A Study of Factors Affecting Moving-Forward Behavior Among People with Spinal Cord

Injury (CE)
Hsiao-Yu Chen, PhD MSc BSc RN Chia-Hsiang Lai, PhD Tzu-Jung Wu, MS RN
Enhancing self-efficacy, self-perception, and social support can be an effective way for
people with spinal cord injury (SCI) to move forward. The purpose of this study was to
explore relationships between moving-forward behavior and demographic and disease
characteristics, self-efficacy, self-perception, and social support among people with SCI. The
study was designed as a descriptive-correlation, cross-sectional study. The participants were
selected using cluster random sampling (n = 210) through the Spinal Injury Association in
Taiwan. A statistically significant relationship was found between moving-forward behavior
and age (t = -2.30, p < .05), self-efficacy ( = -0.25, p < .01), and self-perception ( = -0.39, p
< .01). Age (odds ratio [OR] = 0.964, p < .05) and self-perception (OR = 0.824, p < .05) were
both significant predictors of moving-forward behavior.
Spinal cord injury (SCI) is a catastrophic event in any persons life. SCI can cause complete
or partial impairment of physical mobility, leaving the injured person with the challenge of
coping with and rehabilitating his or her injury (Chen & Boore, 2007, 2008; Chen & Li,
2002; Gill, 1999; Sharma, 2005; Yang & Wang, 2001). During the past 20 years great strides
have been made in SCI treatment. However, current treatment continues to focus on the
provision of care in the acute stage and the prevention and treatment of complications (Yu et
al., 2006). Although many scientists are studying nerve regeneration and conducting stem cell
research, a cure for SCI is still a long way off (Chang, Cheng, & Chang, 2006; Huang,
Cheng, Wu, & Liao, 2003; Jiang, 2003; Pan et al., 2008). As such, SCI continues to affect the
physical, psychological, social, and spiritual lives of those with the injury and their families.
In addition, the economic burden placed on the national health insurance system is
considerable (Chen, 2008; Chen & Boore, 2009; DeSanto-Madeya, 2006, 2009).
According to Chen and Boore (2008), positive results for people with SCI include the ability
to overcome tragedy and having the courage to move forward (Bournes, 2002; Reeve, 2003).
Negative results include the inability to return to work and withdrawal from society. The
focus of our study was to determine methods for helping people with SCI successfully move
forward to prevent work and social withdrawal (Chen & Boore, 2006, 2007; Chen, Boore, &
Mullan, 2005). For people with SCI, moving forward does not necessarily involve living
completely independently, but rather, it involves the ability to make their own life decisions
(Chen & Boore, 2007; Chen, Boore, & Mullan; Gatehouse, 1995). Chen (2010) used Parses
Research Methodology to investigate the meaning of moving forward and understand the
lived experience of 15 Taiwanese people with SCI; their lived experience of moving forward
was defined as a unitary experience of confronting difficulties, going on, and finding selfvalue and confidence in order to affirm oneself while co-creating successes amid
opportunities and restrictions (p. 1132). Moving forward after SCI is a complex experience
that is multidimensional and dynamic, allowing the potential for a wide variety and large
number of factors to influence the process.
On the other hand, self-efficacy refers to a persons belief or sense of confidence in his or her
own ability to perform a particular task or behavior successfully in the future (Bandura,
1977). Self-efficacy is believed to play an important role among people with SCI because it
determines whether an individual will initiate certain behavior changes. Self-efficacy is a

potential universal measure, sensitive to a range of psychological state and trait

characteristics in an individual following an SCI (Middleton, Tate, & Geraghty, 2003).
A rigorous exploration of self-efficacy, self-perception, and social support was an essential
first step for this study. Certain variables among psychosocial factorsfor example, selfefficacy, self-perception, and social supportare linked to moving-forward behavior among
people with SCI (Figure 1; Chen & Boore, 2007, 2008; DeSanto-Madeya, 2006; Gatehouse,
1995; Middleton, Tate, & Geraghty, 2003). However, researchers have not yet adequately
explored the relationships between moving-forward behavior and demographic and disease
characteristics, self-efficacy, self-perception, and social support within a population of those
with SCI. Therefore, the purpose of this study was to explore the relationships between
moving-forward behavior and demographic and disease characteristics, self-efficacy, selfperception, and social support among people with SCI in Taiwan.

Methods
Design
A cross-sectional design with a descriptive correlation approach was used to understand how
the relationship between self-efficacy, self-perception, social support, and moving-forward
behavior is perceived by people with SCI. Data were collected from June 2007 to September
2007.
Population and Sample
The study inclusion criteria were (1) physician diagnosis of SCI, (2) older than 16 years, and
(3) willingness to complete a questionnaire survey and sign the consent form. Cluster random
sampling was used to select four associations (north, central, east, and south) from the 23
spinal injury associations (SIAs) in Taiwan, and then purposive and snowball sampling were
used to select 5060 participants (mostly association members) from each association.
Researchers accessed the initial participant list through the SIAs and conducted interviews at
either the SIAs or participants homes. Although most participants were members of the
SIAs, they identified other nonmembers who were willing to participate in this study,
yielding a total sample size of 210 participants.

Instruments

Based on the theoretical framework (Figure 1), a questionnaire was designed that consisted of
four areas: demographic and disease characteristics, self-efficacy, self-perception, and social
support.
Demographic and disease characteristics were collected, including data regarding age,
gender, educational level, marital status, religion, work or school status, membership with an
SIA, time passed since injury, cause of injury, level of injury, extent of injury, and undergoing
or having undergone a rehabilitation program were collected.
The Moorong Self-Efficacy Scale (MSES) was initially generated by two clinicians
(Middleton and Geraghty) highly experienced in SCI management. Middleton, Tate, and
Geraghty (2003) developed the final version of the MSES, which included 16 items, each
item rated on a 7-point Likert scale ranging from 1 (very uncertain) to 7 (very certain). For
this study, the 7-point Likert scale was considered too difficult to divide and distinguish the
grades of meaning in Chinese; therefore, a 5-point Likert scale, ranging from 1 (very
uncertain) to 5 (very certain), was used. The questionnaire contained 16 questions with a
positive score totaling 80. The original version of this scale was translated into Chinese after
the researchers obtained authorization from the scales original authors (Middleton, Tate, &
Geraghty). The Chinese version of the MSES was translated through a multistep process of
forward and backward translation by two bilingual English- and Chinese-speaking
researchers. The two bilingual researchers compared the backward translation with the
English MSES to check for conceptual discrepancies. The tool was then tested for reliability
in the study. The Cronbachs alpha value for self-efficacy was 0.90, indicating good
reliability.
Chen (2010) identified three core concepts of self-perception of moving forward; these
included eight items in the three core categories, which were confronting difficulties (2
items), going on and finding self-value and confidence (3 items), and cocreating successes
amid opportunities and restrictions (3 items). This section included using a 5-point semantic
scale with a possible total score of 40 points. The questions were: (1) Do you accept your
present physical state? (1 [strongly refuse] to 5 [strongly accept]); (2) Are you able to leave
your family and live in a group? (1 [strongly disagree] to 5 [strongly agree]); (3) Do you care
about other peoples judgments? (1 [strongly care] to 5 [strongly ignore]); (4) Are you
comfortable making friends with not disabled people? (1 [strongly refuse] to 5 [strongly
accept]); (5) Do you feel that your existence has any value? (1 [strongly disagree] to 5
[strongly agree]); (6) Between possession and loss, how would you describe your current
situation? (1 [complete loss] to 5 [complete possession]); (7) Do you hold hope for the future?
(1 [strongly disagree] to 5 [strongly agree]); and (8) Do you face the future with confidence?
(1 [strongly disagree] to 5 [strongly agree]).
The section on social support examined 10 domains, including environment, transportation,
membership in an SIA, support from family, support from friends, financial status, social
resources, work, school, and residential care. Responses were based on a 5-point Likert scale,
which ranged from 1 (strongly disagree) to 5 (strongly agree), with a total positive score of
70 points.
The social support items included (1) At home, there is always a family member who can
give me physical assistance whenever I need it; (2) I believe that becoming a member of an
SIA helps me return to the community; (3) At home, there is always a family member who
can give me mental support whenever I need it; (4) I believe that when I need help or when I

am in a bad mood, I have friends who can help me or listen to my problems; (5) When I need
to go out, I have suitable transportation (car or motorcycle); (6) I believe that government
welfare resources (e.g., school fee exemption for children, reduced public transportation fees,
home-care services for the disabled) are helpful to my family; (7) I can freely leave and enter
the house, bathroom, and toilet and dont need others to help me; (8) If someone with SCI
wants to go back into education, he or she can get adequate help; (9) I believe that the social
benefits offered by the government do not help my economical situation; (10) I feel that the
design of disability-friendly public facilities and spaces should take the needs of disabled
people into consideration; (11) I am satisfied with the guidance on employment offered by the
government; (12) I believe that disability-friendly facilities in the work environment fulfill
my needs; (13) I am satisfied with the job opportunities that society currently offers; and (14)
I believe that if I need to go to a care institution, I will receive good care.
Questionnaire Validity and Reliability
To ensure content validity and confirm that there were enough relevant questions covering all
major aspects of the research question, six experts (including a supervisor of a rehabilitation
ward, a head nurse, a physician, an occupational therapist, a social worker, and a statistician)
evaluated the questionnaire. In addition, prior to the main study, the researchers developed a
pilot study involving 33 people with SCI (not included in the main study) who were recruited
from one of the SIAs and agreed to participate to establish the internal consistency and clarity
of the questionnaire. The Cronbachs alpha values for self-efficacy, self-perception, and social
support were 0.90, 0.82, and 0.70, respectively, indicating high reliability. There were 210
participants in the main study. The Cronbachs alpha values for self-efficacy, self-perception,
and social support were 0.93, 0.87, and 0.78, respectively.
Ethical Considerations
Researchers acquired ethical approval from each association before the study began and sent
letters to individual participants to inform them of the study and ask for their voluntary
written consent. Researchers guaranteed participants that they would not be harmed, would
have the right to withdraw from the study at any time without penalty or effect on their future
care provision, and that all information collected would remain anonymous and kept strictly
confidential to the research team members only.

Data Collection
For the purpose of establishing interrater reliability, a researcher explained the aim of the
study to the social workers of the four SIAs and provided training regarding how to
administer the questionnaire. Permission from each SIA to conduct the study and collect data
by questionnaire was requested and obtained. Subsequently, a social worker collected the
questionnaire data by visiting the majority of participants at their homes to conduct one-onone, face-to-face interviews. Twenty participants preferred to be interviewed on their SIAs
premises. These interviews were conducted in a quiet, private room at a prearranged time.

Statistical Analysis
Researchers performed statistical analyses of the data using SPSS version 14.0 software.
Before these analyses, the data sets for self-efficacy, self-perception, and social support
scores were checked to see whether they were normally distributed; the results confirmed that

they were. Descriptive, Pearson product moment correlation, and multivariate logistic
regression were completed, as appropriate. The significance level was set at 0.05.

Results
A total of 210 questionnaires were collected. Of them, 164 participants (78.1%) perceived
that they were moving forward, while 46 (21.9%) said they were not able to move forward.
Demographic Characteristics
The mean age of participants was 38.9 (SD = 12.7) years; more men (n = 168, 80%) than
women (n = 42, 20%) participated. Most participants (109, 51.9%) reported an educational
level of senior high school; 70 reported junior high school (33.3%), 27 had attended college
or university (12.9%), 3 were illiterate (1.4%), and 1 participant had only attended primary
school (0.5%). Of the 210 participants, 105 (50%) were single, 81 (38.6%) were married, 16
(7.6%) were divorced, and 8 (3.8%) were widowed. Overall, 124 participants (59%) were of
the Taoist/Buddhist faith, while 37 (17.6%) were Christian/Catholic. The remaining
participants reported no religion (36, 17.2%) or other (13, 6.2%). One hundred sixty-seven
(79.5%) participants used to be employed, and 66 (31.4%) still had a job at the time of the
interview. Twenty-nine participants (13.8%) had been attending school at the time of their
injury; of these, 22 had continued their studies. In total, 182 participants (86.7%) were
members of an association related to spinal injury (Table 1).

Disease Characteristics
The mean amount of time passed since injury was 9.6 years (SD = 8.1 years). The most
common cause of injury was a traffic accident (122, 58.1%), followed by falls (39, 18.6%),
and disease (14, 6.7%). The remaining 35 (16.6%) participants reported other or unknown
causes of injury. The most common injury area was the cervical spine (89, 42.4%), followed
by the thoracic spine (82, 39%), lumbar spine (34, 16.2%), and other areas or unknown (5,
2.4%). Nearly half the participants (91, 43.3%) had complete paraplegia, followed by 41
(19.5%) with incomplete tetraplegia, 39 (18.6%) with incomplete paraplegia, and 35 (16.7%)
with complete tetraplegia. Finally, 84.8% (n = 178) had taken part in a rehabilitation program
(Table 1).

Relationships Between Moving-Forward Behavior, Demographic and Disease

Characteristics, Self-Efficacy, Self-Perception, and Social Support
A statistically significant relationship was found to exist between age and moving-forward
behavior (t = -2.3; p < .05). There was no statistically significant difference between any
other demographic characteristic and moving-forward behavior. In addition, the results did
not show any statistically significant difference between any disease characteristic and
moving-forward behavior.
Self-efficacy was reported using a 5-point Likert scale and consisted of 16 items with a
positive score totaling 80 points. The mean score was 56.77 (SD = 16.05), which indicated
that, overall, patients were certain of their self-efficacy. The self-perception area consisted of
eight items with a total score of 40 points; the mean score was 28.11 (SD = 9.42), which
indicated that, overall, the patients had a positive self-perception of moving forward. The
social support scale consisted of 14 items, including the reverse-scored items, with a total
score of 70 and a mean score of 44.37 (SD = 15.21), which indicated that, overall, the
patients satisfaction level with social support was acceptable.
In addition, higher scores for self-efficacy (mean = 57.50, SD = 12.73), self-perception (mean
= 29.60, SD = 6.25), and social support (mean = 43.30, SD = 9.54) were found in people with
SCI who were moving forward rather than those who were not (self-efficacy: mean = 48.30,
SD = 12.65; self-perception: mean = 21.24, SD = 8.46; social support: mean = 42.57, SD =
7.65; Table 2).

A significant correlation was found between moving-forward behavior and age ( = -0.14, p <
.05), self-efficacy ( = -0.25, p < .01), and self-perception ( = -0.39, p < .01; Table 3). There
was a high correlation between self-efficacy and self-perception ( = 0.66, p < .01), a
moderate correlation between self-efficacy and social support ( = 0.53, p < .01), and a
moderate correlation between self-perception and social support ( = 0.33, p < .01; Table 3).

Based on the statistical significance of the results, the variables of age, self-efficacy, selfperception, and social support were chosen as predictive factors in the multivariate logistic
regression analysis. Age (OR = 0.964, p < .05) and self-perception (OR = 0.824, p < .05)
were both significant predictors of moving-forward behavior (Table 4).

Discussion
The findings of this study showed that the factors affecting moving-forward behavior among
people with SCI included age, self-efficacy, and self-perception.
No studies of how demographic and disease characteristics influence moving-forward
behavior for people with SCI exist. This study demonstrated a statistically significant
relationship between age and moving-forward behavior. A long-term, follow-up study by
Livneh and Antonak (2005) found that the longer a chronic disease or debilitating injury
lasted, the higher the level of acceptance was among patients. Because no statistically
significant relationships were found between moving-forward behavior and the cause, level,
or extent of injury, all people with complete or incomplete paraplegia or tetraplegia should be
expected to be able to move forward, provided they receive the appropriate rehabilitative
care.
Although the mean scores of self-efficacy indicated that patients had acceptable self-efficacy,
there were two particularly noteworthy items that received the lowest possible scores (mean
score < 3) on the self-efficacy scale: ability to have a satisfying sexual relationship and
avoiding bowel accidents. With regard to sexual relationships, Teng (2002) and Chen, Boore,
and Mullan (2005) emphasized that people with SCI should increase their understanding of
their own sexual function and that rehabilitation nurses should gain an understanding of this
problem and enhance their counseling skills. Kennedy, Lude, and Taylor (2006) conducted a
study assessing the community needs of people with SCI; occupation, sexual activity, and
pain relief were identified as the areas least satisfactorily addressed. The studys results
indicated that the subject of sexual relationships still requires attention. People with SCI also

lack confidence when it comes to preventing the occurrence of fecal incontinence.

Nonetheless, this stressful situation can be overcome after the spinal shock stage by carrying
out bowel training so that a regular stool routine is established (Chen & Boore, 2006).
Self-perception is significantly correlated to moving-forward behavior and is useful for
predicting moving-forward behavior. This study highlights the importance of self-perception
as a possible comprehensive measure responsive to a range of moving-forward behaviors
among individuals following SCI. The self-perception scale is a new tool that was developed
from qualitative research (Chen, 2010) and refined in this study. Although the self-perception
scale is valuable as a brief, clinically relevant and easily administered tool that may be used
for planning nursing process approaches and measuring patients outcomes of movingforward behavior, further evaluation of its implications for clinical practice is required.
Although there was no significant correlation between moving-forward behavior and social
support in this study, there was a high correlation between social support and self-perception
and self-efficacy, which indicates that social support is also important. Beedie and Kennedy
(2002) emphasized that quality of social support predicts hopelessness and depression after
SCI. Granger (1982) proposed a health accounting functional assessment (ESCROW:
environment, social interaction, cluster of family/members, resource, outlook,
work/school/retirement) of long-term patients. A specially designed tool to measure SCI
patients social support does not exist; however, the new measure used in this study appears
to be capable of capturing information regarding SCI patients social support. Its implications
for clinical practice require further examination.
In this study, participants indicated the most dissatisfaction with employment and home care.
Employment dropped from 79.5% before SCI to 31.4% postinjury. According to Chou, Chen,
and Lai (2008), the unemployment rate among people with SCI in Taiwan is as high as 46%.
Kennedy and colleagues (2006) found that occupation is one of the most important areas
indicative of highest community needs in four European countries. A study by Jang, Wang,
and Wang (2005) found the degree of independence is the main influencing factor in whether
people with SCI return to work. After injury, it is important that activities of daily living
function be restored, followed by reemployment guidance. In the United Kingdom and the
United States, there are comprehensive service systems that provide people with SCI a wide
array of services throughout the continuum of carefrom the acute stage to discharge from
the hospital and home-environment planning, including services related to leisure, recreation,
and employment (Cheng, 2006; Gatehouse, 1995; Grundy & Swain, 2002). In Taiwan, no
such service system exists (Cheng). People are relatively dissatisfied with the social support
system, in particular, employment guidance, job opportunities, and disability-friendly work
environments (Chuang, 2008). In the future, the government should pay more attention to
disability-friendly work environments and provide better employment guidance to help more
people with SCI return to work successfully. Presently, the quality of care in rehabilitation
institutions is inconsistent in Taiwan. It is, therefore, imperative that the quality of care and
the environment in these care institutions be significantly enhanced.

Study Limitations
The participants of this study consisted of people who were discharged from the hospital;
most were members of an SIA and had access to the support services provided by the
association. Therefore, participants moving forward outnumbered those who had not moved
forward. The sample could have been biased because those with SCI living at home or in

residential accommodations who do not belong to an SIA withdrew from society and were
less likely to be included in the study. Further study with a larger sample size is needed and
should include people with SCI who do not belong to an SIA.
Researchers used a cross-sectional survey method to collect data for this study. Collected data
could have been influenced by participants current situational bias. Future research should
focus on a longitudinal study of people with SCI to follow up on the dynamic experiences
and changes related to moving-forward behavior after rehabilitation hospitalization.

Conclusions and Implications for Practice

This study found that age, self-efficacy, and self-perception are influencing factors for
whether people with SCI can successfully move forward, and that self-perception, selfefficacy, and social support are closely related. Therefore, rehabilitation nurses need to
provide humanistic and holistic care, which stems from being attentive to the unique life
experience of each individual. At present, people with SCI mostly resort to self-help, mutual
help, and self-rescue. We suggest providing appropriate nursing assessment and interventions
as soon as possible to help these patients achieve moving-forward behavior so that they may
successfully return to productive and gratifying lives in the community. The following three
nursing interventions have specific implications for rehabilitation nursing practice and should
be considered as methods for helping people with SCI move forward.

nhance self-efficacy. The MSES scale could be used to predict which individuals will
have greater difficulty adjusting after SCI. Moreover, rehabilitation nursing care
should be individually tailored and structured to build an individuals confidence
through procedural goal achievement, with initial successes experienced in
performing specific tasks. For example, with regard to an individuals self-efficacy,
rehabilitation nurses could pay closer attention to the patients sexual dysfunction and
help him or her reestablish a regular stool routine.

einforce peoples self-perception of moving forward. This includes using the selfperception scale to measure peoples impressions of moving forward to provide
appropriate nursing care and understand the significance and meaning of their
injuries, helping to confront difficulties and to go on and find self-value and
confidence to affirm oneself while cocreating successes amid opportunities and
restrictions.

rovide adequate social support and promote social participation. Rehabilitation nurses
should encourage patients to take part in activities outside the hospital, join an SIA,
and extend their interpersonal relationships; nurses should provide information about
social welfare, regular follow-up, and home care. These activities would help more
people to move forward and smoothly transfer from the hospital to the community.

Acknowledgment
The study was supported by the Taiwan National Science Council, grant no. 95-2314-B-166002. The authors acknowledge that all respondents completed the questionnaire truthfully.

About the Authors

Hsiao-Yu Chen, PhD MSc BSc RN, is an associate professor of nursing in the department of
nursing at the National Taichung Nursing College in Taiwan. Address correspondence to her
at yutin@hotmail.com.
Chia-Hsiang Lai, PhD, is an assistant professor of nursing at Central Taiwan University of
Science and Technology in Taiwan.
Tzu-Jung Wu, MS RN, is a nurse supervisor at Chung Shan Medical University Hospital in
Taiwan.

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