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Implementing performance change among health-care professionals Scott, Anne 1980

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IMPLEMENTING PERFORMANCE CHANGE AMONG HEALTH-CARE PROFESSIONALS by ANNE SCOTT B.Sc.(PT), The Un i v e r s i t y of Western Ontario, 1971 M.Sc.(Kinesiology), Simon Fraser U n i v e r s i t y , 1973 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF EDUCATION i n THE FACULTY OF GRADUATE STUDIES (Department of Adult Education) We accept t h i s t hesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA January 1980 © Anne Scott, 1980 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of Brit ish Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Adult Education The University of Br it ish Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date March 10. 1980 ABSTRACT The purpose of this study was to aid i n understanding the process of change i n occupational settings by examining factors that influence an employee to change hi s performance of a task. Five factors thought to be c r i t i c a l to the change process were selected and t h e i r r e l a t i o n s h i p s to both immediate and long-term changes i n employee performance l e v e l s were examined. The factors selected were: an i n d i v i d u a l ' s knowledge about the task, h i s motivation to change, and h i s perceptions of the resources a v a i l a b l e to do the task, the standards required for correct performance and the r e i n f o r c e r s associated with h i s performance. The s p e c i f i c task used to observe changes i n performance l e v e l s was a new method of keeping records i n a h o s p i t a l department, c a l l e d Problem Oriented Recording (POR). The hypothesized r e l a t i o n s h i p s were as follows: i n i t i a l changes i n performance would be more c l o s e l y linked to motivation to change, increase i n knowledge and the perceived presence of performance standards than to the perceived a v a i l a b i l i t y of resources and r e i n f o r c e r s f o r correct performance; and subsequent changes i n performance would be more c l o s e l y linked to the i n d i v i d u a l ' s perceptions of the presence of performance standards and a v a i l a b i l i t y of resources and r e i n f o r c e r s than to his motiva-t i o n to change and loss of knowledge. Four s p e c i a l l y constructed instruments were developed to measure the dependent and independent v a r i a b l e s . Record-keeping behaviour was measured on a c h e c k - l i s t which indicated the presence or absence of required items i n randomly selected patient-care records. A paper and p e n c i l r e c a l l i i i i i t e s t measured the p a r t i c i p a n t s ' knowledge of recording p o l i c i e s , procedures and format, and two a t t i t u d i n a l surveys measured t h e i r motivation to change and th e i r perceptions of performance standards, resources and r e i n f o r c e r s . An i n s e r v i c e education program provided the p a r t i c i p a n t s , 62 phy s i c a l and occupational therapists, with an opportunity to learn about Problem Oriented Recording. The program consisted of seven 1-hour sessions; f i v e sessions were held on consecutive days and the remaining two were held one month l a t e r and a f t e r a further i n t e r v a l of three months. With the exception of motivation to change, which was measured once at the beginning of the study, data c o l l e c t i o n on a l l variables coincided with the de l i v e r y of the i n s e r v i c e program. Thus, va r i a b l e s were measured before the introduction of POR, one month a f t e r i t s introduction and again three months l a t e r . Changes i n each v a r i a b l e were calculated from the differences between scores at baseline and one month, and one month and four months. The data showed that recording behaviour s i g n i f i c a n t l y increased 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. Knowledge also s i g n i f i c a n t l y increased during the f i r s t month but i t remained at that new l e v e l . A s i m i l a r pattern was observed for therapists' perceptions of standards for proper performance. Data c o l l e c t e d at the beginning of the implementation of POR indicated that therapists were motivated to change t h e i r record-keeping p r a c t i c e s . Stepwise multiple regression equations showed that the selected v a r i a b l e s accounted for 33% of observed variance i n a c q u i s i t i o n of recording behaviour and 34% i n the subsequent decline of recording behaviour. General h i e r a r c h i c a l tests confirmed that motivation to change, knowledge and performance standards accounted for s i g n i f i c a n t l y more variance i n the i n i t i a l change of performance than resources and r e i n f o r c e r s ; and performance standards, r e s o u r c e s and r e i n f o r c e r s a ccounted f o r s i g n i f i c a n t l y more v a r i a n c e i n the l o s s of performance. T h e r e f o r e , the h y p o t h e s i z e d r e l a t i o n s h i p s were c o n f i r m e d . The f i n d i n g s imply t h a t i n s e r v i c e e d u c a t i o n programs h e l p employees to r e a c h new l e v e l s o f performance but a d d i t i o n a l a c t i v i t i e s a r e n e c e s s a r y to h e l p them m a i n t a i n the newly a c q u i r e d l e v e l . S e v e r a l recommendations f o r e n s u r i n g maintenance a r e d i s c u s s e d i n c l u d i n g the need f o r c o l l a b o r a t i o n between s u p e r v i s o r s and e d u c a t o r s , the advantages of a s i t u a t i o n a l a s s e s s -ment and the need to e s t a b l i s h how much knowledge has been r e t a i n e d b e f o r e a d e c i s i o n i s made to remedy performance d e f i c i t s through more i n s e r v i c e e d u c a t i o n programs. TABLE OF CONTENTS Page ABSTRACT 1 1 LIST OF TABLES i x LIST OF FIGURES x i ACKNOWLEDGEMENT x i i i Chapter 1. INTRODUCTION TO THE STUDY 1 THE PURPOSE OF THE STUDY 3 THE FOCUS OF THE STUDY 4 THE SIGNIFICANCE OF THE STUDY 6 THE ORGANIZATION OF THE THESIS 7 2. THE RELATED LITERATURE 9 PLANNED CHANGE 9 THE STUDY OF WORK BEHAVIOR 11 Motivation 11 Content theories 12 A process theory 14 Behaviourism 15 Summary 16 TWO MODELS OF PERFORMANCE 17 A Model of Performance 17 A Performance Audit Model 19 AN EDUCATOR'S APPROACH TO CHANGE 21 A SUMMARY OF THE THEORETICAL CONSTRUCTS 26 v v i Chapter Page FACTORS AFFECTING PERFORMANCE CHANGE 28 Studies on Performance Change among Professionals . . . 28 Studies on Employee Knowledge Change 31 A c q u i s i t i o n and retention of knowledge 31 Immediate changes i n knowledge 33 Organizational Factors and Employee Performance . . . . 34 A Summary of Empirical Findings 35 3. DESIGN AND: RATIONALE FOR THE STUDY 38 THE CONCEPTUAL FRAMEWORK 38 The Process of Change 39 Driving and Restraining Forces 39 Knowledge 40 Motivation to change 41 Performance standards 43 Resources 43 Reinforcers 45 Forces Promoting I n i t i a l Change 45 Forces Promoting Maintenance of Change 46 THE VARIABLES AND THEIR MEASUREMENT 49 The Variables 49 Variables of recording behaviour 49 Knowledge v a r i a b l e s 50 Motivation v a r i a b l e s 51 Performance standards 51 Resources 52 Reinforcers 52 v i i C h a pter Page Measurement o f the V a r i a b l e s 52 THE HYPOTHESES 55 PROCEDURES 56 The S e t t i n g and P a r t i c i p a n t s 56 Phases o f the Study and Data C o l l e c t i o n 59 The i n s e r v i c e program 60 Data c o l l e c t i o n 60 The A n a l y s i s o f Data 62 4. INSTRUMENT DEVELOPMENT 64 FORMAT REVIEW AUDIT SHEET 64 CLINICAL RECORD-KEEPING INVENTORY 65 RECORDING NEEDS SURVEY 69 RECORDING OPINIONS SURVEY . . . . . . . 72 5. DATA ANALYSIS AND RESULTS ; . . . 76 ACQUISITION AND MAINTENANCE OF RECORDING BEHAVIOUR . . . 76 ACQUISITION AND RETENTION OF KNOWLEDGE 81 MOTIVATION TO CHANGE 81 TASK-RELATED FACTORS 86 RELATIONSHIPS AMONG THE VARIABLES . . . . . 87 A c q u i s i t i o n H y p o t h e s i s 89 Maintenance H y p o t h e s i s 91 P r o p o r t i o n o f E x p l a i n e d V a r i a n c e 91 R e l a t i v e C o n t r i b u t i o n o f Independent V a r i a b l e s . . . . 97 " B e s t " M o t i v a t i o n to Change V a r i a b l e 100 SUMMARY 101 6. DISCUSSION AND CONCLUSIONS 103 v i i i Chapter Page CHANGES IN RECORD-KEEPING PRACTICES 103 CHANGES IN PERSONAL ATTRIBUTES 105 Increased Knowledge of Recording 106 Knowledge Retention 108 Motivation to Change 109 CHANGES IN ORGANIZATIONAL FACTORS I l l Departmental Guidelines for Recording I l l Reinforcers and Resources 112 ACQUIRING AND MAINTAINING POR 114 7. SUMMARY AND IMPLICATIONS 119 SUMMARY 119 IMPLICATIONS 122 Theoretical Implications 123 P r a c t i c a l Implications 124 Implications f o r Further Research 126 BIBLIOGRAPHY 128 APPENDICES 133 A. Formula for te s t i n g hypotheses 134 B. Explanatory note: regression r e s i d u a l score 135 C. Format Audit Review Sheet 136 D. Data r e l a t i n g to p i l o t test of RNS 137 E. Data r e l a t i n g to p i l o t test of ROS 139 F . Regression data: a c q u i s i t i o n and maintenance hypotheses . . . 144 G. Regression data: summary tables 157 LIST OF TABLES Table Page 1. Concepts and Implications of Motivation and Behaviour Theories 16 2. Personal and Organizational Factors I d e n t i f i e d i n Three Performance Models and Two Motivation Theories 27 3. Factors A f f e c t i n g Performance Change 37 4. Location of P a r t i c i p a n t s 57 5. D i s t r i b u t i o n of Therapists by Country of Graduation . . . . 58 6. D i s t r i b u t i o n of Therapists According to Number of Years since Graduation 59 7. Format Audit Review Sheet Components and Items 66 8. Means and Standard Deviations f o r the C l i n i c a l Record-Keeping Inventory ( P i l o t Test) 67 9. Means, Standard Deviations and t- t e s t s f o r A c q u i s i t i o n of Recording Scores 79 10. Means, Standard Deviations and t - t e s t s f o r Maintenance of Recording Scores 80 11. Means, Standard Deviations and t - t e s t s for Knowledge A c q u i s i t i o n and Retention Scores 83 12. Means and Standard Deviations f o r Motivation to Change Variables 85 13. Means, Standard Deviations and t - t e s t s f o r Task-related Variables 88 14. General H i e r a r c h i c a l Test of the A c q u i s i t i o n Hypothesis 90 15. General H i e r a r c h i c a l Test of the Maintenance Hypothesis 92 16. Variables Attempted i n the A c q u i s i t i o n and Maintenance Regression Analysis 93 ix X Table Page 17. Variance i n Increase i n Recording Components (Ac q u i s i t i o n Phase) Accounted for by Motivation, Knowledge and Task-related Variables 95 18. Variance i n Decline i n Recording Components (Maintenance Phase) Accounted f or by Motivation, Knowledge and Task-related Variables 96 LIST OF FIGURES Figure Page 1. Cummings and Schwab's Model of Performance 17 2. Rummler's Performance Audit Model 20 3. Charters and Blakely's Model of Inservice Education . . . . 23 4. Lewin's Model of the Process of Change 40 5. I n i t i a l Change of Recording Behaviour 47 6. Subsequent Change of Recording Behaviour 48 7. Derivation of Impetus Variable 54 8. Data C o l l e c t i o n 61 9. C l i n i c a l Record-Keeping Inventory Items 68 10. Recording Needs Survey Items 69 11. Recording Needs Survey Items Relating to Importance . . . . 71 12. Resources Items 73 13. Performance Standards Items 74 14. Reinforcers Items 75 15. A Comparison.of Performance Component Scores at Baseline, One Month and Four Months 78 16. A Comparison of General, S p e c i f i c and Total Knowledge Scores at Baseline, One Month and Four Months 82 17. A Comparison of "Important," "Is Present," "Should be Present" and "Gap" Scores with the Response Scale . . . . 84 18. A Comparison of Resources, Performance Standards and Reinforcers Scores with Response Scale 86 19. Contribution of Motivation, Knowledge and Task-related Variables to Increase i n POR Format 98 20. Contribution of Motivation, Knowledge and Task-related Variables to Decrease in,POR Format . . 99 x i x i i Figure Page 21. D i s t r i b u t i o n of Explained Variance i n A c q u i s i t i o n Phase (Complete Record) 115 22. D i s t r i b u t i o n of Explained Variance i n Maintenance Phase (Complete Record) 116 ACKNOWLEDGEMENTS I wish to thank the members of my d i s s e r t a t i o n committee: Dr. Dale Rusnell, Dr. John C o l l i n s , Dr. Graham Kelsey and Dr. George Szasz for t h e i r continuous guidance, encouragement and support. In addition, I am g r a t e f u l to the PTs and OTs of Vancouver for t h e i r willingness to p a r t i c i p a t e i n t h i s study, to Chris Irving for her assistance with the preparation of the graphs and fig u r e s , and to Judi Forsyth for her preparation of the f i n a l manuscript. x i i i Chapter 1 INTRODUCTION TO THE STUDY To change employee performance i s one function of i n s e r v i c e education i n health-care agencies. This function has become p a r t i c u l a r l y important as h o s p i t a l s , c l i n i c s and treatment centres s t r i v e to keep abreast of new developments i n health-care d e l i v e r y and employees have to a l t e r e x i s t i n g performance patterns to meet the r e s u l t i n g changes. Despite the importance of t h i s function, l i t e r a t u r e regarding the contribution made by in s e r v i c e to changes i n performance i n health-care settings i s scarce, and those items which do ex i s t r e f e r more to i d e a l s and intentions than to systematic studies of a c t u a l change i n performance on-the-job. Inservice education i s , of course, not new, although i t s increased impact and importance are. The a c c r e d i t a t i o n bodies that require i t , the h o s p i t a l funding that supports i t , the p r a c t i t i o n e r ' s involvement i n i t , and the many needs i t serves, represent a s i g n i f i c a n t change i n the meaning and purpose of in s e r v i c e education programs. There i s every reason to suppose that i n s e r v i c e w i l l continue to evolve as an i n t e g r a l part of every health-care agency's mandate to d e l i v e r high q u a l i t y patient care. The organizational arrangements f or c o r r e l a t i n g i n s e r v i c e programs with perfor-mance needs of s t a f f seem l i k e l y to show a corresponding growth i n sophis-t i c a t i o n , along with an increase i n demand for proof of effectiveness. Such proof i s scarce at the present time, and i s l i k e l y to remain so u n t i l several issues are explored. One of the more c r i t i c a l issues i s the li m i t e d scope of the adult educator's approach to performance change. 1 2 Conventional program planning models (Hospital Research and Educational Trust, 1970) are intended to prepare employees to be able to meet new performance demands; they do not adequately address the p r a c t i c a l i t i e s of t r a n s f e r r i n g , applying and maintaining those newly acquired s k i l l s and knowledge i n the work-setting. Given t h i s narrow scope, adult educators may proceed with impunity to focus t h e i r attention on an employee's a b i l i t y to do a task and ignore the r e a l i t i e s of on-the-job change i n performance. If the effectiveness of i n s e r v i c e i s judged by the extent to which i t increases knowledge, then t h i s approach i s e f f e c t i v e ; p a r t i c i p a n t s u sually gain knowledge (University of Texas System School of Nursing, 1975). However, i f the effectiveness of i n s e r v i c e should be determined by actual change i n performance, as suggested by several scholars (Charters & Blakely, 1974; Dickinson & Verner, 1974; Hutchinson, 1974), then t h i s approach i s somewhat l i m i t e d . And adult educators may f i n d i t necessary to extend or modify t h e i r approach by incorporating a d d i t i o n a l concepts. Empirical studies of change i n performance among professionals are a p r o f i t a b l e source of a d d i t i o n a l concepts and new ideas about the manage-ment of change. For example, i n a study of a r o l e change among teachers, Gross, Giacquinta and Bernstein (1971), i s o l a t e d f i v e o r ganizational b a r r i e r s to change and suggested that the notion of "resistance to change" should be modified, and i n a ser i e s of studies done i n a St. Louis h o s p i t a l (Coe, 1970), various obstacles to and f a c i l i t a t o r s of change were i d e n t i f i e d . From those and other studies (Davies, 1972; Wolfe & Moe, 1973), i t appears that successful changes i n performance require changes i n both the employee and the work-setting. The personal a t t r i b u t e s most frequently considered to be important and amenable to change are a b i l i t y and motivation. Among the organizational factors considered most l i k e l y to influence change, 3 reinforcement i s a key concept. Other factors are the resources a v a i l a b l e to do the job, the presence of c l e a r l y defined standards of performance, the reward system (pay), the design of the task and supervisory behaviour. As i n s e r v i c e educators assume greater r e s p o n s i b i l i t y f o r implementing changes i n the work-setting i t seems l i k e l y that they w i l l need to consider the impact of some of those fac t o r s . Another issue that cannot be ignored i s the d i f f e r e n c e between the short- and long-term e f f e c t s of an i n s e r v i c e program. As Lewin (1947) points out: A change toward a higher l e v e l of group performance i s frequently s h o r t - l i v e d ; a f t e r a "shot i n the arm", group l i f e soon returns to the previous l e v e l . (p. 34) If i n s e r v i c e education i s expected to be more than a "shot i n the arm" then there i s a need to understand the dynamics of both a c q u i s i t i o n and main-tenance of new behaviours. THE PURPOSE OF THE STUDY The r e l a t i o n s h i p between i n s e r v i c e education i n health-care f a c i l i t i e s and change i n employee performance i s only beginning to be understood. Of the few research studies reported, most have focused either on changes i n p a r t i c i p a n t s ' knowledge (Parker, Sturm & Pierce, 1975; Margolis, Sheenan & Meyers, 1976) or changes i n performance l e v e l s (Davies, 1972; Coe & B a r n h i l l , 1970). The en t i r e spectrum of change i n performance from i n i t i a l a c q u i s i t i o n of knowledge and s k i l l s to th e i r subsequent a p p l i c a t i o n i n the work-place has r a r e l y been studied' i n a health-care s e t t i n g . The purpose of the present study i s to add to a small but growing body of empirical data r e l a t i n g to change i n performance by addressing c e r t a i n aspects of the issues outlined i n the preceding paragraphs. Those issues are the need 4 to broaden an adult educator's approach to change i n performance, and the need to i d e n t i f y the differences between immediate and sustained change i n performance. • An underlying assumption of t h i s study i s that behaviour i s a function of an i n t e r a c t i o n between a person and h i s environment (Lewin, 1938) and that attempts to change behaviour require consideration of both the person and the s i t u a t i o n . From t h i s point of view i t may be argued that personal factors such as: (1) motivation to change, (2) amount of knowledge possessed about the task, and s i t u a t i o n a l factors such as (3) resources, (4) performance standards and (5) r e i n f o r c e r s f o r proper performance, contribute to changes i n employee performance. Furthermore, the contribu-tions of those factors may d i f f e r between the a c q u i s i t i o n and maintenance phases of change i n performance. This study attempts to aid i n under-standing change i n performance through i n s e r v i c e education by i n v e s t i g a t i n g the r e l a t i o n s h i p s among: (1) a c q u i s i t i o n and maintenance of performance, (2) changes i n knowledge, (3) i n d i v i d u a l motivation to change, and (4) i n d i v i d u a l perceptions of selected task-related f a c t o r s . THE FOCUS OF THE STUDY Health-care agencies across the continent are making a concerted e f f o r t to improve the q u a l i t y of patient-care records and, i n many places, i n s e r v i c e educators are expected to contribute to t h i s e f f o r t . During the past decade, many agencies and groups of health professionals have changed t h e i r recording systems to the Problem Oriented Record system (POR). This sytem, devised by Weed (1964), requires the health-care worker to document, i n a new format, the care given to a patient. Instead of the conventional method of narrative record-keeping, which allowed 5 p r a c t i t i o n e r s considerable leeway i n recording s t y l e , POR requires c l i n i c i a n s to adhere c l o s e l y to a d e f i n i t i v e structure and format. The changes i n format are s u f f i c i e n t l y great to warrant an education program for t h e i r proper implementation (Bashook, Sandlow & Hammett, 1975; Fernow, McColl, Mackie & Rendall, 1977). B a s i c a l l y , the purpose of a POR i n s e r v i c e program i s to inform s t a f f of the introduction of the new system and help them learn the concepts and format. Physiotherapists (PTs) and occupational therapists (OTs) are among those health professionals currently involved i n improving t h e i r record-keeping. This movement has been stimulated, i n part, by the increased attention given to patient-care records throughout the health-care industry, but the main impetus can be traced to d i r e c t i v e s issued by the Canadian Council for Hospital A c c r e d i t a t i o n (CCHA) (1977) and the Canadian Physio-therapy Ass o c i a t i o n (CPA) (1976). Both bodies issued standards and guide-l i n e s for recording, and encouraged therapists to improve t h e i r record-keeping. At the present time neither CCHA nor CPA i n s i s t on the POR format, although CPA recommends i t s use. Nevertheless, many PT/OT departments have chosen POR as t h e i r o f f i c i a l recording system. Inservice education i s used by many i n s t i t u t i o n s to help employees gain an understanding of, and become competent i n using POR, but formal research into the effectiveness of those programs i s scarce. Occasionally a report, such as one by Hammett, Sandlow and Bashook (1976), demonstrates a change i n recording practices following a c a r e f u l l y designed educational program, but the greater portion of documentation on t h i s topic i s concerned with describing methods that should be used to e f f e c t change. Many of those a r t i c l e s suggest, but f a i l to confirm, the importance of i n s e r v i c e education. 6 To change recording p r a c t i c e s i s a s p e c i f i c example of changing any behaviour i n any work se t t i n g . As such, i t can be explained, under-stood and ultimately c o n t r o l l e d by a c r i t i c a l examination of those factors shown to influence change i n work-related behaviour. Leading consultants i n i n s e r v i c e and continuing education repeatedly urge educators to recognize the r e l a t i o n s h i p s among an i n d i v i d u a l ' s a b i l i t y , h i s motivation and organizational factors (Charters & Blakely, 1974; Lessinger, 1974). This study investigated these r e l a t i o n s h i p s , using as a s p e c i f i c focus, change i n POR p r a c t i c e s among ph y s i c a l and occupational therapists. The study made a d i s t i n c t i o n between two phases of change, the f i r s t being referred to as " a c q u i s i t i o n , " the second as "maintenance." In the case of a c q u i s i t i o n , i t was suggested that i n i t i a l change i n recording behaviour would be governed by a therapist's motivation to change h i s record-keeping p r a c t i c e s and on understanding POR format. Those two f a c t o r s , motivation and knowledge, were expected to exert s u f f i c i e n t force to overcome organizational b a r r i e r s to change and thus performance l e v e l s should r i s e . In the second phase of change, maintenance, i t was suggested that newly acquired recording practices would be vulnerable to pressure from organizational forces. Lack of resources such as time and materials, and lack of r e i n f o r c e r s for proper recording were expected to exert s u f f i c i e n t force to drive performance l e v e l s down. THE SIGNIFICANCE OF THE STUDY Accountability i s one of the more pressing issues i n times of the shrinking health-care d o l l a r . Inservice education i s expensive; i t con-sumes time and money. Both those commodities are becoming scarce as admin-i s t r a t o r s seek to hold down health-care d e l i v e r y costs. Educational 7 a c t i v i t i e s that f a i l to have a p o s i t i v e l o n g - l a s t i n g e f f e c t on patient-care are a luxury which neither the health system nor the health p r o f e s s i o n a l can a f f o r d . At the present time, the spot l i g h t of ac c o u n t a b i l i t y finds l i t t l e evidence to show that i n s e r v i c e education i s an e f f e c t i v e method of improving p r a c t i t i o n e r performance. By monitoring changes i n record-keeping practices and determining how much change r e l a t e s to learning a c t i v i t i e s and how much to c e r t a i n organization-related f a c t o r s , t h i s study provides some evidence of the extent to which i n s e r v i c e programs contribute to changing employees' performance. In a ddition to providing p r a c t i c a l information, t h i s research project contributes to the body of knowledge concerning planned performance change. One notable gap i n performance change research i s a lack of l o n g i t u d i n a l data. Many studies concentrate on short-term changes i n performance and i d e n t i f y conditions that are conducive to change. On those occasions when a new performance l e v e l f a i l s to ma t e r i a l i z e , lack of follow-up data jeopardizes the search f o r causative fa c t o r s . By using a modified time-series experimental design with a pretest, one-month posttest and three months delayed posttest, t h i s study addresses the issue of short- and long-term changes i n performance. THE ORGANIZATION OF THE THESIS This i n i t i a l chapter has described the purpose of the study, i t s contribution to the body of knowledge r e l a t i n g to i n s e r v i c e education and planned performance change, and the s p e c i f i c problem under i n v e s t i g a t i o n . Chapter 2 reviews the relevant l i t e r a t u r e and Chapter 3 outlines the conceptual framework and study design. Instrument development i s de t a i l e d i n Chapter 4 and the r e s u l t s are presented and analysed i n Chapter 5. 8 Chapter 6 d i s c u s s e s the f i n d i n g s and a f i n a l Chapter 7 summarizes the study and p r e s e n t s the i m p l i c a t i o n s . Chapter 2 THE RELATED LITERATURE Empirical studies concerning performance change among professionals i n t h e i r work-setting suggest that an i n d i v i d u a l i s l i k e l y to change his performance when changes occur i n both the person and the organizational forces that impinge on the s p e c i f i c task. S o c i a l s c i e n t i s t s o f f e r several theories to explain r e l a t i o n s h i p s among personal and organizational factors and to suggest ways by which change can be accomplished. This chapter examines Lewin's (1947) model of planned change, as i t appears to be the most frequently c i t e d ; work behaviour from the perspective of three motivation t h e o r i s t s and a behaviourist; two models of performance derived from those perspectives; and an educator's approach to change. In addition, the chapter contains reviews of several empirical studies on performance change, knowledge change and the e f f e c t s of organizational factors on per-formance change among professionals within and outside the health-care industry. PLANNED CHANGE Lewin (1947), i n h i s pioneer work on change, proposes that any l e v e l of performance i s determined by the combined e f f e c t s of forces operating on an i n d i v i d u a l . He assumes that i n any s i t u a t i o n there are both d r i v i n g and r e s t r a i n i n g forces. Driving forces are those which encourage and f a c i l i t a t e change; r e s t r a i n i n g forces are those which work against change. For example, pressure from a supervisor and an i n d i v i d u a l ' s sense of achievement may act as d r i v i n g forces i n a work s i t u a t i o n , and non-support from colleagues and 9 10 poorly maintained equipment may act as r e s t r a i n i n g forces. The employee's performance l e v e l i s stable when the sum of the d r i v i n g forces equals the sum of the r e s t r a i n i n g forces. Using the notion of opposing forces, Lewin (1947) i d e n t i f i e s three phases of the change process: (1) unfreezing the present l e v e l of perfor-mance, (2) changing to a new l e v e l , and (3) refreezing at the new l e v e l . Changing performance begins with unfreezing the e x i s t i n g l e v e l . Hersey and Blanchard (1972) state: "The aim of unfreezing i s to motivate and make the i n d i v i d u a l or group ready to change" (p. 30). Unfreezing may be induced by increasing c e r t a i n d r i v i n g forces or decreasing some r e s t r a i n -ing forces. Either manoeuvre disturbs the equilibrium and makes i t possible for i n d i v i d u a l s to pay attention to new information (Schein & Kommers, 1972). The second stage, changing, i s concerned with a c q u i s i t i o n of new b e l i e f s , attitudes and patterns of behaviour. Once i n d i v i d u a l s are motivated to change they a c t i v e l y seek new ideas and are receptive to new behaviour patterns (Hersey & Blanchard, 1972; Schein & Kommers, 1972). Trainers and educators often a s s i s t t h i s phase by providing s t a f f with opportunities to acquire needed s k i l l s and knowledge. The f i n a l stage i n the change process, r e f r e e z i n g , i s the s t a b i l i z a -t i o n phase. This i s where new b e l i e f s , attitudes and behaviours are integrated into the t o t a l performance patterns of the i n d i v i d u a l . To maintain a new l e v e l of performance the forces operating on the i n d i v i d u a l must be changed. Hersey and Blanchard (1972) point out that change following t r a i n i n g programs i s often s h o r t - l i v e d because e x i s t i n g forces are not changed. They recommend ca r e f u l attention be paid to reinforcement as i t i s a powerful force i n the refreezing stage. Lewin's approach to planned change i s recommended for use i n a v a r i e t y of sett i n g s . Hersey and Blanchard (1972) sel e c t i t as a s u i t a b l e t h e o r e t i c a l framework for guiding the development of change strategies i n business and industry, Longest (1976) advocates i t s use i n managing change i n health-care agencies, and Schein and Kommers (1972) use t h i s approach to re-structure education programs for professionals. Those and other reports a t t e s t to the value of viewing planned change as a three-step process with a l t e r a t i o n of forces as a c e n t r a l concept. The manager or change agent who wishes to use the Lewinian model of change must be able to i d e n t i f y and select p o t e n t i a l d r i v i n g and r e s t r a i n i n g forces. Reports of attempts at planned change frequently omit the methods used to e s t a b l i s h "forces present". As Haskew (1974) notes, forces "seem to emanate from i n t u i t i v e assumptions of the analysts" (p. 58). This apparent weakness i n some uses of Lewin's theory might be overcome by considering theories and models that purport to explain the behaviour of i n d i v i d u a l s i n the work-place. THE STUDY OF WORK BEHAVIOUR Motivation and behaviourism are among the more prominent theories used to explain work-related behaviour. Those two t h e o r e t i c a l constructs are based on d i f f e r e n t assumptions about the nature of man. The motivation o r i e n t a t i o n considers man to be a purposive, problem-solving being with freedom to make choices i n each s i t u a t i o n . A be h a v i o u r i s t i c o r i e n t a t i o n considers man to be a passive organism governed by s t i m u l i supplied by the external environment. Those two views give r i s e to d i f f e r e n t perspectives for understanding work-related behaviour. Motivation Motivation r e f e r s to the process by which behaviour i s energized, 12 directed and sustained (Porter & Lawler, 1968). This d e f i n i t i o n i d e n t i f i e s three components of motivated behaviour: (1) the presence of an energetic force within the i n d i v i d u a l that "drives" him to behave i n c e r t a i n ways, (2) a sense of d i r e c t i o n toward c e r t a i n ends, and (3) some form of feedback to r e i n f o r c e the behaviour. A l l theories of motivation deal with at least one of those fa c t o r s . Theories of motivation are c l a s s i f i e d by Steers and Porter (1975) as either "content" or "process" theories. Content theories attempt to specify the energizers of behaviours; whereas, process theories attempt to i d e n t i f y the cognitive processes that give behaviour purposeful d i r e c t i o n (Luthans & Kreitner, 1975). Thus, process theories tend to be more complex. Content theories. Needs hierarchy theory (Maslow, 1943, 1965) and dual-factor theory (Herzberg, 1968; Herzberg, Mausner & Snyderman, 1959) are examples of content theories. Maslow's needs hierarchy theory (1943, 1965) i s based on two assumptions. F i r s t , man i s a "wanting" animal, motivated by a desire to s a t i s f y c e r t a i n s p e c i f i c needs. Second, those needs are arranged sequentially i n a h i e r a r c h i c a l form. The needs contained i n the hierarchy are, from lowest to highest: p h y s i o l o g i c a l , safety, love and belonging, esteem, and s e l f - a c t u a l i z i n g needs. Maslow contends that behaviour i s energized by the next higher l e v e l of u n s a t i s f i e d needs. For example, when basic p h y s i o l o g i c a l needs such as hunger and t h i r s t are s a t i s f i e d , t h e i r importance diminishes and needs for protection against danger become the strongest motivator. This process of increased s a t i s f a c t i o n - decreased importance - increased impor-tance of next higher l e v e l repeats i t s e l f u n t i l the highest l e v e l i s reached. McGregor (1960) describes some implications of needs hierarchy theory to changing employee performance. He maintains that management can f a c i l i t a t e motivational l e v e l s by providing employees with opportunities to s a t i s f y t h e i r higher order needs. This can be achieved by: (1) giving people more freedom to d i r e c t t h e i r own a c t i v i t i e s , (2) re-organizing work to encourage acceptance of r e s p o n s i b i l i t y , (3) using p a r t i c i p a t i o n and consultative management p r a c t i c e s , and (4) allowing employees to take more r e s p o n s i b i l i t y for planning and appraising t h e i r own contributions to organizational objectives. Dual-factor theory (Herzberg, 1968; Herzberg et al., 1959) i s another example of a content theory. It also focuses on factors that energize behaviour but, i n contrast to Maslow's work, i t deals with the nature of the task as w e l l as the nature of man. Using semi-structured interviews, Herzberg and h i s colleagues c o l l e c t e d data on events at work that markedly increased or decreased an i n d i v i d u a l ' s s a t i s f a c t i o n . Content analysis revealed two d i s t i n c t sets of f a c t o r s : one set led to job s a t i s f a c t i o n while a d i f f e r e n t set led to job d i s s a t i s f a c t i o n . Those findings led Herzberg et a l . (1959) to conclude that a two-factor theory of motivation i s needed. Job s a t i s f a c t i o n f a c t o r s , or "motivators", included the work i t s e l f , , achievement, p o s s i b i l i t y of growth, r e s p o n s i b i l i t y , and advancement and growth. Factors leading to job d i s s a t i s f a c t i o n , or "hygiene f a c t o r s " , include status, interpersonal r e l a t i o n s h i p s with superiors, subordinates and peers, technical supervision, company p o l i c y and administration, personal l i f e , working conditions, job s e c u r i t y , and salary. The motivators are job content c h a r a c t e r i s t i c s while the hygiene factors are job environ- ment c h a r a c t e r i s t i c s . Implications of dual-factor theory f o r changing employee performance 14 stem from the hypothesised dichotomy of job s a t i s f a c t i o n and job d i s s a t i s -f a c t i o n . Because those are two d i s t i n c t e n t i t i e s and not opposite ends of a continuum, changes i n employee motivation can only be achieved by changing motivators. Motivators are job content c h a r a c t e r i s t i c s ; therefore, i t i s changes within the job that are l i k e l y to improve performance. Herzberg (1968) recommends job enlargement as one means of increasing s a t i s f a c t i o n . A process theory. Vroom's (1964) expectancy/valence theory i s an example of a process theory; i t i s concerned with r e l a t i o n s h i p s among vari a b l e s i n a dynamic state as they a f f e c t behaviour. Vroom (1964) defines motivation as a "process governing choices, made by persons or lower organisms, among a l t e r n a t i v e forms of voluntary a c t i v i t y " (p. 6). He argues that i n a work s i t u a t i o n an i n d i v i d u a l i s faced with a set of a l t e r n a t i v e " f i r s t l e v e l outcomes." The choice made by the i n d i v i d u a l among those f i r s t l e v e l outcomes i s determined by the expected r e l a t i o n s h i p of them to possible "second l e v e l outcomes." Three concepts are used to explain the r e l a t i o n s h i p s i n t h i s model: (1) valence, (2) instrumentality, and (3) expectancy. Valence r e f e r s to the strength of an i n d i v i d u a l ' s desire f or a p a r t i c u l a r outcome. Instrumentality i s the extent to which a f i r s t l e v e l outcome i s seen as leading to the accomplishment of a second l e v e l outcome. And expectancy i s a momentary b e l i e f concerning the l i k e l i h o o d that a p a r t i c u l a r action w i l l be followed by a p a r t i c u l a r outcome. Simply stated, Vroom's expectancy/valence model (1964) predicts that people w i l l choose to behave i n whatever way has the highest motiva-t i o n a l force. For example, workers w i l l be motivated to increase t h e i r p r o d u c t i v i t y i f they f e e l they can be highly productive and i f they see some p o s i t i v e outcome attached to being a high producer. From the expectancy/valence model, i t i s clear that an employee's 15 motivational l e v e l i s heavily influenced by h i s personal goals, thus, attempts to change performance should be preceded by an accurate assessment of the importance of an i n d i v i d u a l ' s goals, h i s perception of r e l a t i o n -ships between organizational objectives and personal goals, and h i s expectancy that organizational objectives can be attained. Behaviourism Behaviourism provides a d i f f e r e n t perspective for understanding the forces operating for and against change i n the work-setting (Campbell, J.P., 1971; Gellerman, 1977; Luthans & Kreitner, 1975; Nisberg, 1976; Nord, 1969; Rummler, 1972). Whereas motivational t h e o r i s t s believe that i n d i v i d u a l s chose the path they wish to follow, behaviourists subscribe to the notion that behaviour i s governed by i t s consequences. According to Dubin and Okun (1973), "Behaviourists concern themselves with the observables of behaviour, namely s t i m u l i and responses. S t r i c t b e h a v i o u r i s t i c doctrine avoids any speculation about what i s going on i n the mind" (p. 4). As current applications of behaviourism i n the work-place are based p r i m a r i l y on Skinner's operant learning theory, i t i s germane to review b r i e f l y the major concepts of that theory. Operant learning i s concerned with those behaviours that are emitted by the organism rather than e l i c i t e d by a known stimulus (Skinner, 1953). Operant behaviour, as conceived by Skinner, i s that behaviour which i s strengthened, maintained or weakened by i t s consequences. Thus, operant learning deals with the observable e f f e c t s of environmental consequences on observable responses. Consequences of behaviour f a l l i n t o three classes: p o s i t i v e , negative and neutral. P o s i t i v e consequences are those events that strengthen a response; negative consequences diminish a response; and neutral consequences are those events that have no noticeable e f f e c t on a response. Reinforcement i s a key concept i n Skinner's system. To re i n f o r c e behaviour simply means to change some aspect of the environment so as to a l t e r the p r o b a b i l i t y of future occurrences of that behaviour. Reinforce-ment may be verbal such as praise, or material such as money, and i t can b scheduled to occur a f t e r every correct response or i n t e r m i t t e n t l y ( C o s t e l l & Zalkind, 1963). Summary Table 1 summarizes the four theories that were discussed i n the previous section. It presents the key concepts and implications for work-related performance. Table 1 Concepts and Implications of Motivation and Behaviour Theories Theory & Exponent Key Concepts Implications Needs Hierarchy (Maslow, 1943) Individual needs Provide opportunities for employees to s a t i s f y t h e i r higher order needs Dual-factor (Herzberg, 1968) Motivators Hygiene factors Re-design j ob (job enlargement) Expectancy/ Valence (Vroom, 1964) Expectancy Valence Instrumentality Assess importance of personal goals, perception of r e l a t i o n -ship between organizational objectives and personal goals Operant Learning (Skinner, 1953) Reinforcement Measure frequency of response, i d e n t i f y r e i n f o r c e r s and rearrange contingencies 17 TWO MODELS OF PERFORMANCE Motivation theories and operant learning theory have generated several models of performance. Two of those models w i l l be examined in this section. They are a model of performance developed by Cummings and Schwab (1973), and a performance audit model by Rummler (1976). A Model of Performance Cummings and Schwab (1973) propose that an individual's performance i s determined by his a b i l i t y and motivation: organization factors influence performance through their impact on those two determinants. Their model of performance i s shown in Figure 1. It i s based on expectancy theory and includes some elements of dual-factor theory. Ability Motivation Satisfaction — Individual variables Organizational variables and outcomes Figure 1 Cummings and Schwab's Model of Performance 18 The two determinants of performance, a b i l i t y and motivation, are d i f f e r e n t i a t e d as follows: a b i l i t y i s an i n d i v i d u a l ' s "current c a p a c i t i e s to perform some task or set of tasks" (Cummings & Schwab, 1973, p. 8), and motivation " r e f l e c t s e f f o r t or energy, a dynamic, often f l e e t i n g character-i s t i c which determines how vigorously c a p a b i l i t i e s w i l l be employed i n some a c t i v i t y " (Cummings & Schwab, 1973, p. 8). When discussing the influence of organizational factors on the a b i l i t y component of t h i s model, Cummings and Schwab note that a t r a i n i n g program i s often the major procedure used by an organization, to manipulate a b i l i t y l e v e l s of i t s employees. Ideally, the t r a i n i n g process involves the following elements: (1) i d e n t i f i c a t i o n of the s k i l l s to be learned, (2) i d e n t i f i c a t i o n of p a r t i c i p a n t s to receive t r a i n i n g , (3) development, or s e l e c t i o n , of procedures that enable p a r t i c i p a n t s to e f f i c i e n t l y learn the required s k i l l s , (4) implementation of procedures, and (5) appraisal of r e s u l t s . The motivational component of t h i s model i s considerably more complex than the a b i l i t y component. An i n d i v i d u a l ' s motivational l e v e l i s shown as a function of s a t i s f a c t i o n with goals attained and with goal a s p i r a t i o n s . Thus, "motivation to perform depends on h i s perception about l i n k s between his e f f o r t and performance, and between performance and valued i n t r i n s i c and e x t r i n s i c outcomes" (Cummings & Schwab, 1973, p. 48). The d i f f e r e n c e between the two types of outcomes appear to be c l o s e l y r e l a t e d to Herzberg's motivators and hygiene f a c t o r s . For example, a sense of accomplishment and the p o s s i b i l i t y of growth are c i t e d as i n t r i n s i c outcomes, and salary and working conditions are included among the e x t r i n s i c outcomes. Organizational factors that may i n d i r e c t l y influence motivational l e v e l s or mediate between a b i l i t y / m o t i v a t i o n and successful performance are task design, task d e f i n i t i o n , managerial behaviour and the company's reward system. Decisions and actions taken i n any of those areas can a l t e r employee perceptions of the l i n k s between motivation, performance, outcomes and goal attainment. For example, i f the requirements and standards f o r a s p e c i f i c task (task d e f i n i t i o n ) are ambiguous or not stated employees w i l l have d i f f i c u l t y performing "properly," even though they are well-motivated and capable. Companies can avoid t h i s s i t u a t i o n by iss u i n g c l e a r l y defined guidelines for task performance. In summary, the model of performance by Cummings and Schwab (1973) suggests that an i n d i v i d u a l ' s a b i l i t y and motivation are the primary determinants of performance. Organizational factors influence performance i n a number of ways including d i r e c t impact on a b i l i t y ( t r a i n i n g programs), i n d i r e c t influence on motivation ( e x t r i n s i c "hygiene" factors) and as a mediator between those two determinants and performance (task design, task d e f i n i t i o n ) . A Performance Audit Model A performance audit model, by Rummler (1972, 1976), i s an example of the a p p l i c a t i o n of operant learning theory to changing employee behaviour. Rummler's approach to understanding performance i s considerably d i f f e r e n t to that proposed by Cummings and Schwab (1973) i n that i t i s p r i n c i p a l l y concerned with the d i r e c t , rather than the mediated, impact of organiza-t i o n a l forces on employee performance. He agrees that a b i l i t y (knowledge) i s a c r i t i c a l element of performance but he chooses to ignore motivation. The model consists of a performance system and f i v e sets of variables The constituent parts of the performance system are: (1) the job s i t u a t i o n or occasion to perform, (2) the performer, (3) the behaviour that i s to occur (4) the consequences of that behaviour to the performer, and (5) feedback 20 of consequences to the performer. This system is graphically represented in Figure 2. JOB • I N D I V I D U A L - ^ R E S P O N S E — • C O N S E Q U E N C E S S ITUATION PERFORMER (Action or O F A C T I O N OR i Dec is ion by DECISION T O j Performer) PERFORMER ! (+,-,9) L FEEDBACK 1 Figure 2 Rummler's Performance Audit Model Within this system Rummler (1976) identifies five sets of variables as potential sources of performance problems: (1) task interference, (2) performance standards, (3) knowledge, (A) consequences, and (5) feed-back mechanisms. Task interference includes such factors as poor physical working conditions; inadequate tools, time and support services; and competing tasks. Performance standards refers to written policies guidelines and procedures for doing a specific job or task. The knowledge variable i s concerned with an employee knowing what to do, how to do i t and when to do i t . Consequences are those external events that occur after the behaviour has been emitted. These events may arise from many sources including the work i t s e l f , colleagues, supervisors and other members of the organizational establishment. Feedback refers to the information received by the performer about his performance. This information should be specific, understandable and reinforcing. 21 Rummler (1976) argues that t h i s form of performance audit has considerable u t i l i t y f o r managers attempting to change l e v e l s of s t a f f performance. It encourages a systematic examination of key var i a b l e s that influence performance l e v e l s . I n i t i a l l y , i t separates d e f i c i e n c i e s of knowledge from d e f i c i e n c i e s of execution. As Mager and Pipe (1971) point out, t h i s d i s t i n c t i o n i s p a r t i c u l a r l y important when t r a i n i n g programs are considered as appropriate solutions to poor performance. They argue that knowledge d e f i c i t s can be overcome by t r a i n i n g programs but execution d e f i c i t s require changes i n external conditions and events. Rummler (1976) believes that as well as being u s e f u l for analysing e x i s t i n g problems, the audit can be used to predict p o t e n t i a l problem areas before changes are introduced. Thus, the performance audit has p o t e n t i a l as a planning t o o l as well as a diagnostic t o o l . AN EDUCATOR'S APPROACH TO CHANGE In recent years several attempts have been made to develop models of inse r v i c e education that l i n k learning experiences to performance change. Most models r e s u l t i n g from those e f f o r t s use the s c i e n t i f i c mode of problem-solving as a basic framework (Brown & Uhl, 1970; Hospital Research & Educational Trust, 1970; Charters & Blakely, 1974). The basic steps i n the problem-solving cycle are: (1) recognize a problem, (2) define the problem, (3) choose a s o l u t i o n from a l t e r n a t i v e s , (4) implement a plan, and (5) assess the outcomes. M i l l e r (1967) believes the problem-solving approach i s appropriate for the educative process because i t p a r a l l e l s the way p r a c t i -tioners d e l i v e r care to t h e i r patients. Under the aegis of the Regional Medical Programs Service (RMPS) a model of the continuing education process was developed (Charters & Blakely, 1974). The RMPS model marks a s i g n i f i c a n t advance i n the area of i n s e r v i c e and continuing education i n that i t provides educators with a t h e o r e t i c a l l y -based, systematic approach to changing on-the-job performance of health-care p r a c t i t i o n e r s . P r i o r to i t s development continuing education for health man-power tended to be sporadic, fragmented, nonsequential and lacking a conceptual base (Hutchinson, 1974) . The RMPS model as outlined by Charters and Blakely (1974), proceeds through nine steps. This model i s presented i n Figure 3. The process begins with the educator c o l l e c t i n g , organizing and analysing data to determine the needs of p r a c t i t i o n e r s . The term "need" as used here means performance d e f i c i t . D e f i c i t s may be found through record audits, peer reviews, performance ap p r a i s a l , observation, interviews and questionnaires. A f t e r the needs are determined they are ranked i n an order of p r i o r i t i e s which r e f l e c t the current objectives of the i n s t i t u t i o n . The next step, Analyse the Nature of the Need and Define the Problem, i s c r i t i c a l because a f a u l t y assumption about the cause of performance d e f i c i t i s l i k e l y to lead to an inappropriate remedy. Educators are urged to c l e a r l y d i s t i n g u i s h d e f i c i t s due to lack of knowledge from those caused by organizational problems, and to concentrate t h e i r s k i l l s on the former. If organizational problems are found to be the cause of performance d e f i c i t s then the educator must seek other remedies. The remaining steps i n the RMPS model deal exc l u s i v e l y with planning an educational program for problems due to lack of knowledge. The fourth step deals with diagnosing the knowledge problem. Three key points i n t h i s step are: (1) the diagnosis must be s p e c i f i c , (2) care-f u l a ttention should be given to the a f f e c t i v e domain, and (3) e f f o r t s to bring about performance change must include changes i n both personal and organizational forces. 1. Determine needs T Within priorit ies select a need Ma in ta in results 3# Ana l y se need a n d def ine the p rob lem T 9. Next steps If sat is f ied If not sat isf ied re-examine If it is a learn ing p rob lem d i a g n o s e cause a n d cure T // / 5. Select a corrective learn ing exper ience I // I V ^ Plan and prepare l ea rn ing exper ience 8. Eva luate outcome Implement correct ive learn ing exper ience Figure 3 Charters and Blakely's Model of Inservice Education 24 The next three steps are concerned with s e l e c t i n g , planning, preparing and implementing a c o r r e c t i v e learning experience. Charters and Blakely recommend that the p r i n c i p l e s and techniques of adult education as outlined by Dickinson and Verner (1974), Knox (1974), and Gagne (1970), are followed throughout these a c t i v i t i e s . The eighth step focuses on assessment of outcomes. In addition to evaluating the e f f e c t of the learning experience on the c l i e n t s , evaluation should encompass the planning and preparation of the program, s e t t i n g of objectives, diagnosing needs and s e t t i n g of goals. The f i n a l step addresses the question: What happens next? The answer depends on whether the r e s u l t s of the program were s a t i s f a c t o r y or unsatisfactory. If they are not s a t i s f a c t o r y a ser i e s of questions should be considered. Is the performance d e f i c i t s u f f i c i e n t l y important to t r y another remedy? What were the probable sources of f a i l u r e ? Was the need i n c o r r e c t l y diagnosed? Is the d e f i c i t caused by an administration problem? Was the learning experience improperly planned or delivered? Answers to those queries help to determine the next steps. If the outcomes are s a t i s -factory the next step i s to ensure maintenance of the performance. Charters and Blakely do not specify how t h i s should be c a r r i e d out but they suggest that educators may f i n d some ideas for accomplishing t h i s task i n the models of planned change (Schein & Kommers, 1972), dissemination and u t i l i z a t i o n of knowledge (Havelock, 1972) and d i f f u s i o n of innovations (Rogers & Shoemaker, 1972). The RMPS model appears to have three major advantages for performance change i n health-care agencies. F i r s t , i t integrates educational a c t i v i t i e s and on-the-job performance. M i l l e r (1967), one of the f i r s t modern c r i t i c s of continuing medical education programs, cogently argues for t h i s form of linkage. He deplores educational programs that have l i t t l e immediate relevance to actual performance needs. He recommends a "process-oriented" method of continuing education where p r a c t i t i o n e r s are encouraged to i d e n t i f y c l i n i c a l problems and seek appropriate learning experiences to solve them. By fi r m l y anchoring educational a c t i v i t i e s to the context of c l i n i c a l p r a c t i c e the RMPS model meets that requirement. Second, the RMPS model distinguishes between performance problems caused by a p r a c t i t i o n e r ' s lack of knowledge or s k i l l and those caused by other factors such as poor administrative p o l i c i e s or inadequate resources. The need for t h i s kind of d i f f e r e n t i a t i o n i s stressed by many health-care consultants including Lessinger (1974) and Fl e i s c h e r (1974). They point out that inadequate analysis of the probable causes of gaps between observed and expected performance leads to inappropriate c o r r e c t i v e actions. Lessinger (1974) recommends the use of Mager and Pipe's (1971) analysis of performance problems. This system uses a series of questions to d i s t i n g u i s h deficiences of knowledge from d e f i c i e n c i e s of execution. For example, could he do i t i f h i s l i f e depended on i t ? A p o s i t i v e answer suggests that the problem i s not due to lack of knowledge. One advantage of the RMPS i s that i t encourages t h i s type of an a l y s i s . The t h i r d advantage of the RMPS model concerns the expansion of the r o l e and r e s p o n s i b i l i t i e s of ins e r v i c e educators. Other models, such as those recommended by the Hospital Research and Education Trust (1970) and King (1976), state that educators are accountable for an employee's a b i l i t y to perform and supervisors are responsible for maintenance of performance. This e x p l i c i t d e l i n e a t i o n of roles i s challenged by Dickinson and Verner (1974) who specify that one of the functions of inservices i s to "insure that changes that have been introduced into the organization are adopted 26 and maintained" (p. 182). The RMPS model subscribes to the second p o s i t i o n by b l u r r i n g the d i s t i n c t i o n between supervisor and educator and st r e s s i n g the need f or co l l a b o r a t i o n . By so doing, i t extends the educator's boundaries to encompass assessment and removal of organizational b a r r i e r s to change. In summary, the RMPS model i s an elaboration of the basic problem-solving c y c l e . It provides educators and supervisors with a systematic approach to l i n k i n g educational a c t i v i t i e s with observed performance d e f i c i t s . By emphasising performance i t s a t i s f i e s some concerns expressed by c r i t i c s of continuing and ins e r v i c e education. A p p l i c a t i o n of t h i s model forces educators to expand t h e i r a c t i v i t i e s beyond the classroom and consider the influence of organizational factors on the performance they are tr y i n g to change. A SUMMARY OF THE THEORETICAL CONSTRUCTS Two objectives guided the review of l i t e r a t u r e . The f i r s t objective was to i d e n t i f y key concepts r e l a t i n g to employee performance and performance change i n the work s e t t i n g from several t h e o r e t i c a l constructs. This was accomplished by examining l i t e r a t u r e on work behaviour i n the context of motivation, behaviourism and in s e r v i c e education. Table 2 aids i n comparing the r e s u l t s of that examination. The table l i s t s the key concepts i d e n t i f i e d i n needs hierarchy theory (Maslow, 1943, 1965), dual-factor theory (Herzberg et al., 1959), a model of performance (Cummings & Schwab, 1973) based on expectancy/valence theory, a performance audit model (Rummler, 1972, 1976) derived from operant learning theory, and a model of ins e r v i c e education (Charters & Blakely, 1974) based on a problem-solving c y c l e . The concepts are c l a s s i f i e d as either personal 27 attributes or organizational factors. From those examples, which are intended to be representative and not exhaustive, there seems to be no generic set of concepts to be applied in a l l instances of performance change. Some theorists focus on the motivational component of work-related behaviour while others emphasize the importance of re-arranging organizational events. Knowledge is recognized as an important part of.the performance equation by behaviourists, inservice educators and motivation "process" theorists. Table 2 Personal and Organizational Factors Identified in Three Performance Models and Two Motivation Theories Source Personal Factors Organizational Factors Maslow (1963) Hierarchical needs Herzberg, Mausner & Snyderman (1959) Motivators Hygiene factors Cummings & Schwab (1973) Ability Motivation Training Task design Task definition Supervision Compensation Rummler (1976) Knowledge Task interference Performance standards Reinforcement Feedback Charters & Blakely (1974) Perceived needs Knowledge Performance deficits Learning experience Evaluation procedures Administrative policy Resources 28 The second objective was to determine from empirical studies of performance change which of the previously i d e n t i f i e d concepts were important to actual performance change. The r e s u l t s of that examination are presented i n the next section of t h i s review. FACTORS AFFECTING PERFORMANCE CHANGE For the purpose of t h i s review, studies dealing with factors that a f f e c t performance change are divided into the following categories: performance change among professionals, employee knowledge change, and organizational factors and employee performance Studies on Performance Change among Professionals Reports of deliberate attempts to change performance patterns of teachers, nurses and physicians i l l u s t r a t e some personal and organizational factors that seem to help or block the change process. Gross et al.(1971), conducted an intensive case study of an attempt to implement a new teaching r o l e among a small group of teachers i n Cambrie. The new r o l e , referred to as " c a t a l y t i c teaching," involved a change i n teaching s t y l e . The dependent v a r i a b l e was degree of implementation, s p e c i f i c a l l y stated as: the extent to which teacher r o l e performance, at a given point i n time, conformed to the new r o l e . Systematic observation of performance by a trained observer, self-administered questionnaires and interviews were the main sources of data. Seven months a f t e r the new r o l e was introduced there was l i t t l e evidence of change. Teachers were s t i l l behaving i n accord with the t r a d i t i o n a l r o l e model. F a i l u r e to implement the desired performance change was a t t r i b u t e d to f i v e circumstances: (1) lack of c l a r i t y about the new performance, (2) lack of c a p a b i l i t y to perform the new r o l e , (3) u n a v a i l a b i l i t y of 29 necessary materials, (4) in c o m p a t i b i l i t y of organizational arrangements, and (5) lack of motivation to make an e f f o r t to implement new performance. Commenting on the f a i l u r e to implement the new c a t a l y t i c r o l e , Gross et a l . (1971) noted that performance change requires changes i n personal forces, such as motivation and knowledge, and changes i n organizational forces such as resources and working arrangements. A c o l l e c t i o n of case studies of planned change i n a St. Louis h o s p i t a l (Coe, 1970) includes one r e l a t i n g to performance change i n nurses. Coe and B a r n h i l l (1970) monitored the implementation and sustained use of a new drug-dispensing system on a. h o s p i t a l ward. The new method required nurses to use a new piece of equipment, a drug-dispensing console, and new drug-report cards. Degree of acceptance of the new system was measured by pre- and post-implementation questionnaires. A d d i t i o n a l data were obtained from observation and interviews. Nine months a f t e r the new drug-dispensing system was introduced, nursing s t a f f had reverted to the t r a d i t i o n a l method of dispensing drugs. Those authors a t t r i b u t e d f a i l u r e to sustain the new method to three f a c t o r s : (1) lack of perceived need to change among s t a f f , (2) i n a b i l i t y of the new system to f u l f i l l expectations, and (3) covert h o s t i l i t y of s t a f f toward persons responsible f o r t h i s new method. Explaining those f i n d i n g s , Coe and B a r n h i l l (1970) note that the new dispensing method was imposed by an outside source: i t resulted from a study done by the human engineering department. Nursing s t a f f did not perceive a need for i t ; they were happy with the e x i s t i n g system. This lack of perceived need was considered to be an important force against the required change i n performance. Studies on attempts to change record-keeping practices of health-care personnel report varying degrees of success. Hammett et a l . (1976) measured the use of a new recording method among 200 physicians at Michael Reese Hospital, Chicago. The new system, Problem Oriented Medical Records (POMR), required c l i n i c i a n s to follow a s p e c i f i c format i n recording patient care. A f t e r an extensive education program, adherence to POMR increased from 57% to 72%. The study did not include a cont r o l group; nevertheless, the authors claim the r e s u l t s probably r e f l e c t the value of the education program. I n i t i a l r e s u l t s from an on-going study of POMR use at Guy's Hospital, London, (Fernow et a l . , 1977) provide further i n s i g h t s into attempts to change physician behaviour. The researchers investigated ways i n which feedback and attitudes a f f e c t the use of POMR. Data were c o l l e c t e d from 336 sets of records completed by 28 physicians over a 12-week period. At regular i n t e r v a l s , each physician received feedback i n the form of a copy of h i s r e s u l t s showing the errors he made, his monthly score and h i s score i n r e l a t i o n s h i p to his colleagues' scores. S i g n i f i c a n t findings include: (1) use of POMR by junior members of a team increased when senior members used i t , (2) no p o s i t i v e e f f e c t s of feedback were demonstrated, and (3) scores were better for physicians with favourable attitudes toward POMR. The influence of organizational forces on performance change i s v i v i d l y demonstrated i n a report of the effectiveness of a management t r a i n i n g program for nurses (Davies, 1972). The main cause of the problem appeared to be the imposition of a new idea by an outside agency. The management t r a i n i n g program resulted from the recommendations of a national committee. They decreed that "management courses should be run i n order to prepare s t a f f for t h e i r management r o l e s " (Davies, 1972, p. 13). However, neither the h o s p i t a l s nor the s t a f f were prepared for implementing change. 31 Selection of p a r t i c i p a n t s for the program was haphazard; trainees e i t h e r volunteered (25%) or were nominated by senior s t a f f (75%) and approximately h a l f the p o t e n t i a l learners had no preparation for the course. Data c o l l e c t e d from the questionnaires, interviews and on-the-job observations revealed the following: (1) nominators of trainees r a r e l y expected any p o s i t i v e behaviour change to r e s u l t from the course, (2) senior s t a f f were unwilling to provide opportunities for nurses to p r a c t i c e t h e i r newly acquired s k i l l s , (3) the t r a i n i n g program helped the learners to gain know-ledge and s k i l l , and (4) colleagues r a r e l y provided feedback to r e i n f o r c e the trainees who did attempt to implement t h e i r new s k i l l s . Studies on Employee Knowledge Change A primary objective of i n s e r v i c e education i s to help s t a f f increase t h e i r knowledge and s k i l l s (Campbell, A.B., 1971; Cooper & Hornback, 1973; Dickinson & Verner, 1974; King, 1976; Medearis & Popiel, 1971), and one method of determining whether t h i s objective has been attained i s through evaluation of the learners. Although the use of evaluation measures i s increasing (Abrahamson, 1968; Long, 1969), published studies are scarce and probably r e f l e c t only a minute portion of evaluation e f f o r t s . The a v a i l a b l e studies f a l l i nto two types, those reporting immediate a c q u i s i t i o n and subsequent retention over a period of several months, and those dealing with the impact of learning on immediate changes i n knowledge. Examples of both types follow: A c q u i s i t i o n and retention of knowledge. One of the more comprehen-sive evaluation studies i n the health-care f i e l d was done by a group of researchers at the U n i v e r s i t y of Texas System School of Nursing (1975). This group attempted to measure changes i n a t t i t u d e s , knowledge and perfor-mance, either s i n g l y or i n combination, among nurses attending 10 continuing 32 education courses. Even though the researchers had to abandon attempts to measure on-the-job performance changes (due to d i f f i c u l t i e s i n data gathering) and they experienced some problems with a t t i t u d i n a l measures, t h e i r report provides u s e f u l data on the effectiveness of i n s e r v i c e and continuing education i n the area of knowledge change. Nurses attending f i v e d i f f e r e n t courses, ranging from a one-day to a six-day workshop, were measured for immediate and long-term changes i n knowledge. For each course, tests were administered at the beginning and end of the course and a f t e r an i n t e r v a l of three months. This evaluation paradigm enabled the researchers to e s t a b l i s h i n i t i a l a c q u i s i t i o n and sub-sequent retention of knowledge. The r e s u l t s , summarized by Deets and Blume (1977) show: (1) post-test and delayed posttest knowledge scores were s i g n i f i c a n t l y higher than pretest scores i n two courses, (2) posttest knowledge means were s i g n i f i -cantly higher than delayed posttest means i n two courses, and (3) delayed posttest knowledge scores were s i g n i f i c a n t l y higher than posttest scores on one course. Thus, i t was concluded that a c q u i s i t i o n of knowledge con-s i s t e n t l y occurred i n a l l courses but retention varied. In two cases there was a small los s of knowledge which was not s t a t i s t i c a l l y s i g n i f i c a n t , i n two other instances the decline was s i g n i f i c a n t , and i n the remaining case knowledge increased s i g n i f i c a n t l y during the three months following the program. High rates of retention and occasional increases i n newly acquired knowledge are not wholly unusual. In a project i n v e s t i g a t i n g the r e l a t i o n -ship between age and retention, Jamieson (1972), tested a c q u i s i t i o n and retention of a binary learning task among 80 female subjects ranging i n age from 24 to 70 years. He found a s i g n i f i c a n t drop i n knowledge occurred i n the older age group (52 to 70 years) a f t e r an i n t e r v a l of four months but no loss occurred i n the younger age group (24 to 39 years). Evidence of s t a t i s t i c a l l y s i g n i f i c a n t increases i n knowledge a f t e r a three-month i n t e r v a l i s reported by Donegan, Reid and Eggers (1976). They evaluated the learning and retention of anesthesiologists p a r t i c i p a t i n g i n s i x , two-day workshops. The number of learners who completed the pre-t e s t , posttest and delayed posttest ranged from 68 to 37. In a l l s i x work-shops the mean knowledge scores on the immediate posttests were s i g n i f i c a n t l y i higher than pretest scores, and i n four workshops the scores three months l a t e r were s i g n i f i c a n t l y higher than immediate posttest scores. In the remaining two workshops, one group mean was higher for the delayed post-test and one group mean was lower but neither was s t a t i s t i c a l l y s i g n i f i c a n t . Knowledge retention scores from the Texas study (University of Texas System School of Nursing, 1975), Jamieson (1972) and Donegan et a l . (1976) underscore the importance of measuring learning a f t e r an elapsed i n t e r v a l of several months. Those studies show that decline i n knowledge should not be taken f o r granted. It i s possible f o r adult learners to maintain newly acquired knowledge at a very high l e v e l for at l e a s t three months and, i n some instances, they may even increase t h e i r knowledge. Immediate changes i n knowledge. Educators should not, of course, take i n i t i a l learning for granted, even though the majority of evaluation studies show p o s i t i v e r e s u l t s from learning experiences. Occasionally a report, such as one by Wolfe and Moe (1973), shows that an i n s e r v i c e program can f a i l to increase p a r t i c i p a n t s ' knowledge. Those authors con-ducted and evaluated a h o s p i t a l supervisory t r a i n i n g program. The program was well-designed, had.face v a l i d i t y of content and format, and s a t i s f i e d the trainees. Despite i t s p o s i t i v e aspects, "the program had absolutely 34 no measurable e f f e c t on the a t t i t u d e and knowledge l e v e l of the group exposed to the program" (p. 74). The researchers note that the t r a i n i n g program and content received low p r i o r i t y from the p a r t i c i p a n t s and t h e i r s u p e r v i s o r s . This l e d them to speculate that l a c k of mot i v a t i o n to l e a r n and apply management concepts were, i n p a r t , r e s p o n s i b l e f o r the program f a i l u r e . The Wolfe and Moe (1973) study i s unusual i n that i t used a c o n t r o l , group i n the experimental design. T y p i c a l l y , educators are content w i t h demonstrating the e f f e c t i v e n e s s of t h e i r e f f o r t s by measuring only the p a r t i c i p a n t s . Two examples of the more usual form of e v a l u a t i o n are provided by Parker et a l . (1975) and Margolis et a l . (1976). Parker and her a s s o c i a t e s (1975) evaluated a POMR workshop f o r nurses. Pre- and post-course measures of knowledge, using seven m u l t i p l e -choice questions, showed the nurses s i g n i f i c a n t l y increased t h e i r POMR knowledge. From those r e s u l t s , the program was judged to be s u c c e s s f u l . However, the authors recognized that t h i s was a l i m i t e d measure and they concluded that i n an i d e a l program " p r e d i c t i v e v a l i d i t y should be assessed wit h regard to whether high post scores are a s s o c i a t e d w i t h on-the-job e f f e c t i v e n e s s " (Parker et a l . , 1975, p. 38). In another POMR study (Margolis et a l . , 1976) the issu e of t r a n s -f e r r i n g s k i l l s to the job was again omitted from the study design. The main o b j e c t i v e was to determine the e f f e c t i v e n e s s of a s e l f - i n s t r u c t i o n workshop. The p e d i a t r i c i a n s attending t h i s workshop increased t h e i r POMR knowledge by 33%. The authors were s a t i s f i e d that t h i s i n d i c a t e d a gain i n knowledge and the a b i l i t y to use POMR. Org a n i z a t i o n a l Factors and Employee Performance Although s e v e r a l w r i t e r s s t r e s s the need to account "f-orvjorganiza-35 t i o n a l b a r r i e r s to performance change i n health-care agencies, s p e c i f i c examples of such e f f o r t s are scarce. F l e i s c h e r (1974) uses anecdotes to i l l u s t r a t e organizational obstacles to performance. In one example he discusses problems with meeting c r i t e r i a established for monitoring acute myocardial i n f a r c t i o n patients; s t a f f were unable to meet the c r i t e r i a because there was a shortage of heart monitors. Inappropriate admitting procedures were also i n t e r f e r i n g with s t a f f performance. Thus, two organizational b a r r i e r s described by F l e i s c h e r are lack of resources and lack of coordination between two parts of the work force. Both sources of interference were removed a f t e r they had been diagnosed. Steckel (1976) provides a l i s t of organizational factors that were selected by nurses as p o t e n t i a l r e i n f o r c e r s . This l i s t provides some ins i g h t into the things s t a f f perceive as l i k e l y to help them improve t h e i r performance. The l i s t included: (1) a three-day weekend, (2) opportunity to leave work two hours early, (3) choice of patient assignments, (4) opportunity to observe surgery, (5) opportunity to attend a continuing education workshop, (6) have a l e t t e r of recommendation placed i n personnel f i l e , (7) work on a project within working time, and (8) have a day with-out complaints. Systematic a p p l i c a t i o n of r e i n f o r c e r s selected from t h i s l i s t was successful. Nurses improved t h e i r recording of nurse-patient i n t e r a c t i o n s s u b s t a n t i a l l y . In addition to working out a l i s t of r e i n -f o r c e r s , nurses were asked to i d e n t i f y t h e i r personal performance goals. This process of goal i d e n t i f i c a t i o n also contributed to performance change as i t forced both nurses and supervisors to c l e a r l y specify what was expected for "good" performance. A Summary of Empirical Findings Empirical studies r e l a t i n g to employee performance change, employee 36 knowledge change, and the e f f e c t s of organizational f a c t o r s on performance were reviewed i n an attempt to i d e n t i f y which personal and s i t u a t i o n a l f a c t o r s are important to r e a l - l i f e performance change among professionals. Table 3 aids i n comparing the r e s u l t s of that i n v e s t i g a t i o n . The table l i s t s the major b a r r i e r s and f a c i l i t a t o r s i d e n t i f i e d i n studies of change among teachers (Gross et a l . , 1971), nurses (Coe & B a r n h i l l , 1970; Davies, 1972; Steckel, 1976), administrative personnel (Wolfe & Moe, 1973) and physicians (Fernow et a l . , 1977; Hammett et a l . , 1976). It i s obvious from those studies that a del i b e r a t e attempt to change employee performance requires changes i n personal and s i t u a t i o n a l f a c t o r s . However, i t i s not clear which of those two dimensions i s the more important or how they i n t e r a c t with each other throughout the i n t r o -ductory and implementation phases of change. There i s some evidence to suggest that motivation and increased knowledge f a c i l i t a t e i n i t i a l change, and data from retention studies (Deets & Blume, 1977; Donegan et a l . , 1976; Jamieson, 1972) imply that loss of knowledge i s an u n l i k e l y b a r r i e r to sustained performance change. Apparently, the presence of c l e a r l y defined performance standards i s one important s i t u a t i o n a l factor and reinforcement from peers, colleagues and supervisors i s another. Other s i t u a t i o n a l f a c tors that a f f e c t change include lack of resources and administrative support. There i s l i t t l e evidence to show whether those fa c t o r s are equally important i n both phases of change or whether t h e i r e f f e c t s vary with each stage. 37 Table 3 Factors A f f e c t i n g Performance Change Investigators Barriers Gross, Giacquinta & Bernstein (1971) Lack of c l a r i t y about new performance Lack of c a p a b i l i t y to perform new r o l e Lack of necessary materials Lack of motivation to change Incompatability of organization arrangements Coe & B a r n h i l l (1970) Lack of perceived need to change Staff h o s t i l i t y I n a b i l i t y of new idea to f u l f i l l expectations Davies (1972) