Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Towards the design of effective short continuing professional education programs Semeniuk, Patricia Louise 1984

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1984_A8 S44.pdf [ 5.72MB ]
Metadata
JSON: 831-1.0055859.json
JSON-LD: 831-1.0055859-ld.json
RDF/XML (Pretty): 831-1.0055859-rdf.xml
RDF/JSON: 831-1.0055859-rdf.json
Turtle: 831-1.0055859-turtle.txt
N-Triples: 831-1.0055859-rdf-ntriples.txt
Original Record: 831-1.0055859-source.json
Full Text
831-1.0055859-fulltext.txt
Citation
831-1.0055859.ris

Full Text

TOWARDS THE DESIGN OF EFFECTIVE SHORT CONTINUING PROFESSIONAL EDUCATION PROGRAMS By PATRICIA LOUISE SEMENIUK B.N., McGill University, 1972 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS In THE FACULTY OF GRADUATE STUDIES (Department of Administrative, Adult and Higher Education) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA Q July, 1984 Patricia Louise Semeniuk, 1984 AUTHORIZAT ION I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d b y t h e H e a d o f my d e p a r t m e n t o r b y h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t b e a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Towards the Design of E f f e c t i v e Short C o n t i n u i n g P r o f e s s i o n a l Education Programs ABSTRACT The goal of c o n t i n u i n g p r o f e s s i o n a l education i s to improve the p r o f e s s i o n a l ' s p r a c t i c e i n the work s e t t i n g . In c o n t i n u i n g education programs f o r nurses the u l t i m a t e g o a l i s to improve the h e a l t h s t a t u s of c l i e n t s . Few c o n t i n u i n g p r o f e s s i o n a l education programs are ever evaluated beyond the l e v e l o f s o l i c i t i n g p a r t i c i p a n t feedback r e g a r d i n g g e n e r a l s a t i s f a c t i o n with a program. While s e v e r a l f a c t o r s account f o r t h i s phenomenon, one o f the g r e a t e s t b a r r i e r s i s the l a c k of a u n i f y i n g conceptual framework that c o u l d be a p p l i e d to eva l u a t e the impact of a program on p a r t i c i p a n t s ' behaviour i n the work s e t t i n g . T h i s r e s e a r c h p r o j e c t i s an attempt to i d e n t i f y f a c t o r s which c o n t r i b u t e to a program's e f f e c t i v e n e s s i n changing work behaviour i n the p r a c t i c e s e t t i n g . Two questions are addressed: what b e h a v i o u r a l changes are a c h i e v a b l e i n s h o r t c o n t i n u i n g p r o f e s s i o n a l education programs and how can the experiences of e f f e c t i v e programs be t r a n s l a t e d i n t o p r i n c i p l e s f o r the plann i n g of programs intended to impact on the nurses' p r a c t i c e i n the work s e t t i n g ? Based on a review of the e v a l u a t i o n frameworks p u b l i s h e d i n - i i -the a d u l t education l i t e r a t u r e and s y n t h e s i z i n g concepts from change theory and adoption theory v a r i a b l e s which are b e l i e v e d to i n f l u e n c e program impact on work behaviour are i d e n t i f i e d . An a p p l i c a t i o n o f these v a r i a b l e s to an a n a l y s i s o f r e s e a r c h r e p o r t s of e f f e c t i v e c o n t i n u i n g p r o f e s s i o n a l education programs r e s u l t s i n the s p e c i f i c a t i o n o f more s p e c i f i c s u b - v a r i a b l e s which c o n t r i b u t e to program impact on work behaviour. T h i s a n a l y s i s o f e f f e c t i v e programs r e v e a l s t h a t the types of o b j e c t i v e s a c h i e v a b l e i n short programs i s l i m i t e d p r i m a r i l y to the realm of s p e c i f i c psychomotor s k i l l s , regimes or procedures. The s u b - v a r i a b l e s i d e n t i f i e d i n the e f f e c t i v e programs are a p p l i e d to a r e s t r o s p e c t i v e process a n a l y s i s o f a s p e c i f i c province-wide program developed by the R e g i s t e r e d Nurses' A s s o c i a t i o n of B r i t i s h Columbia. Based on the r e s u l t s o f the a n a l y s i s o f these programs seven p r i n c i p l e s are proposed as g u i d e l i n e s f o r the development of programs intended to impact on the work behaviour of p a r t i c i p a n t s . A r e s e a r c h study i s proposed to t e s t out these program p l a n n i n g p r i n c i p l e s which are designed to a s s i s t nurses to l i n k the knowledge gained i n a program to a c t i o n i n the p r a c t i c e s e t t i n g . I m p l i c a t i o n s f o r f u r t h e r r e s e a r c h are g i v e n . - i i i -TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES v i LIST OF FIGURES v i i CHAPTER I: INTRODUCTION 1 CHAPTER II : REVIEW OF THE LITERATURE 10 Role of Evaluation 11 Levels of Program Impact 12 Models of Planned Change 21 Cervero's Conceptual Framework for Evaluation 31 State-of-the-Art of Evaluation Research 44 Analysis of E f f e c t i v e Programs 46 Summary 58 CHAPTER I I I : ANALYSIS OF THE SAFETY TO PRACTICE CONFERENCES..64 Program Characteristics 66 Characteristics of Participants 79 Characteristics of the Proposed Behavioural Changes 79 Characteristics of the Social System 82 Summary 83 CHAPTER IV: PLANNING EFFECTIVE SHORT NURSING PROGRAMS 88 Program Planning P r i n c i p l e s 89 Summary 95 - i v -CHAPTER V: PROPOSAL FOR A RESEARCH DESIGN 97 Program Design 97 Evaluation Design 99 CHAPTER VI: SUMMARY AND IMPLICATIONS 107 REFERENCES 116 APPENDIX A: CONFERENCE OBJECTIVES 124 -v-LIST OF TABLES TABLE I: PROGRAM CHARACTERISTICS RELATED TO BEHAVIOURAL CHANGE 62 TABLE II : PARTICIPANT CHARACTERISTICS RELATED TO BEHAVIOURAL CHANGE 62 TABLE I I I : CHARACTERISTICS OF OBJECTIVES RELATED TO BEHAVIOURAL CHANGE 63 TABLE IV: SOCIAL SYSTEM CHARACTERISTICS RELATED TO BEHAVIOURAL CHANGE 63 TABLE V: DESCRIPTIVE DATA SUMMARY OF SCORES 103 TABLE VI: CORRELATION BETWEEN INDEPENDENT VARIABLES AND DEPENDENT VARIABLE 105 - v i -LIST OF FIGURES FIGURE 1: CORBETT'S CONTINUUM OF IMPACT 15 FIGURE 2: MITSUNAGA AND SHORES' SPIRAL OF IMPACT 17 FIGURE 3: DIXON'S CAUSAL CHAIN OF RELATIONSHIPS 19 FIGURE 4: CERVERO'S FRAMEWORK OF IMPACT VARIABLES 32 - v i i -CHAPTER I INTRODUCTION In 1980 the Board of Directors of the Registered Nurses' Association of B r i t i s h Columbia approved a proposal for the development and implemenatation of a series of four related educational conferences which were to to be ca l l e d the "Safety to Practice Conferences" (RNABC News, May 1980). These conferences were intended to help Registered Nurses to consider how to deal with a selected number of issues related to the safe practice of nursing. Between 1981 and 1984 more than one hundred of these conferences were held i n B r i t i s h Columbia. Co-sponsors were RNABC Chapters and Interest Groups, educational i n s t i t u t i o n s and health care agencies. Records of the exact number of participants who have attended these conferences are not ava i l a b l e . Based on the 1981 and 1982 records of p a r t i c i p a t i o n an estimate can be made that approxiamtely 2300 Registed Nurses in B r i t i s h Columbia have attended at least one of these conferences since they were f i r s t offered i n 1981 . Because nurses r a r e l y work independently i t can be assumed that the average nurse interacts on a d a i l y basis, with a minimum of three other nurses i n her work se t t i n g . Hypothetically, the conference - 2 -content, i f discussed with these co-workers, could have had a potential impact on approximately 7,000 nurses i n the province. This represents approximately 36% of the 19,184 nurses registered and p r a c t i c i n g i n the f i e l d as of June 1983 (Roll C a l l , June 1983) . Conferences i n this series have also been bought by other p r o v i n c i a l and t e r r i t o r i a l nursing associations for the purpose of making the contents available to t h e i r own memberships. Records of p a r t i c i p a t i o n i n these conferences outside B r i t i s h Columbia are not a v a i l a b l e . The "Safety to Practice Conferences", as educational proces-ses, were based on what Corbett (1979) c a l l s a continuum of assumptions about the impact of continuing professional education. Impact can be defined as: ...the ef f e c t on or evidence of having made a difference; or being capable of having the potential for inducing an e f f e c t which as yet may not be documented but i s reasonable to posit as possible. (Cooper, et. a l . , 1982:6) Continuing professional education i s based on the premise that participants w i l l learn the material, apply what i s learned and thus improve t h e i r practice, which i n turn w i l l improve the health status of patients or c l i e n t s . Continuing professional education programs consequently are expected, over the long term, to have a p o s i t i v e impact on the recipients of each participant's professional services. This notion that continuing education can ensure the competency of professionals was p a r t i c u l a r l y popular i n the - 3 -United States in the 1970's when several states enacted l e g i s l a t i o n requiring mandatory continuing education as a condition for relicensure in many of the health professions. By 1980 nurses i n nine states required evidence of having participated in continuing education as a condition for t h e i r r e l i c e n s i n g (Cooper, et a l . , 1982). Although continuing education has been used i n these States as a mechanism to assure qua l i t y of care, i t i s an educational system without the authority to assume d i s c i p l i n a r y or regulatory functions related to a participant's professional practice subsequent to the continuing education program. The United States experience with the impact of mandatory continuing education on the health professional's competence has been so disappointing that between 1981 and 1982 no new l e g i s l a t i o n was enacted i n any of the states to require mandatory continuing education i n any profession (Cooper, et a l . ) . No p r o v i n c i a l or t e r r i t o r i a l nursing association i n Canada requires p a r t i c i p a t i o n i n continuing education as a condition for yearly relicensure. Instead, nurses i n Alberta, Newfoundland, the Northwest T e r r i t o r i e s , Quebec and Prince Edward Island who have been out of practice for some time or who have practiced less than a s p e c i f i c number of days i n the previous two to f i v e years are required, by t h e i r p r o v i n c i a l nursing associations, to successfully complete a refresher nursing program before they can become relicensed (Grice, 1983). Despite the fact that mandatory continuing education has - 4 -e x i s t e d i n the U n i t e d States f o r more than a decade and d i s c u s s i o n continues r e g a r d i n g the impact of c o n t i n u i n g p r o f e s s i o n a l e d u c a t i o n , there i s a d e a r t h of e m p i r i c a l evidence a t t e s t i n g to the impact of s h o r t c o n t i n u i n g p r o f e s s i o n a l e d u c a t i o n programs beyond the l e v e l of i n c r e a s i n g a p a r t i c i p a n t ' s knowledge at the time of the e d u c a t i o n a l a c t i v i t y . Even evidence of the p e r s i s t e n c e o f t h i s knowledge g a i n i s l a c k i n g . For the purpose of t h i s paper, shor t programs are d e f i n e d as those e q u i v a l e n t i n l e n g t h to between e i g h t and twenty-four hours of i n s t r u c t i o n . The i s s u e i n the e v a l u a t i o n of the impact of any c o n t i n u i n g p r o f e s s i o n a l e d u c a t i o n program i s to assess the r e l a t i o n s h i p between educ a t i o n and a c t i o n . The concern i s not what p a r t i c i p a n t s know at the end o f the program but what they do i n p r a c t i c e as a r e s u l t of the program. The problem goes back to the f a c t t h a t d e s p i t e the e x i s t e n c e o f over n i n e t y program p l a n n i n g models (Buskey and Sork, 1982) , the r e l a t i o n s h i p between these models and t h e i r e f f e c t i v e n e s s i n impacting on p a r t i c i p a n t s ' work behaviour remains u n t e s t e d . Assessment of the e v a l u a t i o n s t u d i e s r e p o r t e d i n the l i t e r a t u r e i s complicated by the f a c t t h a t no u n i f y i n g conceptual framework f o r e v a l u a t i o n e x i s t s . Consequently, i t i s d i f f i c u l t to i d e n t i f y p a t t e r n s of r e l a t i o n s h i p s among v a r i a b l e s . Most s t u d i e s d e a l w i t h only one or two independent v a r i a b l e s and design compromises d i m i n i s h the c o n f i d e n c e that can be p l a c e d i n the r e s u l t s . - 5 -Few empirical evaluation studies have been published in the f i e l d of continuing nursing education. Some empirical studies have been conducted i n the f i e l d of continuing medical education. Bertram and Brooks-Bertram (1977), Corbett (1979), Knox (1979), Lloyd and Abrahamson (1979), and Stein (1981) have conducted reviews of evaluation studies of continuing medical education programs. In the i r analysis of impact studies, these reviewers, except for Stein (1981), found that formative evaluation appeared to be common while summative evaluation, when conducted, provided inconclusive evidence to support the contention that continuing professional education has any impact beyond the classroom. They found that the "evidence" of program impact cited i n many studies frequently came from summaries of participant s a t i s f a c t i o n and comments through end-of-program evaluation forms. Bertram and Brooks-Bertram (1977) , Corbett (1979) , Lloyd and Abrahamson (1979) and adult educators such as Knowles (1981), M i l l e r (1979), Mitsunaga and Shores (1977) and Sjogren (1979) have speculated as to the reasons why impact evaluation i s such a neglected area i n continuing education and why the small number of studies published provide i n s u f f i c i e n t evidence upon which to draw conclusions that would be of assistance i n the design of new programs. The problems which these authors believe have hindered the implementation and analysis of the cause-and-effeet relationships i n short programs f a l l into several categories: d i s p o s i t i o n a l and s i t u a t i o n a l factors involving participants; unclear program goals; design problems involved i n conducting - 6 -e v a l u a t i o n s ; and p r a c t i c a l and p o l i t i c a l c o n s t r a i n t s . T h i s paper w i l l attempt to determine whether the " S a f e t y to P r a c t i c e Conferences" could have been expected to have had an impact on p a r t i c i p a n t s ' work behaviour. During the process of answering t h i s q u e s t i o n a p o s i t i o n w i l l be taken, based on the a n a l y s i s of e f f e c t i v e programs, as to which types of o b j e c t i v e s seem to be a c h i e v a b l e i n short c o n t i n u i n g p r o f e s s i o n a l education programs. I m p l i c a t i o n s f o r the design of e f f e c t i v e short c o n t i n u i n g p r o f e s s i o n a l e d u c a t i o n programs w i l l be drawn from analyses of the r e s e a r c h s t u d i e s of e f f e c t i v e programs and the " S a f e t y to P r a c t i c e Conferences." These i m p l i c a t i o n s w i l l be presented as a l i s t o f p r i n c i p l e s f o r the design o f e f f e c t i v e s h o r t c o n t i n u i n g n u r s i n g education programs. S e v e r a l f a c t o r s i n f l u e n c e d t h i s w r i t e r ' s d e c i s i o n to conduct a r e t r o s p e c t i v e process a n a l y s i s r a t h e r than an e m p i r i c a l e v a l u a t i o n study of these c o n f e r e n c e s . An i n i t i a l attempt to conduct an e m p i r i c a l r e s e a r c h study had to be abandoned f o r s e v e r a l pragmatic reasons . At the time of the w r i t i n g o f t h i s paper i t could not be p r e d i c t e d whether study samples would be a v a i l a b l e f o r one conference, l e t alone f o r the e n t i r e conference s e r i e s . R e g i s t r a t i o n d e a d l i n e s of one to two weeks p r i o r to each conference meant that a conference could be c a n c e l l e d at a l a t e date due to i n s u f f i c i e n t r e g i s t r a t i o n . Pre-and post-program i n t e r v i e w i n g would have been r e q u i r e d to measure a t t i t u d i n a l and b e h a v i o u r a l changes y e t , of those conferences which d i d take p l a c e d u r i n g the w r i t i n g of t h i s paper, most were o u t s i d e the - 7 -Lower Mainland where personal contact would have been impossible. Few participants attended a l l four conferences and as the names of participants who attended the conferences after 1982 were not avail a b l e , even a retrospective study of the participants' a t t i t u d i n a l and behavioural changes could not have been conducted. In an e f f o r t to further d i f f u s e the conference content among the nursing population of B r i t i s h Columbia, health care agencies were given permission, i n the l a t t e r part of 1983, to adapt the conferences to the s p e c i f i c needs of t h e i r s o c i a l systems. Consequently, the objectives achieved i n such a presentation might not always be the same as those intended for a conference as an entire package. Too l i t t l e would have been known about the educational process in these instances to develop v a l i d evaluation instruments. Chapter II of this paper begins with a review of the evaluation frameworks developed i n the adult education and tr a i n i n g sectors, the continuing medical and nursing education sectors, and includes models of planned change. This review serves as an introduction to Cervero's (1982) conceptual framework for the evaluation of the impact of continuing professional education on behaviour. Finding a framework which could be applied with some confidence to predict a program's impact on a participant's work behaviour i s a problem. Cervero's framework, which i s r e l a t i v e l y simple and easy to implement, seems to hold the most promise for program planners wanting to conduct evaluations of th e i r programs. An adaptation of - 8 -Cervero's framework i s applied to an analysis of ef f e c t i v e programs for the purpose of i d e n t i f y i n g s p e c i f i c sub-variables which seem to influence program impact on partic i p a n t s ' work behaviours. The s p e c i f i c subvariables i d e n t i f i e d as influencing impact f a c i l i t a t e the process of reporting and analysing the "Safety to Practice Conferences" i n Chapter I I I . These subvariables w i l l be applied to a retrospective process analysis of the conferences. A fundamental assumption underlying this retrospective process analysis i s that the process of program planning i s d i r e c t l y related to the outcomes achieved by a continuing professional education program. The fact that this program was being designed for a potential audience of over 15,000 Registered Nurses i n B r i t i s h Columbia influenced many programming decisions. Details of the li m i t a t i o n s and constraints imposed upon the program design w i l l be presented. Based on the analysis of these conferences a judgement w i l l be made regarding the possible impact that any of these conferences may have had on participants' work behaviours. A l i s t of p r i n c i p l e s for the design of e f f e c t i v e impact programs w i l l be presented i n Chapter IV. These p r i n c i p l e s are intended to serve as guidelines for program planners as they make decisions about the goals and the design of continuing professional education programs intended to impact on participants' work behaviours. They are intended to serve as an adjunct to exis t i n g adult education p r i n c i p l e s and selected - 9 -program p l a n n i n g models wi t h s i m i l a r p h i l o s o p h i c a l p e r s p e c t i v e s . Chapter V w i l l propose a r e s e a r c h design f o r a study to t e s t whether these p r i n c i p l e s , i f o p e r a t i o n a l i z e d , would i n f l u e n c e program impact. Each p r i n c i p l e w i l l not be t e s t e d as an independent v a r i a b l e . Rather, the p r i n c i p l e d i v e r g i n g most from c o n v e n t i o n a l program p l a n n i n g models w i l l be s e l e c t e d as the one independent v a r i a b l e w h ile the other p r i n c i p l e s w i l l serve as the moderator or i n t e r v e n i n g v a r i a b l e s . F i n a l l y , i n Chapter VI, the r e s u l t s of t h i s paper w i l l be summarized and suggestions f o r f u r t h e r study w i l l be made. - 10 -CHAPTER II REVIEW OF THE LITERATURE A b r i e f review of the roles and goals of evaluation serve to introduce frameworks for the evaluation of continuing professional education. Evaluation frameworks developed i n the adult education, adult t r a i n i n g , continuing medical and nursing education sectors suggest that programs may have d i f f e r e n t levels of impact. Factors i d e n t i f i e d i n these frameworks as p o s i t i v e l y influencing impact at the l e v e l of performance change or change in work behaviour w i l l be discussed. Models of planned change which propose factors that may influence impact on behaviour w i l l also be included. The factors i d e n t i f i e d i n these frameworks and models provide the foundation for a perspective of Cervero 1s (1982) conceptual framework for the evaluation of continuing professional education, i t s e l f somewhat of a synthesis of these v a r i a b l e s . Cervero provides a framework for the examination of the interaction of factors involved in the relationship between continuing education and behavioural change. An adaptation of Cervero's framework which integrates Rogers' (1983) adoption variables w i l l be applied to an analysis of e f f e c t i v e continuing professional education programs. Subvariables i d e n t i f i e d as - 11 -influencing impact i n these research studies are c l a s s i f i e d under Cervero's independent variables of program c h a r a c t e r i s t i c s , c h a r a c t e r i s t i c s of part i c i p a n t s , c h a r a c t e r i s t i c s of the proposed behavioural changes and c h a r a c t e r i s t i c s of the s o c i a l system. Limitations as to the judgements which can be made as a re s u l t of this analysis exist due to the fact that d i f f e r e n t evaluation frameworks were used i n each of the studies and the methods of reporting also d i f f e r e d . For the purposes of this paper i t i s assumed that factors not mentioned i n a report did not exist in a program. A position w i l l be taken at the end of this section as to which types of objectives seem to be achievable i n short continuing professional education programs. Role of Evaluation During the development. implementation and termination stages of any educational program, evaluative information should be gathered to a s s i s t with decision making. Since there are many kinds of decisions to be made at these stages, numerous conceptual models have been published which categorize the nature of the decisions and propose a co r o l l a r y evaluation process (Provus, 1969; Scriven, 1967; Stake, 1967; Stufflebeam, 1975; Tyler, 1949) . Decision needs d i f f e r s i g n i f i c a n t l y according to the program stage . According to Scriven (1967) , evaluation consists of - 12 -measuring not only i f the objectives or goals were achieved but judging whether these objectives were worthwhile. Evaluation, i n this model, serves two roles: one i s for decision making, the other for accountability. Both formative and/or summative evaluations can be conducted using this model with the evaluator reporting on the goals, design, process and product of the program. Decision making and accountability are the role of evaluation i n Stufflebeam 1s (1975) model. Evaluation, i n this model i s defined as a process of delineating, obtaining, and applying descriptive and judgemental information concerning a program's merit as revealed by i t s v a r i a b l e s . These variables consist of context, input, process and product. Levels Of Program Impact More s p e c i f i c c r i t e r a other than those implied by the two aforementioned models, need to be established i f the impact of a continuing professional education program i s to be evaluated. From the f i e l d s of adult education (Groteleuschen, 1980; Schechter, 1974) adult t r a i n i n g (Bennett, 1976; Kirkpatrick, 1967) continuing medical education (Corbett, 1979) and continuing nursing education (Dixon, 1978; Mitsunaga and Shores, 1977) come propositions and frameworks regarding d i f f e r e n t l e v e l s of impact. To determine what evidence needs to be co l l e c t e d and the standards for measurement an evaluator chooses a framework and - 13 -the l e v e l of impact to be evaluated. Each framework suggests general methods for c o l l e c t i n g data at each l e v e l . Adult Education Frameworks Both Schechter (1974) and Groteleuschen (1980) share the proposition that there are two levels of outcomes that should be measured when evaluating the impact of a program. F i r s t - o r d e r on phase one outcomes are the participant's accomplishments r e s u l t i n g from the educational experience. These authors indicate that f i r s t order outcomes can be within the broad realm of knowledge, understanding or competence, the c r i t e r i a for which are derived from the i n s t r u c t i o n a l objectives for a program. Competence, in this context, means end of program s k i l l s . Second-order outcomes are the participants' on-the-job performance and the effects on c l i e n t s which are a consequence of the f i r s t - o r d e r program accomplishments. Schechter l i s t s program c h a r a c t e r i s t i c s , participant motivation and work environment as factors which may influence second-order outcomes. Adult Training Frameworks Kirkpatrick (1967) proposes four levels of impact: (1) reaction, (2) learning, (3) behaviour, and (4) r e s u l t s . In Bennett's (1976) chain-of-events hierarchy there are seven levels of impact, of which the highest four levels of: (1) reaction; (2) knowledge, s k i l l and attitude change; (3) practice change or adoption; and (4) end results can be viewed as similar to - 14 -Kirkpatrick's hierarchy. These two frameworks suggest that to evaluate behavioural change, practice change, or adoption, information should be gathered systematically through questionnaires and pre- and post-program observations of each participant's work performance. The observations would be conducted by pa r t i c i p a n t s ' supervisors, subordinates or peers. Program i s the primary variable influencing impact i n these frameworks . Bennett implies that the l e v e l of the program objectives should be considered a variable determining at what l e v e l a program would be evaluated. Another pote n t i a l variable he i d e n t i f i e s i s the participant's perceptions of the anticipated benefits and consequences of practice change, factors which would influence the decision to adopt a new behaviour or p r a c t i c e . Continuing Medical Education Frameworks Corbett (1979) states that i t i s the r e s p o n s i b i l i t y of con-tinuing professional education programs to go beyond attempts to remedy def i c i e n c i e s to actually attempt to impact on the o r i g i n a l problem. From this philosophical perspective she proposes a continuum of desired impact which i s i l l u s t r a t e d i n Figure 1 (Page 15). Evaluation of impact, according to Corbett, can occur at only one of three i n t e r - r e l a t e d points at any one time. The f i r s t point of impact i s on what can be termed either professional practice, work behaviour, or performance. Second, is the impact on organizational effectiveness and e f f i c i e n c y as a - 15 -re s u l t of professional performance. F i n a l l y , the ultimate or most desirable point of impact would be on c l i e n t outcomes which would be the indicat i o n of successful professional and agency services. Figure 1 CORBETT'S CONTINUUM OF IMPACT Improved Improved Application Improved Improved Learning > of Learning i n > Organizational > Client Professional Practice Functioning Outcomes Source: Corbett, T. The Impact of Continuing Medical Education on Quality of Care: Implications of the CME Evaluation L i t e r a t u r e . In P.P. LeBreton, et al.