The development of a questionnaire to assess motivation in stroke survivors: a pilot study.
The World Health Organisation defines motivation as "a global mental function--a conscious and unconscious drive--that produces the incentive to act" (W.H.O 2001). Motivation for a particular behaviour can be described along a continuum of self-determination first described by Deci and Ryan (1985) ranging from amotivated behaviour to intrinsically motivated, self-determined behaviour (Deci and Ryan 1985). An individual who is amotivated sees no link between their behaviour and outcomes (Deci and Ryan 1985, Vallerand and O'Connor 1989). The progression from this motivational state is to non self-determined, extrinsically motivated behaviour which is externally regulated, often by rewards or constraints (Deci and Ryan 1985, Vallerand and O'Connor 1989). Individuals that are motivated in this way may undertake a particular behaviour because they feel pressured to do so or to receive some reward, such as praise, approval or a tangible object (Mullan et al 1997).
Extrinsically motivated behaviour may also be self-determined, where the activity is undertaken because of its importance or usefulness, as a means to an end (Deci and Ryan 1985, Mullan et al 1997, Vallerand and O'Connor 1989). In this case the individual experiences feelings of direction and purpose rather than obligation and pressure (Vallerand and O'Connor 1989). Behaviour that is intrinsically motivated is fully self-determined and is undertaken in the absence of any reward other than the feelings that accompany or immediately follow the activity, such as enjoyment or competence (Deci and Ryan 1985).
This concept of motivation can be applied to patients who have suffered a stroke. A patient who sees no link between therapy sessions and recovery would be described as amotivated. Patients who participate in therapy because they feel pressured to do so by the rehabilitation team or their family are extrinsically motivated and their behaviour is not self-determined. Patients who participate in therapy because they see that it will help them return home are extrinsically motivated but display self-determined behaviour. Those patients who participate in therapy because it makes them feel competent or because they enjoy the therapy sessions can be described as intrinsically motivated.
Motivation is a construct that is referred to frequently in the field of rehabilitation. It is commonly accepted that increased levels of motivation lead to more positive outcomes (Maclean and Pound 2000). Many health professionals believe that motivation is the most important factor in determining functional outcomes of stroke rehabilitation (Becker and Kaufman 1995). Several studies have shown a relationship between motivation and outcome of rehabilitation (Friedrich et al 1998, Grahn et al 2000, Maclean et al 2002). However, there is a lack of general consensus as to what constitutes motivation and which factors influence it (Maclean and Pound 2000, Maclean et al 2000, 2002).
Stroke survivors are often categorised as motivated or unmotivated by health practitioners based on single factors such as their general demeanour, compliance with therapy or observed interest in therapy (Maclean et al 2002). This approach fails in that it does not acknowledge the multitude of factors that may influence a patient's level of motivation. These include but are certainly not limited to: environmental factors, the relevance of rehabilitation to the patient, the amount of social support, understanding of the rehabilitation process, relationship with the therapist and importance of recovery to the patient (Holmqvist and von Koch 2001, Maclean and Pound 2000, Maclean et al 2000).
Subjectively assessing a patient's motivation risks an incorrect assessment and may result in a perceived level of motivation that is inconsistent with reality. In a study of motivation conducted by Resnick (1996), patients were chosen to participate after they had been labelled unmotivated by the rehabilitation team. When interviewed however, none of these patients considered themselves unmotivated.
Qualitative research conducted by Maclean and colleagues (2002) suggested that labelling a patient as unmotivated may have a negative effect on their rehabilitation. Some of the health professionals interviewed as part of their research stated that they treated unmotivated patients differently, and found working with them more of a chore (Maclean et al 2002). Becker and Kaufman (1995) argued that using motivational labels put too much responsibility on the patient, which could negatively effect a patient's rehabilitation especially if their recovery was incomplete.
Given the negative consequences of subjectively assessing a patient's motivation, an objective measure would prove useful in the stroke rehabilitation environment. The purpose of this research was to develop a questionnaire that would address the varying factors that affect motivation levels and determine where the patient's motivation lay on the self-determination continuum. Using such a questionnaire in the rehabilitation setting should enable health professionals to gain a better understanding of factors contributing both positively and negatively to their patients' motivation. This should allow them to then determine more effective strategies to maximise patient motivation and thereby improve rehabilitation outcomes.
