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Examination of the reliability and validity of the Triage Assessment Form: Families

ProQuest Dissertations and Theses, 2009
Author: Leslie A Slagel
This study evaluated the reliability and validity of the Triage Assessment Form: Families (TAF: F), a 33-item, 5-point Lickert summated rating scale. The study consisted of 152 college and technical school students. Each participant responded to the TAF: F after reading mild, moderate, marked and severe domestic violence scenarios. Statistical analysis using SPSS 12.0 was performed on the data to determine validity and reliability. Reliability was tested using an internal consistency model. Validity of the TAF: F was evaluated using exploratory factor analysis. In addition, this researched analyzed the capacity of the TAF: F to distinguish among mild, moderate, marked, and severe reactions of families to a crisis situation. The overall statistical data revealed the TAF: F is a reliable instrument, however further studies are needed to strengthen validity and the psychometric properties of instrument.



Abstract iv

Acknowledgements v

Chapter One – Introduction

Statement of the Problem 5

Purpose of the Study 5

Rationale 6

Significance of the Study 7

Limitations 7

Definitions 8

Summary 9

Chapter Two – Literature Review

Crisis Assessment 11

Family Assessment Tools 18

Current Research in Domestic Violence 20

Crisis Intervention 21

Batterers 22

Assessment 26

Women 31

Summary 32

Chapter Three – Methodology

Research Design 33


Sampling 34

Instrument 34

Procedure 37

Data Analysis 39

Hypothesis 40

Null Hypothesis 41

Summary 41

Chapter Four – Results

Demographic Information 42

Reliability 54

Scenario Ratings 56

Correlation Data 58

Factor Analysis 61

Chapter Five - Discussion

Introduction 75

Conclusion 76

Demographic Information 76

Scenario Identification 77

Ranking of Scenarios 78

Reliability of Scenarios 79

Reliability of Subscales 79


Scenario Correlations 80

Recommendations 82

References 85

Appendix A Triage Assessment Form: Families 94

Appendix B Consent to Participate in the Study 95

Appendix C Scenarios 96

Appendix D Demographic Information 99



Table 1 Design of the Study 35

Table 2 Hypothesized Scoring for TAF: F 36

Table 3 Gender by Age 43

Table 4 Victimization by Gender 44

Table 5 Perpetrator by Gender 44

Table 6 Mild Scenario Identification 45

Table 7 Moderate Scenario Identification 46

Table 8 Marked Scenario Identification 48

Table 9 Severe Scenario Identification 49

Table 10 Victims Identification in the Severe Scenario 50

Table 11 Victims Identification in the Marked Scenario 50

Table 12 Victims Identification in the Moderate Scenario 51

Table 13 Victims Identification in the Mild Scenario 52

Table 14 Perpetrator Identification in the Severe Scenario 52

Table 15 Perpetrator Identification in the Marked Scenario 53

Table 16 Perpetrator Identification in the Moderate Scenario 53

Table 17 Perpetrator Identification in the Mild Scenario 54

Table 18 Reliability of the TAF: F 55

Table 19 Cronbach’s Alpha for the Subscales of the TAF: F 56

Table 20 Comparisons of the Hypothesized and Actual Scores 57


Table 21 Correlations by Scenario 61

List of Figures

Table 22 Scree Plot Severe Scenario 62

Table 23 Scree Plot Marked Scenario 65

Table 24 Scree Plot Moderate Scenario 67

Table 25 Scree Plot Mild Scenario 70

Table 26 Scree Plot Combined Scenario 73

Table 27 Correlations between Scenarios 81




The problem of intimate partner violence is well documented in the research literature as well as popular media (Stover, 2005). Dramatic events such as the Lacey Peterson case and the O. J. Simpson trial have contributed to societal recognition of domestic violence. Researchers in the United States estimate that 1 in 6 women are victims of intimate partner violence (Straus, 1999). Not only are the victims of such abuse experiencing this crisis event but other members of the family are affected as well (Dodson & Kurpius, 1977; Fathalla, 2005; Stover, 2005). According to a study conducted by McDonald, Jouriles, Ramisetty-Mikler, Caetano and Green (2006) 15.5 million American children lived in families in which domestic violence had occurred at least one time. Although they may or may not witness the event, children are aware that one parent is being abused, causing stress and trauma for them (Busby, 1996; Kemp, 1998). In the literature, the term domestic violence is used interchangeably with intimate partner violence, marital assault (Ganley, n.d.) and family violence (Volson, 2007). For the purpose of this research the term domestic violence will be used. With respect to the term family, in domestic violence situations where the mother leaves the father or the father leaves mother due to violence/abuse, a family is defined as a mother or father and their children. Historically, intervention and treatment have been ineffective for the victims of domestic violence and exasperating for mental health workers (Dutton & Gondolf, 2000). Typically, in a time of crisis, women and children enter shelters due to a recent physical