(Eds.) Evaluation of Continuing Education for  Professionals: A Systems View, Seattle: University of Washington, 1979, pp 369-393. Corbett acknowledges the problem of confounding variables i n the following statement: At each juncture the e f f e c t i v e role that evaluation can play i n each outcome diminishes, and the number of factors that can influence outcome grows. Corbett (1979:366) In p a r t i c u l a r , i t i s the complexity of the environment i n which the learning i s to be applied where constraints, obstacles and barrie r s may influence a participant's behaviour and, i m p l i c i t l y , c l i e n t outcomes. - 16 -Continuing Nursing Education Frameworks From the nursing sector Mitsunaga and Shores (1977) and Dixon (1978) propose c r i t e r i a for evaluating the impact of continuing nursing education, c r i t e r i a which e s s e n t i a l l y do not d i f f e r s i g n i f i c a n t l y from those hierarchies just discussed. The Mitsunaga and Shores framework i s presented schematically i n Figure 2 (Page 17) as a s p i r a l with four loops representing p o t e n t i a l l y increasing complexity i n the evaluative process. These progress from learner s a t i s f a c t i o n , to knowledge s k i l l s and attitude change, to change i n practice, to the relationship of practice change, to the quality of service or patient outcomes. Recommendations as to how to c o l l e c t data at each l e v e l i n this framework provide no further insights than those provided i n the e a r l i e r frameworks. Within the Mitsunaga and Shores framework a di r e c t relationship i s assumed between one l e v e l and the next. Positive participant reaction to the learning experience coupled with the participant's perception that learning has taken place i s seen as providing information that can be used for decision making. This i s based on the authors' position that: (1) high learner s a t i s f a c t i o n i s d i r e c t l y related to the tendency to seek additional related learning experiences, (2) high learner s a t i s f a c t i o n i s related to actual learning, and (3) self-perception of having learned i s d i r e c t l y related to actual learning. No research i s c i t e d i n t h e i r a r t i c l e to support these statements. - 17 -Figure 2 MITSUNAGA AND SHORES' SPIRAL OF IMPACT Source: Mitsunaga, B. and Shores, L. Evaluation of Continuing Education: Is It Pr a c t i c a l ? Journal of Continuing Education i n Nursing, (IV//), 8 (6) , P . i u . - 18 -Program i s the one predominant factor a f f e c t i n g outcomes i n this framework. Some reference i s made to learner and course goal congruency as a potential factor influencing the impact of a program. A s o c i a l system ready to incorporate change and a participant's position of influence s u f f i c i e n t to accomplish change are s i t u a t i o n a l factors introduced i n the a r t i c l e as p o t e n t i a l l y a f f e c t i n g impact both at the l e v e l of practice change and patient outcomes. Dixon (1978) proposes a framework of level s of impact similar to those already reviewed. The relationships among the levels of impact are considered within the context of a chain-of-events (see Figure 3, p.19) progressing from: (1) participants' perceptions and opinions about the course, to (2) knowledge and attitude change, to (3) professional behaviour in the c l i n i c a l s etting, and f i n a l l y to (4) impact of behaviour change on patient outcomes. Placement of participant perception data within this causal chain i s complicated as perceptions can be influenced by any of the lin k s in the chain. Dixon c l a r i f i e s the issue of the process-product variables of evaluation by i l l u s t r a t i n g that evaluation c r i t e r i a may be conceptualized according to t h e i r frame of reference within the continuum. Within the process-product continuum any single intermediary point may represent a product i n r e l a t i o n to some c r i t e r i a and a process i n r e l a t i o n to others. What i s required, however, i s the operationalization of the broad goal of any - 19 -educational program to allow for s p e c i f i c a t i o n of where behaviour should be evaluated i n this continuum. Dixon believes that po s i t i v e summative evaluation findings at one l e v e l tend to vali d a t e the accuracy of the postulated chain-of-events to that point. Negative results at one l e v e l , on the other hand, would not provide information about levels of impact e a r l i e r i n the chain. Figure 3 DIXON'S CAUSAL CHAIN OF RELATIONSHIPS Course > change i n knowledge and attitudes of participants >Change in c l i n i c a l -behaviour of participants p^ant^ Participants' perceptions of course and i t s results -> Change in patient outcomes Source: Dixon, J . Evaluation C r i t e r i a in Studies of Continuing Education i n the Health Pro-fessions: A C r i t i c a l Review and Suggested Strategy. Evaluation and the Health Pro-fessions, 1978, 1 (2) , 52. The factors i d e n t i f i e d i n these frameworks as p o t e n t i a l l y influencing program impact on a participant's work behaviour include: (1) program design (Bennett, Kirkpatrick, Mitsunaga and Shores, Schechter); (2) work environment or context of application (Mitsunaga and Shores, Corbett, Schechter); (3) participant's motivation for p a r t i c i p a t i o n and/or a par-t i c i p a n t ' s perceptions of anticipated benefits or con-- 20 -sequences (Bennett, Schechter); (4) the nature and type of objectives or program goals (Bennett, Dixon, Mitsunaga and Shores). The higher the l e v e l of impact the more factors are believed to influence impact. To evaluate the higher levels of impact, the evaluator i s not only faced with confounding variables but w i l l require more sophisticated research designs than those which could be used to measure lower levels of impact. Because of the data needed to measure impact at the higher l e v e l s , the input of resources increases s i g n i f i c a n t l y with each l e v e l . Correspon-dingly, the evidence also becomes stronger. Although the frameworks proposed by Schechter, Grotleuschen, Kirkpatrick, Bennett, Corbett, Mitsunaga and Shores, and Dixon, assume di r e c t relationships between levels of impact, no empirical evaluative studies provide decisive evidence of the links between perceptions, attitudes, knowledge, c l i n i c a l behaviour and patient outcomes. Cross c r i t e r i a consistency, consequently, cannot be assumed. Continuing education i s plagued by the lack of an essential tool for studying the relationships among these l e v e l s . These untested frameworks, therefore, off e r l i t t l e guidance regarding the actual design of studies to evaluate the impact of a program on a participant's work behaviour. Probably the most promise for a unifying cenceptual framework l i e s i n Cervero's (1982) conceptual framework for the evaluation of continuing professional education. Cervero's framework attempts to synthesize ex i s t i n g adult education evaluation frameworks i n an - 21 -adaptation of Rogers' and Shoemaker's (1971) adoption theory. Although not e x p l i c i t l y stated, some pr i n c i p l e s of change can also be seen in his framework. A discussion of change theory and of Rogers' (1983) updated adoption theory i s warranted here to serve both as an introduction to, and an adjunct to, Cervero's framework. Models of Planned Change Change Theory The educational task cannot be accomplished merely by working on men's minds without action that effects changes in i n s t i t u t i o n s . (Dewey, 1935:4) A l t e r a t i o n of the forces acting on individual behaviour i s the central concept in Lewin's (1947) three-stage change process of unfreezing, changing, and refreezing. The fundamental notion of change theory i s that individual behaviour i s influenced by the driving and res t r a i n i n g forces found i n a person's environment. Change theory recognizes the importance of the non-cognitive determinants of behaviour as resistances or supporters to changing (Bennis, 1969). Values, attitudes and feelings at the personal l e v e l combined with norms and relationships at the s o c i a l l e v e l are important considerations i n change theory. Application of these change theory concepts to continuing - 22 -p r o f e s s i o n a l e d u c a t i o n would r e q u i r e program planners to design programs that would impact on the s o c i a l f o r c e s i n the p a r t i c i p a n t ' s environment as p a r t of the s t r a t e g y f o r changing i n d i v i d u a l behaviour. As a change agent, the program planner would need to conduct i n t e n s i v e o n - s i t e a n a l y s i s of the s o c i a l f o r c e s then follow-up the p a r t i c i p a n t s i n the p r a c t i c e s e t t i n g s . C u r r e n t l y , networking between the p r o v i d e r s of c o n t i n u i n g n u r s i n g e d u c a t i o n and h e a l t h care agencies i s minimal i n most cases. P r a c t i c a l and p o l i t i c a l f a c t o r s are f r e q u e n t l y c i t e d f o r t h i s apparent l a c k o f c o o p e r a t i o n and c o o r d i n a t i o n between educators and a d m i n i s t r a t o r s . P a r t i c i p a n t s must complete each of Lewin's three stages of the change process i f behaviour i s to change permanently. L i p p i t t (1978) d e s c r i b e s these stages as m o t i v a t i o n , a c q u i s i t i o n and maintenance. During the f i r s t stage the need f o r and the p o s s i b i l i t y o f , change must be r e c o g n i z e d by the persons i n v o l v e d i n the s o c i a l system to open up the system to the i d e a of change. To s o l i c i t s o c i a l system commitment at t h i s stage p o t e n t i a l p a r t i c i p a n t s and those w i t h i n the work environment w i t h the power and a u t h o r i t y to support change would need to be i n v o l v e d i n the d e s i g n , implementation and e v a l u a t i o n of a program. Behaviour and a t t i t u d e s b e g i n to change d u r i n g the a c q u i s i t i o n stage of the change p r o c e s s . I n s t r u c t i o n a l s t r a t e g i e s employed to encourage a c q u i s i t i o n c o u l d i n c l u d e having p a r t i c i p a n t s work towards the development of a c t i o n plans to be implemented upon t h e i r r e t u r n to work. The g o a l d u r i n g t h i s - 23 -stage would be to nurture participants to develop a personal commitment to change. Anticipatory practice i s required. Participants might begin the process of transferring the learning to t h e i r work settings but more planning would be needed to support this transfer of learning. To a s s i s t participants to successfully maintain or refreeze new behaviours, programs would need to b u i l d i n mechanisms for support and reinforcement in the work s e t t i n g . Commitment of participants' superiors obtained in the f i r s t stage of the change process would now function to support and reinforce the participants' integration of the new behaviour into d a i l y p r a c t i c e . Strategies for change proposed by Bennis, Benne and Chin (1969) and Benne and Birnbaum (1969) provide some guidelines for the design of programs. Although antecedent conditions and strategic leverage points for e f f e c t i n g change are mentioned by these authors, i t would be d i f f i c u l t for program planners to control these conditions. General approaches which have been suggested by these authors for improving the problem solving c a p a b i l i t i e s of s o c i a l systems and releasing and fostering growth in the persons who make up the system to be changed, appear d i f f i c u l t to operationalize. Implementation of these strategies would require considerable input of resources for the design and evaluation of short continuing professional education programs. In change theory, the focus i s on management of the process, seemingly to guide change agents and the administrators i n the - 24 -s o c i a l system. Bennis, Benne and Chin and Benne and Birnbaum a l l suggest that the e n t i r e process b e n e f i t s from the u t i l i z a t i o n o f an o u t s i d e , expert change agent whose r o l e would be to a s s i s t i n the a n a l y s i s o f the d r i v i n g and r e s t r a i n i n g f o r c e s i n the environment and to manage the process of change. Judging from the l a c k o f s t u d i e s p u b l i s h e d , pure change theory has not been u t i l i z e d as a conceptual framework f o r the e v a l u a t i o n of c o n t i n u i n g p r o f e s s i o n a l education programs. Probably one o f the f a c t o r s i n f l u e n c i n g the d e a r t h of r e s e a r c h s p e c i f i c a l l y r e l a t i n g change theory to program e f f e c t i v e n e s s l i e s i n the b a s i c p h i l o s o p h y u n d e r l y i n g change theory; t h a t i s , to be e f f e c t i v e , change must be generated from w i t h i n the system i t s e l f where a need f o r and a w i l l i n g n e s s to change e x i s t . A c c o r d i n g to change theory, change cannot be imposed from o u t s i d e the s o c i a l system. Adoption Theory Adoption theory i n t e g r a t e s some p r i n c i p l e s o f change theory as i t i s o l a t e s v a r i a b l e s b e l i e v e d to i n f l u e n c e the adoption of i n n o v a t i o n s . Innovations are new i d e a s , p r a c t i c e s or o b j e c t s p e r c e i v e d as new to an i n d i v i d u a l or an o r g a n i z a t i o n which present a new a l t e r n a t i v e or a l t e r n a t i v e s f o r problem s o l v i n g (Rogers and Shoemaker). S e v e r a l b i a s e s which e x i s t i n the adoption r e s e a r c h l i m i t i t s a p p l i c a t i o n to c o n t i n u i n g p r o f e s s i o n a l e d u c a t i o n programs. F i r s t , the focus of the r e s e a r c h has been on the adoption of - 25 -technological innovations. Second, there i s a tendency in the research to blame the individual for not adopting an innovation while the means by which the innovation was diffused i s not evaluated. Third, individuals are studied rather than systems, separating and i s o l a t i n g the individuals from influences within the s o c i a l system. Fourth, a pro-innovation bias i s assumed and implied i n the research l i t e r a t u r e , consequently, more i s known about adoption than re j e c t i o n and about continued use rather than discontinuance. Based on a review of recent adoption research, Rogers (1983) has i d e n t i f i e d six variables that influence adoption. These are: (1) the innovative-decision process; (2) attributes of the innovation; (3) the type of innovation decision; (4) the nature of the communication channels; (5) the nature of the so c i a l system; and (6) the extent of the change agent's promotional e f f o r t s . Only the f i r s t two variables i n thi s l i s t are discussed in d e t a i l i n his book. The innovative-decision process i s described as a: ...mental process through which an individual (or another decision making unit) passes from f i r s t knowledge of an innovation, to forming an attitude toward the innovation, to a decision to adopt or re j e c t , to implementation of the new idea, and to confirmation of this decision. (Rogers, 1983: 20) During the f i r s t stage of the innovative-decision process, the knowledge stage, the ind i v i d u a l seeks information about what the innovation i s and how and why i t works. ' Should there be - 26 -i n s u f f i c i e n t i n f o r m a t i o n at t h i s stage to i n c r e a s e the i n d i v i d u a l ' s awareness of how and why an i n n o v a t i o n works, the id e a i s l i k e l y to be r e j e c t e d . The next stage i s the pe r s u a s i o n stage where the i n d i v i d u a l seeks i n f o r m a t i o n , p a r t i c u l a r l y e v a l u a t i v e i n f o r m a t i o n from o t h e r s , to decrease the u n c e r t a i n t y about the p o s s i b l e consequences of adopting the i n n o v a t i o n . The i n d i v i d u a l wants to know the degree o f r i s k a s s o c i a t e d w i t h the i n n o v a t i o n . S e l e c t i v e p e r c e p t i o n operates at t h i s stage to i n f l u e n c e the person's p e r c e p t i o n o f the a t t r i b u t e s o f the i n n o v a t i o n . The person t r i e s out the new i n n o v a t i o n v i c a r i o u s l y by mentally a p p l y i n g the i d e a . The main outcome o f t h i s stage i s the formation o f a fa v o u r a b l e or unfavourable a t t i t u d e toward the i n n o v a t i o n . During the t h i r d stage, the d e c i s i o n stage, the person engages i n a c t i v i t i e s t h a t l e a d to a ch o i c e to adopt or r e j e c t the i n n o v a t i o n . Most i n n o v a t i o n s can be t r i e d out e i t h e r by the i n d i v i d u a l or r e s u l t s can be seen when others demonstrate i t s use. P a r t or a l l o f the i n n o v a t i o n may consequently be adopted. Some i n n o v a t i o n s , however, cannot be t r i e d out so the i n n o v a t i o n has to be accepted or r e j e c t e d i n t o t o . Should the d e c i s i o n be made to adopt an i n n o v a t i o n the person progresses to the f o u r t h stage, the implementation stage, where o v e r t b e h a v i o u r a l changes w i l l take p l a c e . The f i n a l stage i s c o n f i r m a t i o n . The implementation and c o n f i r m a t i o n stages are s i m i l a r to the r e f r e e z i n g or maintenance stage o f change theory. - 27 -During these stages the change agent helps i n trying out and re i n f o r c i n g the new behaviour a s s i s t i n g the individual to complete the innovative-decision process. The new behaviour may not p e r s i s t i f , as a res u l t of changing behaviour, the individual receives c o n f l i c t i n g messages i n the work environment about the innovation. The i n d i v i d u a l in such a case may reverse a previous decision to adopt the innovation. Rogers believes that a receiver's perceptions of the attributes of an innovation w i l l influence adoption. The fiv e attributes of innovations are: (1) r e l a t i v e advantage; (2) compatibility; (3) complexity; (4) observability; and (5) t r i a l -a b i l i t y . Few of the studies reviewed by Rogers found a l l fiv e attributes were related to the adoption of a s p e c i f i c innovation but out of twelve studies, 67% c i t e r e l a t i v e advantage, 67% compatibility, 56% complexity, 78% observability and 69% t r i a l a b i l i t y . Despite these percentages, Rogers has taken the position that r e l a t i v e advantage, which indicates the strength of the reward or punishment that might r e s u l t from adopting an innovation, i s one of the best predictors of the "rate" of adoption. Subdimensions of this variable are i d e n t i f i e d as: (1) degree of economic p r o f i t a b i l i t y ; (2) low i n i t i a l cost; (3) decrease in comfort; (4) a savings i n time and e f f o r t ; and (5) immediacy of the reward. According to Rogers the need for immediacy of reward explains why preventative innovations have an es p e c i a l l y low rate of adoption. - 28 -Compatibility i s the degree to which an innovation i s perceived as consistent with the existing values, past experiences and self-perceived needs of i n d i v i d u a l s . The more compatible or congruent an innovation the less change i t represents to the i n d i v i d u a l . Studies conducted by Chickering and Havinghurst (1981), Gould (1972), McCoy (1977) and Sheehy (1976) imply that at various l i f e phases and stages adults are more receptive to certain types of programming. This "readiness to learn" i s one of the basic p r i n c i p l e s of adult education. When discussing this notion of developmental readiness, Knox (1979) predicts that influences within a participant's l i f e can either n u l l i f y the effects of a program or can redouble i t s impact on behaviour. Therefore, compatibility or congruency of program goals with a participant's desired behaviour change would seem to be a strong factor that might contribute to program effectiveness. Complexity refers to the degree to which the proposed change i s perceived as simple to understand and use. Observability i s the degree to which the behavioural changes are v i s i b l e to others. T r i a l a b i l i t y refers to the degree to which a change can be experimented with on a limited b asis. New ideas which can be experimented with on an installment plan generally are adopted more rapidly according to Rogers. The t h i r d adoption variable, the type of innovation decision, refers to whether the decision to adopt can be made independently of others or requires the cooperation of others - 29 -either d i r e c t l y or i n d i r e c t l y . Innovations which have no potential consequences for others i n the s o c i a l system are easier to adopt. The f i f t h and s i x t h variables of the nature of communication channels and the nature of the s o c i a l system are only b r i e f l y discussed i n this model. Mass media channels were found to be r e l a t i v e l y more important at the knowledge stage while interpersonal channels were more important at the persuasion stage. The research studies reviewed by Rogers also revealed that norms within s o c i a l systems could act as barr i e r s to change . Considerable weight i s assigned to the s i x t h v ariable, the extent of the change agent's promotional e f f o r t s . T r a d i t i o n a l l y change agents i n t h i s adoption model were persons employed by a change agency to convince entrepreneurs to adopt technological innovations in a g r i c u l t u r e . Considerable onus for successful adoption i s put on the change agent: His or her success i n l i n k i n g the change agency with his or her c l i e n t system often l i e s at the heart of the d i f f u s i o n process. Rogers (1983:315) C r i t e r i a are presented for the selection of professional change agents who would be homogenous with the c l i e n t population. Rogers assigns these change agents seven roles which read l i k e a problem solving contract with c l i e n t s . Change agents begin by developing the c l i e n t ' s need for change, then est a b l i s h an information exchange relationship to diagnose the c l i e n t ' s problem; then create an intent to change on the part of the - 30 -c l i e n t ; translate t h i s intent into action; then s t a b i l i z e the adoption and prevent discontinuance; and f i n a l l y , terminate the relationship with the c l i e n t . In p r i n c i p l e , t h i s client-change agent relationship implies the i n d i v i d u a l i z a t i o n of needs and i n s t r u c t i o n . This seems to be incongruent and inconsistent with the basic concept upon which adoption theory i s b u i l t , that i s , the adoption of s p e c i f i c innovations. The d i f f u s i o n of a g r i c u l t u r a l innovations would seem to be based on a response to the ascribed needs of c l i e n t s and, might begin with a strategy aimed at convincing or persuading the c l i e n t of his need for the innovation. It i s not the intention of this writer to refute Rogers' focus on change agents. Rather, the purpose of t h i s examination i s to r e a l i z e the l i m i t a t i o n s that would be imposed upon the change agent's scope of practice i n situations where c l i e n t s are employees in a hierarchy rather than entrepreneurs working r e l a t i v e l y autonomously. To attempt to function i n a hierarchal s o c i a l system i n the manner described by Rogers, change agents who were employees of outside providers would also need to be employees i n the p a r t i c i -pants' s o c i a l systems. These change agents would need to gain the confidence of both the participants and t h e i r employers. Change agents selected from opinion leaders within the c l i e n t system, would l i k e l y face considerable c o n f l i c t between their dual roles as f a c i l i t a t o r and employee, an issue recognized but not dealt with in Rogers' (1983) text. Neither change theory nor adoption theory can stand alone as - 31 -conceptual frameworks for the design or evaluation of continuing professional education programs. The most important contribution that change theory has to make i s the need to develop program design strategies that would secure the commitment of p a r t i c i -pants' s o c i a l systems i n diagnosing the need for behavioural change and i n supporting and i n r e i n f o r c i n g the change subsequent to the program. While a l l six variables proposed i n Rogers' model are signifcant, d e t a i l s regarding the innovative-decision process and the attributes of innovations would provide conceptualizations that could be translated into frameworks for the design and evaluation of programs. Cervero's Conceptual Framework For Evaluation Cervero's (1982) conceptual framework for the evaluation of continuing professional education programs has been developed around the assumption that behavioural changes take place within the constraints and opportunities found i n the individual's s o c i a l system. Four sets of variables are proposed in this framework: (1) program c h a r a c t e r i s t i c s , (2) c h a r a c t e r i s t i c s of the p a r t i c i -pants, (3) c h a r a c t e r i s t i c s of the proposed behavioural changes, and (4) c h a r a c t e r i s t i c s of the s o c i a l system in which the profes-sional p r a c t i c e s . A schematic representation of the variables l i n k i n g continuing professional education to behavioural change can be found i n Figure 4. - 32 -Figure 4 CERVERO'S FRAMEWORK OF IMPACT VARIABLES CPE< >Proposed< >Individual< >Social< >Behavioural program Changes Professional System Change Source: Adapted from Cervero, R.M. Continuing Professional Education and Behavioural Change: A Proposed Framework. Paper presented at the Annual Adult Education Research Conference, Lincoln, Nebraska, A p r i l , 1982. Although i t i s Cervero's b e l i e f that the individual's s o c i a l system would be the strongest factor influencing impact, he proposes that variations i n the four sets of independent variables would explain variations i n the extent of behavioural change. Cervero's focus i s on the analysis of the processes of continuing professional education as a means of projecting potential program impact on behaviour. He recognizes that with-out operational measures of the variables, the model i s not yet empirically testable. The s i m p l i c i t y of the model, however, and the low cost of the resources required for i t s implementation should make this framework a t t r a c t i v e to conscientious program planners wanting to conduct formative or summative evaluations of the i r programs. Supporting evidence for the framework i s drawn primarily from Rogers and Shoemaker's early work on the communication of innovations. Rogers new l i s t of adoption variables does not appear to necessitate changes to Cervero's fundamental framework. The innovative-decision process, the nature of the communication - 33 -channels, and the change agent's promotional e f f o r t s can be subsumed under Cervero's program design c h a r a c t e r i s t i c s . A t t r i -butes of the innovation and the type of innovation decision help to define the c h a r a c t e r i s t i c s of a program's objectives. The nature of the s o c i a l system can be subsumed under s o c i a l system c h a r a c t e r i s t i c s . Program Characteristics Within Cervero's framework, "program" refers to a set of processes which include the elements involved in the design and implementation of a program. In th e i r analysis of the descriptive and evaluative dimen-sions of ninety published program planning models, Buskey and Sork (1982) found that cer t a i n categories of models seemed to provide more d e t a i l of the processes than others. In descending order, these were the t r a i n i n g models, general adult education models and continuing professional education models, respectively. Some of the more popular program planning models are those proposed by Boyle (1981), Houle (1976) and Knowles (1981). Each presents a l i s t of processes or elements a l l of which interact with each other. These processes generally include the: (1) i d e n t i f i c a t i o n of an educational need; (2) i d e n t i f i c a t i o n of program objectives; (3) i d e n t i f i c a t i o n of the resources required to develop and implement a program; (4) selection of a suitable - 34 -format for presentation; (5) selection of teaching techniques; (6) marketing the program; and (7) evaluation of the r e s u l t s . There i s a dearth of research r e l a t i n g these program processes or elements to outcomes. While some information about these processes i s available in the adult education l i t e r a t u r e , d i l i g e n t program planners must often look to curriculum models for ideas, hoping that they are appropriate to the unique relationship intended to take place between program and participants i n short continuing professional education programs. Adult educators such as B e l l (1978) , Bowers (1974) , G r i f f i t h (1978), Johnson (1967), Knowles (1981), Monette (1977,1979), and Popiel (1973) , do provide copious information as to "how to" conduct needs assessments and "how to" decide whether or not an educational program would be appropriate to meet the need. Rather than i d e n t i f y i n g how to i d e n t i f y program objectives, adult educators and curriculum developers such as Gronlund (1978), Kibbler, et a l . (1974), Knowles (1981) and Szczypkowski (1980), describe and demonstrate how to write cognitive, psycho-motor and a f f e c t i v e objectives using the correct taxonomy. Formats for presentation of content are usually implied or specified i n the general theory about the d i f f e r e n t types of objectives . Tips regarding how to i d e n t i f y the resources needed to develop and implement a continuing education program are generally provided in the adult education program planning models . - 35 -Suggestions for teaching-learning techniques related to objectives are offered by Bergevin, et a l . (1963), Gagne and Briggs (1974), Knowles (1981), Szczypkowski (1980) and Walter and Marks (1981) . Walter and Marks provide theore t i c a l guidelines as to what d i f f e r e n t techniques can be expected to achieve. To involve participants in program content they suggest the use of such learning a c t i v i t i e s as exercises. Process oriented, exer-cises can be used to guide participants step-by-step through a learning a c t i v i t y allowing group members to become fam i l i a r with information and to practice s k i l l s . They also serve both to generate feelings and reactions and to provide s o c i a l support among the members of a learning group. Exercises thus provide both a context for application and a source of feedback and conditioning. Another technique i s large group interaction which can be used as a vehicle for discussing information presented through other methods. A discussion format can be used for any one of the following purposes: 1. To use resource members of the group; 2. To give students opportunities to formulate application of the p r i n c i p l e s ; 3. To get prompt feedback on how well the leader's objectives are being attained; 4. To help students think in terms of the subject matter by giving them practice in thinking; 5. To help students learn to evaluate the l o g i c of and evidence for th e i r own and others' posi-tions ; - 36 -6. To help students become aware of and to form-ulate problems which necessitate information to be gained from reading or lectures; 7. To gain acceptance for information or theories counter to f o l k l o r e or previous b e l i e f s of students; 8. To develop motivation for learning. (McKeachie 1969:37) Walter and Marks suggest that participants be given clear discussion guidelines for the purpose of participant account-a b i l i t y . The results of th e i r deliberations should also be incorporated formally into the learning experience. They also recommend that case studies be used to allow participants to project themselves into a hypothetical s i t u a t i o n where they must consider facts and take appropriate actions. During group discussions, the leader acts as discussion leader, resource person, hel p f u l expert and r e l a t o r of case material to other content. These authors suggest that individuals b e n e f i t t i n g most from this method are i n t r i n s i c a l l y motivated, highly d i s c i p l i n e d s e l f - s t a r t e r s . The case method, however, does not commit participants to action. One of the most frequently used techniques i s the lecture method. Odiorne (1977) describes i t as a method that can be used to engage participants i n creative l i s t e n i n g and thinking proces-ses when i t i s used to state problems and provides guidelines for thei r r e s o l u t i o n . The lecturer must be seen to be credible, knowledgeable and committed to the material i f the method i s to - 37 -be successful. Devices such as photographs, sl i d e s or films can serve as a stimulus to provoke thoughts and feelings or to generate discus-sion. Visual and/or auditory cues can be used to c l a r i f y or emphasize concepts and ideas to a s s i s t participants to under-stand, integrate and place into perspective t h e i r thoughts, feelings and behaviour. In conventional program planning models marketing seems to be approached primarily from the perspective of attr a c t i n g s u f f i c i e n t participants to cover program costs. F i n a l l y , both formative and summative evaluation are pro-posed for the purpose of c o l l e c t i n g information to improve an existing program or to be u t i l i z e d i n future program planning. Most continuing education programs are designed to a s s i s t the participants to progress through three of the f i v e stages of Rogers' innovation-decision process. Information i s presented to increase the particpant's knowledge and understanding of the innovation and how i t might be implemented. Learning a c t i v i t i e s are generally structured to persuade participants of the value of the innovation. The advantages and disadvantages of application are generally reviewed to help participants v i c a r i o u s l y apply the innovation. Discussion with peers about the u t i l i t y of the s k i l l or information, when b u i l t into a program, would provide reinforcement to a s s i s t i n the persuasion process. Well respected opinion leaders as program leaders/change agents can also provide this reinforcement. When participants can practice - 38 -new s k i l l s or observe a demonstration of a s k i l l i n the i n s t r u c t i o n a l setting and see i t s consequences they are more l i k e l y to pass successfully through the decision stage of the process. Psychomotor s k i l l s lend themselves to tangible r e i n f o r -cement during the i n s t r u c t i o n a l event. The decision to adopt abstract s k i l l s i s more d i f f i c u l t as the complexities of the participant's work environment ine v i t a b l y confound the a p p l i -cation of the s k i l l . Changes in problem solving behaviour which involve a high in t e r a c t i o n component present more of a r i s k to participants than the implementation of a psychomotor s k i l l . Few continuing professional education programs are designed to a s s i s t participants through the implementation and c o n f i r -mation stages of the adoption process . Only the occasional continuing professional education program employs project s t a f f to follow-up participants i n t h e i r practice settings . Characteristics of Participants Motivation to change must exist before any program can induce behavioural change. Motivation overlaps with participant-course goal congruency, one of the attributes of objectives i d e n t i f i e d by Rogers. Perceived need and motivation to change were p o s i t i v e l y related to behavioural change in programs studied by Wadell (1978) and Derby (1982). Cervero does not refer to any studies which compare persons who changed t h e i r behaviour to those who did not change. - 39 -Instead, c h a r a c t e r i s t i c s are attributed to participants according to t h e i r "rate" of adoption i n concurrence with the Rogers' and Shoemaker's theory where participants' dominant attitudes toward th e i r professional practice and the nature and extent of their education were believed to be correlated to the rate of adoption. Rogers' and Shoemaker's subvariables of participant c h a r a c t e r i s t i c s are: (1) more education, (2) more specialized operations, (3) more favourable attitudes toward change, r i s k , education and science, (4) more information seeking, (5) higher knowledge of innovations, and (6) more opinion leadership. Cervero suggests that the variables of participant character-i s t i c s can, with some d i f f i c u l t y , be manipulated i f d i f f e r e n t strategies are used for d i f f e r e n t groups of p a r t i c i p a n t s . He does not refer to any s p e c i f i c l i t e r a t u r e r e l a t i n g strategies to the d i f f e r e n t c l a s s i f i c a t i o n s of adopters. Cervero's b e l i e f that this variable i s manipulatable i s l i k e l y based on the pro-innovation bias of adoption research. Characteristics of the Proposed Behavioural Changes Although Cervero defines this variable as the "type" of proposed change desired, perhaps the "nature" of the proposed change would more aptly capture the essence of t h i s independent variable . Change may be s p e c i f i c or broad and may deal with attitudes or behaviour (Walter and Marks). The a c q u i s i t i o n of attitudes or - 40 -s k i l l s that are e a s i l y circumscribed can be termed s p e c i f i c changes. Broad changes refer to issues which are d i f f i c u l t to separate e a s i l y from a participant's t o t a l personality or behaviour and are consequently more d i f f i c u l t to measure. Attitudes w i l l influence program outcomes regarding participant reaction, learning, behavioural change, and conse-quences of practice change. Zimbardo (1970) sees attitudes as enduring predispositions operating as a f a i r l y large class of evaluative responses . The evaluative component affects the d i r e c t i o n of the attitude; that i s , p o s i t i v e or negative, to-wards the proposed change. In writing about changing attitudes Zimbardo states that changes i n attitude are not always accompanied by changes i n behaviour. Attitudes are manifested i n d i f f e r e n t ways, consequently programs aimed at changing attitudes may aim to achieve changes at any one of three l e v e l s : (1) a f f e c t i v e , (2) cognitive or (3) behavioural. In the a f f e c t i v e component a person's evaluation, l i k i n g of, or emotional response to some object or person can be measured by physiological res-ponses or o v e r a l l statements of l i k e or d i s l i k e . At the cog-n i t i v e l e v e l are b e l i e f s and knowledge of an object, topic or person which can be measured by s e l f - r a t i n g s of b e l i e f s or by the amount of knowledge the person has about the object, topic or person. F i n a l l y , at the behavioural l e v e l i s the overt behaviour which can be measured by d i r e c t l y observing behaviour in a s p e c i f i c s i t u a t i o n . Based on t h e i r own attitudes and perceptions, participants - 41 -w i l l attribute to the proposed behavioural changes one or more of the following c h a r a c t e r i s t i c s outlined by Rogers: (1) r e l a t i v e advantage, (2) compatibility, (3) complexity, (4) observability and (5) t r i a l a b i l i t y . Of the d i f f e r e n t types of behavioural objectives, the adoption of new psychmotor s k i l l s would seem to be the easiest for participants to implement. A l l f i v e attributes could be assigned to new psychomotor s k i l l s . L i t t l e r i s k would be involved in experimenting with new psychomotor s k i l l s in the practice s e t t i n g . Results of the new s k i l l s would provide quick feedback to allow for confirmation i n the innovative-decision process. Should t r i a l of the new behaviour r e s u l t i n negative consequences or no results at a l l , the person could e a s i l y reverse the decision to adopt the innovation. Congruency, complexity and observability were the three attributes Knox (1979) found most r e l a t i v e to impact i n his overview of the l i t e r a t u r e on impact evaluation. He found that programs which dealt d i r e c t l y with s p e c i f i c and achievable changes i n performance which were important to the adult learner, amenable to educational influence, and could be re a d i l y documented were those that had a po s i t i v e impact. To these he added the variable of reasonable intervention; that i s , the type and amount of program appropriate to achieve the desired changes. Just what percentage of participant/course goal congruency exists i n every continuing professional education program i s not known. Chambers (1976) found that only 5% of participants in a - 42 -continuing dental education program enrolled because they wanted to change t h e i r behaviour. The motives of 63% of the participants i n this study were quite discrepant from those anticipated by the program planners. General interest was cited by participants as the i r major motive for e n r o l l i n g i n the program. No further studies were found to determine whether the Chambers study represents a t y p i c a l example of how few participants e n r o l l i n short continuing professional education programs because they want to change the i r behaviour. That so many participants do not expect to change the i r behaviour might explain why so few programs are reported to be e f f e c t i v e in changing participants' work behaviour. Characteristics of the Social System Programs aimed at changing work behaviour require that the changes take place in the work setting or organization, implying a change to the s o c i a l system. Bobbitt, et a l . (1978) define an organization as a group of people who work together to achieve a common goal. Because people working in the organization have more than one goal, membership implies compromise and influence. C o n f l i c t due to differences i n values and goals i s not uncommon. Each participant's perception of the organization and his or her personal influence provides the frame of reference for the adoption process. This i s the participant's own context of appl i c a t i o n . In t h e i r e a r l i e r work, Rogers and Shoemaker found that work - 43 -environments with certain c h a r a c t e r i s t i c s were p o s i t i v e l y related to adoption. Work environments where there was a positive attitude toward the proposed changes, which had close interpersonal communications among members,and where the so c i a l system legi t i m i z e r s were involved in the decision making process related to the innovations, seemed to support behavioural changes. In an h i s t o r i c a l review of impact studies i n nursing, Cooper, et a l . (1982) c i t e the Farley (1979), Kuramoto (1979) and Mastrian (1979) studies as examples of where nursing supervisory support and peer group reinforcement of learning following a continuing education a c t i v i t y contributed to the application of the content. In an evaluation study of ten continuing nursing education courses of varying scope and duration, Deets and Blume (1977) found that where there was no opportunity for practice of certain s k i l l s or tasks the reported frequencies of the particpants 1 a b i l i t y to perform the s k i l l s was not ranked as highly as those s k i l l s which had been practiced. Based on this finding, they concluded that practice appeared to enhance learning and retention of new behaviour. Positive reinforcement of new behaviour either through pra c t i c e , praise of others, support by supervisory s t a f f and positi v e results seem to f a c i l i t a t e the adoption of changes i n pra c t i c e . Lack of the opportunity to practice and the absence of support and feedback would therefore be important b a r r i e r s to the - 44 -adoption of an innovation. Program c h a r a c t e r i s t i c s , the c h a r a c t e r i s t i c s of p a r t i c i -pants, the c h a r a c t e r i s t i c s of the proposed behavioural changes and the c h a r a c t e r i s t i c s of the s o c i a l system have been proposed by Cervero (1982) as four independent variables which influence program impact on work behaviour. Theories which support or further c l a r i f y some of the components in each of the four major variables, have served to provide the framework with more depth. An analysis of research studies of e f f e c t i v e programs would seem to be a necessary part of the discussion of Cervero's framework in order to examine which of the four major variables stand the test of consistency. Sp e c i f i c subvariables i d e n t i f i e d i n the research studies w i l l f a c i l i t a t e the application of this framework to the "Safety to Practice Conferences." A discussion of the state-of-the-art of evaluation research i n continuing professional education i s warranted here before the research studies of e f f e c t i v e programs are analyzed. State-of-the-Art of Evaluation Research Bertram and Brooks-Bertram (1977) , in a survey of the research published between 1969 and 1977, found that most of the studies were descriptive or explorative and provided d i v i s i v e