RELATIONAL SECURITY IN SECURE SERVICES

Student number: 10037047 Running Head: RELATIONAL SECURITY IN SECURE SERVICES

An Evaluation of Measures of Relational Security used within Secure Services

A dissertation submitted in partial requirements for the degree of Master of Science in the subject of Forensic Psychology Submitted August, 2012 London Metropolitan University School of Psychology

Student Number: 10037047 Supervisor: Wendy Morgan

Word Count - 9607

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Student number: 10037047 Acknowledgements I would like to thank my university supervisor, Wendy Morgan for her guidance and support throughout all stages of the research process. I would also like to thank my workplace supervisor, Dr Regi Alexander, for his support for the project. I would like to thank all the staff from Partnerships in Care Learning Disability Services that took part in the research. Finally, I would like to thank my employers, Partnerships in Care Learning Disability Services, for supporting the research.

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Student number: 10037047 Contents Abstract

4

Introduction

5

Method

9

Results

11

Discussion

28

References

33

Appendices Contents

36

Appendices

37

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Student number: 10037047 Abstract Background – Relational security is the knowledge, and therapeutic relationships between staff and patients within secure services, and the way this knowledge, and relationships are used in order to manage security and risk. Until recently, there have been no direct measures of relational security to assist practitioners in this area. However, two measures of relational security have been introduced. The psychometric properties of these measures have not been evaluated. Aims – This study aims to evaluate the psychometric properties of two measures of relational security, namely; internal consistency, construct validity, contrasted groups validity and principal components analysis. In addition, the study will examine the clinical utility of such measures, from the viewpoint of staff working in secure services. Method – The Relational Security Explorer (DH, 2010) and the See, Think, Act scale (Tighe & Gudjonsson, 2012) were administered to n = 89 members of staff working within a secure intellectual disability service. Internal consistency of the two tools was examined using Cronbach’s a and CITC coefficients. Construct validity was assessed using Pearson’s r. MANOVA were used to explore differences between groups upon scores on each of the two measures. Thematic analysis was used to explore the qualitative data. Results – CITC and Cronbach’s a indicated that both measures had acceptable internal consistency. MANOVA analyses revealed significant differences on scores on subscales of the Relational Security Explorer and the See, Think, Act scale, as predicted by relevant theory. Conclusions – This study provides preliminary data regarding the psychometric properties of two measures of relational security. The measures appear sensitive enough to detect differences between groups on scores of relational security. The study highlights a number of strengths and weaknesses of relational security measures, as reported by staff members.

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Student number: 10037047 Introduction Within secure services, there are three components to effective security; physical, procedural and relational (Collins & Davies, 2005). Breaches in any of these can result in security concerns, but the role of breakdowns in relational security has recently been highlighted as central to a number of significant incidents (Allen, 2010). Despite this, it has been suggested that relational security has been the ‘poor relation’ of the three security processes (Tighe & Gudjonsson, 2012). This is in terms of focus (Aitken & Noble, 2001; Exworthy & Gunn, 2003), policy and procedures (Parry-Crooke & Stafford, 2009), empirical attention, and conceptualising the definition (Chester & Morgan, in press). Definitional Issues The concept of relational security is subject to numerous definitional issues (Chester & Morgan, in press). A literature review highlighted many existing definitions of relational security, all referencing slightly different phenomena. These definitions are detailed in Table 1. Some definitions focus on relational security in terms of quantitative aspects only, such as staff: patient ratio (Bergman-Levy et al., 2010; Kennedy, 2002). Such definitions are rather simplistic, suggesting that if these factors are present; relational security is achieved. Other definitions focus upon factors such as the therapeutic relationship, but did not reference ‘security’ or ‘risk’ (e.g. DH, 2010). Definitions which appear to be of more practical use emphasised exactly how relational issues can affect risk and security (e.g. Dale & Storey, 2004; Collins & Davies, 2005). These reflect the ways in which staff working in secure settings manage potential risks and actual incidents every day. They tended to have two stages, emphasising the link between: 1. Staff knowledge of patients, and patient and staff therapeutic relationships. 2. The way that knowledge of patients and therapeutic relationships are used; to foresee and manage potential and actual, risk or security incidents. Therefore, relational security is intrinsically linked to the assessment and management of risk within secure settings.