Two groups of participants were recruited for this research: an expert group and a patient group.
Inclusion criteria for experts were current involvement in stroke rehabilitation and/or psychology, and at least five years experience in this field. Experts were known to the authors and their contact details were available in the public domain.
Two inclusion criteria for patients were a history of stroke, and current involvement in a community stroke group. The patient sample was one of convenience. Patients were sourced from the Young Stroke Survivors community group. Informed consent was obtained from both expert and patient participants. The study was approved by the University of Newcastle Human Research Ethics Committee (approval number: H-514-0307)
A literature search was conducted on the Medline database using the keywords "motivation" and "rehabilitation". Additional articles were sourced from hand-searches of the bibliographies of electronically located articles.
Literature was deemed relevant if it discussed motivation in the context of rehabilitation, or discussed motivation in the context of self-determination theory.
From these articles, two item lists were compiled. The first included factors that were suggested to affect motivation in the context of rehabilitation. Items that duplicated ideas were deleted from this list. The second listed items that described the various stages of self-determined behaviour; amotivation through to intrinsic motivation.
Both lists were formatted to form a two-part questionnaire. Guidelines for design were taken from work by Mullin and colleagues (2000), and the Australian Aphasia Association (2006).
The questionnaire was emailed to expert participants who were asked to rate the relevance of each item on a five-point numerical Likert scale. Items judged to be "not relevant at all" received a score of one; those thought to be "somewhat relevant" scored a three; and items judged to be "extremely relevant" received a score of five. Items that received a score of less than three from all experts were removed from the questionnaire. Expert participants were also asked to state any additional items which they considered should be included. Items that were suggested for inclusion by more than one expert were added to the questionnaire.
The amended questionnaire was given to the patient group who were similarly asked to rate each item in terms of its relevance to their motivation following their stroke. Patient participants were also asked to list any additional items that they felt should be included.
Statistical analysis of both patient and expert responses was performed using the statistical program JMP (Version 6.0.0, 2005, SAS Institute Inc., Cary, NC). Cronbach's alpha values were computed to estimate internal reliability. The alpha coefficient is an indication of the correlation among the items in a questionnaire (Kielhofner 2006). Higher coefficients indicate increased homogeneity of the items (Kielhofner 2006). Homogeneity between items in a questionnaire is desirable as it suggests that all items are related to the same domain, which in our case is motivation. Cronbach's alpha values of above 0.70 were considered acceptable (Nunally 1978). We computed values for each of the thirty-three items in the questionnaire. These values give an estimate of how well that particular item correlates with all other items in the questionnaire. We also computed a value for the questionnaire as a whole, which gives an estimate of the overall homogeneity of the questionnaire.
Pearson Product Moment correlations were computed to estimate item-total correlations. The correlation coefficient generated also gives an estimate of the homogeneity of the scale, but examines it from a different point of view (Kielhofner 2006). This statistical test gives an estimate of how well each item in the questionnaire correlates to the total score; whereas Cronbach's alpha looks at the relationship between the items themselves. The scores for items that are related to the domain of the questionnaire should correlate highly with the total score of the questionnaire. Correlations above 0.70 were considered acceptable (Streiner and Norman 1995). We did not test for statistical significance in this pilot study, as the small sample size does not allow adequate power for that purpose. We acknowledge that there is no validity in doing a statistical test with so few data; however the results provided us with a general picture of the questionnaire's internal reliability and homogeneity which may be useful for future research.
Thirteen studies from the literature were deemed to be relevant for this research, the details of which are presented in Appendix 1.
From these studies a list of nineteen factors that affect motivation was compiled. These were subdivided into three categories: social factors (six items), environmental factors (five items) and personal factors (eight factors). A second list of a further eleven items describing the motivation continuum from amotivation to intrinsic motivation was compiled: amotivation (one item), non self-determined extrinsic motivation (three items), self-determined extrinsic motivation (four items), and intrinsic motivation (three items).
These lists were formatted to create the questionnaire, which was then emailed to the expert participants. Seven experts were emailed; one neurologist, two psychologists and four physiotherapists. Of these, one expert (female physiotherapist, fourteen years experience) completed the questionnaire as asked. Two others (male neurologist, female psychologist) replied with suggestions for additional items but did not complete the questionnaire. The other four experts did not reply to our email.