and seemingly unrelated r e s u l t s . Lloyd and Abrahamson (1979) i n t h e i r review of two hundred and seventeen published studies found that objective methods were - 45 -seldom used to evaluate the results of a program. They looked for evidence of program impact at three l e v e l s : physician com-petence or knowledge, work performance, and patient health status. Few of the studies they reviewed were r e p l i c a b l e . Lloyd and Abrahamson (1979) concluded that the p r o b a b i l i t y of continuing medical education impacting on any one of the three leve l s was approximately .50. Stein (1981), on the other hand, was able to find eight s c i e n t i f i c a l l y conducted evaluation studies published between 1973 and 1979. Studies conducted by Caplan (1973); Inui (1976); Kattwinkel, et a l . (1979); Laxdal and associates (1978); Manhan, et a l . (1978); Rubenstein (1973); Talley (1978); and Wang and co-workers (1979), reported that the programs they evaluated had e f f e c t i v e l y changed physician performance. Each of these prog-rams met Stein's (1981) c r i t e r i a for sound evidence of posi t i v e program impact. F i r s t , each study or report described the learning program and the educational intervention undertaken. Second, the methodology used for the analysis of data displayed face v a l i d i t y and s t a t i s t i c a l l y s i g n i f i c a n t objective data. Third, a c l i n i c a l l y important change in performance was reported. F i n a l l y , the reported change persisted for at least six months. Based on his review, Stein concluded that well-planned continuing medical education programs which u t i l i z e d sound educational p r i n c i p l e s could change physicians' performance and presumably might impact on patient care and outcomes. Forni and Overman (1974) surveyed sixty-eight providers of - 46 -continuing nursing education i n the United States. State nursing associations, college nursing programs, and junior college nursing programs indicated that the transmission of information was the most frequent purpose of t h e i r educational programs, followed by the development of attitudes, with a c q u i s i t i o n of s k i l l s l a s t . According to Forni and Overman, most of the objectives outlined i n the course syllabuses for these programs were unclear. Analysis of E f f e c t i v e Programs Evaluation reviews and studies of e f f e c t i v e short continuing professional education programs conducted by Stein (1981), Cox and Baker (1981), Heick (1981), Peterson (1982), Penn (1978), and Scott (1980), w i l l now be analysed u t i l i z i n g Cervero's (1982) conceptual framework for the evaluation of continuing professional education programs. Program Characteristics In the evaluation studies analysed by Stein, each program had a s p e c i f i c small target audience and potential learners were involved both i n the diagnosis of the need and the entire program planning process. "Need" was interpreted to be a deficiency state. Each program focused on changing performance. The teaching techniques and methods u t i l i z e d were self-assessment exercises, self-study packages, small group discussions, in d i v i d u a l and group learning a c t i v i t i e s , and assistance i n the - 47 -practice setting where t u t o r i a l s and consultations were used. The emphasis in these programs was on performance, reinforcement and feedback in the practice s e t t i n g . Follow-up reinforcement and feedback by project s t a f f , who could be interpreted as change agents, was b u i l t into each program. These interpersonal channels would have f a c i l i t a t e d each participant's progress through the l a s t stages of the innovative-decision process. Each program had established a pre-program baseline then used more than one method to c o l l e c t information about post-program performance in order to validate information used for evaluation. In an evaluation study of a continuing nursing education program Cox and Baker u t i l i z e d a quasi-experimental research design. Pre- and post-testing and chart audits of an experimental group arid an untreated control group were conducted to gather data. The test group was found to have s i g n i f i c a n t l y increased th e i r knowledge base at the end of the program and demonstrated c l i n i c a l application of the s k i l l s taught in the program as late as six months afte r the program. The program was developed by a health care agency for a s p e c i f i c small audience of i t s community health nurses. Both potential participants and t h e i r supervisors had agreed upon the need for the program. The "need" was a deficiency state. Educators, pr a c t i t i o n e r s and administrators who had an interest i n seeing the course content applied to the c l i n i c a l setting participated i n the planning of the program. Follow-up c l i n i c a l p r actice, supervised and evaluated by project s t a f f who could be interpreted as change agents in th i s instance, - 48 -was an integral part of the program design. Educational materials were developed s p e c i f i c a l l y for the program. The teaching methods and techniques u t i l i z e d were lectures, rounds i n the c l i n i c a l s e t t i n g , s e l f - p r a c t i c e , and c l i n i c a l sessions. It would seem that this program was designed to take participants through a l l of the steps of the innovative-decision process. Interpersonal channels of communication were used e f f e c t i v e l y to a s s i s t participants to apply the new s k i l l s i n the practice s e t t i n g . Heick u t i l i z e d a less rigorous evaluation design to study the impact of twelve one-day professional development sessions for a s p e c i f i c audience of county community health nurses. Information was gathered from participants and t h e i r supervisors in a follow-up questionnaire sent two months afte r participants had completed the program. The same supervisors were surveyed eight months after the program. No pre-testing was done nor was any control group used in this study. The instruments used to c o l l e c t data appeared to lack r e l i a b i l i t y or v a l i d i t y as they involved open-ended questions and checking o f f whether certain a c t i v i t i e s had been performed. Despite the soft evidence Heick (1981:23) concluded from her findings that the program "...achieved success i n having a p o s i t i v e impact on maternal health services in Iowa." C r i t e r i a for determining the impact were broad . The provider of the program was the State Department of Health, the employer of the nurses. Involvement of the potential participants i n the program planning process i s not - 49 -specified in the report. A nursing supervisor, a medical direc t o r and faculty with expertise i n the content areas, participated in the design of the program. The learning needs of the target audience were ascribed to them by th e i r supervisors. No apparent follow-up practice and reinforcement i n the practice setting seemed to have been b u i l t into the program design. Whether the evaluation design, which required feedback from the supervisors to the provider, had the e f f e c t of r e i n f o r c i n g the new behaviour in the practice setting i s not discussed in the report. Because these programs were judged by the evaluator to be e f f e c t i v e i t might be assumed that the program did succeed in getting supervisory commitment and support in the work setting, thus participants were assisted through the l a s t stages of the innovative-decision process. Petersen evaluated a three-day continuing education program for d i e t i c i a n s which was intended to educate the d i e t i c i a n s about teaching methods and materials i n order to increase th e i r e f f i c i e n c y as diabetes educators. A quasi-experimental evaluation design was used in t h i s study to measure knowledge gain and behavioural change. Pre- and post- tests of knowledge were administered and a six month follow-up questionnaire was sent to participants who, rated, on a five-point scale, the frequency with which they performed the targeted behaviours. Without a control group or an object ive evaluation of the parti c i p a n t s ' post-program performance, generalizations cannot r e a l l y be made from the results of t h i s study. Because of the - 50 -dearth of studies of programs having had a pos i t i v e impact on work behaviour, however, an analysis of the scant d e t a i l s about this program might provide some insight into the possible factors which contributed to a s t a t i s i c a l l y s i g n i f i c a n t change i n the behaviour of the d i e t i c i a n s who attended the program. Develop-ment of t h i s course was based upon an educational needs assessment of 496 registered d i e t i c i a n s in New England. The report does not indicate whether the potential audience was i n v o l -ved in the program planning process. I n s u f f i c i e n t information i s provided about the design of the program to analyse whether the program took participants through a l l of the stages of the innovative-decision process. C r i t e r i a for the evaluation of successful impact on behaviour were not specified i n the study. The data gathered does not immediately translate to e f f i c i e n c y as diabetes educators, the goal of the program. Other variables, not discussed in the study, would influence t h e i r e f f i c i e n c y . Penn administered an open-ended questionnaire to r e h a b i l -i t a t i o n professionals three to t h i r t y months afte r they participated in a three-day workshop. The goal of the workshop had been to teach the diverse participants the use of behaviour management procedures. Scant information i s provided by the evaluator as to the program design. Only the teaching techniques used i n the program are discussed. Lectures, videotaping, interviewing, role playing and practice sessions during the i n s t r u c t i o n a l event were used. whether the program was designed to take participants through a l l of the stages of the - 51 -innovative-decision process i s not known. It must be assumed that no interpersonal communication channels nor change agents were u t i l i z e d i n the work s e t t i n g . Scott conducted an evaluation study of an in-service program for occupational and physio therapists which was aimed at changing t h e i r record-keeping behaviour. The purpose of her study was to contribute to the understanding of the change process i n occupational settings. To do this she examined the factors that influenced employees to change the i r performance of a task. Tools used to c o l l e c t the data, pre-program and at one and three-month post-program, included paper and pencil tests of knowledge; chart audits of record-keeping behaviour; and attitude surveys measuring motivation to change, and perceptions of perfor-mance standards, resources and r e i n f o r c e r s . At the l e v e l of performance change Scott found that recording behaviour increased s i g n i f i c a n t l y during the f i r s t month and s i g n i f i c a n t l y decreased during the next three months. An in-depth discussion of the program planning process i s not provided by Scott. Although a pre-performance charting baseline would have been known because of the design of t h i s study, Scott does not indicate whether th i s information was taken into account during the program planning process. What i s stated, however, i s that the supervisors of the participants had made the decision to adopt the new record-keeping system, demonstrating a willingness and a commitment to change. Whether or not the participants were involved in this decision or any of the program planning i s not - 52 -discussed. Supervisory reinforcement and feedback following the educational event was not b u i l t into the program. This program, therefore, appears to have been designed to take participants through the knowledge, persuasion and decision stages only. No interpersonal channels of communication i n the work setting were used in the design. Participants did not have the support of change agents who could have contributed to the endurance of the new behaviour, hence, the behaviour change did not pe r s i s t over time . Characteristics of Participants In the studies of the programs just reviewed i n s u f f i c i e n t information i s provided to allow for an analysis of the character-i s t i c s of p a r t i c i p a n t s . Comparisons of participants who changed their behaviour with those who may not have changed i n the test samples are not provided. Perceived need and motivation to change existed in those participants who changed the i r work behaviour in the studies analysed by Stein and i n the programs evaluated by Cox and Baker and Scott. Participants i n the programs evaluatedby Heick had been selected because they had a s p e c i f i c need which they themselves acknowledged and the programs had been developed to meet these needs . Whether the participants i n these programs were motivated to change i s not s p e c i f i e d . Participants i n the program studies analyzed by Stein and - 53 -the programs evaluated by Cox and Baker and Heick, a l l worked f a i r l y independently of d i r e c t immediate supervision i n their d a i l y p r a c t i c e . This finding w i l l be discussed l a t e r i n the analysis of the s o c i a l system c h a r a c t e r i s t i c s associated with these programs. Characteristics of the Proposed Behavioural Changes The objectives in each of these e f f e c t i v e programs a l l had at least one common att r i b u t e : o b s e r v a b i l i t y . To some extent, this might explain why these programs were chosen to be evaluated in the f i r s t place. Both in the program studies analysed by Stein and the program evaluated by Cox and Baker (1981) the proposed objectives possessed a l l f i v e a t t r i b u t e s . The proposed behavioural changes in the program evaluations analysed by Stein were very s p e c i f i c and easy to understand and use. They included: (1) psychomotor s k i l l s , (2) s p e c i f i c p r e s c r i p t i v e regimes, and (3) procedures for dealing with patient problems. The proposed changes i n the program evaluated by Cox and Baker were in the realm of s p e c i f i c psychomotor s k i l l s . The objectives for the program evaluated by Heick possessed four att r i b u t e s : (1) r e l a t i v e advantage, (2) participant/course goal congruency, (3) observability and (4) t r i a l a b i l i t y . Objectives i n the programs evaluated by Petersen, Penn and Scott each possessed three to four attributes each. Generally, in these programs the decision to adopt the new - 54 -behaviour could be made independently. Only in the Penn (1978) program was the cooperation of others required i n the process of adopting the new behaviour. Characteristics of the Social System It i s worth noting who the participants were in these programs. Their influence in the s o c i a l system and the amount of autonomy they had i n decision making would seem to be related to the success of the programs. Participants i n the eight studies analyzed by Stein were physicians . The programs evaluated by Cox and Baker and Heick were for community health nurses. Participants i n the Petersen, Penn and Scott programs were other health professionals employed in large health care i n s t i t u t i o n s . Looking at these studies i t would seem that continuing professional education programs for physicians are more success-f u l than programs for other groups . Possible reasons which could be postulated for th i s apparent phenomenon include: the substantial input of resources into planning programs for physicians, more resources available to evaluate continuing medical education, the types of terminal objectives for physicians' programs, and the amount of power and control physicians have i n th e i r s o c i a l system. In most health care agencies physicians are generally considered the head of the health team. Not considered employees, they are accountable primarily to t h e i r patients. At the top of the decision making - 55 -hierarchy regarding patient care, they are in a position of power to influence and control their s o c i a l system and are able to manipulate the forces in favour of change. Other professional workers i n health care i n s t i t u t i o n s are employees operating within a hierarchy. We see from the results of the evaluation studies analysed here that continuing profes-sional education programs have less impact on the work behaviour of those employees who have less influence i n t h e i r s o c i a l systems. The r e a l i t y of functioning within an i n s t i t u t i o n a l hier-archy may also explain why no p o s i t i v e impact studies were found of programs which were offered to nurses employed and functioning within large health care i n s t i t u t i o n s . Only programs developed for community health nurses had any incidence of success . Nurses in this type of practice make the i r d a i l y decisions f a i r l y autonomously without the constraints that might be imposed within an i n s t i t u t i o n a l hierarchy. The point being made here i s that the autonomy of physicians and community health nurses may account, to some extent, for their a b i l i t y to change t h e i r perfor-mance in t h e i r practice settings subsequent to p a r t i c i p a t i o n i n a continuing professional education program. In the program studies analysed by Stein reinforcement in the c l i n i c a l setting was an i n t e g r a l part of the i n s t r u c t i o n a l event. Follow-up s o c i a l system support may not operate as a variable in a physician's application of new psychomotor s k i l l s , or the prescribing of new medication regimes, or the use of new diagnostic equipment. Structural support, of course, would be - 56 -required in the form of the a v a i l a b i l i t y of the medications and the equipment but presumably the physicians would have subs-t a n t i a l control in this area. Participants i n the program evaluated by Cox and Baker had supervised practice both during and after p a r t i c i p a t i o n in the program. Evaluation of the new s k i l l s was also a form of follow-up feedback and reinforcement but as i t was conducted by the project s t a f f , i t can be c l a s s i f i e d as a program design v a r i a b l e . Supervisory support and commitment had been obtained during the program planning stage as the supervisors had agreed upon the new standards of practice which were to be adopted by the p a r t i c i p a n t s . I t could be assumed that adoption of the new behaviours was an expectation both of the participants and their supervisors. In addition to the teaching s t a f f acting as change agents doing follow-up reinforcement and evaluation, the supervisors would also have been i n f l u e n t i a l in the implemen-tatio n and confirmation stages of the innovative-decision process . Some degree of supervisory reinforcement may be assumed in the program evaluated by Heick although i t may have operated more as a program variable than a s o c i a l system v a r i a b l e . Supervisors participated with participants i n a one-day follow-up educational session regarding implementation of the s k i l l s . The reason for this follow-up, according to Heick (1981:19) was to " . . . i d e n t i f y how enrollees were applying course content and to provide guidance in problem areas." The reader must assume that the - 57 -ov e r a l l rationale for this was to encourage s o c i a l system reinforcement from the participants' supervisors although the supervisors did not seem to have been d i r e c t l y involved in the educational process p r i o r to this one-day meeting. Without this p r i o r commitment from the same supervisors the value of the meeting could be questioned. Social system support had not been b u i l t into the program planning process i n the program evaluated by Petersen. Upon returning to work participants reported that they had encoun-tered structural constraints i n the form of i n s u f f i c i e n t time, s t a f f , and budgets. Factors which f a c i l i t a t e d the implementation of some of the new s k i l l s are not discussed in the study. Because participants i n the program evaluated by Penn were i n t e r - d i s c i p l i n a r y , some peer group reinforcement in the t r i a l and application of new s k i l l s might be assumed. Social system follow-up reinforcement i s not a variable s p e c i f i c a l l y discussed in this study. Although supervisors had been part of the program planning process i n Scott's study, participants in the program f e l t that the s i t u a t i o n a l factors of performance standards, i n s u f f i c i e n t resources and lack of reinforcers accounted for t h e i r f a i l u r e to maintain the behaviour changes. - 58 -Summary Tables I through IV (p.62-63) represent matrices of the subvariables i d e n t i f i e d in the research studies as p o s i t i v e l y influencing program impact on work behaviour. The subvariables of program c h a r a c t e r i s t i c s included: (1) a s p e c i f i c small homogeneous target audience, (2) a s p e c i f i c educational need which could be c l a s s i f i e d as a deficiency state, (3) cooperation and coordination of educators, p r a c t i t i o n e r s and administrators in the program planning process which assured administrative commitment to the change, (4) use of a v a r i e t y of individual and group teaching and learning techniques, (5) c l i n i c a l follow-up and feedback by project s t a f f , and (6) an internal provider able to exert influence within the s o c i a l system. Three s i g n i f i c a n t participant c h a r a c t e r i s t i c s were: (1) per-ceived need, (2) motivation to change and, (3) degree of the practice autonomy of the professional. Proposed behavioural changes which possessed: (1) Rogers' attributes of r e l a t i v e advantage, participant/course goal congruency, comprehensibility, s i m p l i c i t y , o b s e r v a b i l i t y , and t r i a l a b i l i t y , and (2) were in the realm of s p e c i f i c psychomotor s k i l l s , regimes and procedures, and (3) did not require the - 59 -co-operation of others to implement, were p o s i t i v e l y related to impact. Goals that were e x p l i c i t seemed to be p o s i t i v e l y related to impact. E x p l i c i t outcome standards can c l a r i f y program aims for p a r t i c i p a n t s , serve as post-program performance guidelines for both participants and t h e i r supervisors, and f a c i l i t a t e the feedback and evaluation process between supervisors and p a r t i c i p a n t s . Programs which demonstrated the most evidence of successful impact were those of which the aim was to teach new psychomotor s k i l l s or technical procedures or regimes where the cooperation of others was not required for t h e i r implementation. Psychomotor s k i l l s and the learning of technical procedures or regimes, when described behaviourally, could e a s i l y possess a l l f i v e of Rogers' attributes of innovations. None of the e f f e c t i v e programs had aimed to change the risk-taking behaviour of p a r t i c i p a n t s . The s o c i a l system subvariables i d e n t i f i e d i n the research studies included: (1) the professional's autonomy in decision making, (2) the opportunity to practice, (3) peer group reinforce-ment, and (4) supervisory commitment obtained p r i o r to the implementation of the program. Being self-employed, or i f an employee, working outside a large i n s t i t u t i o n , plus r e l a t i v e freedom in decision-making related to d a i l y practice seems to contribute to a participant's a b i l i t y to adopt the new behaviour learned. Examples of this were the physicians and community health nurses who participated i n the programs analysed. The fourth subvariable in this l i s t i s s i g n i f i c a n t i n that i t i s - 60 -meant to i l l u s t r a t e that there i s a difference between gaining commitment during the early stages of program planning and gaining acceptance once a program has been developed. Input by the s o c i a l system into the development process seems to s i g n i f y that the s o c i a l system has a p o s i t i v e attitude toward the proposed changes while i t also legitimizes the program and creates the expectation of change. Presumably i t also creates the opportunity for participants to practice in the work settings and to get constructive feedback. Based on this analysis, no unequivocal answer can be given as to whether