make i f he were forced to rank every statement. Q-Methodology has been both praised and c r i t i c i z e d . Kerlinger viewed i t as a flexible and useful tool for the psychological and educational investigator. It could profitably be used for comparing the characteristics of groups of individuals with regard to their relations with the group. He f e l t that the novel approach of Q-Method-7 ology made i t interesting to most people. 6 Jonas A. Gootschalk and Arthur H. Auerbackr "Methods of Research" in Psychotherapy, 1966. Appleton-Century^Crafts, New York. p. 438. 7 F. Kerlinger, Foundations of Behavioral Research p. 592. 27 Cronbach saw value in the forced choice procedure 8 of the Q-Sort. In the Q-Sort there i s a ; variant of.the forced choice procedure which - has. many ;;- psychometric advantages. For one thing, this method of interrogation is much more penetrating than the common questionnaire where the person can say "yes" to a l l the favorable symptoms and "no" to a l l the unfavorable ones. The method is free from those idiosyncracies of response which cause some persons to respond "cannot say" twice as often as others, and so make their scores noncomparable. III. ADVANTAGES AND DISADVANTAGES Among the disadvantages Kerlinger cited the matter of sampling. Q-Sort was not a method well suited to cross-sectional or large sample purposes. On the other hand, he pointed out that one may not wish to generalize to populations, but rather to test theories on small groups of individuals chosen for specific characteristics. With them i t was possible to explore unknown areas and variables for their identity and interrelations. Regarding the forced choice nature of 8 Lee J. Cronback, "Correlations Between Persons as a Research Tool", in Psychotherapy. Theory and Research, edited by H. Mower, New York. Ronald Press, 1953. p. 378. 23 the Q-Sort, Kerlinger believed that more criticism and dissatisfaction was inferred by those who opposed forced choices than was actually experienced by participants in such studies. He suggested that the advantage of forcing individuals to make discriminations that they often would not make unless required to do so outweighed 9 any disadvantages. IV. LITERATURE REGARDING THE USE OF Q-SORT IN HEALTH SCIENCE Acceptance of the Q-Sort as a psychological measuring device in the health professions was hastened 10 by i t s use by Rogers as reported by Mowrer for assess-ing perceptions of changes in persons undergoing psycho-therapy. 11 12 In Nursing, Gorham and Butler have used Q-Sort 9F F. Kerlinger, Foundations of Behavioral Research New York. Holt, Rinehart and Winston Inc., 1964. p. 594. 10 H. Mowrer, Psychotherapy: Theory and Research New York, Ronald Press, 1953. 11 D. Gorham, "An Evaluation of Attitudes Toward Psychiatric Nursing Care", Nursing Research 2, 1958. 12 Herbert J. Butler, "The Role of the Psychiatric Nurse as Perceived by Nurses, Members of the Related Disciplines Within the Mental Hospital and Nursing Students". Ph: Ed. Dissertation, Boston University, 1959. 29 to evaluate a t t i t u d e s towards p s y c h i a t r i c n u r s i n g care. 13 MacAndrew and E l l i o t t used i t to study v a r y i n g images of the p r o f e s s i o n a l nurse. 14 15 16 Draper Bower and Dunlap used t h i s technique to measure a t t i t u d i n a l change as a r e s u l t of an e d u c a t i o n a l 17 experience, and Liebman used i t t o study the a l l o c a t i o n of nursing personnel i n an Extended Care F a c i l i t y . 13 C. F. MacAndrew & G. E l l i o t t , "Varying Images of the P r o f e s s i o n a l Nurse: A Case Study". Nursing  Research. Winter 1959. p. 33. 14 James A. Draper, "A Study of P a r t i c i p a n t Objectives i n a Selected Management I n s t i t u t e " . Ph. D. D i s s e r t a t i o n . U n i v e r s i t y of Wisconsin, 1964. 15 E l i M i c h a l Bower, "The A p p l i c a t i o n of Q-Methodology i n I n v e s t i g a t i n g Changes i n S e l f and I d e a l -S e l f as a Result o f Mental Health Workshop". I\ Ed. D i s s e r t a t i o n . SfcaraioffdtUniversity, 1954. 16 M a r j o r i e S. Dunlap & Betty J . Hadley, "Quasi-Q-Sort Methodology i n S e l f - E v a l u a t i o n of Conference Leadership S k i l l " , Nursing Research 14, 1965. pp. 199-125. 17 J . Liebman, J . P. Young & M. Bellmore, " A l l o c a t i o n of Nursing Personnel i n an Extended Care F a c i l i t y " , Health Services Research. F a l l 1973- p. 200 30 These studies were done with successful r e s u l t s to either evaluate an attitude change or to assess the degree of attitude change demonstrated by members of the various health professions. The health professions have had an increasing use of Q-Sort techniques because of the s a t i s f a c t o r y results of the method. CHAPTER IV ASSUMPTIONS, LIMITATIONS AND DEFINITIONS I. UNDERLYING ASSUMPTION The underlying assumption was that every disabled person must go through the process of adaptation to loss during his rehabilitation period. Some may take a longer time to achieve the adapt-ation to their d i s a b i l i t y and some may take less time. If there i s a reliable tool to measure the stage of a patient's adaptation to his disability, i t may help the nurse to give suitable intervention and help the patient to move toward the next stage of adaptation. II. LIMITATIONS This study was subject to the following limitations: 1. Only spinal cord injury patients who were either paraplegic or quadriplegic were administered the Q-Sort which was developed for this study. 2. Only two rehabilitation units in the Greater Vancouver area were used. 31 32 3. Patients selected were involved in rehabilitation programs. III. DEFINITIONS Q-Sort The Q-Sort can be considered as essentially an inventory consisting of a number (56 statements in this study) of descriptive statements. Disability This term is used to classify any condition where permanent physical and/or psychological impairment results in functional loss. Decreased strength, reduced coordination and endurance, loss of self-confidence, intellectual capacity, motivation, are a l l indications 1 of the severity of the impairment. Adaptation This refers to the process or utilization of coping behaviors by an individual when faced with new, 2 different or threatening stimuli. 1 S. Z. Magi, Disability and Rehabilitation, The Cleveland Press, 1970. 2 F. Bower, Key Concepts for the Study and  Practice .of Nursing. The C. V. Mosby Co., 1972. p. 21. 33 Stages of Adaptation 1. First stage; denial and disbelief. This represents a threat to self when a disability-occurs. He resorts to denial of the threatening condition to protect himself against the impact of i t . 2. Second stage; developing awareness. As the disabled person moves further along in adaptation and he becomes less able to maintain the denial he begins to become more aware of what has happened to him and he wants to know more about his disability. 3 . Third stage; reorganization. The dis-abled person has known more about himself. The individual develops a modified self-image and a renewed sense of worth. 