2 attack on the mother. At this time, the mother feels her life is in danger (Stainbrook & Hornik, 2006). During her stay at a shelter, assessment of lethality, housing, employment, education, counseling and support are available to her and her children. A woman will leave her relationship up to seven times before she terminates the relationship (J. Scott, personal communication, May 9, 2009). The phenomenon in which woman return to their abuser raises the question for this researcher as to the assessment of these women and their children in this time of crisis. If proper crisis assessment is completed, could the cycle of returning to an abusive relationship be interrupted? There is no consensus for defining how an individual experiences crisis; however, similarities can be found. For example, in the way many people respond to a perceived crisis. Hoff (1995) defined crisis as “an acute emotional upset arising from situational, developmental, or sociocultural sources and resulting in a temporary inability to cope by means of one’s usual problem-solving devices” (p. 4). James and Gilliland (2001) defined crisis as “a perception or experiencing of an event or situation as an intolerable difficulty that exceeds the person’s current resources and coping mechanisms” (p. 3). According to Myer (2001) a crisis is a subjective experience of an event or situation as defined by the person or persons experiencing the crisis. He further states that the person “…must believe the event to be overwhelming and perplexing” (p. 4). Individuals experiencing a crisis have an inability to cope using their normal coping methods. Not only do they have an inability to cope, they experience physical symptoms such as a pounding heart, racing thoughts, an inability to eat or sleep, relational problems, extreme emotionality or restricted emotion (Collins & Collins,

3 2005). According to Lewis and Roberts (2001), in order to resolve the crisis situation an individual must master certain affective, cognitive and behavioral tasks throughout the crisis phase. Although crisis has been studied and described as an individual experience; it can be also understood as a family experience (Dodson & Kurpius, 1977; Fathalla, 2005; Stover, 2005). There are multiple perspectives on how families experience crisis. Families in crisis attempt to cope with an extraordinary situation which has disrupted their normal life routine in undesirable ways. “When the family’s reservoir of coping behaviors become depleted or outmoded and they do not know what to do they are in a crisis” (Ahrons, 1999, p. 385). Hoff (1995) believed that not only is the individual experiencing a crisis, but the members of that individual’s family system are in crisis as well. Hoff further explained that if the source of trouble lies within the family, as opposed to external sources (e.g., flood, fire or racial prejudice), the crisis and the family systems responses are more intense. According to Bowen (1994), families respond to each others needs, emotions, behaviors, thoughts, expectations and individual stressors. The family members become interdependent because of the connectedness and reactivity. The emotional interdependence supports the cohesiveness and cooperation families need to protect shelter and feed their members. Crisis can intensify these processes that support unity and collaboration; anxiety can escalate and spread through the members which can lead to problems (Bowen). According to Goldenberg and Goldenberg (2000), a family’s usual developmental trajectory becomes disrupted when a crisis occurs consequentially changing the nature of familial relationships within the family system. A family’s susceptibility to crisis is also determined by how it defines a traumatic situation. For