short continuing professional education programs can be e f f e c t i v e . The research suggests that programs which aim at changing behaviour in the psychomotor realm can be successful. Subvariables related to a program's impact have been i d e n t i f i e d in the analysis of the research studies yet i t i s the interaction of these subvariables which r e a l l y seems to determine whether a program achieves i t s desired impact on pa r t i c i p a n t s ' work behaviour. While program planners have substantial control over the program and behavioural change c h a r a c t e r i s t i c s , manipulation of participant and s o c i a l system c h a r a c t e r i s t i c s would be more tenuous, p a r t i c u l a r l y for short programs. Short programs ra r e l y set entry standards for r e g i s t r a t i o n . Demonstration of need, motivation and intention to apply the content i n practice i s r a r e l y a pre-requisite for p a r t i c i p a t i o n . Manipulation of s o c i a l system support and reinforcement should exist as part of the - 61 -design of a program, thus q u a l i f i a b l e as a program c h a r a c t e r i s t i c . What i s known about enhancing support and reinforcement i n the practice setting should be incorporated into the program design. As a means of a l t e r i n g forces in participants' work environments, i t might be more e f f e c t i v e to allocate limited resources to the development and reinforcement of the supportive aspects of s o c i a l systems rather than to the reduction of blocks i n the same system. - 62 -TABLE I PROGRAM CHARACTERISTICS RELATED TO BEHAVIOURAL CHANGE Subvariables Stein Cox (1981) (1981) STUDIES Heick Petersen Penn Scott (1981) (1982) (1978) (1980) -specific, small homogeneous target audience -"need" a deficiency state -cooperation, coordination in program planning pro-cess by educators, practi-tioners, and administrators -variety of individual and group teaching/learning techniques -clinical follow-up by project staff -internal provider x x TABLE II PARTICIPANT CHARACTERISTICS RELATED TO BEHAVIOURAL CHANGE Subvariables Stein Cox (1981) (1981) STUDIES Heick Petersen (1981) (1982) Penn Scott (1978) (1980) -perceived need -motivation to change -practice autonomy x x - 63 -TABLE III CHARACTERISTICS OF OBJECTIVES RELATED TO BEHAVIOURAL CHANGE Subvariables STUDIES Stein Cox Heick Petersen Penn Scott (1981) (1981) (1981) (1982) (1978) (1980) -relative advantage x -participant/course x goal congruency -simplicity x -observability x -trialability x -psychomotor skills, x regimes, procedures -cooperation of others not required for adoption x x x x x TABLE IV SOCIAL SYSTEM CHARACTERISTICS RELATED TO BEHAVIOURAL CHANGE Subvariables STUDIES Stein Cox Heick Petersen Penn Scott (1981) (1981) (1981) (1982) (1978) (1980) -professional autonomy -opportunity to practice -peer group reinforcement -commitment of superiors obtained prior to program implementation - 64 -CHAPTER III ANALYSIS OF THE SAFETY TO PRACTICE CONFERENCES The "Safety to Practice Conferences" were designed to have an impact on participants on two l e v e l s : awareness and behaviour. Each of the four conferences i n this series was equivalent to one day i n length. The behavioural changes implied by the objectives were in the realm of improving participants' problem solving behaviour. The results of the analysis conducted in Chapter II reveal that, as a r u l e , the behavioural changes achievable i n short continuing professional education programs are those where participants perform new psychomotor s k i l l s or follow new procedures i n t h e i r p r a c t i c e . Where program objectives are oriented towards problem solving and r i s k management, success i s more a l l u s i v e . The objectives for these programs, while being less tangible, are none-the-less important as the response to a program i t s e l f demonstrates an awareness of a perceived need on the part of the pa r t i c i p a n t s . The subvariables i d e n t i f i e d i n the analysis of the research studies of e f f e c t i v e programs w i l l now be applied to a retrospective analysis of the "Safety to Practice Conferences". Considering that these conferences were concerned with the scope - 65 -and environment of nursing practice rather than s p e c i f i c s k i l l s , the conclusions of the foregoing analysis are somewhat predictable given the conclusions of the analysis of the research studies. Never-the-less, insights valuable for future programming can be derived from this exercise. The t i t l e of the four conferences were as follows: / / l Safety to Practice: The Basics //2 Safety to Practice: Taking Charge of Your Own Practice //3 Safety to Practice: Evaluating Nursing Practice //4 Safety to Practice: Influencing Patient Care Conditions The f i r s t conference in this series was designed as an introductory conference. The purpose of this conference was to a s s i s t participants to develop an awareness of the issues a f f e c t i n g t h e i r safe practice and to increase t h e i r confidence in thei r own a b i l i t y to deal with these issues. Participants i n this conference were to develop a sense of r e s p o n s i b i l i t y for changing as well as a fee l i n g of readiness and potency to do something about i t . Conferences //2, 3, and 4, ca l l e d the follow-up conferences, were intended to further develop the d i f f e r e n t s k i l l s and strategies outlined i n the f i r s t conference. By providing learning a c t i v i t i e s within an educational setting which allowed participants to practice new s k i l l s and strategies in the follow-up conferences, i t was f e l t that participants would transfer to t h e i r own practice setting those strategies which - 66 -they f e l t to be most relevant. The numbering of the follow-up conferences suggests that sequential p a r t i c i p a t i o n would f a c i l i t a t e the learning and appplication of the content. In fact, this was not necessary as the numbering system was meant primarily to communicate to participants that there were four conferences i n the series addressing the basic issues of autonomy, se l f - r e g u l a t i o n and power. For the purpose of f a c i l i t a t i n g p a r t i c i p a t i o n and program a c c e s s i b i l i t y a decision had been made p r i o r to the development of the program that p a r t i c i p a t i o n i n the introductory conference was not mandatory for p a r t i c i p a t i o n i n any of the follow-up conferences . Program Characteristics Audience and Need With approximately 25,000 nurses registered i n B r i t i s h Columbia these conferences were developed for p r a c t i c i n g members who were involved d i r e c t l y or i n d i r e c t l y with patient care. About 80% of the membership would f a l l into t h i s category representing a diverse group of participants i n terms of educational backgrounds, work experiences, areas of practice, positions, ages, attitudes and expectations of themselves, the profession and t h e i r professional association. The origins of any continuing professional education program provide the context for the development of a program. Program objectives are derived from these foundations. Analysis of the "Safety to Practice Conferences" consequently must begin from - 67 -within this context. In 1977, a "Safety to Practice Program" had been approved by the Board of Directors of the Registered Nurses' Association of B r i t i s h Columbia (RNABC. Committee on Assessment of Safety to Practice, 1976). One of the purposes of this "Program" was to provide support services and resources to the membership regarding commonly encountered issues of safe p r a c t i c e . The Board made a five year commitment to develop s p e c i f i c tools and services that would a s s i s t nurses to make decisions and take action for t h e i r own safe practice of nursing. By 1980 the "Program" was well underway. The Board then decided to communicate to the membership information about these tools and services. I t was decided that the most appropriate method of transferring this information would be through a series of conferences where the tools and services would be discussed i n the context of the issues they were intended to address (RNABC News, May 1980). A project plan was proposed and approved (RNABC, STP Conferences Project Plan,1980). This writer was hired i n August 1980 to develop the i n s t r u c t i o n a l and administrative plans for these conferences. It was o r i g i n a l l y intended that once developed, the conferences would be offered for a period of approximately two years . Coincidentally, at approximately the same time as the decision was made to develop these conferences, a survey of membership attitudes about th e i r professional association was being conducted (Canadian Facts, 1980). Although intended for other purposes, some of the findings reinforced the need for the conferences. Average p r a c t i c i n g nurses were finding t h e i r jobs - 68 -very s t r e s s f u l and were having d i f f i c u l t y i d e n t i f y i n g what action or actions could be taken to reduce this stress . Heavy workload was a problem i d e n t i f i e d as s t r e s s f u l . Although nurses were not s p e c i f i c a l l y asked to comment further on the problem i t could be assumed that these nurses were concerned that this stress had implications regarding t h e i r safe practice of nursing. The nurses seemed to f e e l that they were powerless, had no decision making autonomy and could not change t h e i r work conditions . They f e l t that "others" were and should be, responsible for reducing the stress and changing the conditions i n t h e i r work environ-ments. "Others" were: (1) the Registered Nurses' Association, (2) t h e i r union, and (3) the i r employers. Most of the nurses surveyed had limited contact or involvement with the Association. The conclusions drawn by the researchers (Canadian Facts, 1980) were that nurses in B r i t i s h Columbia: (1) had limited awareness of the services offered by the i r professional association, (2) had limited awareness and were confused about the a c t i v i t i e s and r e s p o n s i b i l i t i e s of the Association, (3) perceived that the a c t i v i t i e s of the Association were not relevant to most nurses, and (4) that the Association was e l i t i s t and suffered from s e l f -interest (RNABC News, November-December, 1980). The series of four "Safety to Practice Conferences" was to involve the membership i n interacting with the "Safety to Prac-t i c e Program" objectives and support tools and resources. The goals, format for presentation, content outline, implementation and evaluation guidelines, administrative objectives and budget were a l l outlined i n the six-page project plan drawn up by a - 69 -planning committee (RNABC, STP Conferences Project Plan 1980). The conferences were to translate to the participants the d i f f e r e n t strategies nurses might use when faced with some issues commonly encountered in nursing p r a c t i c e . Participants would be assisted to perceive that the tools and services of the Asso-c i a t i o n could be a relevant and available source of help. The basic premise upon which the conference series was developed was that, as professionals, Registered Nurses possess s p e c i f i c p r i v i l e g e s which carry attendant obligations. The three fundemental p r i v i l e g e s i d e n t i f i e d were: (1) autonomy, (2) s e l f -regulation, and (3) power. In the Project Plan (1980:1) professional "autonomy" was described as . . . s e l f - d i r e c t i o n with r e s p o n s i b i l i t y for c o n t r o l l i n g the nature and continuing development of one's p r a c t i c e . Lewis and Batey (1982) and L i t t l e (1981) describe autonomy as the freedom to decide and to act independently within the scope of nursing p r a c t i c e . The exercise of c r i t i c a l judgement i s required in the decision making and action. These authors indicated that the c r i t i c a l factors associated with the exercise of a nurse's autonomy were the functional attitudes and the work environment. A t t i t u d i n a l autonomy exists when nurses are expected, i n the context of t h e i r work, to use judgement in the provision of patient services (Batey and Lewis, 1982). More d e t a i l about a t t i t u d i n a l and s t r u c t u r a l constraints w i l l be discussed i n the analysis of c h a r a c t e r i s t i c s of the s o c i a l systems i n which nurses work. - 70 -"Self-regulation", for the purposes of these conferences, was defined i n the Project Plan (1980:1) as " . . . r e s p o n s i b i l i t y for peer and self-evaluation." Again, s e l f - d i r e c t i o n i s implied. The setting and meeting of standards i n nursing practice i s i m p l i c i t in this d e f i n i t i o n . "Power" was defined i n the Project Plan (1980:1) as "...power to influence patient care conditions, with r e s p o n s i b i l i t y for using this i n patient's i n t e r e s t s . " Rights and power are words frequently used to define authority. Peplau (1971), in a study of nurses working in specialized areas, found that knowledge and expertise were strong indicators of power. Increased knowledge and expertise increased the power base of the nurses i n her study. A l l four conferences were to deal with operationalizing these concepts as rights and r e s p o n s i b i l i t i e s . Nurses were to be shown that they can influence and have the power to influence what happens to them, and are reponsible as individuals for taking action to prevent something or to make something happen. Intergroup Cooperation, Coordination and Commitment Attempts to gain s o c i a l system support had been sought more than a year p r i o r to the development of these conferences. Top l e v e l administrators from health care agencies throughout the province had been invited to attend a one-day conference where de t a i l s about the Safety to Practice Program and i t s goals and purposes has been discussed. During the conference the administrators were informed of the tentative plans to - 71 -disseminate the same type of information to s t a f f nurses through the series of "Safety to Practice Conferences". During the actual development and f i e l d testing of the conferences' series for nurses, s t a f f members took every opportunity i n their meetings with administrators to keep them informed regarding the purposes of these conferences. These strategies were intended for the administrators' awareness about the Safety to Practice Program and Conferences and to gain t h e i r support, i n p r i n c i p l e , for the conferences. During the planning and f i e l d testing of the "Safety to Practice Conferences" p r a c t i t i o n e r s and administrators were represented by nurses who sat f i r s t on the Planning Committee and then on the Steering Committee. Members of the Steering Com-mittee consisted of the Director of Nursing of a large hospital in the lower mainland; a Head Nurse of an Intensive Care Unit in a large hospital in the B.C. I n t e r i o r who was a Board member; a s t a f f nurse from a hospital on Vancouver Island, also a Board member; a s t a f f nurse i n a r u r a l hospital who was representing the nurses' union; and two e x - o f f i c i o s t a f f members. These three primary r e s p o n s i b i l i t i e s assigned to this Committee were to: (1) review draft materials and conference a c t i v i t i e s to ensure t h e i r a c c e p t a b i l i t y and relevance to various segments of the nursing community and to the "Safety to Practice Program; (2) give general d i r e c t i o n to development of plans for program evaluation; and (3) advise on matters of project administration. (Project Plan, 1980:5) - 72 -Because of the size of the potential audience, a centralized d i f f u s i o n system was adopted and the conferences were pre-packaged for presentation. The aim of the pre-packaging was to make the conferences accessible to nurses throughout the province for the lowest possible cost. The sponsorship process for these conferences sought the involvement of l o c a l nursing leaders. Intended to involve opinion leaders d i r e c t l y i n the conferences, l o c a l leaders were to be chosen as Conference Leaders to lead the group through the conference materials. Guidelines for the selection of Conference Leaders were designed to help groups to i d e n t i f y opinion leaders who would also be good group leaders. Local nursing adminis-trators and educators could be involved d i r e c t l y or i n d i r e c t l y through sponsoring a c t i v i t i e s . I n d i v i d u a l i z a t i o n of the content to l o c a l conditions could not be b u i l t into the packages. Although the option of changing the learning a c t i v i t i e s within each conference was not spec i f i e d i n the Conference Leader's Manuals, innovative Conference Leaders could adapt the learning a c t i v i t i e s to l o c a l experiences. Specialty groups who sponsored these conferences during 1981 were involved i n the design of learning a c t i v i t i e s p a r t i c u l a r l y relevant to the i r area of p r a c t i c e . Frequently, i t was the higher echelons among the specialty group hierarchy who made the decision to sponsor and lead a conference. Administrative p a r t i c i p a t i o n at that l e v e l of the nursing hierarchy may have resulted i n th e i r commitment to the changes proposed in the - 73 -conferences. However, th i s was never evaluated. Similar cooper-ative e f f o r t s between l o c a l sponsors and the RNABC were not possible after June, 1982 when the funding for the program planner/coordinator position was terminated, as planned. As the conferences were pre-packaged presentations, Conference Leaders were not required to be content experts. Under these circumstances they could not have been expected to formally follow-up or reinforce, i n the i r practice s e t t i n g , the changes proposed i n the conferences. Reinforcement by Conference Leaders and peers may have occurred i n c i d e n t a l l y i n smaller communities where par t i c i p a n t s , although in temporary groups for the conferences, worked together i n the same practice settings. Instructional Techniques The decision to of f e r the conferences in a pre-packaged format had been made p r i o r to the h i r i n g of a program planner and an appropriate budget allocated to t h e i r development. I t was f e l t that this would be the most cos t - e f f e c t i v e method of ensuring the a c c e s s i b i l i t y of the conferences to nurses through-out the province. The i n s t r u c t i o n a l strategies used were those believed to be most e f f e c t i v e for the general s t a f f nurse, the target of the conferences . The introductory conference was pre-packaged for oral presentation by a Resource Person while the three follow-up conferences were audio-visual packages which participants were led through by a Conference Leader. Resource Persons were - 74 -distinguished from Conference Leaders as having more dire c t f a m i l i a r i t y with the operations of the Registered Nurses' Asso-c i a t i o n . This often meant that Resource Persons were present or past Board members, committee members or Chapter presidents. Resource Persons were expected to draw upon the i r knowledge of the Association when discussion of the support tools and services took place i n the conference. Enrollment i n the introductory conference was limited to forty p a r t i c i p a n t s . Due to the audio-v i s u a l nature of the follow-up conferences enrollment was r e s t r i c t e d to twenty participants to f a c i l i t a t e group interaction which was f e l t to be a c r i t i c a l component of the teaching-learning transaction. The c r i t e r i a for the selection of Conference Leaders were that he or she be seen i n the community as a role model and innovator i n nursing p r a c t i c e . In addition, leaders were to be familiar with the content concepts, l i k e l y to have applied some of the strategies to th e i r practice and be competent group leaders. Comparatively speaking, as the follow-up conferences aimed at changing work behaviour, i t was the Conference Leaders who had the most d i f f i c u l t task yet they were generally less experienced than the Resource Persons. Rather than using the interpersonal network to induce change the follow-up conferences depended primarily on the audio-visual media. More f i n a n c i a l resources had been allocated to the development and implementation of the introductory conference which aimed at developing participant awareness and a willingness or desire to - 75 -change and a r e c e p t i v i t y to help. Fewer resources had been allocated to the follow-up conferences which aimed at changing behaviour. I t i s possible that the audio-visual media might have been f a i r l y e f f e c t i v e i n increasing awareness while the interpersonal presentation may have been more appropriate for the follow-up conferences . Materials for the introductory conference consisted of: (1) a Resource Person's Manual with the entire conference content including learning a c t i v i t i e s and guidelines for group discussions, plus supporting audio-visual aids, and suggestions for summarizing discussions; (2) a Participant's Workbook; and (3) a Sponsor's Planning Guide. Each of the follow-up conferences consisted o f : ( l ) a Conference Leader's Manual; (2) a Participant's Workbook; and (3) a Sponsor's Planning Guide. The Conference Leader's Manual came complete with synchronized slide-tapes, videotapes, the narrative for the tapes, learning a c t i v i t i e s with guidelines for discussion and suggestions for summarizing and r e l a t i n g the discussions to the conference obj ec t i v e s . The Participant's Workbook for each conference included: (1) an outline of the the o v e r a l l purpose of the conference; (2) the role of the Resource Person or Conference Leader; (3) the role of the participants; (4) the general objectives and s p e c i f i c objectives for each unit; (5) directions for the learning a c t i v i t i e s ; - 76 -(6) a bibliography; (7) a l i s t and description of the RNABC resources available; (8) copies of selected RNABC publications; and f i n a l l y , (9) a participant reaction evaluation form. Sequencing of the conference content and learning a c t i v i t i e s followed the same rationale i n each of the conferences. Presentation of an overview of the conference content was f o l -lowed by a non-threatening learning a c t i v i t y intended to have participants r e f l e c t upon relevant past experiences. The over-view and the discussion of the participants' experiential base was to f a c i l i t a t e the apprehending phase of learning, attempting to create a bridge between new and existing knowledge. It was expected that some par t i c i p a n t s , due to unpleasant previous experiences, would hold negative attitudes about some of the issues that were to be addressed i n the conferences. Small group discussions were u t i l i z e d for the purpose of revealing the di f f e r e n t perspectives that could be associated with each issue. As each conference progressed participants were required to apply conference content to problem solve hypothetical situations meant to be similar to those encountered i n th e i r d a i l y p r a c t i c e . In each of the follow-up conferences small group a c t i v i t i e s aimed at having participants apply the strategies presented i n the conference to case studies. Participants were to consider a range of possible solutions and the potential consequences of each alternative s o l u t i o n . These a c t i v i t i e s were meant to be the equivalent of s k i l l practice s i t u a t i o n s . Application of the - 77 -conference content was expected to play a large part in each group's selection of a solution which would be an image of how things should or could be. Fi n a l exercises i n the follow-up conferences were to direc t participants to translate the insights gained into action plans for change i n th e i r practice settings. No means of ensuring commitment to these plans, however, was b u i l t into the conference design. Application of the innovative-decision process to the analysis of the teaching-learning transactions reveals that participants were taken through the knowledge and persuasion stages only. Because these conferences aimed at having p a r t i c i -pants adopt proactive rather than reactive behaviours i t would have been d i f f i c u l t for many participants to progress to the l a