Ethical approval was obtained from Riverside Research Ethics Committee (see
Appendix D). A stipulation of the ethics committee was that each participant had a written information sheet (see Appendix E), and that written consent be obtained for each participant to say they had read this information and agreed to take part in the study (see Appendix F). Due to the hospital context of recruitment it was stressed to patients that the study was independent of the hospital, and that their treatment would be unaffected by their choice of whether or not to participate. A further ethical consideration pertinent to the group under study was their state of physical well being, and the investigator was sensitive to arranging interviews in terms of recovery from surgical procedures, nausea as a side-effect of medication etc.
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2.5.1 Assessment a t Time One
All patients meeting the criteria for the study were approached by the investigator who spoke briefly about the aims of the study and explained what participation would involve. Patients were then given an information sheet (Appendix E) to read at their leisure. The investigator returned in two to five days to answer any further questions about the study and to ask patients whether they would agree to take part. If they agreed, patients were asked to complete and sign a standard consent form (Appendix F), and the assessment was conducted at that point. In general, this interview lasted for between one and one and a half hours.
Participants were interviewed in their hospital beds, either in individual rooms or on a shared ward with curtains drawn around the bed. Some interruptions from medical staff and visitors occurred and were negotiated so that all of the first session was completed in one day. The three questionnaires were completed in order of: the Impact of Events Scale (IBS - Horowitz et al., 1979); the Hospital Anxiety and Depression Scale (HADS - Zigmond and Snaith, 1983); and the Short-form McGill Pain Questionnaire (Melzack, 1987). As some participants were lying on their backs during the interview it was anticipated that this might produce some difficulty in writing. To account for this, participants were given a copy of the questionnaire (with the title removed), and the researcher read out the instructions and each item. Participants were asked to respond verbally as the researcher marked their response on another copy.
The repertory grid procedure was tape-recorded with participants’ consent. This section of the assessment was introduced as follows:
‘This task is difficult to describe, but it is a straightforward way of looking at what is important to you, your thoughts and feelings about yourself and the world, and how these might have changed since your injury. It’s a good method of asking for your perspective on the experience of a having serious injury.”
2.5.1.1 Eliciting grid elements and constructs
Elements
In order to allow comparisons across participants element role descriptions were provided by the investigator. Element roles were chosen to represent the area under study, namely perceptions of self in relation to time and in relation to others. The repertory grid contained eleven elements of which five were descriptions of self (me now, my ideal me, me before my injury, me at discharge, and me in 5 years time). The remaining six elements were used to provide reference points, and they targeted aspects of relationships considered pertinent to the study. For these, participants were asked to think of someone they knew who fitted the descriptions given (someone I am close to, someone I dislike, a typical person of my age, someone with a similar injury, someone I admire, someone I pity). Some participants found it difficult to identify people they knew to fill these roles, particularly a person they dislike, or someone with a similar injury. In these instances they were asked to think of someone from public life or a television character, or failing that to imagine a stereotype. Each element was written on a card.
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Constructs
In accordance with the exploratory nature of the study, all constructs were generated by the participants*®. Constructs were elicited using Kelly’s triadic technique. In this method three element cards are selected and placed in front of the participant and they are instructed to think of some important way in which two are alike and different from the third. Participants were told to think wider than physical characteristics such as eye colour, but to think more generally about each element as a person.
In the initial assessment at Time One, cards were attached to a magnetic board which could be held at any angle to allow bed-ridden participants to view triads comfortably. The first triad presented consisted of three non-self elements, as this was considered to be easier for people to conceptualise. Following this, the composition of triads was varied, guided by the need to cover a range of alternatives and the participants ease of conceptualising. Constructs which were considered to be not applicable to all elements, for example specific occupations held, were prompted to be expanded upon. In addition, if triad elicitation produced multiple responses the participant was asked if the descriptors covered the same idea or constituted several different ideas. In the latter case, the response was divided into several constructs. If not produced spontaneously, the contrast poles were elicited through questions such as: “So these two [elements] are X. How is this one different?”, or “Some people are X. What is the opposite of this for you?”. Constructs were elicited until repetition indicated that
no further constructs would be obtained, or until tiredness expressed by participants prompted the end of construct elicitation.
2.5.7.2 Rating
Following elicitation of constructs, the participant was asked to describe each element in terms of every construct, using a rating scale. Kelly (1955) described several methods for obtaining this information, but for the present study the rating method was chosen to construct the grid, as it allows for greater flexibility in responding than ranking elements or dichotomising (Fransella and Bannister, 1977). Participants were instructed to rate each element on a scale from 1 to 7 between the two poles of the generated constructs. A seven-point scale permitted participants to select a neutral position (4) when they felt that elements were neither one pole nor the other. A written scale of 1 to 7 was attached to the magnetic board in view of the participant. The first pole of the construct was written on a card and placed at number one, and the contrast pole was written on a card and placed at number 7. Elements were read out by the investigator, and the number assigned to each by the participant was written in a table by the investigator (see Appendix G). This process was repeated with all of the generated constructs, varying the order in which elements were provided, to prevent a responding bias.
At the end of the session participants were asked if they had any questions and these were addressed. The investigator explained that the second part of the study (assessment at Time Two) would involve completing the three questionnaires and rating the grid elements on the seven-point scale. They were then asked if they agreed
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to be contacted in three months time to complete the second assessment. The investigator enquired as to the participants’ date of birth, ethnic origin, occupation, and marital status. Further information such as mechanism of injury, nature and severity of the injury, and details of the present hospital admission and treatment was obtained from the participants medical records with the permission of Hammersmith Hospitals NHS Trust.
2,5,2 Follow-up Assessment at Time Two
At the time of the second assessment (three months after the first interview) all participants had been discharged from hospital. Due to distance of participants’ residences, participants’ mobility problems and infrequent outpatient appointments, the second assessment was completed via postal questionnaires or telephone interview. Participants were sent a pack of the three questionnaires and a personalised repertory grid form (see Appendix H), plus a covering letter requesting their participation (see Appendix I). They were advised to contact the investigator with any questions or if they preferred to complete the assessment over the telephone". If no response was received within three weeks, a second letter and pack of questionnaires was sent.
Completion of the grid at Time Two required participants to re-rate the same elements and constructs from Time One to allow for comparison over time. One exception was the replacement of the element ‘me at discharge’ used at Time One,
with ‘me on admission’. This exchange was intended to investigate the accuracy of participants’ perception and anticipation of themselves at the different times of grid completion. Although the period of time until discharge varied among individuals it was felt that this time-frame was easier for participants to conceptualise and more meaningful than ‘three months time’. Participants were requested to state whether their chosen people still fitted the descriptions.