4 example, what one family perceives as a crisis situation may not faze another family (Hoff). Traditionally, crisis assessment and intervention has taken an individual approach (Aguilea, 1998; Hoff, 1995; Myer, 2001; Slaikeu, 1990). When a crisis occurs that is intrafamilial, such as domestic violence, those who are most traumatized often are the ones who lack support (Gilliland & James, 2005). Typically, crisis intervention workers focus on the women leaving the abusive relationship, or the child who witnessed the violence, but not on the family as a system. Between 1979 and 2003 at least 33 different instruments were developed and designed to measure domestic violence (Waltermauerer, 2005). During the 1970s much of the research was qualitative, where women reported on their violent experiences (Dobash & Dobash, 1979). Domestic violence researchers looked at time frames of victimization (Tolman, 1989) and screening tools, such as interviewing and questionnaires, were developed to identify abused women (Brown, Lent, Brett, Sas & Pederson, 1996; Lewis, 1985). Research on how victims experience crisis situation as it pertains to domestic violence is plentiful. However, little is known about how the crisis affects the family system affectively, behaviorally or cognitively. When families are experiencing domestic violence often they enter into shelters or treatment facilities in crisis. Mental health workers need to provide crisis assessment and intervention strategies to appropriately respond to the family’s situation (Rathus & Feindler, 2004). The following are two examples of popular assessment tools currently used to evaluate families in crisis situations. McCubbin, Olson and Larson (1981) developed the Family Crisis Oriented Personal Evaluation Scales (F-Copes). This tool is

5 useful when families are experiencing difficult or stressful situations. The F-Copes focuses on two levels of interaction, how families handle stress between members, and how families handle external problems which affect their members (McCubbin, Thompson, & McCubbin, 1996). The Family Functioning Scale (FFS) was created by Bloom, 1995 (cited in Swan & Harringan, 1995) to measure family functioning in a variety of situations. These situations include career choices, abused families, alcoholism, and gender differences (Swan & Harrigan). Tools to measure family functioning are plentiful but none measure a family’s affective, behavioral and cognitive response to crisis. Statement of the Problem

Domestic violence is a widespread problem affecting the individual victim and their families (Ganley, n.d.). While individual crisis intervention approaches are important, a failure to view the impact on the family as a whole has created a dearth of literature on treatment of the family as a system when violence occurs. Green (2003) considers the family to be a system of interrelated parts equally influencing one another (van Geert & Lichtwarck-Aschoff, 2005). Therefore, if one member is experiencing a crisis all members of the family will have a reaction to the situation. “Rarely is a treatment program designed and aimed at the family system level” (Gelles & Maynard, 1987). This study was conducted to provide mental health workers in the domestic violence field with an effective tool to evaluate families in crisis situations. Purpose of the Study The purpose of this study is to determine the validity and reliability of the Triage Assessment Form: Families (TAF: F) developed by Myer & Conte (2006) in order to

6 measure the impact of a domestic violence crisis on families. Validity of the TAF: F was assessed using exploratory factor analysis. Reliability was tested using an internal consistency model. Finally, the research evaluated the capacity of the TAF: F to distinguish among mild, moderate, marked and severe reactions of families to domestic violence situations. Rationale Family violence has been around for generations (Barnett, Miller-Perrin, & Perrin, 2005). As increased numbers of women and their children in acute crisis stemming from domestic violence situations seek assistance from agencies, advocates and counselors must be prepared to provide assistance (Roberts & Roberts, 2000). Mental health providers must first address how this crisis situation has impacted the people experiencing the situation (Maxmen & Ward, 1995; Myer, 2001). Families who endure a crisis situation experience a breakdown in communication, coping, problem solving strategies (McCubbin, Thompson, & McCubbin, 1996) and family support (Navia & Ossa, 2003). Crisis intervention is moving in the direction of an ecological or systems approach. A review of the literature revealed a lack of assessment tools designed to measure a family’s response to a crisis situation. Specifically, no assessment tool designed to measure the affective, behavioral and cognitive responses after a crisis was found. To determine the magnitude of the crisis and monitor progress, accurate measurement is necessary (Lewis & Roberts, 2001). As a connection between the crisis worker and the families experiencing the crisis is formed, the ability to measure the affective, behavioral and cognitive responses will facilitate and promote healing within the family.

7 Significance of the Study Bureau of Justice Statistics reported that between 1998 and 2002, 11% of all reported and unreported incidences of violence were in the family. Families should provide its members with warmth, security and intimacy, but often members experience fear, intimidation and violence from their loved ones (McKie, 2005). Specifically, domestic violence has traumatic effects on all members of the family (Kemp, 1998). Crisis intervention must be done swiftly and effectively (Hoff, 1995). Ineffective interventions which ignore any or all members of the family system may lead to the development psychological disorders (James & Gilliland, 2001). Historically, interventions have been ineffective for the victims of domestic violence and exasperating for mental health workers (Dutton & Gondolf, 2000). Myer and Conte (2006) developed an assessment tool, the Triage Assessment Form: Families (TAF: F), to measure the impact of a crisis on families. The TAF: F has been adapted from the Triage Assessment Model (Myer et al., 1992). Establishing the reliability and validity of the TAF: F will provide professionals in the field of crisis intervention the ability to more confidently determine a family’s affective, behavioral and cognitive reactions to a domestic violence situation and other crisis situations. In turn, more effective interventions can be applied to return the family to a state of equilibrium with the ability to more effectively respond to the crisis and avoid psychological disturbances. Limitations The purpose of this research is to measure the validity and reliability of the TAF:F. There are several limitations to this study. A limitation is defined as factors

