Nursing and Health Sciences (2005), 7, 281 – 283© 2005 Bla.docx

Nursing and Health Sciences (2005), 7, 281 – 283
© 2005 Blackwell Publishing Asia Pty Ltd
Correspondence address: Joanne R. Duffy, The Catholic
University of
America, School of Nursing, Washington DC 20064, USA.
Email:
[email protected]
Received 19 April 2005; accepted 2 June 2005.
Research Article
Critically appraising quantitative research
Joanne R. Duffy, dnsc, rn, ccrn, associate professor
The Catholic University of America, School of Nursing,
Washington DC, USA
Abstract Critical appraisal of quantitative research is a skill that
is necessary for adequate evidence-based
practice. This paper describes critical appraisal and offers a
process for its implementation. Four
categories of quantitative studies are reviewed and associated
links to relevant critical appraisal
frameworks are provided. The implications for students, nursing
faculty members, and practicing
nurses are discussed.
Key words appraisal, critique, evidence-based practice,
instruments, research.

INTRODUCTION
The current emphasis on evidence-based practice and
the desire to achieve “magnet status” has renewed
interest in nursing research in many health-care
institutions. The Magnet Recognition Program, devel-
oped by the American Nurses Credentialing Center
(ANCC), recognizes health-care organizations that
provide exceptional nursing care through a rigorous
system of standards and written documentation, culmi-
nating in a site visit and the resultant award (ANCC,
2005). This benchmark allows consumers of nursing
care to judge an institution’s quality and provides evi-
dence of nursing excellence. Evidence-based practice
assumes that nurses are able to appraise whether or not
a research study is scientifically sound/rigorous. It is
but one step in the very challenging process of clinical
decision-making. Although most nurses complete a
research course during their educational programs,
many have little practical experience in this skill and
they are now looking for ways to help them efficiently
appraise the value of research. Furthermore, graduate
students frequently are asked to critique research and
faculty members continue to search for methods to
help students better learn this skill. Finally, it has been
this author’s experience that, as health-care institutions
journey towards magnet status, many are partnering
with research faculty members for guidance in revising
nursing research committees, completing research,
and/or learning about research.
The quest by clinicians, nursing administrators and
students for more knowledge and skill in the research
process leads to the need for readily available methods
to critically evaluate research studies. Traditional nurs-
ing research texts offer guidelines related to critiquing

research; for example, Burns and Grove (2003) and
Polit and Beck (2004) contain chapters addressing this
issue. Most of these guidelines are written in an open-
ended question format requiring a verbal or narrative
reply. Although this method is thought-provoking, it is
subjective and often requires some prior knowledge of
the research process. Furthermore, it is not an efficient
way for busy professionals who have limited time to
judge a study’s worth.
A recent textbook, Evidence-Based Practice in Nurs-
ing and Healthcare (Melnyk & Fineout-Overholt,
2005) offers two chapters on critical appraisal of
research with an emphasis on rating the strength of
available evidence to inform clinical decisions and the
resultant nursing actions. In fact, the evidence-based
practice movement has yielded numerous articles
describing the types of evidence and procedures for
grading the quality of studies (Cochrane, 1970; Guyatt
et al., 1994; Greenlaugh, 1997; Melnyk, 2003). A recent
systematic review of critical appraisal tools yielded 121
published instruments available for this purpose
(Katrak et al., 2004). Of these, there were considerable
variability and overlap, and few documented psycho-
metric properties. Most instruments related to quanti-
tative studies and 49 summarized results in a numerical
format.
The need for practical research-appraisal instru-
ments, coupled with the numerous existing tools, cre-
ates information overload and can be frustrating for
busy consumers of research (clinicians) and faculty
282 J. R. Duffy