None of the items were given a rating below three, so all were kept for the amended version. Based on unanimous response from the expert respondents an additional three items were added to the questionnaire: social factors (one item), non self-determined extrinsic motivation (one item), and self-determined extrinsic motivation (one item). The finalised list of items is outlined in Table 1.
Six members of the Young Survivors Stroke Group were present on the day of our visit. Of these, two declined to participate. One patient consented to participate but due to time constraints was unable to complete the questionnaire. The three patients who were able to complete the questionnaire were all male, with a mean age of 56.33 years (54-60 years). Mean time since stroke was 2.5 years (2-3 years). Two of the participating patients were unable to read as a result of their stroke. The author read the questionnaire to these patients. No guidance was given in regard to responses.
Cronbach's alpha values were computed for each of the thirty-three items in the questionnaire and for the questionnaire as a whole. The individual values ranged from 0.9090 to 0.9451. Specific values for each item are listed in Table 1. The Cronbach's alpha value for the questionnaire as a whole was 0.9195. Pearson Product moment correlations were computed for each of the thirty three items, estimating the relationship between the score for each individual item and that of the entire questionnaire. Values ranged from -0.4813 to 0.9961. Specific values for each item are outlined in Table 1.
Following an extensive literature search and feedback from expert and patient participants, a questionnaire was developed to assess motivation in stroke survivors.
This pilot study was conducted for the purpose of stage one of instrument development. It was not intended to test the usefulness of the instrument in a clinical population; more research must be conducted before it can be used clinically. Cronbach's alpha and Pearson Product Moment correlations were calculated to assess the internal reliability of the scale.
There are some limitations to this research which affect the validity of the conclusions drawn. The sample was smaller than intended due to circumstances beyond the authors' control. This limited the statistical significance of the results and meant it was not possible to determine the reliability and validity of the instrument.
There were several opportunities for bias in this study. Two of the participants were unable to read and had their questionnaire read to them by one of the authors. This may have introduced response bias but was unavoidable as the group convenors were busy and unable to assist. The patients were not offered any guidance in answering the questions.
Further opportunity for bias is due to the two years which had elapsed since the stroke for all participants. This introduced the possibility of recall bias. Furthermore, the participants were not representative of the acute and sub-acute hospital patients for whom this questionnaire is designed, affecting the generalisability of the results.
Every item on the scale scored a Cronbach's alpha coefficient of greater than 0.90, suggesting high internal reliability and homogeneity between items. However, these results could have been greatly affected by the small sample size of this study.
Thirteen items scored a Pearson Product Moment coefficient of less than 0.70. Given the lack of validity of these results due to small sample size no items were deleted from the questionnaire. More data are necessary to determine whether or not this questionnaire is reliable.
To determine the items to be included in the questionnaire, an extensive literature review was conducted and opinion sought from both experts and patients. This procedure follows guidelines for determining content validity, which refers to how adequately an instrument captures all aspects of the construct it aims to measure (Kielhofner 2006, Nunally 1978).
To determine criterion validity, an instrument needs to be compared to another instrument that is known to measure the same construct, preferably one that is considered to be the "gold-standard" (Fayers and Machin 2000). As there is currently no method or instrument available to assess motivation this was unable to be determined.
Construct validity requires several studies to produce cumulative evidence and so could not be determined by this research (Fayers and Machin 2000, Kielhofner 2006). One aspect of construct validity is homogeneity, which has been demonstrated by the Cronbach's alpha results discussed earlier. However, the validity of these results is also affected by the small sample size mentioned previously.
The first section of this questionnaire assesses the current stage of self-determination of an individual patient. This is clinically useful as it can help determine strategies that will best suit the patient in their current stage and will help them progress to more self-determined behaviour. The second section of the questionnaire becomes useful at this point as it allows the health practitioner to determine which factors are helping or hindering the patient's motivation. For example, a patient who indicates they have non self-determined motivation for rehabilitation may also reveal that they have a poor understanding of strokes or the rehabilitation process. In such a case, the patient may benefit from education about the rehabilitation process and how it will help them achieve their goals. Having a clearer perception of the path their rehabilitation will follow and the gains that can be made may assist the patient to progress to more self-determined behaviour.