4. Fourth stage; adaptation to a di s a b i l i t y . Evidence of successful adaptation is that a patient has the a b i l i t y to live comfortably, or resignedly with himself as a person who has a specific condition. CHAPTER V DEVELOPMENT OF THE EVALUATION Q-SORT The evaluation Q-Sort consists of 56 statements (see Appendix A) which were collected from patients' own descriptions of their d i s a b i l i t i e s . The 56 statements were divided into four categories to des-cribe the process of adaptation to a di s a b i l i t y . I. THE DEVELOPMENT OF THE Q-SORT Item Selection Statements were obtained from disabled patients. The author interviewed approximately one hundred patients after they had been injured and recorded their statements of feelings. (Recently injured and rehabilitated patients were included) Other sources of statements were obtained from medical staffs' ob-servations. (Nurses, physiotherapists and vocational counsellors) Category Selection 1 Following Crate's adaptation model a l l state-ments were distributed into four categories; (1) denial and anger; (2) developing awareness of disa b i l i t y or 1 M. Crate, "Nursing Function in Adaptation to Chronic Illness", American Journal of Nursing, Oct. 1965-p. 72 34 35 seeking information; (3) reorganization, and (4) adaptation. Denial as an adaptive maneuver is used to reduce anxiety generated by crippling, disabling or 2 socially unacceptable diseases. Denial i s a defense mechanism operating outside of and beyond conscious awareness in the endeavor to resolve emotional conflict and to allay; anxiety. It achieves its purpose by disowning, rejecting :dr ignoring one or more of the elements of the conflict. Patients in this stage manifest the signs of f£ar, guilt, inferiority, sensitiveness, threat, anger, depression and frustration, etc. The-the stage of developing awareness there occurs a renewed encounter with reality and, consequently, 3 a renewed period of stress. The person no longer finds i t possible to escape reality, whether he likes i t or not. He experiences the loss of his valued self-image. Reality makes him unable to fight this change. He has to know more about himself and his disability and try to adjust to i t . He starts to 2 M. M. Kiening, "Denial of Illness" in Behavioral  Concepts of Nursing Intervention, edited by C. E. Carlson, J. B. Lippincott Company, Toronto, 1970. p. 9 . 3 Stephen L. Fink, Crisis and Motivation: A Theoretical Model, p. 394. 36 seek information concerning himself and what i s happening to him. In the stage of reorganization, the disabled person has gathered enough information about himself, his capability, in spite of his disability and his limitations imposed by the disability. The individual develops a modified self-image and renewed sense of 4 worth. He can say to himself, "Maybe I am not, nor ever w i l l be quite the same person I was before, but basically I am s t i l l me and there are ways in which I can be of value to the world around me". He begins to "try himself out", explore resources within himself, and test them against the limitations and expectations of reality. When the stage of adaptation is reached, new satisfactions are experienced and with this, a gradual lessening of anxiety and depression. The person is very careful about his physical body in ways which w i l l prevent future complications. Thinking and planning are organized in terms of present resources and future potentials. The outlook is generally toward the future. He i s planning to go back into the community. 4 IBID, p. 595. 37 Test for Validity of Statements Six second-year graduate students in nursing at the University of British Columbia served as a panel of judges to determine the relevance and im-portance of the 115 statements which were submitted to them. The judges examined each statement to determine i t s relationship to any one of the four stages of adaptation. Finally, 56 items were selected as Q-Sort statements. Test for Validity of Category Four graduate students in nursing at the University of British Columbia were asked to rearrange the statements into the four categories in order to validate the arrangement of statements into four categories which had been done by the researcher. In addition, five nurses (one supervisor and four head nurses) ten physiotherapists, two vocational counsellors and two social workers were asked to sort the 56 items into four piles which represented the four stages of adaptation. Finally, a l l 56 items were seledted into four categories by the twenty health professionals. (Table 1) 3a TABLE I The D i s t r i b u t i o n of Sex and P r o f e s s i o n s of Judges Nurses Physio- V o c a t i o n a l S o c i a l Workers T h e r a p i s t s C o u n s e l l o r s Male 2 Female .6 : 10 2 As shown from the r e s u l t s of agreement of the statements i n each category (see Appendix 6.) t h e r e i s h i g h e r agreement i n C a t e g o r i e s I and IV than on Categories I I and I I I . Perhaps t h i s i s because i t i s easy to d i s t i n g u i s h the two extreme stages, while on Category I I and I I I the boundaries of each stage may o v e r l a p . Therefore from the statements i n the second and t h i r d stages i t was e s p e c i a l l y hard t o make a judgment. The statements, 17, 25, 26 and 27 i n Category I I , a c c o r d i n g t o the judges' o p i n i o n , may need some adjustments. They were l e f t as t h e y were f o r th i s study. 39 II. SETTING The sample on which the evaluation Q-Sort was tested was drawn from a population of patients from one acute hospital with a rehabilitation ward and another hospital designed as a rehabilitation center, both in the Vancouver area. Only patients who were paraplegics or quadriplegics were selected. The f i r s t group consisted of 10 patients who were in a rehabilitation ward of an acute hospital. They were past the acute stage of their d i s a b i l i t y and were waiting for transfer to a rehabilitation institution to start a regular rehabilitation program. Another group was made up of ten inpatients in a rehab-i l i t a t i o n center. The value of the Q-Sort in this study was determined 'by comparing the sorting done by the patients in an acute hospital and the sorting done by the patients in a rehabilitation center. III. TESTING Testing the Q-Sort can be described as follows: A sample of 56 statements on 56 cards were well shuffled and the operator sorted the cards into 9 piles on a quasi-normal frequency basis, as in the following table: 40 TABLE II Q-SORT: SCORES AND FREQUENCY Most Significant Least Significant Score 9 8 7 6 5 4 3 2 1 Frequency 2 4 6 10 12 .10 6 4 2 In practice, attention is f i r s t given to a l l 56 items by the operator, who gained a "general impression" about them as a whole and probably reached something akin to "choice equilibrium" in relation to them. The next step required him to place items highly "significant" at the higher score end, items least "significant" at the lower score end, and items judged to be doubtful, neutral, or the like at the center of the distribution. The results of the test were then transferred to a raw data tabulation sheet (Appendix B) and scored. 41 IV. METHOD OF SCORING Scores of p a t i e n t s were determined by using a four point system: F i r s t stage — 1 Second stage — 2 Third stage — 3 Fourth stage — 4 To get a p a t i e n t ' s score the f i r s t three p i l e s of items which represented the most s i g n i f i c a n t items t o him were c a l c u l a t e d , then the l a s t three p i l e s , which i n d i c a t e d the l e a s t s i g n i f i c a n t items. In determining the score, the higher the score of the most s i g n i f i c a n t items, and the lower the score of the l e a s t s i g n i f i c a n t items, the higher the l e v e l of adaptation. V. PRETESTING A t e s t - r e t e s t method was used f o r p r e t e s t i n g to t e s t the r e l i a b i l i t y of the t o o l . Two p a t i e n t s were se l e c t e d from a r e h a b i l i t a t i o n s e t t i n g to be administered the development Q-Sort. The f i r s t t e s t of one p a t i e n t (Case 1) revealed the most s i g n i f i c a n t items' score to be 2.75• In the r e t e s t (done the f o l l o w i n g day) i t was 2 . 