8 which may negatively affect or weaken the study for which the researcher has no control (Gay, Mills, & Airasian, 2006). There are situations in research that create a threat to external validity and limit generality (Krathwohl, 1993). There are four possible limitations which could threaten the external validity of this study: the Hawthorne Effect, the subjects thoughts about the study (Huck & Cormier, 1996), novelty (McMillan & Schumacher, (2006) and the disruption effect (Houser, 1998). The Hawthorne Effect may occur when the subjects are aware they are participating in a research investigation and they act differently or alter their answers because they are being observed (Huck & Cormier, 1996). The subjects’ thoughts can make a difference in the results of the research (Huck & Cormier). For example, if participants were once victims, currently victims, in close proximity to an abusive relationship, or working in the field of domestic violence, that could have an effect on the way they rate the scenarios presented. The novelty effect is a concern due to the possibility participants will respond with increased enthusiasm because they are doing something new and different (McMillan & Schumacher, 2006). The disruption effect occurs when an unpredicted disturbance occurs during the experiment (Houser, 1998). For example, fires drill during the experiment. The final limitation to this study is that the participants are responding to hypothetical situations as opposed to real life scenarios. Consequently, there may be a discrepancy between reading about a hypothetical situation and a family’s reaction to experiencing a crisis situation. Definitions Domestic Violence – A pattern of controlling behaviors (i.e. physical, emotional, verbal, sexual, and financial abuse) between intimate partners.

9 Family – A mother or a father and children. Family Crisis – An experience of an event which disrupts the homeostasis of the family altering the family’s ability to use their normal coping methods and disrupting their normal routine patterns. Mild Reaction – In regard to the TAF: F a response to a crisis that indicates the need for minimal and indirect crisis intervention. Moderate Reaction - In regard to the TAF: F a response to a crisis that indicates the need for reasonable and collaborative crisis intervention. Marked Reaction – In regard to the TAF: F a response to a crisis that indicates the need for more direct crisis intervention. Severe Reaction – In regard to the TAF: F, a response to a crisis that indicates the need for rigorous and direct crisis intervention. Conte (2005, p. 13), developed the operational definitions for reaction to organizational crisis in his research. The current definitions of mild, moderate, marked and severe reactions to crisis have been borrowed from his research. Summary If one family member is experiencing a crisis situation, all of the members of the family will be affected by the consequences of the crisis. Having an effective assessment tool designed at the family systems level is essential to facilitate and promote healing. Myer and Conte (2006) developed an assessment tool, the Triage Assessment Form: Families, to measure the impact of a crisis on families. Specifically, the TAF: F measures the families’ affective, cognitive and behavioral reactions to the crisis. This study was designed to establish the reliability and validity of the TAF: F.



In 1942 the catastrophic event of the fire at Cocoanut Grove Melody Lounge in Boston that killed 492 people and injured hundreds launched the field of crisis intervention. At that time Eric Lindemann (1944) developed a model for acute grief that has served as the groundwork for crisis intervention. As a result, the amount of literature in the field of crisis intervention has grown significantly. Dramatic events such as the terrorist attacks of 9/11, the Red Lake School shootings and Columbine School Massacre, hurricanes Katrina and Rita, the tsunami in Southeast Asia, and the Washington D.C. sniper shootings, have contributed to the growth in the literature. Another factor expanding crisis intervention literature is the areas of research in domestic violence, family violence, and sexual assault ( Kreidler & England, 1990; Salter, 1988; Walker, 1989). The recognition that specialized treatment is needed to prevent more serious psychological problems for people who have experienced a crisis has also sparked this growth (Ursano, 1999; Wilson & Raphael, 1993). This literature review will be divided into three sections. The first section will focus on assessment for crisis intervention, and assessment models. The second section will focus on current family assessment tools measuring crisis in families. The last section will contain current research being conducted in the field of domestic violence.