s t stages of the innovative-decision process. The consequences of adopting the behaviour proposed, d e f i n i t e l y presented r i s k s to each p a r t i c i p a n t . Demonstration of the behaviour was b u i l t into the conferences but only at the l e v e l of role playing or acting on a videotape. Follow-up Feedback Follow-up feedback i n the participant's practice setting was not a component of the design of this program. However, through-out each of the conferences participants were given the message to contact the RNABC Practice Consultants for further information regarding resources or services or for moral support i n implemen-- 78 -ting the new behaviour. Between 1981 and 1983 and again in 1984 members have been able to c a l l the Association t o l l free from any area i n the province. Many of the c a l l s Practice Consultants receive about safety to practice issues are from nurses who either have attended one of the conferences or were referred to a consultant by someone who was a participant ( C a r r o l l , 1984). Follow-up support and feedback to a l l participants i n each of the conferences had been deemed, from the inception of the conferences, impractical and too c o s t l y . The compromise had been to have participants seek follow-up consultation and reinforce-ment from the Association. Internal Provider The primary purpose of the RNABC i s to ensure the safe practice of nursing i n B r i t i s h Columbia. Although two of i t s functions, required by law (Nurses' A.ct, 1979), are the setting of nursing standards and the d i s c i p l i n e of the membership for unethical or incompetent behaviour i t has no power or authority to control the work settings i n which members p r a c t i c e . The Association can only enter the work setting as a representative of a member or members when ca l l e d i n by that member or members. Being r e l a t i v e l y distant from each nurse's practice setting, therefore, does not q u a l i f y the Association as an internal provider. E s s e n t i a l l y , i n these conferences, the Association was teaching participants from a distance and o f f e r i n g long distance follow-up support. - 79 -Characteristics of Participants L i t t l e information i s available about the participants i n these conferences. A narrative report written i n 1982 indicates that 21 .4% of the participants attending the early conferences were i n management l e v e l positions (RNABC. STP Evaluation Report, 1982). Whether the same percentage of management l e v e l nurses were attending conferences offered l a t e r i s a matter for speculation, p a r t i c u l a r l y as these conferences were developed with s t a f f nurses as the target audience. The e a r l i e r patterns of p a r t i c i p a t i o n could have represented what Rogers and Shoemaker c a l l the early adopters while l a t e r adopters could have been attending the conferences held two and three years after the program commenced. There i s no data to indicate i f , i n fact, this has been the pattern. No hard data i s available to permit an analysis of the c h a r a c t e r i s t i c s of the participants who attended these conferences . Characteristics of the Proposed Behavioural Changes The o v e r a l l goal of the conferences series was to have nurses who participated in any one of the conferences: ...demonstrate personal r e s p o n s i b i l i t y for the safe care of patients by using one or more of the services/tools which the Board of Directors i s developing through the Safety to Practice Program. (Project Plan, 1980:1) - 80 -Two objectives are implied by this goal: (1) personal respon-s i b i l i t y and (2) the use of the RNABC services or too l s . Although the goal attempted to specify how the "personal r e s p o n s i b i l i t y " was to be demonstrated i t s t i l l represents a broad spectrum of possible behavioural manifestations. Each of the four conferences aimed at discussing possible behavioural manifestations of "personal r e s p o n s i b i l i t y . " Recognizing the l i m i t a t i o n s as to what any one-day program could achieve, none of the confer ences i n the series s p e c i f i c a l l y stated in t h e i r objectives that participants would change the i r behaviour or performance in the work setting s o l e l y as a re s u l t of p a r t i c i p a t i o n . The o v e r a l l purposes of the follow-up confer-ences were as follows: //2 Safety to Practice: Taking Charge of Your Own Practice The purpose of this one-day conference on "Safety to Practice: Taking Charge of Your Own Practice i s to a s s i s t Registered Nurses to consider s t r a -tegies that can be used to take charge of t h e i r own p r a c t i c e . //3 Safety to Practice: Evaluating Nursing Practice The purpose of this one-day conference on "Safety to Practice: Evaluating Nursing Practice" i s to a s s i s t Registered Nurses to develop strategies for evaluating t h e i r own nursing practice, in t h e i r practice s e t t i n g , with the end goal of improved nursing s k i l l s and better patient care. //4 Safety to Practice: Influencing Patient Care Conditions The purpose of t h i s one-day conference on "Safety to Practice: Influencing Patent Care Conditions i s to a s s i s t Registered Nurses to consider actions they can take when conditions of practice a f f e c t t h e i r a b i l i t y to maintain a safe standard of nur-sing care . - 81 -The key behavioural words here are "to consider" and "to develop." Under these o v e r a l l purposes, f i v e to six s p e c i f i c objectives for each conference were l i s t e d , a l l of which were in the cognitive and a f f e c t i v e domain of behavioural change (see Appendix A). Practice changes are not specified yet an impact on participant behaviour i s implied for each conference. Because of the diverse audience one of the assumptions underlying each conference was that participants would f i l t e r the content to determine what was not relevant to them, then adopt those stra-tegies which they perceived as relevant to the issues they encountered or anticipated encountering i n t h e i r own p r a c t i c e . Application of Rogers' l i s t of attributes of innovations to these objectives reveals that few of the proposed changes possessed any of the attributes associated with adoption. These are less tangible than psychomotor objectives. None of the subdimensions of the a t t r i b u t e of r e l a t i v e advantage can be found in these objectives. I n s u f f i c i e n t information i s available about participants to permit analysis of participant/course goal congruency. F i e l d testing results indicated that participants were attending for a v a r i e t y of reasons. Either they wanted the information, or the information was of general i n t e r e s t , or they thought that the information might be relevant to them in t h e i r present r o l e . Although the objectives were simple to understand in t h e i r cognitive form they were i n f i n i t e l y more complex to apply i n the practice setting where, to some extent, the cooperation of others was needed. Implementation of the - 82 -objectives, even on a t r i a l basis, required participants to assert themselves and also presented some r i s k as to the consequences of the i r action. Many participants may have anticipated d i f f i c u l t i e s and rejected p a r t i a l adoption. Others may have experienced some discomfort and encountered opposition i n attempts to try to implement what they had learned. Characteristics of the Social System No studies were found by this writer e x p l i c i t l y analysing the environments in which nurses i n B r i t i s h Columbia work. Nurses' roles are t y p i c a l l y described as being independent, in t e r -dependent and dependent. Hospital t r a i n i n g programs, which were the predominant mode of basic nursing preparation u n t i l the late 1960's, did not s o c i a l i z e nurses to act autonomously. Hospital p o l i c i e s encouraged and reinforced nurses deferring decisions to physicians. H i e r a r c h i c a l structures then and now prescribe t h e i r interpersonal relationships, formal l i n e s of communication and prescribed leaders. Although nursing education was transferred to the community colleges and u n i v e r s i t i e s i n the 1960's, the t r a n s i t i o n to professional autonomy has not been easy. Structural constraints s t i l l p e r s i s t and act as b a r r i e r s to the development of autonomous nurses. As both Batey and Lewis (1982) and L i t t l e (1981) noted, autonomy i n nursing w i l l and can occur only i f the s o c i a l systems allow i t and the in d i v i d u a l nurses are w i l l i n g to exercise i t . - 83 -In a study of a continuing nursing education program, Keltner (1983) found that most respondents did not perceive that they had an opportunity to apply what they had learned in a program to their practice settings. Only 48% of the nurses i n her study f e l t supported i n the i r attempts to apply t h e i r new knowledge. Carlley (1980) concluded from her study of a continuing nursing education program that nurses are not encour-aged or expected to disseminate information gained through continuing education classes. Nurses do not seem to perceive their employers as supportive of th e i r e f f o r t s to apply knowledge gained from continuing education programs. Although some work environments are favourable to change i t must be assumed from the above that for the average nurse in B r i t i s h Columbia the work environment i s slow to encourage change. Changes such as those proposed in these conferences, which could have the potential of changing the structure of so c i a l systems, would l i k e l y have been discouraged by i n s t i t u t i o n s comfortable with the status quo. Summary This analysis revealed that few of the subvariables i d e n t i f i e d i n the research studies as p o s i t i v e l y influencing program impact on work behaviour were present in these conferences. These conferences attempted to unfreeze and move participants to new levels of behaviour. While an informal - 84 -process of s o l i c i t i n g s o c i a l system support was u t i l i z e d p r i o r to and during the development of these conferences i t i s questionable that i t would have been adequate for refreezing of the new behaviour. Using the subvariables from the research studies as the c r i t e r i a for e f f e c t i v e programming, the conclusion must be drawn that i t i s not probable that any of the conferences had a l a s t i n g impact on the work behaviour of participants . Even i f a participant attended a l l four conferences over a period of time, given the design of the program and the nature of the objectives, the conferences would not l i k e l y have had a cumulative impact on the work behaviour of that p a r t i c i p a n t . Changes in participant behaviour, i f they occurred after attendance at any one or a l l four of the conferences, would have l i k e l y been due to highly motivated participants who possessed the c h a r a c t e r i s t i c s i d e n t i f i e d i n the research studies and who worked i n s o c i a l systems supportive of the proposed changes. Several mitigating factors can be summarized as having impeded the successful impact of these conferences. F i r s t , desig-ning a packaged program for such a large, geographically dispersed, diverse audience made i t impractical to seek the input of p r a c t i t i o n e r s and administrators throughout the province in the program planning process. Although input was required at the l o c a l l e v e l for sponsorship there was no formal plan to s o l i c i t the support of the l o c a l health care agency administrators i n endorsing the changes proposed at the time that a conference was being held. Even i f l o c a l p r a c t i t i o n e r s and administrators had - 85 -cooperated i n the sponsorship of a conference t h e i r input into the conference as a packaged product would have been minimal and would have been inadequate to guarantee s o c i a l system support of the planned changes . Second, the behavioural changes were i n the realm of preven-t a t i v e behaviours. Rogers' review of the adoption research l i t e r a t u r e revealed that preventative innovations are r a r e l y adopted. The conference objectives aimed at developing the s e l f - d i r e c t e d behaviour of p a r t i c i p a n t s , yet to implement the proposed behaviours required participants to be s e l f - d i r e c t e d . Third, the proposed behavioural changes may have posed a threat to the status quo of the s o c i a l systems i n which the participants were employed. Expecting participants to adopt behaviour that would challenge exi s t i n g p o l i c i e s and practices within t h e i r s o c i a l systems represented a considerable r i s k for the participants . Support and reinforcement of the new behaviour would not occur i n s o c i a l systems wanting to r e s i s t these changes . F i n a l l y , the networking of the Association was at too great a distance from participants to allow on-site follow-up support and reinforcement of the behavioural changes. Consultations with the RNABC Practice Consultants had the potential of providing support and reinforcement at a distance. The relationship between long distance support and reinforcement and post-program behavioural changes has not been reported on i n the research l i t e r a t u r e . - 86 -I f p articipants' attitudes changed about t h e i r a b i l i t y to change what happens to them, then, to some extent, the conferences could be judged successful acording to the s p i r i t of t h e i r intention. To c l a r i f y this point, i t was stated e a r l i e r in this paper that i t was the intention of the conferences to increase awareness; to show nurses that they could influence, had the power to influence what happens to them and that they were responsible as individuals for taking action to prevent something or to make something happen. Should participants have perceived, afte r attending one or more of the conferences, that t h e i r professional association could contribute to achieving those outcomes, then the goal of a t t i t u d i n a l change was achieved. No baseline of attitudes i s known nor was any formal follow-up evaluation conducted to determine whether nurses' awareness or attitudes changed as a consequence of attending any of the conferences. Because these conferences represented a unique phenomenon unparalleled i n the past, comparisons of teaching strategies and outcomes are d i f f i c u l t to make. In the future, programs of such magnitude may not occur because the cost of resources that would be required to ensure that the presence of subvariables i d e n t i f i e d i n the e f f e c t i v e programs would be too great for a short program. No income was generated by these conferences; they represen-ted an expenditure in which there was no way of measuring cost-effectiveness . Just t h e i r existence manifested an act of f a i t h - 87 -of nurses in themselves and i n the self-directiveness of the membership; a t r a i t that was to be nurtured and encouraged within the context of each of the conferences. Educational or health care i n s t i t u t i o n s are not l i k e l y to attempt to duplicate this type of e f f o r t , primarily because of f i n a n c i a l reasons. Princip l e s for the development of impact programs can be derived from the results of the subvariables i d e n t i f i e d i n the analysis of the e f f e c t i v e programs and from the analysis of this conference seri e s . Chapter IV w i l l present a l i s t and a discussion of these proposed p r i n c i p l e s . - 88 -CHAPTER IV PLANNING EFFECTIVE SHORT NURSING PROGRAMS Seven p r i n c i p l e s for the development of continuing nursing education impact programs w i l l be proposed here. General adult education p r i n c i p l e s would s t i l l be applied i n the program planning process but are not mentioned here for purposes of brevity. These seven p r i n c i p l e s are meant to act as guidelines for the development of e f f e c t i v e impact programs and would need to be tested before being adopted. They are presented within the con-text of the limited types of objectives achievable as evidenced in the analysis of e f f e c t i v e programs and take into account the t y p i c a l resources allocated to the development of short contin-uing nursing education programs. Some of the p r i n c i p l e s are congruent with general strategies for change while others are similar to elements found i n conventional program planning models. The p r i n c i p l e s would seem to be most compatible with Boyle's (1981) program planning model. Boyle's model i s one of the few models that suggests steps for integrating learners and i n f l u e n t i a l persons from participants' s o c i a l systems into the program planning process . Programs may be designed to take participants through the - 89 -innovative-decision process but personal and s i t u a t i o n a l factors, often outside the planner's control, can impede progress through the process. Rather than having a program operate from outside the participant's s o c i a l system these p r i n c i p l e s provide sugges-tions for integrating the s o c i a l systems into the program design. In addressing one of the issues i n program planning, the bridging of educational programs to work environments, these p r i n c i p l e s require the existence of three fundamental conditions i f they are to be applicable. F i r s t , the conference content must have immediate relevancy to the participants' p r a c t i c e . Second, mastery of the content i s required as a pre-requisite for the application of content to practice and as such must be tested i f behavioural changes are to be evaluated. Thirdly, motivation to change i s also a prerequisite for change i n work behaviour. Program Planning P r i n c i p l e s 1 . Programs should be developed for s p e c i f i c small homogenous audiences. The less diverse the audience and the more that i s known about them the easier i t would be to match the program to th e i r needs, baseline behaviours, learning s t y l e s , previous experi-ences, areas of practice and positions while integrating the content into the context of th e i r work environments. 2. The learning need for any program should be one i d e n t i f i e d - 90 -by p r a c t i t i o n e r s , educators, and administrators as a deficiency state which i s d i r e c t l y related to patient care. Underlying this p r i n c i p l e i s the congruency between p a r t i -cipant goals and course goals which i s necessary to motivate participants to change. Deficiency states are more l i k e l y to be observable, provide a baseline of the performance, and allow for the development of a clear d e f i n i t i o n of the problem and the performance standards to be achieved by a program. Projections of the desired state provide a post-program standard for comparison. The provision of a standard of safe patient care i s a goal common to nursing p r a c t i t i o n e r s , educators and administrators. With safe patient care as the underlying goal, agreement among these groups i s more l i k e l y and may encourage reinforcement of behavioural changes i n the practice s e t t i n g . At l e a s t , negative sanctions are u n l i k e l y to be imposed on participants wanting to implement new behaviours to improve patient care. 3. Liason between educators, p r a c t i t i o n e r s and administrators from the partic i p a n t s ' s o c i a l systems i s required throughout the entire program planning process. Program planners have been urged by G r i f f i t h (1981) and Del Bueno (1977) to work more clos e l y with the agencies i n which participants are employed i f t h e i r programs are to succeed i n impacting on participants' work behaviour and patient outcomes. Commitment of administrators and pra c t i t i o n e r s to change cannot be achieved through t h e i r token representation on planning - 91 -committees. Partnership throughout the program planning process i s required to gain acceptance of the desired program outcomes by those involved i n making the changes and those affected by i t . Involving the s o c i a l system i n the program planning process w i l l also help, according to G r i f f i t h , to i d e n t i f y the s i t u a t i o n a l factors which would influence application; thus involving those with authority to restructure the work environment who, i n turn, could encourage, support, reinforce and reward behavioural changes. This would constitute the l e g i t i m i z a t i o n and support required from the formal power structure of the s o c i a l system. Planning teams may consist s o l e l y of employees of the participants' employing agencies or may include inside and outside members. Outside members would l i k e l y be the program planner/change agent. The more committed the power structure i s to the proposed behavioural changes, the more l i k e l y they w i l l f a c i l i t a t e a participant's progress through the innovative-decision process. Brown (1980) has stated that s o c i a l systems have rights and r e s p o n s i b i l i t i e s regarding t h e i r employees who p a r t i c i p a t e i n continuing education programs. While employers have the right to expect participants to change t h e i r behaviour subsequent to p a r t i c i p a t i o n they also have the r e s p o n s i b i l i t y for r e i n f o r c i n g and supporting the changes i n participant behaviour. 4. Programs should be scheduled and sequenced to allow for independent study and practice between sessions. - 92 -Grabowski (1983) terms this "multiphase programming". The sequencing of i n s t r u c t i o n a l sessions to allow for independent practice sessions i s a fundamental approach employed i n formal education programs. Short continuing professional education programs have t r a d i t i o n a l l y been offered i n one, two or three day consecutive f u l l day sessions. Several d i f f e r e n t factors could be at the root of this t r a d i t i o n . Program planners may believe that scheduling longer sessions over fewer days f a c i l i t a t e s attendance and persistence i n a program. Also, because continuing education i s frequently a marginal a c t i v i t y of educational i n s t i t u t i o n s i t may sometimes be cheaper and l o g i s t i c a l l y simpler to schedule a small number of longer sessions than several short sessions. The cost to outside providers of sending project workers into the work setting for follow-up support and reinforcement of participants' behavioural changes would add s u b s t a n t i a l l y to the fees charged for continuing professional education programs. The question then arises as to how refreezing can be ensured. Certainly management commitment to change would contribute to refreezing. Other support systems are possible when programs are scheduled to allow participants time to go back to t h e i r work setting to try out the new s k i l l s . Participants make decisions and operate as individuals i n t h e i r practice settings. Individual exercises designed to encourage the development of action plans to be implemented i n the work setting would seem to be desirable. The aim would be to - 93 -l i n k plans to action. The opportunity for practice can help to take participants to the implementation stage of the innovative-decision process. Requiring participants to practice in t h e i r work settings during the intervals between classroom sessions encourages commitment to action plans. Support can be provided i n the classroom setting p r i o r to practice while feedback and reinforcement of the new s k i l l s could be an integral component of the next session. This type of feedback mechanism would provide classroom support for risk-taking behaviour. The experience of a l l the participants experimenting with the new behaviour in t h e i r practice settings should also have a re i n f o r c i n g e f f e c t . Individual study and practice between i n s t r u c t i o n a l sessions should contribute to consolidation and would be the compromise for not having project workers do an on-site follow-up of p a r t i c i p a n t s . 5. Team attendance should be encouraged. When two or more participants from any c l i n i c a l area attend a program mutual reinforcement and feedback i n the practice setting i s possible as they try out t h e i r new s k i l l s between classroom sessions. This peer support and reinforcement may pe r s i s t following the completion of the program. 