6 0 . The 42 scores of least significant items in the f i r s t test was 2 . $ 0 . In the retest i t was 2 .50 . A correlation test for a l l items had been done for the two tests. The coefficient of correlation (r) was 0.456. In the f i r s t test of the second patient (case 2) the most significant items' score was 3.25; the least significant was 1.74. The result of a retest was 3 .00 in most significant items and l.$0 in least significant items. The correlation test for a l l items had been done for the two tests. The coefficient of correlation (r) was 0.412. This shows a significant positive correlation on retesting after 24 hours, and suggests that scores are relatively stable for short-term retesting. CHAPTER VI TESTING OF THE PATIENTS Two groups of- tenrf patients were selected in two rehabilitation areas in Vancouver to try out the developed Q-Sort. The results of the study are presented in two sections. The f i r s t part i s the analysis of items of the tool; the second part shows the findings from the testing of the patients. Of the twenty patients involved in this study, ten patients were in a rehabilitation ward of an acute general hospital (group A). They were waiting to be transferred to a rehabilitation setting. Five of the ten patients were paraplegics and five were quadriplegics; four of them were female. Their ages ranged from four-teen to twenty-four. The mean of the age was 19.7. Injury had occurred to these patients from one to seven months previously. A l l the ten patients were involved in some rehabilitation activities while waiting f or transfer. Another ten patients were in a rehabilitation Center (Group B). They were receiving a f u l l rehabili-tation program which concentrated on physiotherapy, 43 44 occupational therapy, gymnastic exercises, vocational counselling, etc. They were a l l male, aged from nine-teen to forty-two years. The mean of the age was 2$.4. Half of the patients were paraplegics and half were quadriplegics. The duration of d i s a b i l i t y of this group was from three months toibhir^yssix months. (See Table III) I. ANALYSIS OF ITEMS Most Significant and Least Significant Items The twelve most significant and the twelve least significant items as identified by the total samples were listed in Tables VI, VII, VIII and IX of each group. Because one of the chief advantages of the Q-Sort technique i s that i t forces individuals to make discriminations, the items placed in the extreme 1 piles represent considered evaluations. 1 Edwin W. Johnson, "The Importance Assigned te Counselling Function® by Students in a Public Adult Night School", The University of British Columbia, 1970. Unpublished Thesis. TABLE I I I DISTRIBUTION OF PATIENTS BY AGE, SEX, DIAGNOSIS, DURATION OF DISABILITY, DEGREE OF INDEPENDENCE, MOTIVATION AND SCORES S u b j e c t Age Sex D i a g n o s i s P a r a . , Quad. D u r a t i o n of D i s a b i l i t y Degree of Independc. M o t i v a t i o n o r . Fu t u r e P l a n s S c o r e s High Low A l 21 M Q 4 mo' s. 50$ no 2 . 7 5 2 . 2 5 U2 21 M Q 3 tt 17% yes 2 . 7 5 2.00 A3 16 F P 4 it 83$ yes 3.00 2 . 3 3 A4 14 F P 4 tt 83$ no 3 .00 2 . 1 6 A§. 24 M Q 7 tt 66$ yes 2 . 5 0 2 . 3 3 A6 17 F P 1 tt 66$ no 3.00 2 . 2 5 A7 19 M Q 4 J i l 17$ no 2 . 6 6 2 . 7 5 A3 20 M P 3 tt 83$ no 2 . 7 5 2 . 5 0 A9 19 M Q 7 tt 50$ no 2 . 8 5 1 . 7 5 AlO 23 F P 2 tt 83$ yes 2 . 3 3 2 . 2 5 B l 22 M P 1 0 tt 83$ no 3.00 2 . 1 6 B2 24 M P 24 tt 100$ yes 3 . 1 6 1 . 6 6 B3 29 M Q 36 it 83$ no 3 . 4 1 1 . 8 3 B4 42 M P 4 tt 83$ yes 3 . 6 6 1 . 5 0 B5 20 M Q 18 tt 50$ no 3 . 2 5 1 . 9 1 B6 34 M Q 36 tt 66$ yes 3.16 1.50 B7 20 M Q 5.' ; ttr 33$ no 2 . 8 3 2 . 0 8 B8 19 M P 24 tt 83$ no 2 . 5 8 1 . 5 8 B9 24 M P 6 it 66$ no 2 . 3 3 2 . 3 3 BIO 20 M Q 8 tt 3 3 $ no 2 . 8 3 1 . 7 5 46 The Twelve Most Significant Items Seven of the twelve (58%) most important items of Group B patients were in the adaptation stage. None of the items were in the denial stage. This meant that patients in this group showed a high degree of adaptation to their d i s a b i l i t y . On the other hand, the Group A patients only had two of the twelve {17%) most important items in the adaptation stage, but had four of the twelve (33%) of most important items in the denial stage, which indicated they showed a l©w degree of adaptation to their d i s a b i l i t y . The follow-ing Table IV illustrates the comparisons between Group A and Group B patients. TABLE IV The Most Significant Items Between Group A and Group B Group A No. % Group B No. % 1st Stage 4 33% 0 2nd n 3 25% 2 17% 3rd tl 3 25% 3 25% 4th M 2 17% 7 58% 47 The Twelve Least Significant Items For the Group B patients eight of the twelve {83%)- least important items were in the denial stage, none in the adaptation stage, while the Group A patients had f i v e of the twelve (41.5$) least important items in the denial stage but also had 17$ in the adaptation stage and 41.5$ in the reorganization stage. Results indicated that these patients were at a low level of adaptation. The following table (V); i s a comparison of the two groups. TABLE V The Least Significant Items Between Group A and Group B Items in Stages of Adaptation No Group A $ Group B No. $ 1st Stage 5 41.5$ 8 66 $ 2nd " 0 3 2.5$ 3rd » 5 41 .5$ 1 8 .3$ 4th " 2 19/' $ 0 Interestingly enough, l i s t i n g some of the most important items shows the different feelings and needs of a patient in the two different settings. 48 The Group A patients (in a rehabilitation ward of an acute hospital setting), whose top rank of the twelve most significant items (Table VI) was "I believe there is a miracle waiting for me i f I work hard enough on myself", and the next few whose rank was "I want to hear more about how to rehabilitate myself", "I feel lonely, I was pretty scared, though i t would help i f I could find someone to discuss my problems", "I want to be l e f t alone" or "I am afraid of sex. I have lots of questions about i t " . These statements a l l indicate that most of them are either in the denial stage or seeking for information stage. Of the Group B patients in a rehabilitation setting, the top ranking statements of the most impor-tant items were (Table VIII) "I am no different from anyone else", "In spite of my disability I can s t i l l be a successful person", "I feel that even i f people can't walk they can s t i l l be a successful person", "My l i f e is s t i l l busy and useful" or "You can't disable ambition, and you w i l l have a lot more a b i l i t y than you have disability i f you really try". A l l statements reflected a positive attitude and better adjustment. TABLE VI THE TWELVE MOST SIGNIFICANT ITEMS OF GROUP A PATIENTS IN RANK ORDER Rank of No. of Items Items Items Ca t e g o r i e s 2 3 4 6 7 8 9 10 11 12 14 I b e l i e v e t h e r e i s a m i r a c l e w a i t i n g f o r me i f I work hard enough on myself. 3 1 I get along f i n e with other p a t i e n t s . 16 I want t o hear more about how t o r e h a b i l i t a t e myself. 