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Student number: 10037047 Table 1 Definitions of Relational Security Study

Definition

Kennedy (2002)

Quantitative: the staff-to-patient ratio and amount of time spent in face-to-face contact. Qualitative: the balance between intrusiveness and openness; trust between patients and professionals.

Dale & Storey (2004)

“The professional relationships between staff and patients so that there is a build up of trust, that will enable the staff to get to know and understand their patients, their moods and problems, to facilitate interventions before these become major problems, or lead to incidents of a security nature.”

Collins & Davies

“A detailed understanding of those receiving secure care and how to manage them. This will include potential risk behaviors and a relationship with the patient that includes an open acknowledgement of the potential for dangerous behavior. This level of knowledge allows the practitioner to constantly assess behaviors, patterns of behavior and changes in mental state that have a direct relationship to any immediate or potentially dangerous behavior or similarity to offending patterns”.

(2005)

Bergman-Levy et al. (2010)

Department of Health (2010) Tighe & Gudjonsson (2012)

“…a measure that relates to quality of care. It is customary to discuss the quantitative component that measures the correlation between the number of nurses or staff in the department and the number of patients, but it is even more important to quantitatively measure the percentage of time devoted by the care-giving staff to interaction with the patient. This interaction enables the development of communication and trust between the staff and patients”. “…the knowledge and understanding staff have of a patient and of the environment; and the translation of that information into appropriate responses and care.” “…the concept concerns the quality of therapeutic relationship clinicians have with their patients and the way that this relationship is used to maintain safety through the recovery process.”

The Department of Health (2010) recently developed a further conceptualisation of relational security, as part of a project entitled, See, Think, Act. This work was the result of a consultation project investigating relational security in secure services. The consultation team talked to key stakeholders within forensic services about what relational security meant to them. Stakeholders included; patients, ward staff (domestic, nursing, clinical, admin), carers 6

Student number: 10037047 and advocates, service managers, the National Patient Safety Agency, the Ministry of Justice and commissioners. An analysis of the themes of these discussions highlighted eight areas described as key to relational security. A summary of the definitions of these eight dimensions is provided in Table 2. Table 2 Eight Dimensions of Relational Security (Department of Health, 2010). Therapy

Therapy should give patients realistic hope and belief in their recovery and allow them to build trust in those providing their care.

Boundaries

The principle that boundaries keep everyone safe and ensure that patients receive the kind of care they need in order to recover and develop the skills they need.

Patient Mix

The mix of patients on a ward presents its own set of risks. These risks need to be understood and necessary actions taken if presented.

Patient Dynamic

The relationships that exist between patients shape how a ward community feels and influence the ability to promote a positive culture of recovery.

Personal World

Some events can act as triggers for patients. The histories of patients need to be known in order to understand how they feel.

Physical Environment

The need to understand how the physical environment affects the ability to engage with patients, and maintain relational security.

Visitors

Visitors can have a significant impact on the relational security of a ward. The need to be aware when that impact is good – and when it is unhelpful.

Outward Connections

Contact with the outside world can have a noticeable effect on patients. The need to be aware of the possible risks and know when to act.