The questionnaire is not intended to provide health practitioners with a score to rate a patient's motivation. As outlined previously, labelling patients as motivated or unmotivated can have a negative effect on the rehabilitation process (Becker and Kaufman 1995, Maclean et al 2002). It is the author's concern that similar effects could be experienced if too much focus is placed on a numerical score. Instead, the instrument is intended to provide information for clinicians to form a holistic view of a patient's motivation.
It is also important to consider the responses to this questionnaire in conjunction with other factors. Many patients experience depression, emotional or behavioural impairments or disruptions in cognitive function following a stroke (Linden et al 2007, Zinn et al 2007). These factors would also affect the rehabilitation process, and some may affect the way the patient answers the questionnaire. The questionnaire is designed to be used as part of a multi-faceted assessment process, and the results should be interpreted with these additional factors in mind. The addition of an instrument to specifically assess motivation may improve the rehabilitation environment for an individual.
Future research, conducted on a larger sample of patients who are in the acute to sub-acute period following a stroke would allow the validity and reliability of this instrument to be determined. The instrument must not be used in clinical care until such research has been completed.
Following a review of the literature and consultation with both experts and patients, a questionnaire to assess motivation following stroke was developed. The instrument is designed to determine the patient's stage of self-determination as well as positive or negative factors affecting their motivation. This will provide health practitioners with a broader understanding of the many factors influencing their patients' rehabilitation, and enable them to develop strategies to best suit each individual. By gaining a better understanding of the factors affecting a patient's motivation, health practitioners will be able to facilitate self-determined behaviour and this may lead to improved rehabilitation outcomes. Further research is needed to determine the validity and reliability of this questionnaire before it can be used in clinical care.
* Motivation is an important part of the rehabilitation process and effects functional outcomes.
* Several factors influence motivation, all of which should be considered in order to provide an optimal rehabilitation environment. A questionnaire composed of the various factors that influence motivation was developed to assess motivation and self-determination following stroke.
* Further research is needed to determine the reliability and validity of this instrument. The evidence from this pilot study is insufficient to recommend the clinical use of the instrument.
Appendix 1: Details of relevant studies retrieved by literature search: Items gained from Study Details Type of Research research Becker and Kaufman (1995) Qualitative Social, Environmental, Personal Deci and Ryan (1987) Literature review Self-determination Holmqvist and von Koch Literature review Environmental (2001) Maclean and Pound (2000) Literature review Social, Environmental, Personal Maclean et al (2000) Qualitative Social, Environmental, Personal Maclean et al (2002) Qualitative Social, Environmental, Personal Merrill (1994) Literature review Social, Personal Mullen et al (1997) Quantitative Self-determination Pelletier et al (1995) Quantitative Self-determination Resnick (1996) Qualitative Social, Personal Siegert and Taylor (2004) Literature review Social, Environmental, Personal Vallerand and Bissonnette Quantitative Self-determination (1992) Vallerand and O'Connor Qualitative Self-determination (1989)
The authors would like to thank the members of the 'Young Stroke Survivors' community stroke group for their assistance with this project and the clinicians who reviewed the questionnaire.
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Deci EL, Ryan RM (1985): Intrinsic Motivation and Self-Determination in Human Behaviour. New York: Plenum Press.
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Friedrich M, Gittler G, Halberstadt Y, Cermak T, Heiller I (1998): Combined Exercise and Motivation Program: Effect on the Compliance and Level of Disability of Patients with Chronic Low Back Pain: A Randomised Controlled Trial. Archives of Physical Medicine and Rehabilitation 79: 475-487.
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Pelletier LG, Fortier MS, Vallerand RJ, Tuson KM, Briere NM, Blais MR (1995): Toward a new measure of intrinsic motivation, extrinsic motivation, and amotivation in sports: The sport motivation scale (SMS). Journal of Sport and Exercise Physiology 17: 35-53.
Resnick B (1996): Motivation in Geriatric Rehabilitation. Journal of Nursing Scholarship 28: 41-45.
Siegert RJ, Taylor WJ (2004): Theoretical aspects of goal-setting and motivation in rehabilitation. Disability and Rehabilitation 26: 1-8.
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Vallerand RJ, Bissonnette R (1992): Intrinsic, extrinsic and amotivational styles as predictors of behaviour: a prospective study. Journal of Personality 60: 599-620.
Vallerand RJ, O'Connor BP (1989): Motivation in the elderly: a theoretical framework and some promising findings. Canadian Psychology 30: 538-550.
W.H.O (2001): ICF: International classification of functioning, disability and health. Geneva: World Health Organisation.
Zinn S, Bosworth HB, Hoenig HM, Swatzwelder HS (2007): Executive function deficits in acute stroke. Archives of Physical Medicine and Rehabilitation 88: 173-180.
Physiotherapy Honours Student, University of Newcastle Australia
Kerry Baker, BAppSc (Physiotherapy), PhD
Physiotherapy Lecturer, University of Newcastle Australia
ADDRESS FOR CORRESPONDENCE
Sarah Hallams, 4/47 Todman Avenue, Kensington, NSW 2032, Email: firstname.lastname@example.org
Table 1: Questionnaire items with associated Cronbach's [alpha] and Pearson Product Moment correlation coefficients Cronbach's Item-Total [alpha] Correlation Item value (p-value) Part 1: I participate in rehabilitation because ...: Amotivation: I don't know 0.9910 0.9961 (0.0039) ([dagger]) Non self-determined extrinsic motivation: I'm told to do so 0.9265 -0.4813 (0.5187) * I want to make others happy 0.9164 0.6982 (0.3018) * I feel pushed to do so 0.9170 0.7127 (0.2873) I worry about what might happen if 0.9234 0.4160 (0.5840) * I don't Self-determined extrinsic motivation: I can see that rehabilitation will 0.9150 0.9091 (0.0909) help me get to my goals The amount of effort that 0.9150 -0.0652 (0.9348) * rehabilitation requires is worth it Taking part in rehabilitation makes 0.9129 0.4813 (0.5187) * me feel better about myself I want to get home to be with my 0.9090 0.9271 (0.2446) family Getting better is important to me 0.9113 0.9091 (0.0909) Intrinsic Motivation: I want to take part 0.9150 0.8733 (0.1267) I enjoy rehabilitation 0.9451 -0.6002 (0.3998) * Rehabilitation itself is important 0.9150 0.9091 (0.0909) to me PART 2: Social Factors: My family/friends/carers support me 0.9133 0.8334 (0.1666) too much My family/friends/carers support me 0.9207 0.5226 (0.4774) * too little My family should look after me 0.9095 0.9130 (0.2676) I have a good relationship with the 0.9158 0.8645 (0.1355) rehabilitation team I receive mixed messages from the 0.9186 0.5679 (0.4321) * rehabilitation team Seeing other patients improve 0.9207 0.3705 (0.6295) * encourages me Seeing other patients improve 0.9265 0.3088 (0.6912) * discourages me Environmental Factors: My surrounding environment is 0.9170 0.6075 (0.3925)* stimulating I take part in the goal setting 0.9150 0.9091 (0.0909) process I receive enough encouragement 0.9150 0.8645 (0.1355) I receive enough information about 0.9129 0.4160 (0.5840) * strokes I receive enough information about 0.9234 0.8645 (0.1355) the rehabilitation process Personal Factors: I feel positive about my recovery 0.9158 0.9091 (0.0909) I feel positive about life in general 0.9150 0.9091 (0.0909) I can cope with my life at the moment 0.9113 0.6796 (0.3204) * I have a good understanding of the 0.9113 0.9961 (0.0039) rehabilitation process ([dagger]) I have a good understanding of 0.9110 0.8645 (0.1355) strokes I have the time and energy for 0.9158 0.9091 (0.0909) rehabilitation Rehabilitation challenges me enough 0.9150 0.9091 (0.0909) I find rehabilitation too difficult 0.9113 0.9091 (0.0909) * Indicates P.P.M coefficient below acceptable. ([dagger]) Indicates significant p-value
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|Title Annotation:||Research Report|
|Author:||Hallams, Sarah; Baker, Kerry|
|Publication:||New Zealand Journal of Physiotherapy|
|Date:||Jul 1, 2009|
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