44 I f e e l t h a t even i f people can't walk they can s t i l l be u s e f u l to s o c i e t y and they can have good jobs. 23 I f e e l l o n e l y . I was p r e t t y scared, though i t would he l p i f I could f i n d someone t o d i s c u s s my problems. 7 I want t o be l e f t a l o n e . 24 I am a f r a i d of sex. I have l o t s o f questions about i t . 35 I f e e l l u c k y t h a t I j u s t have some p h y s i c a l d i s -a b i l i t y due t o my i n j u r y . 43 I am a r e r i p p l e d man but I don't f e e l any shame or i n f e r i o r i t y . 52 In some ways, I t h i n k my d i s a b i l i t y has brought out the best that was i n me. 34 A f t e r I was i n j u r e d I d i d n ' t want v i s i t s from any of my f r i e n d s . I don't wish them to come to see me e i t h e r . I don't belong to that group any more. 5 I don't t h i n k the doctor r e a l l y understands me. T h e r e f o r e I don't f e e l f r e e to d i s c u s s my problems with him. D e n i a l R e o r g a n i z a t i o n Awareness Adaptation Awareness D e n i a l Awareness Reorgani z a t i on Adaptation Adaptati on D e n i a l D e n i a l TABLE VII THE TWELVE LEAST SIGNIFICANT ITEMS FOR GROUP A PATIENTS IN RANK ORDER Rank of No. of Items Categories Items Items 1 8 1 feel shame about my disability. Denial 2 50 In spite of my d i s a b i l i t y I can s t i l l be a success- Adaptation f u l person. 3 40 I make strong demands on myself. Reorganization 4 34 I would like to stay with my family and find a job Reorganization which suits me. 5 10 I am less good, less worthy, because of my dis- Denial a b i l i t y . It i s something to be hidden, and something to be made up for. 6 1 I am finished; I've no hope, no future. I am no Denial one. Nothing really seems to be me. 7 40 I express my emotions freely. Adaptation 8 42 I want to be a super-quadriplegic. Reorganization 9 38 I don't trust my emotions. Reorganization 10 37 I try to overcome my disability. Reorganization 11 12 It takes so long. I intend to change to an Denial alcoholic. 12 7 1 want to be l e f t alone. Denial O TABLE V I I I THE TWELVE MOST SIGNIFICANT ITEMS IN GROUP B PATIENTS IN RANK ORDER Rank of No. of Items l i t e m s Items Categories 1 2 4 5 6 7 s 9 10 11 12 56 I am no d i f f e r e n t from anyone e l s e . 50 In s p i t e of my d i s a b i l i t y I can s t i l l be a success-f u l person. 44 I f e e l that even i f people can't walk they can s t i l l be u s e f u l to s o c i e t y and they can have good jobs. 48 I express my emotions f r e e l y . 51 My l i f e i s s t i l l busy and u s e f u l . 47 I am l i k e d by most people who know me; I don't .'feel any d i f f e r e n c e between the time before I was i n j u r e d and since I have been i n j u r e d . 46 You can't d i s a b l e ambition, and you w i l l have a l o t more a b i l i t y than you have d i s a b i l i t y i f you r e a l l y t r y . 38 I don't t r u s t my emotions. 35 I f e e l l u c k y t h a t I j u s t have some p h y s i c a l d i s a b i l i t y due to my i n j u r y . 30 At times I get so t e r r i b l y depressed that I j u s t don't want to attempt anything. 18 I am i n a l o t of t r o u b l e : I want to t a l k to someone. 16 I want t o hear more about how to r e h a b i l i t a t e myself. Adaptation Adaptation Adaptation Adaptation Adaptation Adaptation Adaptation Reorganization Reorganization Reorganization Awareness Awareness -TABLE IX THE TWELVE LEAST SIGNIFICANT ITEMS OF GROUP B PATIENTS IN RANK ORDER Rank of Items No. of Items Items Categories 1 1 I am f i n i s h e d ; I've no hope, no f u t u r e . I am no one. Nothing r e a l l y seems to be me. Denial 2 4 I want to give up t r y i n g t o cope with the world. I do not l i k e to be shown how t o do t h i n g s . Denial 3 I f e e l shame about my d i s a b i l i t y . Denial 4 6 I don't l i k e the way that medical s t a f f s t r e a t me, a s . i f I were a c h i l d . I t h i n k I can manage every-t h i n g very w e l l myself. Denial 5 7 I want t o be l e f t alone. Denial 6 10 I am l e s s good, l e s s worthy, because of my d i s a b i l -i t y . I t i s something t o be hidden, and something to be made up f o r . Denial 7 3 A f t e r I was i n j u r e d I didn't want v i s i t s from any of my f r i e n d s . I don't wish them to come to see me e i t h e r . I don't belong to t h a t group any more. Denial 20 I don't know why I get angry, but I sure do. Awareness 9 26 Nobody t e l l s me what to do. Awareness 10 23 What am I going to do now that I have l o s t my legs? Awareness 11 31 I get along f i n e w i t h other p a t i e n t s . Reorganization 12 12 I t takes so long, I intend t o change t o an a l c o h o l i c . Denial 53 I I . ANALYSIS OF FINDING FROM TESTING OF PATIENTS A n a l y s i s here i s based on s e l e c t e d v a r i a b l e s : adaptation and r e h a b i l i t a t i o n s e t t i n g , age, sex, i n j u r y and d u r a t i o n , f u t u r e plans, independency. Adaptation and R e h a b i l i t a t i o n S e t t i n g The r e s u l t s from t h i s study i n d i c a t e d t h a t the p a t i e n t s i n a r e h a b i l i t a t i o n s e t t i n g (Group B) compared wit h the p a t i e n t s i n a r e h a b i l i t a t i o n ward of an acute h o s p i t a l (Group A) scored higher i n adaptation to t h e i r d i s a b i l i t y . (Table X) The mean of most s i g n i f i c a n t items of Group B p a t i e n t s was 3 .07 while Group A p a t i e n t s showed a mean of 2 .76. (Na=10) On the other hand, the l e a s t s i g n i f i c a n t items o f the Group B p a t i e n t s was 1.77, while Group A was 2 .27 . The higher score of most s i g n i f i c a n t items and the lower score of l e a s t s i g n i f i c a n t items of a person means that he has a higher l e v e l of adaptation t o h i s d i s a b i l i t y . Since the chosen l e v e l of s i g n i f i c a n c e was . 0 5 , the t value of p a t i e n t s ' most s i g n i f i c a n t items was 2.512, which showed over 0.025 s i g n i f i c a n t l e v e l . The t value of p a t i e n t s ' l e a s t s i g n i f i c a n t items was 3.037 which exceeded .005 l e v e l . 5 4 TABLE X The Scores of Adaptation t o D i s a b i l i t y Between Group A and B Subject Scores of Group A Scores of Group B High Low High Low 1 2 . 7 5 2 . 2 5 3 . 0 0 2 . 1 6 2 2 . 7 5 2 . 0 0 3 . 1 6 1 . 6 6 3 3 . 0 0 2 . 3 3 3 . 4 1 1 . 8 3 4 3 . 0 0 2 . 1 6 3 . 6 6 1 . 5 0 5 2 . 5 8 2 . 3 3 3 . 2 5 1 . 9 1 6 3 . 0 0 2 . 2 5 , 3 . 1 6 1 . 5 0 7 2 . 6 6 2 . 7 5 2 . 8 3 2 . 0 8 8 2 . 7 5 2 . 5 0 2 . 5 8 1 . 5 3 9 2 . 8 3 1 . 7 5 2 . 8 3 2 . 3 3 1 0 2 . 3 3 2 . 2 5 2 . 8 3 1 . 7 5 High Scores of Group A mean: 2 . 7 6 5 S: 0 . 2 1 2 N a : . = 1 0 Low Scores of Group A mean: 2.257 s: 0.268 N a =10 High Scores of Group B mean: 3•071 S: 0.321 N t r=10 f Value : 2.512 df =18 P < .025 Low Scores of Group B Mean: 1.830 s: 0.287 N D =10 t Value = 3.437 df =18 p <C .005 55 Age. Sex. Diagnosis and Duration of Disability There were no significant differences between ages and sex in adaptation to disability. In Group A patients the mean of age was 19.7. Most were under the age of twenty. In Group B patients the ages ranged from 19-42. The mean of age was 25.4. (Table XI) The coefficient of correlation between combined age and adaptation scores for the two groups of patients was 0.353. This was not significant. Adaptation scores were compared between paraplegics and quadriplegics. In Group A paraplegics had higher scores than quadriplegics: (Table XII; 2.81 compared to 2.71) In Group B quadriplegics (3.13) scored higher than paraplegics. (3.04) If we examine the data carefully we find there were two paraplegic patients in this group with lower scores. Otherwise, paraplegic patients' scores seemed slightly higher than those of the quadriplegics'. A comparison of adaptation scores of paraplegics and quadriplegics showed no significant difference .