Measurement of relational security Given the complexities associated with defining the concept of relational security, there are inevitably a number of challenges with measuring it. Tighe and Gudjonsson (2012) recently reviewed all of the available measures relevant to relational security. The authors note that until recently, there has been no attempt to provide a direct measure of relational security (Tighe & Gudjonsson, 2012). Previously available measures only measure partial aspects of relational security, or relational security on an individual, patient-needs basis. A direct measure of relational security would give an insight into the overall quality of 7

Student number: 10037047 relational security provided within secure wards and services. Such tools would need to be sensitive enough to detect differences between different staff groups and teams, providing insight into strengths and weaknesses in relational security provision. This would allow practitioners to explore background causes, and respond accordingly with appropriate interventions, before an incident occurs. In order to rectify this issue, two instruments have recently been developed which aim to directly measure relational security. These are the Relational Security Explorer (DH, 2010) and the See, Think, Act scale (Tighe & Gudjonsson, 2012). The See, Think, Act scale (DH, 2010) is the first attempt to create a measure which directly measures relational security. Items within the See, Think, Act scale were developed from the conceptualisation of relational security provided by the Department of Health (2010). The authors carried out a principal components analysis of the measure, recruiting participants from the nursing staff of a forensic service which provides medium and low secure beds for male and female inpatients. The analysis were performed on a sample size of n = 159. The analysis confirmed a four-component structure of the measure. The four components are; Therapeutic Risk Management, Pro-Social Team Culture, Boundaries and Patient Focus. Items reflect a number of relational security scenarios, e.g. “We speak up if we think we can see that a colleague has been put in a difficult position that could weaken security”. Users select how closely their team resembles provided statements, using a likert scale from ‘Just like our team’, ‘Quite like our team’, ‘A little like our team’ and ‘Not like our team’. The tool provides a score for each participant on each of the four subscales. The Relational Security Explorer (DH, 2010) is a tool designed to help clinical teams working within secure settings to discuss relational security issues on their ward. In order to facilitate this, the tool requires teams to discuss a number of provided statements that depict best practice in this area. Items relate to the eight areas of relational security conceptualised by the Department of Health (2010) and described in Table 2. The team completing the tool are asked to provide a numerical score regarding how confident they feel in each of the eight areas, on a likert scale ranging from 1 (No confidence) to 10 (Extremely confident). The tool requests users to create action plans around any issues regarding relational security that have been raised during the discussion. This aims to ensure that these discussions can be used to effect positive change. At present, there has been little research which has evaluated the reliability, validity and clinical utility of tools which aim to measure relational security in secure mental health

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Student number: 10037047 services. This analysis should include construct validity, convergent validity, internal consistency and the latent structure of the tools. Internal consistency relates to one aspect of the reliability of a given measure, the extent to which all items within a scale are measuring the same underlying construct (Streiner & Norman, 2008). Internal consistency is measured by Cronbach’s a and CITC coefficients. According to Helmstadter (1964), a values should exceed .70, and a CITC above .50 is considered high (cut-off of .30). Convergent, or criterion validity, investigates the extent to which measures which purport to measure the same or similar phenomena, correlate with each other as expected (Streiner & Norman, 2008). The present study will investigate whether the two available measures of relational security correlate as expected. At present, the underlying latent structure of measures of relational security have not been extensively explored. Latent structures are important when trying to conceptualise and model phenomena which cannot be directly measured (Field, 2009). Relational security is a prime example of such phenomena, as it is not a tangible entity. As such, there is a need to understand the underlying constructs captured by measures of relational security. At present, the underlying structure of the Relational Security Explorer has not yet been investigated. The See, Think, Act scale has been the subject of a principle components analysis performed by the authors, Tighe and Gudjonsson (2012) at various stages of the tool’s development. The authors have noted the need for further exploration of the measure within multiple services. Another aspect of validity which can be measured in order to evaluate a tool is construct validity. One aspect of construct validity is assessed using the “method of contrasted groups”. This method examines whether test scores from distinct groups vary as predicted by theory (Shaughnessy et al., 2003). Tighe and Gudjonsson (2012) found that staff working on higher security wards rate relational security higher than those working on lower levels of security. Quinn, Thomas and Chester (2012) also reported that staff working on higher security wards rate ward climate higher than those working on lower levels of security. Based on these research findings, it was hypothesised that staff working on wards of lower levels of security will rate relational security higher than staff working on higher secure wards. Research has suggested that the security needs of women within secure services are qualitatively different to those of men (Parry-Crooke, Robinson, & Zeilig, 2012). It has been noted that most women in medium-secure units requires less emphasis on physical security and more on relational security (Department of Health, 2002). In addition, it has been 9

Student number: 10037047 suggested that working with women within secure settings places unique demands on staff. Barber, Short, Clarke-Moore, Lougher, Huckle and Amos (2006) describe attachment relationships between staff and female secure patients as often unstable, with rapid changes of mood and behaviour. It was therefore hypothesised that there will be a difference in scores on relational security provided by those working on female wards, than on male wards. The present study will provide an examination of the psychometric properties of the two available measures, the Relational Security Explorer (DH, 2012) and the See, Think, Act scale. The study will also examine the clinical utility of the tools, from the viewpoint of staff working in secure services. This will focus on the usefulness of the tools, in relation to their designed purpose, and the way in which they are currently implemented within clinical practice. In addition, no studies known to the author have investigated relational security within forensic services for those with intellectual disabilities. The present study will investigate relational security within a forensic intellectual disability service.. Method Design The current study employed a mixed-methods design, including quantitative and qualitative sources of data. The quantitative element of the study involved a within participants (reliability testing) and between participants (method of contrasted groups) crosssectional design. Qualitative data was used to gain an in-depth insight into the clinical utility of measures of relational security, from the viewpoint of staff. Triangulation was used to integrate the findings from the quantitative and qualitative elements of the study. Participants Participants were recruited from a secure service for offenders with intellectual disabilities in the East of England. Staff members who have contact with patients as part of their role were eligible for the study. At the time of data collection, the service employed 216 clinical staff (defined as those who had some level of patient contact). Of this group, n = 89 completed questionnaires, reflecting a response rate of 41%. Of those who responded, n = 56 were female (63%) and n = 32 were male (36%). One participant did not state their gender. Of the 89 participants, n = 55, 57.3% were from the nursing department, n = 14 were from occupational therapy (16%), n = 8 (9%) from psychology, n = 5 from social work / CPA, and n = 2 from psychiatry. Six participants were from the housekeeping department. Two participants rated their department as ‘other’. Of the total sample, n = 84 provided information on their length of experience working within secure services. The mean length of experience was six years, and the median was four years (ranging from one month to 20 10

Student number: 10037047 years). There are eight wards within the service. Participants responded from all wards. A proportion of participants stated that they worked across a number of wards (n = 23, 25.8%). Level of security could be calculated for those who worked full-time upon a specific ward (n = 60). Of these participants, n = 21 (23.6%) worked upon medium secure wards, n = 24 (27%) on low secure wards, and n = 15 on rehabilitation wards (16.9%). The gender of patients that the staff members worked with could be calculated for those who worked fulltime upon a specific ward, that provided single-sex accommodation (n = 50) n = 34 worked on wards providing treatment for male patients, and n = 16 worked on wards caring for female patients. Materials Demographic Questionnaire (See Appendix 3) - Participants were asked to provide information on a number of demographic variables, which were; Gender, Length of experience working in secure services, Usual ward worked upon, and Staff Department / Discipline (See Appendix 3). The Relational Security Explorer (DH, 2010) (See Appendix 5) – The Relational Security Explorer is a tool designed to facilitate discussion about relational security within clinical teams. The tool requires users to give a score of their confidence on eight items, which relate to eight areas of relational security; Therapy, Boundaries, Patient Mix, Patient Dynamic, Personal World, Physical Environment, Visitors and Outward Connections. For the purposes of the research, participants were asked to complete the Relational Security Explorer on an individual basis, rather than in their teams. This was a theoretical exercise, designed to establish whether scores on this measure correlate with other measures of relational security, and in order establish whether the current approach to scoring is reflective of all the views of individual members of the team. The See, Think, Act Scale (Tighe & Gudjonsson, 2012) (See Appendix 4) – The See, Think, Act scale is a 28-item measure of relational security within secure services. Items belong to one of four subscales; Therapeutic Risk Management, Pro-Social Team Culture, Boundaries and Patient Focus. Initial validations of this measure have indicated that the measure correlated as expected with relation measures, and that the subscales are internally consistent (Tighe & Gudjonsson, 2012). The Relational Security Evaluation Form (See Appendix 6)– This questionnaire was designed the seek the professional opinions of staff in regards to clinical utility of the Relational Security Explorer. This measure was focused upon as it is used routinely within the service in which the study took place. As such, staff working within the service are 11