members as they try to help students learn the research
appraisal process. Therefore, the purpose of this paper
is to describe the critical appraisal of research as it
relates to quantitative methods and to suggest a
process for choosing the most effective and efficient
process.
CRITICAL APPRAISAL OF
QUANTITATIVE RESEARCH
Appraisal is defined as a process of classification of
someone or something with respect to its worth (Prin-
ceton University, 2003a). The word “critical” connotes
careful, exact evaluation and judgment (Princeton
University, 2003b). It follows that the critical
appraisal of quantitative research is a careful process
of judging a quantitative study’s worth (or value) for
the purposes of informing clinical decisions. It can be
thought of as an objective, structured approach that
results in a better understanding of a study’s strengths
and weaknesses. At the conclusion of a critical
appraisal, the evaluator should be able to distinguish
if a study is important enough to influence clinical
decision-making.
The appraisal of quantitative research assumes a cli-
nician has concerns or wants to learn the best possible
intervention(s) for a given patient population. This, in
turn, will generate a question. For example, a newly
diagnosed breast cancer patient tells you that her
friend with the same disease was prescribed a certain
course of chemotherapy and wonders why she is not on
the same medication. To assist the patient and allay her

fears about appropriate treatment for her cancer, a
nurse might formulate a question such as, “In breast
cancer patients, what is the effect of treatment A com-
pared to treatment B?” Such a succinct question pro-
vides key words to guide a search of the literature on
the topic. The resultant literature will yield a number of
studies that can then be categorized and subjected to
the critical appraisal process.
CRITICAL APPRAISAL PROCESS
A preliminary step in the appraisal process is to distin-
guish among several types of quantitative studies. Four
broad categories of studies are presented: case studies,
non-experimental cross-sectional or cohort studies,
randomized clinical trials, systematic reviews, including
meta-analyses. Case studies describe the trajectory of a
patient; they tend to be detailed descriptions that alert
health professionals to conditions that are not rou-
tinely seen in practice. As such, they are interesting,
but not the result of a systematic inquiry. Non-
experimental cross-sectional studies examine clinical
issues in similar patient populations at one point in
time. A non-experimental cohort study examines
clinical issues in a patient population over a desig-
nated amount of time. These studies might compare
interventions or treatments, but lack random
assignment to groups. Randomized clinical trials com-
pare the effectiveness of an intervention/treatment.
Participants in these studies are randomly assigned to
respective groups and their outcomes are compared
with each other and a control group that receive the
usual care. As a result of these features, randomized
clinical trials are experimental and continue to be the
“gold standard” study design for judging the effective-

ness of an intervention/treatment. Finally, systematic
reviews are a collection of studies that addresses a
specific clinical issue. They incur a detailed literature
review, critical appraisal, and a summary of results of
several studies. A meta-analysis is a special form of sys-
tematic review that employs statistical tests to deter-
mine an estimate of treatment effect. Systematic
reviews, including meta-analyses, are considered to be
the highest level of evidence (Melnyk, 2003) and are
used to generate clinical guidelines and influence
clinical decisions.
Distinguishing among these types of quantitative
studies will guide the appraiser in choosing the appro-
priate framework. A research course and general
understanding of research methods will help the clini-
cian in this step. Once the particular type of study is
known, the appraiser should read the entire study first
to understand the population, intervention/treatment,
and the results. A framework chosen by the appraiser
and unique to the type of quantitative study should be
employed to guide the evaluation process. Appendix I
provides links to various critical appraisal tools. As
many such tools exist, it is important to choose only
those that fit the type of quantitative study and have
established validity and reliability. Such information is
found by carefully examining original peer-reviewed
publications and other studies that have used the spe-
cific instrument. The format and practicality are also a
concern; many critical appraisal tools have open-ended
questions that require careful narrative responses
while others are scored numerically.
Using each item, the study is evaluated by answering
the relevant questions. These results will identify the
overall strengths and weaknesses of a study and sug-

gest its relative worth. Clinicians can then combine the
appraisal results with clinical experience, professional
values, and patients’ wishes to inform their clinical
decisions (Appendix II). Finally, once clinical decisions
are made based on evidence, the clinician should eval-
uate them both individually and in aggregate in an
effort to continuously improve practice.
Critiquing quantitative research 283
CONCLUSION
As nursing research and evidence-based practice
advance the practice of nursing, nurses at all levels
need critical appraisal skills. Students, faculty mem-
bers, and practicing nurses can use this overview of the
critical appraisal process for quantitative studies to
reduce their confusion about the process and to influ-
ence learning. Students in research courses will find it
helpful in reinforcing the process required for judging
the value of quantitative research reports. Follow-up
using the specific links to critical appraisal tools will
provide a rich repertoire of credible information nec-
essary for evidence-based practice. Practicing nurses
might find the process and associated links helpful as
they search among a myriad of critical appraisal tools.
Finally, it could be useful to faculty members who teach
research courses because it sheds light on the term
“appraisal” and describes the appraisal process as it
relates to evidence-based practice.
REFERENCES

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APPENDIX I
Links to critical appraisal frameworks
http://www.library.kent.ac.uk/livrary/info/subjectg/
healthinfo/critapprais.shtml.
http://www.shef.ac.uk/scharr/ir/units/critapp/
appres.htm.
http://.jama.ama-assn.org/cogi/content/full/.
http://bmj.bmjjournals.com/cgi/content/full.
http://www.phru.nhs.uk/casp/casp.htm.
http://www.shef.ac.uk/scharr/triage/index/critic.htm.
http://hsc.uwe.ac.uk/dataanalysis/crithome.htm.
http://www.city.ac.uk/library/subject_guides/nursing/
critical_appraisal.html.
http://www.ephu.man.ac.uk/Teaching/Undergrad/
CritApp/what.htm.
http://www.surgical-tutor.org.uk/default-
home.htm?amazon/appraisal.htm∼right.
http://www.be-evidence-based.com/secure_pages/
skills.php?id=40.
http://www.lshtm.ac.uk/hsru/casp/.

APPENDIX II
Process for critical appraisal of
quantitative studies
1. Distinguish among the types of quantitative
research.
2. Read the entire study and summarize the
population characteristics, intervention/treatment, and
results.
3. Choose and use an appropriate critical appraisal
framework.
4. Evaluate the study.
5. Combine the results of the evaluation with
clinical experience/expertise, professional values, and
patients’ preferences.
6. Use results to inform clinical decisions.
http://www.nursingworld,org/ancc/magnet/index.html
http://www.dictionary
http://www.dictionary
http://www.library.kent.ac.uk/livrary/info/subjectg/
http://www.shef.ac.uk/scharr/ir/units/critapp/
http://bmj.bmjjournals.com/cgi/content/full
http://www.phru.nhs.uk/casp/casp.htm
http://www.shef.ac.uk/scharr/triage/index/critic.htm
http://hsc.uwe.ac.uk/dataanalysis/crithome.htm
http://www.city.ac.uk/library/subject_guides/nursing/
http://www.ephu.man.ac.uk/Teaching/Undergrad/
http://www.surgical-

tutor.org.uk/defaulthome.htm?amazon/appraisal.htm%E2%88%
BCright%00
http://www.be-evidence-based.com/secure_pages/
http://www.lshtm.ac.uk/hsru/casp/
Rehabilitation Nursing • Vol. 36, No. 3 • May/June 91
Rehabilitation NURSING
A Study of Factors Affecting
Moving-Forward Behavior
Among People with Spinal
Cord Injury
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 demo-
graphic 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 (γ = -0.25, p < .01), and self-perception (γ = -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 person’s life. SCI can cause complete or partial
impairment of physical mobility, leaving the injured
person with the challenge of coping with and reha-
bilitating 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 treat-
ment 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 re-
sults include the inability to return to work and with-
drawal from society. The focus of our study was to
determine methods for helping people with SCI suc-
cessfully 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 inde-
pendently, but rather, it involves the ability to make

their own life decisions (Chen & Boore, 2007; Chen,
Boore, & Mullan; Gatehouse, 1995). Chen (2010)
used Parse’s 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 self-value and confidence in
order to affirm oneself while co-creating successes
amid opportunities and restrictions” (p. 1132). Mov-
ing forward after SCI is a complex experience that is
multidimensional and dynamic, allowing the poten-
tial for a wide variety and large number of factors to
influence the process.
On the other hand, self-efficacy refers to a person’s
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 be-
cause it determines whether an individual will initiate
certain behavior changes. Self-efficacy is a potential
universal measure, sensitive to a range of psychologi-
cal state and trait characteristics in an individual fol-
lowing 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 psychoso-
cial factors—for example, self-efficacy, self-perception,
and social support—are 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
KEY WORDS
quantitative research
rehabilitation
spinal cord injury
Rehabilitation NURSING Rehabilitation NURSING
RNJ_11_MAY JUNE.indd 91 4/8/11 8:31 AM
92 Rehabilitation Nursing • Vol. 36, No. 3 • May/June
of this study was to explore the relationships between
moving-forward behavior and demographic and dis-
ease characteristics, self-efficacy, self-perception, and
social support among people with SCI in Taiwan.
Methods
Design
A cross-sectional design with a descriptive correla-
tion approach was used to understand how the rela-
tionship 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 diag-
nosis of SCI, (2) older than 16 years, and (3) willing-
ness 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 50–60 participants
(mostly association members) from each associa-
tion. 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 col-
lected, including data regarding age, gender, educa-
tional 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 ini-
tially 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 Chi-
nese; 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 ob-
tained authorization from the scale’s 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 transla-
tion with the English MSES to check for conceptual
discrepancies. The tool was then tested for reliability in
the study. The Cronbach’s 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 confront-
ing 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
A Study of Factors Affecting Moving-Forward Behavior Among
People with Spinal Cord Injury

Figure 1. Moving-Forward Behavior and Its Related Factors
Demographic and disease characteristics: age,
gender, educational level, marital status, religion,
work or school status, membership with a spi-
nal injury association, time passed since injury,
cause of injury, level of injury, extent of injury,
rehabilitation
Moving-forward behavior
Self-efficacy
Self-perception
Social support
5 [strongly agree]); (3) Do you care about other people’s
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 situa-
tion? (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 dis-
abled) are helpful to my family; (7) I can freely leave
and enter the house, bathroom, and toilet and don’t
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 satis-
fied 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 (includ-
ing 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 Cronbach’s
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 par-
ticipants in the main study. The Cronbach’s 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. Research-
ers 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 train-
ing 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-on-one,
face-to-face interviews. Twenty participants pre-
ferred to be interviewed on their SIA’s 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, Pear-
son 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%), fol-
lowed 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 com-
mon 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 tetraple-
gia. 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 charac-
teristic 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
Table 1. Demographic and
Disease Characteristics of
Participants (N = 210)
Variables n (%)
Gender
Male 168 (80)
Female 42 (20)
Education level
Illiterate 3 (1.4)

Primary school 1 (0.5)
Junior high school 70 (33.3)
Senior high school 109 (51.9)
College or university 27 (12.9)
Marital status
Single 105 (50)
Married 81 (38.6)
Widowed 8 (3.8)
Divorced 16 (7.6)
Religion
Taoist/Buddhist 124 (59)
Christian/Catholic 37 (17.6)
None 36 (17.2)
Other 13 (6.2)
Employment (before injury)
Yes 167 (79.5)
No 43 (20.5)
Employment (present)
Yes 66 (31.4)
No 144 (68.6)
Member of an SIA
Yes 182 (86.7)
No 28 (13.3)
Cause of injury
Traffic accident 122 (58.1)
Falls 39 (18.6)
Disease 14 (6.7)
Others 35 (16.6)
Level of injury

Cervical 89 (42.4)
Thoracic 82 (39.0)
Lumbar 34 (16.2)
Other or unknown 5 (2.4)
Extent of injury
Complete paraplegia 91 (43.3)
Incomplete paraplegia 39 (18.6)
Complete tetraplegia 35 (16.7)
Incomplete tetraplegia 41 (19.5)
Unsure 4 (1.9)
Rehabilitation
Yes 178 (84.8)
No 32 (15.2)
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-percep-
tion of moving forward. The social support scale con-
sisted 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 for-
ward 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 (γ = -0.14, p < .05),
self-efficacy (γ = -0.25, p < .01), and self-perception (γ
= -0.39, p < .01; Table 3). There was a high correlation
between self-efficacy and self-perception (γ = 0.66, p <
.01), a moderate correlation between self-efficacy and
social support (γ = 0.53, p < .01), and a moderate cor-
relation between self-perception and social support
(γ = 0.33, p < .01; Table 3).
Based on the statistical significance of the results,
the variables of age, self-efficacy, self-perception, 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 fac-
tors 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 com-
plete or incomplete paraplegia or tetraplegia should
be expected to be able to move forward, provided
they receive the appropriate rehabilitative care.
Table 2. Differences in Moving-
Forward Behavior and Self-
Efficacy, Self-Perception, and
Social Support (N = 210)
Moving
Forward n Mean SD
Self-efficacy No 46 48.30 12.65
Yes 164 57.50 12.73
Self-perception No 46 21.24 8.46
Yes 164 29.60 6.25
Social support No 46 42.57 7.65
Yes 164 43.30 9.54
Table 3. Relationships Between Moving-
Forward Behavior and Age, Self-Efficacy,
Self-Perception, and Social Support (N = 210)
Variables Age
Moving
Forward

Self-
Efficacy
Self-
Perception
Social
Support
Age 1.0 -0.14* -0.08 0.049 -0.14*
Moving forward 1.0 -0.25** -0.39** -0.10
Self-efficacy 1.0 0.66** 0.53**
Self-perception . 1.0 0.33**
Social support 1.0
*p < .05; **p < .01.
Table 4. Multivariable Logistic Regression Analysis of Age,
Self-
Efficacy, Self-Perception, and Social Support on Moving-
Forward
Behavior (N = 210)
Moving-Forward Behavior B SE Wald OR CI p-value
Age -0.037 0.018 4.057 0.964 0.930–0.999 .044
Self-efficacy -0.031 0.027 1.279 0.970 0.919–1.023 .258
Self-perception -0.193 0.045 18.832 0.824 0.755–0.899 .001

Social support 0.064 0.035 3.340 1.066 0.995–1.142 .068
OR = odds ratio; CI = confidence interval.
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 rela-
tionship 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 activ-
ity, and pain relief were identified as the areas least
satisfactorily addressed. The study’s 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 incon-
tinence. Nonetheless, this stressful situation can be
overcome after the spinal shock stage by carrying out
bowel training so that a regular stool routine is estab-
lished (Chen & Boore, 2006).
Self-perception is significantly correlated to mov-
ing-forward behavior and is useful for predicting

moving-forward behavior. This study highlights the
importance of self-perception as a possible compre-
hensive measure responsive to a range of moving-
forward behaviors among individuals following SCI.
The self-perception scale is a new tool that was devel-
oped from qualitative research (Chen, 2010) and re-
fined 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 nurs-
ing process approaches and measuring patients’ out-
comes of moving-forward behavior, further evalua-
tion of its implications for clinical practice is required.
Although there was no significant correlation be-
tween 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 qual-
ity of social support predicts hopelessness and de-
pression after SCI. Granger (1982) proposed a health
accounting functional assessment (ESCROW: envi-
ronment, social interaction, cluster of family/mem-
bers, 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 dis-
satisfaction with employment and home care. Em-
ployment 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 impor-
tant 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 activi-
ties 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 care—from 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 rela-
tively 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 institu-
tions is inconsistent in Taiwan. It is, therefore, impera-
tive that the quality of care and the environment in
these care institutions be significantly enhanced.
Key Practice Points
1. Although many scientists are studying nerve regeneration and

conducting stem cell research, a cure for spinal cord injury
(SCI) remains a long way off.
2. SCI has a constant effect on 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.
3. Age, self-efficacy, and self-perception are influencing factors
for whether people with SCI can successfully move forward;
self-perception, self-efficacy, and social support are closely
related.
4. Three nursing interventions that rehabilitation nurses can
use in practice to help people move forward are (1) enhance
self-efficacy, (2) reinforce people’s self-perception of moving
forward, and (3) provide adequate social support and promote
social participation.
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, par-
ticipants 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, self-efficacy, and social
support are closely related. Therefore, reha-
bilitation 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 provid-
ing appropriate nursing assessment and interven-
tions as soon as possible to help these patients
achieve moving-forward behavior so that they
may successfully return to productive and gratify-
ing 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.
1. Enhance 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
individual’s confidence through procedural goal
achievement, with initial successes experienced
in performing specific tasks. For example,
with regard to an individual’s self-efficacy,
rehabilitation nurses could pay closer attention
to the patient’s sexual dysfunction and help him
or her reestablish a regular stool routine.
2. Reinforce people’s self-perception of moving
forward. This includes using the self-perception
scale to measure people’s 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.
3. Provide 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-166-002. The
authors acknowledge that all respondents com-
pleted 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 Taic-
hung Nursing College in Taiwan. Address correspondence to
her at [email protected]
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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