(t=0.l62, p;>.05) The duration of dis a b i l i t y of Group A patients ranged from one to nine months in length. The length of disab i l i t y of Group B patients was from three to thirty-six months. The correlation coefficient between adaptation scores and duration of dis a b i l i t y was .384. (not significant) TABLE XI SCORES OF PATIENTS BY AGE Age 14 16 17 19 20 21 22 23 24 29 34 42 % 10% 10% 10% 20% 10% 20% 10% 10% Group A Hi 3 .00 3 . 0 0 3 .00 2.74 2.75 2.75 2.33 2.38 n tt Lo 3.33 2 . 1 6 2.25 2.25 2.50 2.12 2.25 2.33 % 10% 30% 10% 20% 10% 10% 10% Group B Hi 2.58 2.97 3.00 2.99 3.41 3.16 3.16 it »?• Lo 1.58 1.91 2.16 1.99 1.83 1.50 1.50 Mean Age o f Group A, 19.7 Mean Age o f Group B, 25.4 A = 0.353 p>- .05 57 TABLEAU I Scores of Patients by Diagnosis Paraplegic % Quadriplegic $ Group A Hi 2.31 50$ 2.71 50$ Lo 2.32 2.25 Group B Hi 3.05 50$ 3.14 50$ Lo 1.85 1.65 t = 0.162 P .05 58 TABLE X I I I Duration of D i s a b i l i t y 1-6 7-12 13-18 19-24 25-30 31-36 Over 36 M. M. M. M. M. M. M. Group A Hi 2.76 2.83 Lo 2.31 1.75 % 10% 10% Group B Hi 3.10 2.91 3.25 2.87 3.16 3.41 Lo 1.97 1.95 1.91 1.62 1.50 1.83 % 30% 20% 10% 20% 10% 10% Ji* = O.384 p>.05 o 59 How long does i t take from the time a p a t i e n t has been i n j u r e d to s t a r t h i s r e h a b i l i t a t i o n program? I t depends on the i n d i v i d u a l medical s i t u a t i o n and the degree of i n j u r y . In Group A, most of the p a t i e n t s took one to fo u r months a f t e r they had been i n j u r e d . In Group B, 30% of these p a t i e n t s took one to three months, and 30% of them took from f o u r t o s i x months. 1Q%'. took seven to nine months, 28% took ten to twelve months, 10% took nineteen to twenty-one months to s t a r t r e h a b i l i t a t i o n programs a f t e r they had been i n j u r e d . There seemed t o be no r e l a t i o n s h i p between the length of time taken to s t a r t a r e h a b i l i t a t i o n program a f t e r the p a t i e n t was i n j u r e d and h i s adaptation to a d i s a b i l i t y . (Table XIV) The ,it value was 0.115. This was not s i g n i f i c a n t at 0105 l e v e l . 60 TABLE 'XIV Duration From I n j u r y to S t a r t of R e h a b i l i t a t i o n Program 1-3 M. 4^6 M. 7-9 M. 10-12 13-15 16-18 M. M. M. 19-21 M. Group A Hi Lo 2.77 2.17 2.75 2.47 % 70% 30% Group A Hi 3.11 3.13 3.41 2.70 3.16 Lo 1.73 1.91 1 .83 1.95 1.50 % 30% 30% 10% 20% 10% si= 0.115 P>~.05 61 Scores of Mo t i v a t i o n and Future Plans From the study of two groups of p a t i e n t s i t was shown that p a t i e n t s who had motivation or f u t u r e planning toward r e h a b i l i t a t i o n scored higher on scores of adaptation to d i s a b i l i t y . When p a t i e n t s were asked whether they had motivation toward t h e i r r e h a b i l i t a t i o n or not, 60% of Group A p a t i e n t s s a i d "yes". (e.g., they were anxious to go back to school or t o t r y t o be independent) T h e i r mean was 2.88. The sample (20%) who had f u t u r e plans had higher scores r e f l e c t i n g a higher l e v e l of adaptation. 40% of the sample had no motivation toward t h e i r r e h a b i l -i t a t i o n ; t h e i r mean was 2.69. The 80% wit h no f u t u r e plans had a mean of 2 .71 . (Table XV) Of Group B p a t i e n t s , on the other hand, 70% had motivation toward t h e i r r e h a b i l i t a t i o n . T h e i r mean was 3 . 4 . 40% had f u t u r e plans. Their mean was 3.245* 30% of the p a t i e n t s s a i d "no" on the motivation q u e s t i o n n a i r e . The mean of t h i s group was 2 . 7 5 . (Table XVI) 60% had no future plans. T h e i r mean was 2 .955. Adaptation scores were s i g n i f i c a n t l y higher on those p a t i e n t s who were motivated toward t h e i r r e h a b i l i t a -t i o n . (t=3.411 , p< . 0 0 5 ) and i n those who had f u t u r e plans. (t=2.1009, p< . 0 2 5 ) (See Tables XV and XVI) 62 Comparison was a l s o made between p a t i e n t s regarding whether they r e c e i v e d help from the f a m i l y or not. Those who stated they had help from f a m i l i e s i n Group B had a high l e v e l of adaptation score. 70% of those who s t a t e d they had l i t t l e help had low scores. (Table XVII) The t-value was 2 . 6 9 3 . I t was s i g n i f i c a n t at 0.025 l e v e l . 63. TABLE XV Future Plans and Scores on Adaptation ...Scale"' Yes No % Score High Low % Score High Low Group A ;J20% 3. 2.25 80% 2.71 2.23 » B 40% 3.245 1.705 60% 2.955 1.913 t =§ 2.1009 p <- .025 64 TABLE XVI M o t i v a t i o n and Scores on Adaptation Scale Yes No Group A Hi 60% 2.88 40% 2.69 ti A Lo 2.18 2.31 Group B Hi 70% 3.21 30% 2.75 ti B Lo 1.76 1.99 + t - 3.411 p .005 65 TABLE XVII Scores of Help From P a t i e n t s ' Family During R e h a b i l i t a t i o n Period L i t t l e $ F a i r Amount $ Very Much $ Group A Hi 2.60 80$ 2 .75 20$ None " A Lo 2.30 2.00 • " B H i 2.93 70$ 3.28 20$ 3.66 10$ " B Lo 1.90 1 .74 1 .55 t = 2.683 p < .025 66 Independency In t h i s study the c r i t e r i a . used t o judge whether a p a t i e n t was p h y s i c a l l y independent were as f o l l o w s : Does a p a t i e n t : (1) dress himself (2) d r i v e a c a r (3) t r a n s f e r himself (4) feed himself (5) w r i t e (6) manage h i s bowels I f a p a t i e n t gave a p o s i t i v e answer t o each item, i t meant he had 16.6% degrees of independence, and i f he could manage a l l s i x items then he had 100$ degree o f independence. (This r e f e r s to the above s i x items only) There was no evidence shown i n Group A p a t i e n t s regarding the r e l a t i o n s h i p between dependency and adapt-a t i o n to d i s a b i l i t y . The reason may be that i n an acute s e t t i n g the p a t i e n t has assumed a s i c k r o l e , and t h e r e f o r e 3 was dependent on the n u r s i n g s t a f f . In a r e h a b i l i t a t i o n center p a t i e n t s are expected t o move toward independence. In Group B i t was shown that p a t i e n t s had higher scores of adaptation to a d i s a b i l i t y , but there was one exception to t h i s group. The p a t i e n t w i t h 33 .6$ degrees of independency had a high score of adaptation 3 G. A. Best, "The M i n o r i t y Status of the P h y s i c a l l y Disabled", Cerebral Palsy J o u r n a l 1967, 3 8 . pp. 3 - 4 . 67 4 to his d i s a b i l i t y . (Table XVIII) B e l l argues that adaptation to a d i s a b i l i t y may not necessarily be r e f l e c t e d in a t o t a l l y positive behavioral pattern. He points out that "passive adaptation" indicates that the i n d i v i d u a l has i d e n t i f i e d completely with a disabled population and i s not motivated to be active. Such an i n d i v i d u a l , according to B e l l , would tend to be dependent and l e t others do f o r him what he might do f o r himself. TABLE XVIII Scores and Degrees of Independency Scores of Degrees of Independency Degrees of Independence 16.6% 33.6% 50.2% 67.2% 83.8% 100% Group A Hi 2 .70 2.79 2.79 2.79 " A Lo 2.37 2.00 2.29 2.31 Group B Hi 2.83 3.25 2.99 3.16 3.16 " B Lo 1.91 1.91 1.91 1.76 1.66 ^ = 0.283 p > .05 4 A. Howard B e l l , "Measure f o r Adjustment of the Physically Disabled" Psychological Reports. 1967, 21 p. 776 CHAPTER V I I SUMMARY, CONCLUSION AND RECOMMENDATION A t o o l was developed f o r h e a l t h p r o f e s s i o n a l s , e s p e c i a l l y f o r nurses to use f o r measuring adaptation of s p i n a l cord i n j u r y p a t i e n t s t o d i s a b i l i t y . The t o o l developed by using a Q-Sort technique c o n s i s t s of f i f t y - s i x statements. These statements were c o l l e c t e d from s p i n a l cord i n j u r y p a t i e n t s and were d i s t r i b u t e d i n t o f o u r categories by f o l l o w i n g Crate's adaptation model. The f i f t y - s i x statements were v a l i d a t e d by twenty h e a l t h p r o f e s s i o n a l s and t e s t e d on twenty s p i n a l cord i n j u r y p a t i e n t s . Relevant v a r i a b l e s were s e l e c t e d f o r a n a l y s i s . The r e s u l t s of t h i s study showed that the p a t i e n t s i n a r e h a b i l i t a t i o n ward i n an acute h o s p i t a l s e t t i n g who haive not been d i s a b l e d f o r more than a few months might s t i l l be i d e n t i f y i n g w i t h the p h y s i c a l l y normal population and r e j e c t i n g t h e i r own d i s a b i l i t y . On the other hand, the r e h a b i l i t a t i o n group, most of whom have been d i s a b l e d f o r s i x t o eight months or more, have had the opportunity to face the r e a l i t y of the s i t u a t i o n . They have begun to i d e n t i f y w i t h the p h y s i c a l l y d i s a b l e d p o p u l a t i o n , and 68 69 have begun to adapt t o t h e i r s i t u a t i o n and accept i t f o r what i t i s , r e c o g n i z i n g t o a c e r t a i n extent t h a t they are i n some ways d i f f e r e n t from p h y s i c a l l y normal persons, but not completely so. Another f i n d i n g i n t h i s study was t h a t p a t i e n t s who had a goal or f u t u r e plans were w e l l motivated and tended to have a higher l e v e l of adaptation than those who were without goals or plans f o r the f u t u r e . The f i n d i n g a l s o showed that p a t i e n t s w i t h s i g n i f i c a n t persons might reach adaptation e a r l i e r than p a t i e n t s who d i d not have any s i g n i f i c a n t person. The impact of s i g n i f i c a n t persons on a p a t i e n t ' s adaptation t o d i s a b i l i t y i s an area f o r f u r t h e r study. The t o o l which was developed i n t h i s study t o measure the stage of adaptation t o d i s a b i l i t y was p r i m a r i l y designed f o r the s p i n a l i n j u r y p a t i e n t . I t might be used t o measure the adaptation of other c h r o n i c a l l y d i s a b l e d p a t i e n t s w i t h c e r t a i n changes i n the Q-Sort statements, but a new v a l i d i t y t e s t would have to be performed. The e v a l u a t i o n Q-Sort i s not intended, i n i t s present form, to be used as a t o o l t o assess the p a t i e n t ' s progress i n h i s t o t a l r e h a b i l i t a t i o n . I t i s only intended as an instrument t o a s s i s t i n e v a l u a t i n g adaptation t o d i s a b i l i t y of the s p i n a l cord i n j u r y p a t i e n t s . 70 More extensive v a l i d i t y t e s t i n g i s r e q u i r e d to demonstrate the stages i n t o which the p a t i e n t has pro-gressed so that the nu r s i n g i n t e r v e n t i o n s appropriate to each stage can be i d e n t i f i e d . Therefore i t i s recommended that f u r t h e r study be done using the t o o l to evaluate the adaptation to d i s a b i l i t y of a c o n t r o l group and an experimental group r e c e i v i n g planned n u r s i n g i n t e r v e n t i o n s . Such a study w i l l not only demonstrate the usefulness of the t o o l but w i l l a l s o provide the g u i d e l i n e s f o r determining nursing i n t e r -ventions to a s s i s t the p a t i e n t i n h i s progress toward adaptation to d i s a b i l i t y . BIBLIOGRAPHY 71 BIBLIOGRAPHY A. BOOKS Adl e r , A. Understanding Human Nature. New York Free Press, 1928:' Bandura, A. R. and Walters, R. Socia 1 Learning and  P e r s o n a l i t y Development, New York: H o l t , Rinehart and Winston, 1963. B e l l , A. H. " A t t i t u d e s o f Selected R e h a b i l i t a t i o n Workers and other H o s p i t a l Employees toward the P h y s i c a l l y Disabled", P s y c h o l o g i c a l Report 10, 1962. p. 183. Cronback, Lee J . " C o r r e l a t i o n s between Persons as a Research Tool" i n Psychotherapy. Theory and Research. Edited by Mower, H., New York. Ronald Press, 1953. C u l l , J., and Hardy, R. Understanding D i s a b i l i t y f o r S o c i a l  and R e h a b i l i t a t ion S e r v i c e s , S p r i n g f i e l d , Charles C. Thomas, 1973. Fordyce, W. E. "Behavioral Methods i n R e h a b i l i t a t i o n " i n W. Neff (ed.) R e h a b i l i t a t i o n Psychology , 1971. Gellman, W. "Fundamentals of R e h a b i l i t a t i o n " i n R e h a b i l i t a t i o n P r a c t i c e s w i t h the P h y s i c a l l y Disabled, e d i t e d by J . Garrett and S. Levine, New York Columbia U n i v e r s i t y Press, 1973. Goble, R. E., and N i c h o l s , P. J . R., "Re^abj.^ Severely Disabled", I-Evaluation of a 'Disabled  L i v i n g U n i t , Butterworths, London, 1971 Gottschalk, Jonas A. and Auerback, Arthur H. 'Methods o f Research i n Psychotherapy, 1966. Appleton-Century-C r a f t s , New York, ' " Horney, K, The Neurotic P e r s o n a l i t y of Our Time, New York. Norton, 1937. K e l l e y , H. H., Hastorf, A. H., Jones, E. E., T h i b a u l t , J . W. and Usdane, W. "Some Im p l i c a t i o n s o f S o c i a l P s y c h o l o g i c a l Theory f o r Research of the Handicapped. L o f q u i s t , L. H., (ed.) P s y c h o l o g i c a l Research and  R e h a b i l i t a t i o n , Washington, D.,C. American P s y c h o l o g i c a l A s s o c i a t i o n , I960. 72 73 K e r l i n g e r , Fred N. Foundations of Behavioral Research, New York. H o l t , Rinehart and Winston I c , 1964. K e s s l e r , Henry. R e h a b i l i t a t i o n of the P h y s i c a l l y Handicapped. Columbia U n i v e r s i t y Press, New York, 1947. . K e s s l e r , Henry. P r i n c i p l e s and P r a c t i c e s of R e h a b i l i t a t i o n . P h i l a d e l p h i a , Lea and F e b r i g e r , 19o~0. Kiening, M. M. "Denial of I l l n e s s " i n Behavioral Concepts and Nursing I n t e r v e n t i o n . Edited by C. G. Car l s o n , J . B. L i p p i n c o t t Company, Toronto, 1970. 0 . 9. Ma l i t e m , D., and Rusalem ( e d s . ) . V o c a t i o n a l R e h a b i l i t a t i o n  of the Disabled, An Overview. New York, New York U n i v e r s i t y Press, 1969. Maslow, A. H. Motivation and P e r s o n a l i t y (Rev. Ed.) Harper and Row, 1970. McDaniel, J . W. P h y s i c a l D i s a b i l i t y and Human Behavior. Elmsford, New York, Pergamon Press, 1969. N i c h o l s , P. J . R. " R e h a b i l i t a t i o n of the Severely Disabled." Aspects o f R e h a b i l i t a t i o n , National Fund f o r Research Into C r i p p l i n g Disease, London, 1968. Parsons, T. S o c i a l S t r u c t u r e and P e r s o n a l i t y , New York Free Press, 1964. Saad ,' NTagi,. D i s a b i l i t y and R e h a b i l i t a t i o n . L e g a l , C l i n i c a l . and Self-Concepts and Measurement, Ohio State U n i v e r s i t y Press, 1969- >: • Saratoreg, Mi•.eha1e 1 :y.•-.The; Gur<rent Scene i n V o c a t i o n a l R e h a b i l i t a t i o n of the Disabled: An Overview, edited by D. M a l i k i n and H. Rusalem, New York U n i v e r s i t y Press, New York, 1969. --•< Schoenberg, B., Carr, A. C , Peretz., D., Kutscher, A. H. L., (eds.) "Loss and Grief'/, P s y c h o l o g i c a l Management i n Medical P r a c t i c e . New York, Columbia U n i v e r s i t y Press, 1970. Shantz, F. C. "Severe Chronic I l l n e s s " , i n J . F. S t a r r e t t and E. S. Levine (eds.) P s y c h o l o g i c a l P r a c t i c e s  with the P h y s i c a l l y Disabled. Columbia U n i v e r s i t y Press, New York, 1962. 74 Stephenson, W i l l i a m , The Study of Behavior: Q-Technique  and i t s Methodology. Chicago. U n i v e r s i t y of Chicago Press, 1 9 6 1 . T h i b a u l t , W., and K e l l o g , H. H. The S o c i a l Psychology  of Groups. Wiley, New York, 1959 . V i 'right, B. (Ed.) Psychology and R e h a b i l i t a t i on , Washington, D. C. American P s y c h o l o g i c a l A s s o c i a t i o n , 1 9 5 9 . Wright, B. P h y s i c a l D i s a b i l i t y : __A P s y c h o l o g i c a l  Approach, New York, Harper and Row, I 9 6 0 . Zamir, L. J . Expand in g Dimension s i n Rehabil i t a t i o n Charles C. Thomas, Pub., S p r i n g f i e l d , U.S.A., 1967 , -B. PERIODICALS B e l l , A. H. "Measure f o r Adjustment of the P h y s i c a l l y D i s a b l e d " i n Psychologic a l Reports: Southern U n i v e r s i t y P r e s s " 1967 , P. 7 7 3 . B e l l , A. H. "Measure f o r Adjustment of the P h y s i c a l l y D i s a b l e d " i n P s y c h o l o g i c a l Reports: Southern U n i v e r s i t y P ress, 1967 , p. 7 7 6 . " B e l l , A. H. " A t t i t u d e s of S e l e c t e d R e h a b i l i t a t i o n Workers and Other H o s p i t a l Employees toward the P h y s i c a l l y D i s a b l e d " , P s y c h o l o g i c a l Report 10 , 1962 . JJ. 183_ Best, G. A. "The M i n o r i t y Status o f the P h y s i c a l l y D i s a b l e d . " C e r e b r a l P a l s y J o u r n a l . 1967 , 2 8 . pp. 3 - 4 . B u t l e r , Herbert J . "The Role o f the P s y c h i a t r i c Nurse as Perceived by Nurses, Members of the Related D i s c i p l i n e s Within the Mental H o s p i t a l and Nursing Students. Ph: Ed. D i s s e r t a t i o n , Boston U n i v e r s i t y , 1 9 5 9 . Crate, M. "Nursing Function i n Adaptation to Chronic I l l n e s s " . American Journa l of Nursing, Oct. 1965 , p. 72 Cohn, N. "Understanding the Process o f Adjustment of D i s a b i l i t y " , J o u r n a l of R e h a b i l i t a t i o n , 1 9 6 1 , 2 7 . pp. 1 6 - 1 8 . 75 Dembo, T., L e v i t o n , G. L., and Wright, B. H. "Adjustment to M i s f o r t u n e — A Problem of S o c i a l P s y c h o l o g i c a l R e h a b i l i t a t i o n " , A r t i f i c i a l Limbs 3 , 1956, pp. 4-62 Draper, James A. "A Study of P a r t i c i p a n t O b jectives i n a Selected Management I n s t i t u t e " , Ph. D. D i s s e r t a t i o n . U n i v e r s i t y of V/isconsin, 1964. Dunlap, M a r j o r i e S. and Hadley, Betty J . "Quasi Q-Sort Methodology i n S e l f - E v a l u a t i o n of Conference Leadership S k i l l " , Nursing Research 14. pp. 119-125, 1965. Engel, G. L. " G r i e f and G r i e v i n g " , American J o u r n a l of  Nursing, September, 19o4. Fink, L. " C r i s i s and M o t i v a t i o n : A T h e o r e t i c a l Model". Archives o f P h y s i c a l Medic in e and R e h a b i l i t a t i o n . T9677~£3, p. 592. Gerham, D. "An E v a l u a t i o n of A t t i t u d e s Toward P s y c h i a t r i c Nursing Care." Nursing Research. June, 1958. p. 71. K r y s t a l , H. (ed.) Massive Psychic Trauma. New York, I n t e r n a t i o n a l U n i v e r s i t i e s Press, 1968. Ku r t z , R., and H i r t , M. "Body A t t i t u d e and P h y s i c a l H e a l t h " . J o u r n a l o f C l i n i c a l Psychology. 1970, 26. pp 149-151. Liebman, J . , Young, J . P., and Bellmore, M. " A l l o c a t i o n of Nursing Personnel i n an Extended Care F a c i l i t y " . Health S e r v i c e s Research. F a l l , 1973, p. 200. MacAndrew and E l l i o t t : "Varying Images of the P r o f e s s i o n a l Nurse, A Case Study". Nursing Research. Winter, 1959. p. 33. Mattsson, A. and Cross, S. " A d a p t a t i o n a l and Defensive Behavior i n Young Hemophiliacs and t h e i r P a t i e n t s " . American Journa l of P s y c h i a t r y . 1966, 122, pp. 1349-135^: McDaniel, J . V/. "Psychoendocrine Studies of P a t i e n t s w i t h S p i n a l Cord Lesions'.'. J o u r n a l of Abnormal Psychology. 1970, 76. pp. 117-122. •Shontz, F. C , Fink, S. L., and Hollenbeck, C. E., "Chronic P h y s i c a l I l l n e s s as Threat". Archives of P h y s i c a l  Medicine and R e h a b i l i t a t i o n I960, 41 , p. 143. 76 Shontz, F. C , "Reactions to C r i s i s " , V o l t a Review 1965, ' 6 7 , PP. 364-370. S i l l e r , J . " P s y c h o l o g i c a l S i t u a t i o n s of the Disabled w i t h S p i n a l Cord I n j u r i e s " , R e h a b i l i t a t i o n L i t e r a t u r e . 1969, 30 . pp. 290-296. S u l l i v a n , H. S. "A Note on the I m p l i c a t i o n s of P s y c h i a t r y , The Study of I n t e r p e r s o n a l R e l a t i o n s f o r I n v e s t i g a t i o n i n the S o c i a l Sciences". American  Jo u r n a l of Sociology, 1937-42. p. 848. Whiting, Frank, "Q-Sort: A Technique f o r E v a l u a t i n g Perceptions of I n t e r p e r s o n a l Relationships'.'. Nursing Review, October, 1955, p. 7 0 . C. GOVERNMENT PUBLICATIONS Dominion Bureau o f S t a t i s t i c s , Censu s 1961. Ottawa, Canada. Queen's P r i n t e r , 1963. N a t i o n a l Center f o r Health S t a t i s t i c s , U.S. Department of Health, Education and Welfare, 1969. Current  Estimates f o r Health Interview Survey, U.S., 1967. Washington, D.C., U.S. Department of Health, Education and Welfare. N a t i o n a l Health and Welfare and the Dominion Bureau of S t a t i s t i c s , " I l l n e s s and Health i n Canada". Canada Sickness Survey. 1950-51. Ottawa, Canada. Queen's P r i n t e r , I960. D. UNPUBLISHED REPORTS Bower, E l i M i c h a l . "The A p p l i c a t i o n of Q Methodology i n I n v e s t i g a t i n g Changes i n S e l f and I d e a l - S e l f as a Result of Mental Health Workshop". P. Ed. D i s s e r t a t i o n , Stanford U n i v e r s i t y , 1954. Johnson, Edwin W. "The Importance Assigned to C o u n s e l l i n g Functions by Students i n a P u b l i c Adult Night School. The U n i v e r s i t y of B r i t i s h Columbia, 1970. Unpublished Thesis. 77 Neylan, Margaret S. "The Development of an Ev a l u a t i o n Q-Sort: A Study of Nursing I n s t r u c t o r s " . Unpublished Master's Thesis. U n i v e r s i t y o f " B r i t i s h Columbia, 1966"^ APPENDIX 73 APPENDIX A Q-SORT ITEMS ARRANGED BY CATEGORIES 79 Q-SORT ITEMS ARRANGED BY CATEGORIES F i r s t Stage: Denial and Anger 1. I am f i n i s h e d ; I've no hope, no f u t u r e . I am no one. Nothing r e a l l y seems to be me. 2. The doctor t o l d me t h a t I can never walk again but I t h i n k i f I t r y to do my best I might be one of the exceptions. 3. A f t e r I was i n j u r e d I d i d n ' t want v i s i t s from any of my f r i e n d s . I don't w i s h them t o come t o see me e i t h e r . I don't belong t o that group any more. 4. I want t o give up t r y i n g t o cope w i t h the world. I do not l i k e t o be shown how t o do t h i n g s . 