Student number: 10037047 familiar with the background and aims of the measure, and should have had time to form opinion regarding its usefulness. In contrast, the See, Think, Act scale was administered solely for the purposes of the research. Questions related to the usefulness of the tool in regards to its designed purpose (Outlined in DH, 2010) and the way in which it is currently used within the service in which the research took place. Procedure Staff eligible for the research were given time within their shift to meet with the researcher. During this meeting, informed consent was sought from potential participants. The researcher went through a Participant Information Sheet (Appendix 1), which provided all the necessary information for a potential participant to make an informed decision about whether to take part in the research. The researcher was available to discuss the research, and to answer questions. A consent form was used in order to record informed consent (Appendix 2). This form required no information by which staff may be identified. After informed consent was obtained, staff members were asked to complete the three questionnaires. This was either done during the meeting, or the participant took the forms away and returned the three questionnaires to the researcher. A debrief form was provided for participants (Please see Appendix 7). Ethics Ethical approval for the study was sought and obtained by the Ethical Committee of the School of Psychology, London Metropolitan University. The planned project was to take place in a service governed by NHS Research and Development policy. As such, ethical approval was also sought from the NHS Norfolk Research & Development office. The office advised that under their terms of reference, the project is classified as service development. Therefore it did not require NHS ethical or research governance approval. Results Participant scores on the two measures, the Relational Security Explorer (DH, 2010), and the See, Think, Act scale (Tighe & Gudjonsson, 2012) were examined for the purpose of analysing the psychometric properties of the two tools. The scores were also examined for internal consistency within-measures, convergent validity between-measures, and betweengroups, as predicted by relevant theory. The underlying latent structure of the measure was also examined. The qualitative data provided by participants was analysed for themes. Assumption Testing Prior to beginning the main analysis, a number of examinations of assumptions for the use of parametric tests were carried out. Measures of normality indicated that this assumption 12

Student number: 10037047 was violated, as the data were negatively skewed. Tests of homogeneity of variance indicated that this assumption had also been violated. In order to address the distribution and the unequal variances, the data were first reverse-scored and then transformed, using a log transformation. After the transformation, problems remained with the homogeneity of variance and the distribution of the data. However, as MANOVA is robust to violations of multivariate normality and to violations of homogeneity of variance (Leech, Barrett, & Morgan, 2009), analyses went ahead using the transformed dataset. Multicollinearity did not appear to be an issue for the individual items of the See, Think, Act scale. For the subscales of this measure, there were very high correlations between variables, indicating that multicollinearity may be an issue. The assumption of multicollinearity was not violated for any of the items of the Relational Security Explorer. Data was assessed for the presence of outliers. A number of cases appeared as outliers for all outcome variables. Notably, these cases were from one occupational department, housekeeping. This group had scored significantly lower than all other groups on all outcome variables. This is not a surprising finding. As the housekeeping department are in direct contact with patients, due to their work in patient areas, they are expected to have training and hold knowledge around relational security issues. However, this department are not involved in many of the relational security processes investigated by the two measures. These outliers were removed for the purposes of further analyses. There were a number of instances whereby a particular variable had missing data. This was where participants had not filled in the questionnaires according to instructions. Many participants had missed out filling out the Relational Security Explorer (DH, 2010), which meant that there were between 14-16 missing cases for each subscale of this measure. This was less pervasive with the See, Think, Act scale, however due to the way in which the total score for each subscale was computed, there ended up being between 6-14 missing cases for each variable. This was where participants had missed out odd items, which were central to the calculation of the total score. This did negatively affect the sample size for some analyses. For further details of the process of assumption testing and data cleaning, please see Appendices 8-12. The reverse-scored, transformed dataset was used for the internal consistency, construct validity, contrasted groups and principal components analyses. Reliability Analysis Internal consistency of the two measures was assessed using Cronbach’s a and Corrected Item-Total Correlation (CITC) coefficients. The overall Cronbach’s a for the 13

Student number: 10037047 Relational Security Explorer was .727. Internal consistency on the individual subscales of the Relational Security Explorer was variable. All subscales of the Relational Security Explorer exceeded the CITC cut-off of .30, excepting the Physical Environment scale at .279. This suggests that there may be an issue with the internal consistency of this scale. The overall Cronbach’s a for the See, Think, Act scale was .932. All individual items of the See, Think, Act scale reached the CITC cut-off. Removing any of the items would have increased the overall Cronbach’s a. All subscales of the See, Think, Act scales had high CITC scores, all over < .8. Table 3 displays the Corrected Item-Total Correlation (CITC) coefficient values and Cronbach’s a if deleted for each subscale of the two measures. Table 3 Corrected Item-Total Correlation (CITC) coefficient values for subscales of the Relational Security Explorer and the See, Think, Act scale Measure

CITC Cronbach’s a if deleted

Relational Security Explorer Therapy Boundaries Patient Mix Patient Dynamic Personal World Physical Environment Visitors Outward Connections

.340 .464 .513 .330 .318 .279 .515 .603

.716 .693 .680 .717 .718 .727 .682 .658

See, Think, Act scale Therapeutic Risk Management Pro-Social Team Culture Boundaries Patient Focus

.810 .896 .826 .928

.920 .892 .915 .915

Construct validity Construct validity was assessed using convergent validity, tested for by correlating subscales of the See, Think, Act scale and subscales of the Relational Security Explorer using Pearson’s r. The Pearson’s values for each variable can be seen in Table 4. All four subscales of the See, Think, Act scale correlated significantly with each other. Subscales of the Relational Security Explorer did not all correlate significantly with each other. There was little convergent validity between the subscales of the two measures. The ‘Personal World’ subscale of the Relational Security Explorer correlated significantly with all subscales of the See, Think, Act scale. 14

Table 4 Correlations matrix of subscales of See, Think, Act scale and Relational Security Explorer Measure

See, Think, Act Therapeutic Risk Management

See, Think, Act scale Therapeutic Risk Management Pro Social Team Culture Boundaries Patient Focus Relational Security Explorer Therapy Boundaries Patient Mix Patient Dynamic Personal World Physical Environment Outward Connections Visitors

ProSocial Team Culture

Boundaries

Relational Security Explorer Patient Focus

Therapy

Boundaries

Patient Mix

Patient Dynamic

Personal World

Physical Environment

Outward Connections

Visitors

1 .772**

1

.726** .797**

.837** .802**

1 .729**

1

.028 .126 -.129 -.077

.102 .294* .017 .029

.047 .233 -.025 .038

.046 .253 -.098 -.183

1 .328** .443** .223

1 .206 .152

1 .432**

1

.468**

.333**

.356**

.367**

.041

.184

.117

.217

1

.039

.064

.145

.187

.144

.222

.224

-.097

.083

1

.143

.193

.159

.233

.338**

.543**

.174

.220

.162

.210

1

.068

.227

.213

.179

.070

.392**

.383**

.307*

.403**

.332**

.521**

**. Correlation is significant at the 0.01 level (2-tailed).

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Principal Components Analysis A Principal components analysis was performed for both the See, Think, Act scale, and the Relational Security Explorer. Principal components analysis was chosen However, problems arose with the analysis, as all of the items were loading onto all components (Please see Appendix 16). This may be due to the non-normal distribution of the data. O'Connor (2010) (cited by Basto & Pereira, 2012) suggested that traditional factor analysis procedures produce meaningful results only if the data is continuous and is also multivariate normal. It is also possible that the analyses was affected by the sample size, which was reduced to n = 83 after the removal of outliers, and also affected by the volume of missing data. The overall Kaiser Meyer Olkin Measure of Sampling Adequacy indicated an acceptable sample size at.841. However, the Kaiser Meyer Olkin Measure of Sampling Adequacy values for the individual items of the scale were not of acceptable levels. Contrasted groups analysis In order to investigate one aspect of construct and face validity, the “method of contrasted groups” was employed. Scores on the subscales of the See, Think, Act scale and Relational Security Explorer were examined for significant differences as predicted by relevant literature. Demographic variables measured were; Level of security, Gender of ward, Gender of staff member, Ward and Staff discipline / department. MANOVA analyses were used as each subscale of the two measures was to be treated as an outcome variable for the purposes of comparing between groups. For the Relational Security Explorer, there were eight outcome variables, and four for the See, Think, Act scale. Although ANOVA’s could have been performed separately for each outcome variable, there would have been an increased likelihood of these multiple comparisons generating significance by chance (Brace, Kemp, & Snelgar, 2006). MANOVA were performed on both the transformed and non-transformed data. This was to ensure that any differences between groups highlighted by the MANOVA on the transformed dataset could be attributed to the effect of the original scores. If a significant effect was found for the MANOVA, further separate univariate ANOVA’s were performed. If significant effects were found for any of the outcome variables on the ANOVA, post-hoc tests were performed, which established the direction of the difference. Level of security For this variable, there were n = 13 staff who worked on medium secure wards, n = 17 who worked on low secure wards, and n = 14 who worked on rehabilitation wards. Table 5

Student number: 10037047 provides the descriptive information for this variable, including means and standard deviations. Table 5 Descriptive statistics for Level of Security’ on transformed scores on the See, Think, Act scale and Relational Security Explorer Measure

See, Think, Act scale Therapeutic Risk Management Pro Social Team Culture Boundaries Patient Focus Relational Security Explorer Therapy Boundaries Patient Mix Patient Dynamic Personal World Physical Environment Visitors Outward Connections

Level of Security Mean (s.d.) Non-Transformed data Transformed data Medium Low Rehab Medium Low Rehab

2.34

(.44)

2.54

(.39)

2.8

(.25)

.20 (.13) .16 (.12) .07 (.09)

2.34

(.49)

2.52

(.48)

2.68

(.41)

.20 (.14) .16 (.14)

2.5 2.5

(.43) (.45)

2.64 2.76

(.41) (.49)

2.83 7.76

(.31) (.34)

.16 (.13) .13 (.13) .06 (.09) .16 (.13) .16 (.14) .08 (.1)

7.46 (1.61) 7.47 (.26) 8.07 7.85 (1.21) 8.3 (.26) 8.3 7.54 (.97) 7.1 (1.56) 8.71 7.15 (1.34) 7.1 (1.34) 8.3 7.31 (1.7) 7.41 (1.18) 8.5 7.23 (1.7) 7.88 (1.4) 8.07

(1.61) (1.21) (.61) (.83) (1.09) (1.33)

.78 .81 .8 .85 .59 .85

(.26) (.25) (.24) (.08) (.18) (.08)

.75 .74 .78 .78 .55 .77

(.29) (.35) (.22) (.21) (.15) (.3)

.1

.83 .8 .87 .85 .39 .76

(.12)

(.25) (.34) (.25) (.25) (.22) (.33)

7.0 (1.09) 7.0 (1.12) 7.64 (1.98) .84 (.06) .84 (.07) .65 (.37) 7.23 (1.36) 7.17 (1.74) 8.07 (1.59) .85 (.09) .78 (.23) .75 (.33)

Using Roy’s Largest Root, there was a significant effect of Level of Security upon subscales of the Relational Security Explorer, F(8, 35) = 1.310, p