11 Crisis Assessment The need for effective crisis intervention depends on quick and accurate assessment (Greenstone & Leviton, 1993; Hoff, 1995; Myer, 2001). Crisis intervention is a growing human services field, and accurate assessment is necessary to provide appropriate intervention services (Hoff, Myer, 2001). Failure to correctly evaluate crisis reactions can be perilous to both the person in crisis and the mental health worker (Hoff). Assessment is vital but sometimes an overlooked element in effective crisis intervention (Lewis & Roberts, 2001, Myer, Williams, Otten, & Schmidt, 1992). Assessment provides the groundwork for the intervention plan. According to Myer (2001), assessment should be continual with mental health workers, checking the client’s reactions on an ongoing basis to establish what level of intervention is needed. Determining the most effective approach and resources for the client demands that the crisis worker have the ability to properly assess the client’s cognitive, emotional and behavioral reactions to a crisis situation (Kulic, 2005; Lewis & Roberts, 2001; Myer 2001). There are three basic forms of assessment tools used for crisis assessment; rapid assessment instrument (RAI), the interview (Lewis & Roberts, 2001; Myer, 2001) and general personality assessments (Myer et. al., 1992). RAIs measure a client’s reactions to specific crisis events. Not only do RAIs provide information applicable to a specific crisis event, but they also provide a means of monitoring a client during treatment and allowing crisis workers to plan interventions based on the individual’s need (Corcoran & Roberts; 2000; Myer, 2001). RAIs allow crisis workers to foresee the course of treatment, to predict setbacks (Corcoran & Roberts) and to look for possible symptoms that may

12 emerge as treatment progresses (Myer). However, a disadvantage of using RAIs is that symptoms not typically associated with a specific crisis may be missed because the appropriate questions are not asked (Myer). Also, diverse cultural perspective must be considered because symptoms may be misinterpreted unless the instrument has been validated using individuals from different cultures (Prediger, 1994). The most widely used assessment practices in crisis intervention range from unstructured to structure interviews. In the unstructured interview, crisis workers pose questions in a seemingly random manner, hoping to uncover material that will lead to effective and appropriate intervention (Myer, 2001). Myer notes that if crisis workers use a cognitive approach, they will focus on the client’s perception. If crisis workers are more affectively oriented, they will be apt to ask questions to assess the client’s emotions. The structured interview involves asking a set of predetermined questions (Durlak & Roth, 1983). A drawback of the structured interview process is that crisis workers may become so involved in getting through the list of questions that they fail to explore some areas and omit others because they are not on the list. In addition, the questions may be unintentionally biased if they are not culturally inclusive (Myer, 2001). The third assessment practice is general personality instruments. During the past three decades, criticism of these personality assessments has given rise to new instruments. Some of these assessment tools measure anxiety, depression, suicide, criminal behavior, and other problems or disabilities (Aiken, 1999). These types of instruments are sometimes adapted for use in crisis situations (Myer et al., 1992). The foundation for effective crisis intervention is accurate assessment (Greenstone & Leviton; 2002; Myer, 2001). Having an assessment model will help crisis

13 workers structure their approach when gathering information in a crisis situation (Hoff, 1995; Myer). Hoff developed the Vulnerability Model that involves two levels of assessment: safety and the ability to function. Level One assessment must be done by the crisis worker. This level of assessment is essential; it has life and death dimensions and provides information to determine if emergency services are needed. The questions that need to be asked by the crisis worker are: “Is there a potential threat to life; either to the client or the lives of others?”, “Has the person been abused?” and “What are the risks of suicide, homicide or an assault?” Level Two involves assessing personal and social characteristics of the troubled person. Level Two assessment is thorough and includes five elements: (a) identifying the crisis, the crisis event, and socio-cultural factors, (b) determine the developmental pathway and assessment of the crisis; is the person in the initial or acute phase of crisis? (c) looking for manifestations of crisis, how the person views the event and corresponding emotional, cognitive behavior and biophysical responses, (d) is the crisis perceived as a threat, loss or challenge? (e) how does the client cope with stress? Slaikeu (1990) developed a comprehensive model of crisis intervention. Built on existing clinical and research reports, the comprehensive model makes a distinction between first and second order crisis intervention. First order of crisis intervention is described as psychological first aid. Psychological first aid involves immediate assistance and takes one session. Psychological first aid is brief, taking anywhere from several minutes to hours depending upon the emotional upset of the person and the skill of the helper. According to Slaikeu, components of psychological first aid include: make psychological contact, explore dimensions of the problem, examine possible solutions

14 and assist in taking concrete action. The main goal of intervention is getting the client through the immediate crisis event and planning the next step. This goal has three sub- goals: providing support, reducing lethality and connecting the client with other community resources. Second order of crisis intervention is Crisis Therapy which refers to a short term therapeutic intervention aimed at assisting the person in working through the crisis experience. The goal of this intervention is to help the client return to a precrisis state and emerge equipped to face the future. The counselor examines behavioral, affective, somatic, interpersonal and cognitive aspects of the client’s crisis state. This level of intervention requires more skill and training on the part of the counselor. The entire therapeutic process is structured around four tasks: physical survival, expression of feelings, cognitive mastery, and behavioral/interpersonal adjustments. Psychological first aid can be performed anywhere (over the phone, in a hallway). Crisis Therapy requires physical space conducive to and appropriate for traditional therapy session (Slaikeu, 1990). The Triage Assessment Model (TAM) developed by Myer, et al., (1992), can assist crisis workers in understanding the client’s reaction to the crisis situation, therefore providing the groundwork for appropriate intervention. The TAM suggests that there are three domains of a crisis reaction: affective (i e., emotions), behavioral (i.e., actions) and cognitive (i.e., thoughts). Each domain (affective, behavioral and cognitive) is divided into three types of responses that represent the reaction of a client’s experience in crisis situations (Myer, 2001). For example, the affective domain includes anger/hostility, anxiety/fear, and sadness/melancholy. The behavioral domain includes approach,

15 avoidance and immobility. Behavioral reactions are either blatant or hidden in an attempt to solve the crisis. When avoidant behavior is present, the client may ignore, evade or escape the crisis event. Immobility refers to a self-defeating, nonproductive, or disorganized attempt to cope with the crisis (Myer, 2001). These behavioral reactions may be either constructive or maladaptive (Myer & Otten, 1991). For example, in a domestic violence shelter a woman may actively seek new housing for herself and her children in a new location away from her abuser. This would be an example of constructive behavior. However, to stop looking altogether is an example of maladaptive immobility behavior. The cognitive domain includes transgression, threat and loss. Cognitive refers to the client’s thoughts about the crisis and the areas of his or her life that may be affected by the crisis. Transgression refers to the perception of the violation and how a person is thinking in the present. Myer states that a client may experience transgression, threat or loss in each of the following life dimensions: (a) physical (health, shelter, safety), (b) psychological (self-concept, identity, and emotional well-being), (c) social relationships (family, friends, co-workers), and (d) moral/spiritual (personal integrity, values, and belief system). Clients in crisis will usually react using one of these three behaviors (transgression, threat or loss) in an attempt to resolve the crisis. To effectively measure a clients reaction to a crisis Myer et. al. (1991) developed the Triage Assessment Form: Crisis Intervention (TAF); which includes a severity scale to measure each domain (affective, behavioral and cognitive). Initially, the crisis worker should address the domain with the highest reaction. The higher the score in the domain, the more aggressive the intervention should be. Assessment should be given several times while the client is receiving treatment. Therefore, the crisis workers can adjust the

Full document contains 110 pages
Abstract: This study evaluated the reliability and validity of the Triage Assessment Form: Families (TAF: F), a 33-item, 5-point Lickert summated rating scale. The study consisted of 152 college and technical school students. Each participant responded to the TAF: F after reading mild, moderate, marked and severe domestic violence scenarios. Statistical analysis using SPSS 12.0 was performed on the data to determine validity and reliability. Reliability was tested using an internal consistency model. Validity of the TAF: F was evaluated using exploratory factor analysis. In addition, this researched analyzed the capacity of the TAF: F to distinguish among mild, moderate, marked, and severe reactions of families to a crisis situation. The overall statistical data revealed the TAF: F is a reliable instrument, however further studies are needed to strengthen validity and the psychometric properties of instrument.