5. I don't t h i n k the doctor r e a l l y understands me. Therefore I don't f e e l f r e e to d i s c u s s my problems w i t h him. 6. I don't l i k e the way that medical s t a f f s t r e a t me, as i f I were a c h i l d . I t h i n k I can manage everything very w e l l myself. 7. I want t o be l e f t alone. 8. I f e e l shame about my d i s a b i l i t y . 9. I am fed up w i t h people who g i v e me too much sympathy because of my d i s a b i l i t y . 10. I am l e s s good, l e s s worthy, because of my d i s a b i l i t y . I t i s something t o be hidden, and something t o be made up f o r . 11. For some reason I f e e l uncomfortable around other d i s a b l e d people. 12. I t takes so long, I intend t o change t o an a l c o h o l i c . 13. I don't l i k e people t o p i t y me. I do not want or need any help from anybody. 14. I b e l i e v e there i s a m i r a c l e w a i t i n g f o r me i f I work hard enough on myself. Second Stage: Seeking f o r Information 15. Am I s t i l l a u s e f u l man? How can I work out my f u t u r e ? 80 81 16. I want to hear more about how t o r e h a b i l i t a t e myself. 17. I enjoy p h y s i c a l e x e r c i s e . 18. I am i n a l o t of t r o u b l e . I want t o t a l k t o someone. 19. I want t o know more about my d i s a b i l i t y . 2 0 . I don't know why I get angry, but I sure do. 21 . My husband was drunk, my daughter was c r y i n g at home. What can I do t o help her? 22. I would l i k e to marry my f i a n c e e , but how could I? 23. I f e e l l o n e l y . I was p r e t t y scared, though i t would help i f I could f i n d someone t o d i s c u s s my problems. 24. I am a f r a i d of sex. I have l o t s of questions about i t . 25. I t h i n k that being d i s a b l e d gives me the p r i v i l e g e to ask people to help me. 26. Nobody t e l l s me what to do. 27. I have to p r o t e c t myself w i t h excuses, w i t h r a t i o n a l i z i n g . 28. What am I going t o do now that I have l o s t my legs? Third Stage: Reorganization 2°). I l i k e t o p a r t i c i p a t e i n a l l a c t i v i t i e s t h a t are held i n the h o s p i t a l . 3 0 . At times I get so t e r r i b l y depressed t h a t I j u s t don't want to attempt anything. 31 . I get along f i n e w i t h other p a t i e n t s . 3 2 . I don't l i k e people to help me unless I ask them t o do so. 33• I need help when I can't solve my problems. 34. I would l i k e t o stay w i t h my f a m i l y and f i n d a job which s u i t s me. 3 5 . I f e e l lucky that I j u s t have some p h y s i c a l d i s a b i l i t y due to my i n j u r y . 36. The nurse and the p h y s i o t h e r a p i s t have given me so'much help and support. They made me f e e l much b e t t e r . 82 37. I t r y to overcome my d i s a b i l i t y . 3 8 . I don't t r u s t my emotions. 39. I am very worried about my f a m i l y . 4 0 . I make strong demands on myself. 41. I ' l l buy a home, a car. I am going home. 4 2 . I want t o be a s u p e r - q u a d r i p l e g i c . Fourth Stage: Adaptation 4 3 . I am a c r i p p l e d man but I don't f e e l any shame or i n f e r i o r i t y . 44. I f e e l t h a t even i f people can't walk they can s t i l l be u s e f u l to s o c i e t y and they can have good jobs. 4 5 . I am i n a wheelchair, but when I am at my job I am j u s t as good as anybody except f o r some inconvenience f o r me. 46. You can't d i s a b l e ambition, and you w i l l have a l o t more a b i l i t y than you have d i s a b i l i t y i f you r e a l l y t r y . 47. I am l i k e d by most people who know me; I don't f e e l any d i f f e r e n c e between the time before I was i n j u r e d and since I have been i n j u r e d . 4 8 . I express my emotions f r e e l y . 4 9 . I t h i n k i t i s important t o re s t o r e p h y s i c a l independence i n order t o gain s e l f - r e s p e c t . 50. In s p i t e o f my d i s a b i l i t y I can s t i l l be a s u c c e s s f u l person. 51. My l i f e i s s t i l l busy and u s e f u l . 52. In some ways, I t h i n k my d i s a b i l i t y has brought out the best that was i n me. 53. Making important d e c i s i o n s i s easy f o r me t o do. 54. I have never f e l t that my d i s a b i l i t y was a problem. 55. As a r u l e , I f i n d i t d i f f i c u l t t o refuse an i n v i t a t i o n . 56. I am no d i f f e r e n t from anyone e l s e . APPENDIX B DATA SHEET 83 DATA SHEET 1. CASE NAME: 2. APPEARANCE: 3. AGE: 4. SEX: 5. EDUCATION: 6. PROFESSION: 7. DIAGNOSIS: 8. HOW LONG SINCE THE PATIENT HAS BEEN INJURED: 9. HOW LONG HAS IT TAKEN TO START A REHABILITATION PROGRAM: 10. FAMILY: Do your parents or spouse help you wit h your r e h a b i l i t a t i o n ? — L i t t l e — A f a i r amount— Very much--11. FUTURE PLANS: 12. THE DEGREES OF INDEPENDENCE: --1. P a t i e n t d r e s s i n g by h i m s e l f — 2. D r i v i n g a c a r — 3. T r a n s f e r r i n g — 4. F e e d i n g — 5. W r i t i n g — 6. Bowel management— 13. THE MOTIVATION OR GOAL OF REHABILITATION: 14. COMMENTS: 84 RAW DATA TABULATION SHEET 12 10 10 6 6 4 4 2 1 i l e 9 8 2 6 5 4 . 1 £ 1 Most S i g n i f i c a n t Least S i g n i f i c a n t Items Items 35 CONSENT FORM I, ; hereby consent to p a r t i c i p a t e i n a research study which i s being conducted and has been f u l l y explained to me by JACK KAO, a graduate student i n the School of Nursing at U.B.C. As I understand, there i s no r i s k i n v o l v e d i n t h i s research and I can a l s o withdraw completely at any time i f I wish to do so. I also understand t h a t any informat i o n I give w i l l be c o n f i d e n t i a l and i s only used f o r the purposes of t h i s study. Signature .! Address Witness Date 86 APPENDIX C AGREEMENT OF ITEMS IN STAGES 37 AGREEMENT OF ITEMS IN STAGES STAGE I : DENIAL Items 1st Stage % 2nd Stage % 3rd Stage % 4th Stage % 1 1 9 9 5 % 1 5% 2 1 6 8 0 % 2 10% 1 5% 1 5% 3 17 8 5 % 2 10% 1 5% 4 2 0 1 0 0 % 5 12 6 0 % 6 3 0 % 2 10% 6 1 8 9 0 % 2 10% 7 1 8 9 0 % 1 5% 1 5% a 1 6 8 0 % 2 10% 2 10% 9 15 7 5 % 1 5% 4 2 0 % 1 0 1 8 9 0 % 2 10% 1 1 15 7 5 % 1- 5% 2 10% 2 10% 12 1 6 8 0 % 2 10% 2 10% 13 17 8 5 % 3 15% 14 17 8 5 % 2 10% 1 5% Average agreement of a l l items i s 8 1 . 5 % . 8 8 89 STAGE I I : SEEKING INFORMATION 1st Stag e % 2nd Sta ge % 3rd Stag e % 4 t h Stage % 15 16 80% 2 10% 2 10% 16 20 100% 17 4 20% 6 30% 10 50% 18 20 100% 19 20 100% 20 9 45% 10 50% 1 5% 21 17 85% 2 10% 1 5% 22 1 5% 15 75% 3 15% 1 5% 23 1 5% 17 85% 2 10% 24 1 5% 18 90% 1 5% 25 13 65% 2 10% 5 25% 26 15 75% 4 20% 1 5% 27 11 55% 4 20% 5 25% 28 1 5% 17 85% 2 10% Average agreement of a l l items i s 66%. 90 STAGE I I I : REORGANIZATION 1st Stage % 2nd Stage % 3rd Stage % 4th Stage % 29 13 65% 7 35% 30 2 10% 2 10% 13 65% 3 15% 31 1 5% 3 15% 8 40% 8 40% 32 5 25% 12 60% 3 15% 33 8 40% 11 55% 1 5% 34 1 5% 13 65% 6 30% 35 2 10% 9 45% 9 45% 36 2 10% 11 55% 7 35% 37 2 10% 16 80% 2 10% 38 4 20% 4 20% 12 60% 39 4 20% 16 80% 40 1 5% 1 5% 11 55% 7 35% 41 3 15% 14 70% 3 15% 42 4 20% 1 5% 12 60% 3 15% Average agreement of a l l items i s 61%. 91 STAGE IV: ADAPTATION 1st Stage % 2nd Stage $ 3rd Stage $ 4th Stage $ 43 4 20$ 16 80% 44 5 25% 15 75% 45 6 30$ 14 70$ 46 1 5 $ . - 3 15$ 16 80$ 47 5 25$ 15 75$ 48 1 5$ 7 35$ 12 60$ 49 2 10$ 6 30$ 12 60$ 50 5 25$ 15 75$ 51 5 25$ 15 75$ 52 5 25$ 15 75$ 53 1 5$ 6 30$ 13 65$ 54 6 30$ 14 60$ 55 9 45$ 11 55$ 56 8 40$ 12 60$ Average agreement of a l l items i s 70$. 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0099911/manifest

Comment

Related Items