6. F l e x i b i l i t y must be b u i l t into any program, p a r t i c u l a r l y i n the learning a c t i v i t i e s which can be adapted to ensure - 94 -appropriateness to p a r t i c i p a n t s . Many continuing nursing education programs are offered to more than one group of nurses over a period of time. Potential participants and nursing administrators from the agencies i n i t i a l l y requesting the program may be involved i n the development of the program. Frequently the program format, content and learning a c t i v i t i e s are not changed or adapted to new groups after the f i r s t o f f e r i n g . Programs, even i f they consist predominantly of teacher-learner i n t e r a c t i o n , i n a sense, become packaged products. It i s generally known during program development that a program may be suitable for several groups of nurses i n diverse f i e l d s of p r a c t i c e . P r a c t i t i o n e r s and administrators from these areas of practice should be involved i n i t i a l l y i n the program planning process. However, should new audiences a r i s e , liason and input from these members affected by the program should take place and the program should be adjusted to t h e i r needs and environments. Sometimes only a small portion of the content would need changing and new learning a c t i v i t i e s could be developed or selected from those o r i g i n a l l y developed for the program. Developing a selection of case studies during the i n i t i a l program development phase which could be appropriate to a diverse group of participants would contribute to the f l e x i b i l i t y of a program. 7. Objectives should be limited to the realm of psychomotor - 95 -s k i l l s , s p e c i f i c nursing assessment s k i l l s or protocols, nursing techniques or procedures. These objectives focus on i n d i v i d u a l change not requiring the cooperation of others to implement. The r e l a t i v e advantage of the new behaviours should be related to patient care and should be demonstrable to p a r t i c i p a n t s . Participants need to be able to interpret participant/course goal congruency i n th e i r s e l f - s e l e c t i o n to attend a program. Clear, e x p l i c i t objectives f a c i l i t a t e a participant's comprehension of a program's goals and allow matching of needs to goals. Objectives, i n addition to being simple to understand, must be r e l a t i v e l y easy to implement with p o s i t i v e results observable to participants i n the short term. Objectives should also allow for t r i a l without f u l l commitment. Summary Several key concepts appear i n these p r i n c i p l e s . Con-gruency, lia s o n , commitment, involvement, practice, feedback, reinforcement, support and f l e x i b i l i t y are the concepts to be applied to the design of programs intending to impact on a p a r t i -cipant 's work behaviour. Most adult education program planning models l i s t sequential and over-lapping processes for the design of programs. Integration of a model's philosophical basis into these processes i s not always obvious i n the l i s t s of steps. Responsible and accountable program planners must be cognizant of the philosophies underlying the - 96 -program planning model they intend to use. Compatibility between a model's philosophical basis and a program's goals i s necessary i f programs are to be e f f e c t i v e . The p r i n c i p l e s proposed i n this paper, although they primarily represent concepts, have attempted to i l l u s t r a t e a relationship between the concepts and decision steps . These p r i n c i p l e s are intended as a supplement to existing program planning models. Because they attempt to integrate some pr i n c i p l e s of planned change these p r i n c i p l e s would seem to be most compatible with Boyle's (1981) i n s t i t u t i o n a l framework for program development and the f i f t e e n concepts he l i s t s as "important" for program development. Features i n the above pr i n c i p l e s d i s t i n c t i v e from Boyle's i n s t i t u t i o n a l framework for program development are: (1) the d e f i n i t i o n of need, (2) speci-f i c a t i o n of the types of objectives achievable i n short continuing professional education programs, and (3) the scheduling of i n s t r u c t i o n a l sessions to allow for independent practice i n the work s e t t i n g . Empirical testing of the v a l i d i t y of each of these p r i n -c i p l e s as independent variables influencing outcome would be d i f f i c u l t . Considering the importance of pr a c t i c e , support, feedback and reinforcement to refreezing of behavioural changes i t would be worth testing the e f f e c t of sequencing as the independent variable influencing impact. - 97 -CHAPTER V PROPOSAL FOR A RESEARCH DESIGN Although the p r i n c i p l e s proposed i n Chapter IV would represent a unique int e r a c t i o n of variables, the study proposed here would test the impact of one p r i n c i p l e only, the scheduling of program sessions to allow for independent c l i n i c a l practice between sessions. The Cox and Baker (1981) and Heick (1981) studies along with the Kattwinkel (1979), Ruebenstein (1981), Inui (1976), and Laxdal, et a l . (1978), studies analyzed by Stein (1981) involved multiphase programming with supervised practice between sessions. Evaluation studies of multiphase programming without supervised practice could not be found i n the l i t e r a t u r e . Participant and course goal congruency contributed to program impact i n the programs evaluated by Cox and Baker and Heick and i n the program studies analyzed by Stein. Derby (1982) suggests that scheduling courses to allow time for r e f l e c t i o n and the opportunity to apply content i n the practice setting might contribute to participant/course goal congruency. Program Design A background for a hypothetical continuing nursing education - 98 -program t i t l e d "Developing Hospital P o l i c i e s for Safe Patient Care" i s proposed here. The purpose of the program would be to a s s i s t nurses to develop and improve t h e i r policy making s k i l l s . The program would focus on: (1) general p o l i c i e s needed i n acute care f a c i l i t i e s , (2) factors to consider when evaluating current p o l i c i e s , (3) renewing current p o l i c i e s , (4) diagnosing the need for new p o l i c i e s and (5) guidelines for the development and evaluation of new p o l i c i e s . The need for this program was f i r s t recognized by several members of a policy making committee i n an acute care agency who f e l t that t h e i r lack of s p e c i f i c t r a i n i n g and experience was i n t e r f e r i n g with the expediency with which they could review and renew exis t i n g p o l i c i e s and develop new p o l i c i e s for the safe care of patients . Nurses on other p o l i c y making committees in the same agency experienced si m i l a r problems as they had no systematic method of approaching the work expected of these committees. Nurses on these committees were at the l e v e l of s t a f f nurses, head nurses, c l i n i c i a n s and supervisors. Two representatives from these committees held a meeting with the nursing management of the agency to communicate the need for an educational program to correct this deficiency. The nursing management agreed with the need and made a commitment to seek out or develop an appropriate educational program. Discussion of this need i n a meeting with nursing managers from other acute care f a c i l i t i e s resulted i n two other agencies agreeing that nurses i n th e i r respective agencies had the same need. These two - 99 -agencies v e r i f i e d the need with t h e i r own p o l i c y committees. A task force was subsequently set up with representation from management and potential p a r t i c i p a n t s . Nurses s i t t i n g on p o l i c y committees i n these agencies were surveyed by the task force for the purpose of i d e n t i f y i n g s p e c i f i c problems. Once i d e n t i f i e d the problems were c l a s s i f i e d and relationships between s t a f f p o s i t i o n , committee, and problems were noted. A provider with content expertise was subsequently contacted by the task force and agreed to design a program to address these problems. Members of the task force then became members of the program planning committee. S p e c i f i c behavioural objectives were outlined and program content was developed. The s p e c i f i c learning objectives were behaviours that nurses would be expected to demonstrate i n t h e i r c l i n i c a l settings upon completion of the program. A variety of learning experiences i n the form of case studies and situations s p e c i f i c to problems encountered by subgroups were developed. Evaluation Design The question to be answered by the study would be: Does mulitphase programming with independent practice between sessions contribute to the impact of a program on a nurse's work behaviour? Two levels of program impact would be measured i n this study: (1) knowledge gain at the time of course p a r t i c i p a t i o n ; and (2) behavioural changes i n the practice setting two months - 100 -following the program. A quasi-experimental research design would be employed. Pre- and post-program knowledge tests would be administered. Pre-and post-program data on participants' work behaviour would also be gathered. Independent Variable Multiphase programming with independent practice i n the intervals between sessions versus sequencing of program content with no i n t e r v a l for pr a c t i c e . The multiphase program would be four three-hour sessions at two week i n t e r v a l s . Dependent Variables Knowledge gain immediately a f t e r p a r t i c i p a t i o n i n the program and adoption of the changes proposed i n the program's objectives. Content experts would help to operationalize these objectives into s p e c i f i c behaviour which could be observed. Method Study Group. Two d i s t i n c t groups would complete the program within four months: an experimental group and a control group. Long range recruitment due to contracting between the provider and the p a r t i c i p a t i n g agencies would make i t possible to assign participants to the two groups. The second program would serve as a control for the f i r s t . Because participants would be tested within two months of completion of the program, maturation would - 101 -not be a s i g n i f i c a n t fact or that would aff e c t r e s u l t s . Team leader, assistant head nurse, head nurse and c l i n i c i a n members of p o l i c y making committees i n the p a r t i c i p a t i n g agencies who indicated on t h e i r r e g i s t r a t i o n forms the need to develop or improve t h e i r p o l i c y making s k i l l s would be accepted into the program. As more than one member from any given committee could choose to attend, random assignment to groups would not be pos-s i b l e as i t could r e s u l t i n one member being in the experimental group while another member from the same committee could be in the control group. Some control would be possible i f participants were a l l assigned numbers. When teams of two or more from the same committee registered they would be assigned the same number. Numbers would then be chosen randomly and assigned to the experimental group. While the e f f e c t of team p a r t i c i p a t i o n could be tested the design would be compromised to some extent. Groups would not be equivalent according to th e i r pre-test scores and more participants would be i n the experimental group than i n the control group. The experimental group would attend four bi-weekly three-hour sessions where they would be expected, between sessions, to attempt to apply the content to t h e i r practice settings. The study would assume that this scheduling would allow the experimental group to attempt to apply the content. The control group would attend the same program over two consecutive days where independent practice sessions would not be part of the program. Program content would be the same for a l l - 102 -i n s t r u c t i o n a l groups regardless of the i n t e r v a l between sessions. Data C o l l e c t i o n . Pre- and post- program knowledge testing plus pre-program and follow-up questionnaires would be administered to each of the participants i n the two groups. Pre-and post-program data on participants' behaviour would also be obtained from participants' supervisors. Each participant would select a supervisor whom they believed to already possess p o l i c y making s k i l l s . Participants and supervisors would be asked to sign a contract to agree to p a r t i c i p a t e i n the follow-up study. Content experts would devise forty questions to test knowledge. To minimize the testing e f f e c t on the r e s u l t s , these questions would be randomly assigned to the pre- and post-tests. Based on the data collected i n the needs survey conducted by the task force the pre-program questionnaire would ask each participant to complete: (1) a personal p r o f i l e , (2) a s e l f - r a t i n g of the frequency of t h e i r performance of the targeted behaviour, (3) a s e l f - r a t i n g of t h e i r s k i l l s i n performing the stated behaviours, and (4) a r a t i n g of the opportunities they might have to implement the targeted behaviours. Supervisors would be asked i n the pre-program and follow-up questionnaires to rate the participants': (1) frequency of performance of the targeted behaviours, (2) l e v e l of s k i l l i n the performance of these behaviours and (3) opportunities available for performance of these behaviours. In a follow-up questionnaire participants would be asked to complete: (1) a s e l f - r a t i n g of the frequency of their - 103 -performance of the targeted behaviours following completion of the program, (2) a s e l f - r a t i n g of t h e i r s k i l l s i n performing the targeted behaviours, and (3) an inventory of the opportunities they had to perform these targeted behaviours. In addition, participants would be asked to comment on why they thought their behaviours had or had not changed. To increase the r e l i a b i l i t y of the instruments, f i e l d tests would be conducted with nurses s i t t i n g on similar committees i n non-participating agencies. Data Analysis. A " t " test of the experimental group's pre-and post-program knowledge scores would be conducted to establish whether there was a s t a t i s t i c a l l y s i g n i f i c a n t gain i n knowledge. Comparisons would be made between the mean, standard deviation and range of pre-and post-program scores of the experimental and the control group to examine s t a t i s t i c a l s i g nificance (see Table V, below). Table V Descriptive Data Summary of Scores Resulting from Pre- and Post-testing of E and C Groups Pre-Test Post-Test E C E C Mean S .D. Range Comparison of the experimental group's pre-program and - 104 -follow-up s e l f - r a t i n g s of performances would indicate i f any s i g n i f i c a n t changes in behaviour occurred. Comparisons between the s e l f - r a t i n g s of both groups would be made using " t " t e s t s . Supervisors' pre-program and follow-up ratings of participants' behaviour would also be analysed to determine i f s i g n i f i c a n t differences occurred within groups and between groups. Comparison of supervisory ratings with participant s e l f - r a t i n g s would be made. Tables of the frequency with which the selected behaviours were performed p r i o r to and two months subsequent to pa r t i c i p a t i o n i n the program would be provided. In this table, t-values and the significance of the experimental group's frequency of performance would be compared with the control group's performance. The strength of the relationship between the several independent variables and the dependent variable would be analyzed using multiple l i n e a r regression. For example, relationships between behavioural changes and: (1) age, (2) education, (3) years i n nursing practice, (4) posi t i o n , (5) area of practice, (6) type of committee, (7) opportunity to implement, (8) supervisory support, (9) team attendance and (10) perception of obstacles, w i l l be explored. Table VI (Page 105) provides an example of how these results might be i l l u s t r a t e d . Generalizations from this study would be limited to the nursing population studied and the s p e c i f i c s i t u a t i o n and the - 105 -procedures employed i n the design of the program. One study would not be s u f f i c i e n t to prove or disprove the impact of the independent v a r i a b l e . Further evaluation studies would need to be conducted of programs which attempted to apply the p r i n c i p l e s proposed i n this thesis to the design of continuing nursing education programs. Table VI Correlation Between Independent and Dependent Variables i n Experimental Group Independent Variables Dependent Variables Change Self- Supervisory Score Rating Rating Age Education Years i n nursing practice Position Area of practice Type of committee Opportunity to implement Supervisory support Team attendance Perception of obstacles At the conceptual l e v e l , however, the r e s u l t s of this proposed research study could be applicable to other continuing professional education programs where participants are highly motivated, have both the time and the opportunity to practice i n their c l i n i c a l settings between sessions, and where there i s a mechanism for discussion and feedback regarding each participant's intervening c l i n i c a l experiences of applying the - 106 -program content i n the work s e t t i n g . This mechanism should a s s i s t participants through the innovative-decision process. Maintenance of the changed behaviour would not be ensured by application of these p r i n c i p l e s to the program design. Continuing education programs alone cannot continue to bombard participants with reinforcement, support or incentives to maintain new behaviours once a program has been completed. This r e s p o n s i b i l i t y must be transferred to the participant and the employer at this stage. Educators need to explore methods of assuring that this follow-up occurs. - 107 -CHAPTER VI SUMMARY AND IMPLICATIONS Basic nursing education programs can never produce a finished product. To maintain t h e i r competence i n a f i e l d that i s constantly changing nurses must be l i f e l o n g learners. Some nurses maintain t h e i r knowledge and s k i l l s through s e l f - d i r e c t e d learning while many others look to p a r t i c i p a t i o n i n continuing nursing education programs as one means of maintaining t h e i r professional competence. Nurses placement of such confidence i n continuing education i s not u n r e a l i s t i c but makes imperative the need for the development of quality continuing nursing education programs and the means to validate t h e i r effectiveness. Gulino (1983) presents a convincing argument regarding the potential cost-effectiveness of program evaluation from which insights could be translated into the development of e f f e c t i v e continuing nursing education programs. She refers to a study by Spitzer and Grace (1983) where they state that because nursing services account for approximately 40% of the operational budget of the average h o s p i t a l , there i s a need to validate the benefits of nursing service i n r e l a t i o n to the provision of that service. Guilino speculates that i f costs per unit of nursing service were correlated to outcomes, the significance of nursing - 108 -might become more v i s i b l e and hence the value of updating nurses' knowledge and s k i l l s through continuing education might become more sa l i e n t to p r a c t i c e . Continuing nursing education programs are expensive. Costs include the r e g i s t r a t i o n fees paid by the participants and the costs borne by the health care agencies which provide the nurses with the time o f f to attend these programs. The health care agency subsequently passes on the cost to the t h i r d party, the health care consumer. Nurses, t h e i r employers, and health care consumers obviously a l l have a stake i n the effectiveness of any continuing nursing education program. Despite the fact that no empirical model exists for the evaluation of continuing nursing education, providers must begin to demonstrate attempts to evaluate the effectiveness of th e i r programs. Of the evaluation frameworks and models reviewed i n this paper, Cervero's (1982) conceptual framework, while not empirically testable, has the pot e n t i a l of being adapted by program planners who want to conduct process evaluations of t h e i r programs. Cervero has proposed that four independent variables influence program impact on work behaviour. While most program planners find that they can manipulate only two of these variables: program c h a r a c t e r i s t i c s and the proposed behavioural changes; they do have some control over the part i c i p a n t s ' s o c i a l system i f i t i s integrated into the program planning process at the inception of the program. Few empirical evaluation studies of continuing professional - 109 -education programs have been published. Only eleven studies were able to demonstrate that the programs they evaluated had a p o s i t i v e impact on participants' work behaviours. Two possible reasons for this phenomenon can be postulated. F i r s t are the problems encountered i n the evaluation of continuing professional education programs. Second, few continuing professional education programs seem to be e f f e c t i v e i n changing work behaviour. In the f i r s t category, problems which are believed to affect the implementation and analysis of cause-and-effeet relationships f a l l into several categories: (1) d i s p o s i t i o n a l factors, (2) s i t u a t i o n a l factors, (3) unclear program goals, (4) design problems, (5) p r a c t i c a l constraints, and (6) p o l i t i c a l r e s t r a i n t s . D i s p o s i t i o n a l factors include the d i v e r s i t y of learners in terms of education, experiences, motives and i n t e r e s t s . The s i t u a t i o n a l factors are the diverse work environments of the p a r t i c i p a n t s . Unclear program goals occur when the r e a l purpose of the program i s unclear, not stated, or generally not evident. Design problems are several: inadequate sample size; s e l f - s e l e c t e d biased samples; d i f f i c u l t y in obtaining control groups; d i f f i c u l t y gaining access to c l i n i c a l settings for follow-up of participants; unreliable, inappropriate or i n v a l i d measurement tools; and costs i n terms of the time, personnel and f i n a n c i a l resources needed to conduct methodologically sound evaluations. P r a c t i c a l constraints are related to the short term nature of continuing professional - 110 -education programs and the outcomes that can r e a l i s t i c a l l y be expected. P o l i t i c a l l y , sponsors may be s a t i s f i e d with the evidence that participants enjoyed the learning experience and may not want to deal with any further data. In the second category, there may be a multitude of factors whose absence or presence may i n t e r f e r e with the effectiveness of any program. There i s always the p o s s i b i l i t y that short continuing professional education programs cannot r e a l i s t i c a l l y be expected to achieve, with any consistency, impact beyond increasing p a r t i c i p a n t s 1 awareness. It could be argued that i f i t was accepted that short programs could not change behaviour then resources which might have been spent on the shorter programs could be transferred to the longer programs. But the analysis conducted i n this paper of the research studies of programs which did have a p o s i t i v e impact on work behaviour revealed that length and outcome have no magical c o r r e l a t i o n . Instead, length and i t s appropriateness to the learning objectives were found to be related to impact on work behaviour. Short programs can be e f f e c t i v e i n changing behaviour! Program planners could benefit from reviewing Tables I through IV (see pages 62 and 63) where the subvariables i d e n t i f i e d i n the analysis of the e f f e c t i v e programs are summarized. These subvariables have implications for the design of e f f e c t i v e impact programs. Each of the subvariables i d e n t i f i e d under program c h a r a c t e r i s t i c s are mutually enhancing and seem to have a cumulative t o t a l e f f e c t . The involvement of - I l l -potential participants and t h e i r managers i n program planning links the groups to be affected d i r e c t l y and i n d i r e c t l y by the proposed behavioural changes. I t also begins the process of administrative support for the proposed changes. These factors should f a c i l i t a t e the opportunity for participants to practice and should contribute to the development of a feedback mechanism within the work environment regarding the performance of the new s k i l l s . The types of behavioural changes achieved i n the e f f e c t i v e programs analysed were those i n the realm of s p e c i f i c psychomotor s k i l l s , regimes or procedures. These were changes which involved minimal r i s k to p a r t i c i p a n t s , did not require the p a r t i c i p a t i o n or cooperation of others to implement and were easy to observe. The participant and s o c i a l system c h a r a c t e r i s t i c s outlined in Cervero's conceptual framework cannot e a s i l y be manipulated by program planners. In the analysis of the e f f e c t i v e programs the subvariables i n these two categories were s i g n i f i c a n t l y d i f f e r e n t than those proposed by Cervero. Participants i n the successful programs understood t h e i r need to change, were motivated to change and practiced outside large i n s t i t u t i o n s . The s o c i a l system subvariables i d e n t i f i e d i n these same programs as professional autonomy, supervisory commitment to the proposed changes, the opportunity to practice, and peer group reinforcement over-lapped with the other categories of independent variables i n Cervero's framework. Separating these subvariables from the other categories would seem to serve to - 112 -maintain the present distance that exists between education and p r a c t i c e . I t i s this author's b e l i e f that obtaining front-end commitment from the nursing management hierarchy i n the potential part i c i p a n t s ' employing agencies would have more p o s i t i v e effects than attempting to obtain i t after the program has been developed. An application of these subvariables to the analysis of the "Safety to Practice Conferences" revealed that few of the subvariables were consistently present i n the program. In retrospect, any pre-packaged program for such a large, diverse, and geographically dispersed audience would have d i f f i c u l t y providing follow-up and reinforcement of behavioural changes i n the practice s e t t i n g . Consequently, such programs cannot change work behaviours. It i s quite possible, however, based on the observations and perceptions of the RNABC Practice Consultants, that the awareness of many of the participants did increase. There i s also a f e e l i n g that this awareness had somewhat of a r i p p l e e f f e c t i n the nursing communities where conferences were held. Further studies are needed to confirm this speculation. To the extent that these conferences succeeded i n changing awareness they can be judged as successfully having had some impact on p a r t i c i p a n t s . Based on the analysis of the research studies of e f f e c t i v e programs and the "Safety to Practice Conferences", pr i n c i p l e s for the development of programs aimed at changing the practice behaviour of nurses were developed. Seven p r i n c i p l e s were - 113 -proposed as guidelines for program planners followed by an experimental design to test out these p r i n c i p l e s . Most of the p r i n c i p l e s proposed have been addressed by a number of other authors as general p r i n c i p l e s of adult education. Gross (1984) reported that a set of standards consisting of eighteen p r i n c i p l e s was endorsed at an annual meeting of professionals i n continuing education and tr a i n i n g which was held i n Wisconsin. Meant to serve as program planning guidelines, these p r i n c i p l e s covered the quality of course content, student performance, marketing, administration, learning experiences, and other topics . Adult education p r i n c i p l e s generally remain untested and therefore cannot be put forward as standards for adult education. What i s unique about the p r i n c i p l e s proposed i n this paper i s t h e i r combination within a single continuing nursing education program. Multiphase programming with planned independent, c l i n i c a l practice with feedback at subsequent i n s t r u c t i o n a l sessions i s a c r i t i c a l variable i n the l i s t of p r i n c i p l e s . The need for practice i s not disputed i n the l i t e r a t u r e , however, studies to test the variable of planned independent practice have not been conducted. Because cost i s an important issue i n continuing professional education while practice seems to be such a c r i t i c a l factor, planned independent practice should keep costs reasonable while contributing to program effectiveness. Where the intention of a continuing nursing education program i s to impact on work behaviour, the program planner must attempt to evaluate the r e s u l t s . Certainly, a unifying - 114 -conceptual framework for evaluation would f a c i l i t a t e the implementation of evaluation designs as well as standardize the reporting of the r e s u l t s . More research needs to be conducted i n the f i e l d of evaluation of continuing professional education. Also, the cost of evaluating continuing nursing education must be weighed against the cost of i n e f f e c t i v e programs using up limited resources that do not maximize effectiveness. Analysis of more research studies of e f f e c t i v e impact programs needs to be conducted to determine whether the subvariables i d e n t i f i e d i n this paper appear with any consistency. Enough information about e f f e c t i v e continuing professional education programs i s available to permit action to be taken to improve the present program planning process . Of top p r i o r i t y i s the l i n k i n g of providers to the practice settings for the purpose of cooperative and coordinative e f f o r t s to develop programs that succeed i n changing behaviour. Objectives for these programs must be related to problems perceived by pr a c t i t i o n e r s and amenable to change through education. Only i f educators, p r a c t i t i o n e r s , administrators and researchers work together can e f f e c t i v e , accountable continuing nursing education programs be developed and implemented. Strategies to achieve t h i s l i a i s o n need to be explored. Further studies analysing nursing management's perceptions of program impact may shed more l i g h t on why pra c t i t i o n e r s perceive that t h e i r s o c i a l systems do not support behavioural changes. Nurses, educators and administrators can then work at eliminating the factors that - 115 -compromise the effectiveness of continuing nursing education. New strategies that would support and reinforce behavioural change could then be developed. A goal common to a l l continuing nursing education programs should be better patient care. Programs with t h i s aim i n mind with s p e c i f i c measurable objectives which apply a l l the p r i n c i p l e s proposed i n this paper should be able to demonstrate t h e i r impact on part i c i p a n t s ' work behaviours. - 116 -REFERENCES Batey, M.V. and Lewis, F.M. C l a r i f y i n g Autonomy and Account-a b i l i t y i n Nursing Service: Part 1. Journal of  Nursing Administration, 1982, 12 (9), 13-15. B e l l , D.F. Assessing Educational Needs: Advantages and Disad-vantages of Eighteen Techniques. Nurse Educator, September-October 1978, 15-21. Benne, K.D. and Birnbaum, M. P r i n c i p l e s of Changing. In W.C. Bennis, K.D. Benne and R. Chin (Eds.) The Planning  of Change. 2nd e d i t i o n . New York: Holt, Rinehart and Winston, 1969, 328-335. Bennett, C.F. Analyzing Impacts of Extension Programs. United States Department of Agriculture, A p r i l 1976. Bennis, W.G., Benne, K.D. and Chin, R. The Planning of Change. New York: Holt, Rinehart and Winston, 1969. Bergevin, P., Morris, D. and Smith, R.M. Adult Education  Procedures• New York: The Seabury Press, 1963. Bertram, D.A. and Brooks-Bertram, P. The Evaluation of Continuing Medical Education: A L i t e r a t u r e Review. Health Education Monographs, 1977, 7 (4), 330-362. Bobbitt, H.R., Reinholt, R.H., Doktor, R.H. and McNaul, J.P. Organizational Behaviour: Understanding and  Pr e d i c t i o n . 2nd e d i t i o n . Englewood C l i f f s , New Jersey: Prentice-Hall, 1978. Bowers and Associates. A Guide to Needs Assessment i n Community Education. Washington: United States Department of Health, Education and Welfare, 1974. Boyle, P.G. Planning Better Programs. New York: McGraw H i l l , 1981 . Brown, S.J. Proposition: Continuing Education Must Impact on P r a c t i c e . Journal of Continuing Education i n  Nursing, 1980, U (1), 8-14. Buskey, J.H. and Sork, T.J. From Chaos to Order i n Program Planning: A System for Selecting Models and Ordering Research. Paper presented at the Annual Adult Education Research Conference, Lincoln, Nebraska, A p r i l , 1982. - 117 -Canadian Facts. An Evaluation of the Attitudes of Members Toward the Registered Nurses' Association of B r i t i s h Columbia and the Nursing Profession. Volume 1: General Summary of Results, Cross-Section of Membership Study. Vancouver, B.C., 1980. Caplan, R.M. Measuring the Effectiveness of Continuing Medical Education. Journal of Medical Education, 1973, 48, 1150-1152. Carl l e y , C.A. Comparison of Nurses' and Their Employers' Expectations About Dissemination of Knowledge Acquired Through Continuing Nursing Education. Unpublished Doctoral Di s s e r t a t i o n . Indiana University, Indiana, 1980. C a r r o l l , E. RNABC Nursing Practice Consultant. Interview, 24 A p r i l , 1984. Cervero, R.M. Continuing Professional Education and Behavioral Change: A Proposed Framework. Paper presented at the Annual Adult Education Research Conference, Lincoln, Nebraska, A p r i l , 1982. Chambers, D.W. How Can Learning Experiences i n Continuing Dental Education be Evaluated i n Relation to Patient Benefit? Journal of American College of Dentists, 1976, 43, 238-248. — Chickering, A.W. and Havinghurst, R.J. The L i f e Cycle. In A.W. Chickering and Associates (Eds.) The Modern American  College: Responding to the New R e a l i t i e s of Diverse  Students and a Changing Society. San Francisco: Jossey-Bass, 1981. Cooper, S .S. Popiel, E.S. and Yoder Wise, P.S., Eds. Special Issue on The Impact of Continuing Education on the Nursing Profession. Journal of Continuing Education  in Nursing, 1982, 13 WT-Corbett, T.C. The Impact of Continuing Medical Education on Quality of Care: Implications of the CME Evaluation L i t e r a t u r e . In P.P. LeBreton, et a l (Eds.) The  Evaluation of Continuing Education for Professionals:  A Systems View. Seattle, Washington: University of Washington, 1979, 369-393. Cox, C.L. and Baker, M.G. Evaluation: The Key to Accountability i n Continuing Education. Journal of Continuing  Education i n Nursing, 1981, 12 (1) , 11-19 . - 118 -Deets, C. and Blume, D. Evaluating the Effectiveness of Selected Continuing Education Offerings . Journal of Continuing  Education i n Nursing, 1977, 8 (3) , 63-71 . Del Bueno, D.J. Continuing Education: Spinach and Other Good Things. Journal of Nursing Administration, 1977, 7, 32-34. Derby, V.L. Learners and Course Goal Congruence: Impact on Learning Outcomes. Journal of Continuing Education  i n Nursing, 1982, 13 (4), 16-25 . Dewey, J . Liberalism and Social Action. New York: G.P. Putnam's Sons, 1935. Dixon, J . Evaluation C r i t e r i a in Studies of Continuing Education in the Health Professions: A C r i t i c a l Review and Suggested Strategy. Evaluation and the Health  Professions, 1978, 1 (2) , 47-65. Farley, J . Effectiveness of a Continuing Education Program E n t i t l e d "Nursing Process." American Nurses' Asso-c i a t i o n Council on Continuing Education, unpublished data, August 1979. Forni, P.R. and Overman, R.T. Does Continuing Education Have an Eff e c t on the Practice of Nursing? A Survey. Journal  of Continuing Education i n Nursing, 1974, 5_ (4) , 44-51 . Gagne, R.M. and Briggs, L.J. P r i n c i p l e s of Instructional Design. 2nd e d i t i o n . New York: Holt, Rinehart and Winston, 1974. Gould, R. The Phases of Adult L i f e : A Study i n Developmental Psychology. American Journal of Psychiatry, 1972, 129 (5), 521-531. Grabowski, S.M. How Educators and Trainers Can Ensure On-the-Job Performance. In S.M. Grabowski (Ed.) New Directions  for Continuing Education, 1983, 18, 5-W. Grice, Helen. RNABC Registrar. Telephone Interview on 15 February 1983. G r i f f i t h , W. Developing a V a l i d Data Base for Continuing Education i n the Health Sciences. Mobius, 1981, 1 (2), 83-91. G r i f f i t h , W. Educational Needs: D e f i n i t i o n , Assessment and U t i l i z a t i o n . School Review, 1978, 86 (3), 382-394. - 119 -Gronlund, N .E. Stating Objectives for Classroom Instruction. 2nd e d i t i o n . New York: Macmillan Publishing, 1978. Gross, R. New Set of P r i n c i p l e s for Adult Education. New York  Times Spring Education Supplement, A p r i l 15, 1984, 63-64. Groteleuschen, A.D. Program Evaluation. In A.B. Knox and Associates (Eds.)Developing , Administering, and  Evaluating Adult Education7 San Francisco: Jossey-Bass, 1980, 75-123. Gulino, C. Commentary on "The Perceived Impact of Continuing Education on the Practice of Nurses Working i n Acute Care F a c i l i t i e s " by N.L. Keltner, Western Journal of  Nursing Research, 1983, 5 (1), 21-W. Heick, M.A. Continuing Education Impact Evaluation. Journal of  Continuing Education i n Nursing, 1981, 12 (4;, 15-23. Houle, C.O. The Design of Education. San Francisco: Jossey-Bass, 1976. Inui, T.S., Yourtee, E.L. and Williamson, J.W. Improved Outcomes in Hypertension After Physician T u t o r i a l s . Annals  of Internal Medicine, 1976, 84 (6), 646-651. Johnson, R.B. Determining Training Needs. Training and Development Handbook of the American Society for  Training and Development, New York: McGraw-Hill, 1967. Kattwinkel, J . , Cook, L. J . , Nowacek, G.A., Ivey, H.H. and Short, J.G. Improved Perinatal Knowledge and Care i n a Community Hospital Through a Program of S e l f - I n s t r u c t i o n . P e d i a t r i c s , 1979, 64, 451-458. Keltner, N .L. The Perceived Impact of Continuing Education on the Practice of Nurses Working i n Acute Care F a c i l i t i e s . Western Journal of Nursing Research, 1983, 5 (1), 21-40. Kibbler, R.J., Gegala, D . J ., Miles, D.T. and Barker, L.L. Objectives for Instruction and Evaluation. Boston: A l l y n and Bacon, 1974. Kirkpatrick, D.L. Evaluation of Training. In R. Craig and L. B r i t t e l (Eds.) Training and Development Handbook. New York: McGraw-Hill, 1967, 87-112. Knowles, M.S. The Modern Practice of Adult Education. 2nd e d i t i o n , New York: Association Press, 1981. - 120 -Knox, A.B. Impact Evaluation: What Difference Does It Make? New Directions for Continuing Education, 1979, 3_, 1-28. Knox, A.B. and Associates. Developing, Administering, and  Evaluating Adult EcTucation. San Francisco: Jossey-Bass, 1980. Kuramoto, A. I n i t i a t i v e i n Quality Assurance: A Workshop for Maternal-Child Nurse Pra c t i t i o n e r s i n Primary Care Settings. Amercian Nurses' Association Council i n Continuing Education, unpublished data, June 1979. Laxdal, O.E., Jennet, P.A., Wilson, T.W. and Salisbury, G.M. Improving Physician Performance by Continuing Medical Education. Canadian Medical Association, 1978, 118, 1051-1055": Lewin, K. Sociometry Monographs //17 . Research Centre for Group Dynamics. New York: Deacon House, 1947. Lewis, F.M. and Batey, M.J. C l a r i f y i n g Autonomy and Account-a b i l i t y i n Nursing Service: Part 2. Journal of  Nursing Administration, 1982, 12 (10), 10-15. L i p p i t t , R., Hooyman, C , Sashkin, M. and Karian, J . Resource-book for Planned Change. Ann Arbor, Michigan: Human Resource Development Associates of Ann Arbor, 1978. L i t t l e , D.E. A Formula for Professional Nursing Care. R e h a b i l i t a t i o n Nursing, February 1981, 19-22. Lloyd, J.S. and Abrahamson, S. Effectiveness of Continuing Medical Education: A Review of the Evidence. Evaluation and the Health Professions, 1979, 2 (3), 251-280. — Manhan, J.M., P h i l i p s , B. and Constanzi, J . Patient Referrals: A Behavioural Outcome of Continuing Medical Education. Journal of Medical Education, 1978, 53, 201-211. Mastrian, K. The E f f e c t of a Decubitus Ulcer Prevention Education Program on the Incidence and Severity of Decubitus Ulcers. American Nurses' Association Council on Continuing Education, unpublished data, June 1979. McCoy, V.R. Adult L i f e Cycle Changes: How Does Growth Affect Our Education Need? L i f e l o n g Learning: The Adult Years, October, 1977, 14-18, 31. McKeachie, W.J. Teaching Tips: A Guidebook for the Beginning  College Teacher. Lexington, Ma.: Health, 1969. - 121 -M i l l e r , E. Evaluation of Long-Term Career Education for Profes-sionals Public Managers. In P.B. LeBreton, et. a l . (Eds.) The Evaluation of Continuing Education for  Professionals: A Systems View. Seattle: University of Washington, 1979, 394-403. Mitsunaga, B. and Shores, L. Evaluation of Continuing Education. Is I t Prac t i c a l ? Journal of Continuing Education i n  Nursing, 1977, 8 (6), 7-14. Monette, M.L. Needs Assessment: A Critique of Philosophical Assumptions. Adult Education, 1979, 29 (2), 83-95. Monette, M.L. The Concept of Educational Need: An Analysis of Selected L i t e r a t u r e . Adult Education, 1977, 27 (2), 116-127. Nurses' Act. Government of B r i t i s h Columbia, 1979. Odiorne, G.S. The Role of the Lecture i n Teaching Organizational Behavior. Exchange: The Organizational Behavior Teaching Journal, 1977 , 2 (3J. 7-14. Penn, P.D. Project BORN FREE. Evaluation of the 1978 BORN FREE  National Institute"; ED. //193595 . 1978 . Peplau, H. Responsibility, Authority, Evaluation and Account-a b i l i t y of Nursing i n Patient Care. Michigan Nurse, 1971, 7, 5-7, 20-23. Petersen, C .B. An Evaluation of the Impact of a Continuing Education Course i n Diabetes. Evaluation and the Health  Professions, 1982, 5 (3), 259-27T: Popiel, E.J. Nursing and the Process of Continuing Education. St. Louis: C.V. Mosby, 1973. Provus, J . Evaluation of Ongoing Programs i n the Public School System. In R.W. Tyler (Ed.) Educational Evaluation:  New Roles, New Means. Part 2. Sixty-eighth Yearbook of the National Society for the Study of Education. Chicago: University of Chicago Press, 1969, 242-283. RNABC. Committee on Assessment of Safety to P r a c t i c e . Report to the Board of Directors, November 1976. RNABC News. STP Conference for RNABC Members. May 1980, 7. RNABC News. Workshop Considers Survey Issues. November-December 1980, 8-9. RNABC. STP Conferences Project Plan, March 1980. - 122 -RNABC. STP Evaluation Report. Unpublished report, June, 1982. RNABC. //I STP: The Basics. Conference Leader's Manual. June 1982 . RNABC. #2 STP: Taking Charge of Your Own Pra c t i c e . Conference Leader's Manual. August 1982. RNABC. //3 STP: Evaluating Nursing Pra c t i c e . Conference Leader's Manual. June 1982. RNABC. //4 STP: Influencing Patient Care Conditions. Conference Leader's Manual. June 1982. Rogers, E.M. and Shoemaker, F.F. Communicating Innovations. New York: Free Press, 1971. Rogers, E.M. The Dif f u s i o n of Innovations. 3rd e d i t i o n . New York"! The Free Press, 1983. Ro l l C a l l . D i v i s i o n of Health Services Research and Development University of B r i t i s h Columbia, June 1983. Rubenstein, E. Continuing Education at Stanford: The Back-to-Medical School Program. Journal of Medical Education, 1973, 48, 911-918. Schechter, D.S. Agenda for Continuing Education: A Challenge to  Health Care I n s t i t u t i o n s . Chicago: Hospital Research and Educational Trust, T974. Scott, A. Implementing Performance Change Among Health Care Professionals. Unpublished Doctoral Thesis. University of B r i t i s h Columbia, Vancouver, B r i t i s h Columbia, 1980. Scriven, M. The Methodology of Evaluation. In R.W. Tyler (Ed.) Perspectives of Curriculum Evaluation. Chicago: Rand McNally, 1967, 39-83. Sheehy, G. Passages: Predictable Crises of Adult L i f e . New York! button, 1976. Sjogren, D .D. Issues i n Assessing Educational Impact. New  Directions for Continuing Education, 1979 . 3_, 109-115. Spitzer, R.B. and Grace,H.K. Cost Containment: Impact on Nursing Service and Nursing Education. The Impact of Changing  Resources on Health P o l i c y . American Academy of Nursing, 1981, 65-87. - 123 -Stake, R.E. The Countenance of Educational Evaluation. Teachers  College Record, 1967, 68, 492-501. Stein, L.S. The Effectiveness of Continuing Medical Education: Eight Research Reports. Journal of Medical Education, 1981, 56 (2), 103-110. Stufflebeam, D.L. Evaluation as a Community Education Process. Community Education Journal, March/April 1975, 9-12, W. Szczypkowski, R. Objectives and A c t i v i t i e s . In A.B. Knox and Associates (Eds.) Developing, Administering, and  Evaluating Adult Education. San Francisco: Jossey-Bass, 1980, 37-74. Tal l e y , R.C. Effects of Continuing Medical Education on Practice Problems. Journal of Medical Education, 1978, 53, 602-603. : ~~ Tyler, Ralph. Basic P r i n c i p l e s of Curriculum and Instruction. Chicago: University of Chicago Press, 1949 . Waddell, W. P r o f i l e //2 . Continuing Medical Education - Data for Modeling. Background Paper for AAMC Modeling Project, 1978. Walter, G.A. and Marks, S.E. Experiential Learning and Change• New York: John Wiley and Sons, 1981. Wang, V.L., Flynn, J.W., Green, L.W. Evaluation of Continuing Medical Education for Chronic Obstructive Lung Diseases. Journal of Medical Education, 1979, 54 (10), 803-811. Woog, P and Hyman, R.B. Evaluating Continuing Education. Evaluation and the Health Professions, 1980, 3 (2), 171-190 . Zimbardo, P. and Ebbesen, E .B. Influencing Attitudes and  Changing Behavior. Menlo Park, C a l i f o r n i a : Addison-Wesley, T977. - 124 -APPENDIX A CONFERENCE OBJECTIVES // l STP: THE BASICS At the end of this conference participants should be able to: - define the term "safe practice of nursing" - discuss the rights and r e s p o n s i b i l i t i e s of RN's for safe practice - i d e n t i f y actions each nurse should take to control own safe practice - discuss the general requirements for evaluation of nursing practice - i d e n t i f y actions a nurse can take when encountering unsafe nursing behaviours - describe a general approach that could be taken when a nurse feels that conditions of practice are unsafe. //2 STP: TAKING CHARGE OF YOUR OWN SAFE PRACTICE At the end of this conference participants should be able to: - discuss why RN's must take charge of t h e i r own safe practice - describe the scope of nursing practice i n own practice setting - discuss how to communicate own s k i l l s and l i m i t a t i o n s r e l a t i v e to the functions of a job - i d e n t i f y the factors to be considered i n making decisions about the transfer of medical functions to nurses - propose actions for taking charge of one or more aspects of own nursing practice //3 STP: EVALUATING NURSING PRACTICE At the end of this conference participants would be able to: - discuss each RN's r e s p o n s i b i l i t y for evaluating nursing practice - describe how nurses i d e n t i f y a focus for evaluation - discuss how standards for process, outcome and structure can be used to plan nursing care - discuss two methods that can be used to c o l l e c t information systematically about your own practice - i d e n t i f y how to analyse information collected about nursing practice so that actions for improvement can be taken - discuss examples of evaluation of nursing practice conducted by health care agencies, the profession and society - 125 -#4 STP: INFLUENCING PATIENT CARE CONDITIONS At the end of this conference participants should be able to: - i d e n t i f y the r e s p o n s i b i l i t y members of the health care team share for providing safe patient care - i d e n t i f y the r e s p o n s i b i l i t y of RN's i n d i v i d u a l l y and c o l l e c t i v e l y for influencing patient care conditions - describe how nurses i d e n t i f y unsafe patient care conditions - demonstrate the documentation of a nursing practice concern about patient care conditions - explain the purpose of the RNABC Protocol - describe the steps involved i n submitting the RNABC Protocol form 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
https://iiif.library.ubc.ca/presentation/dsp.831.1-0055859/manifest

Comment

Related Items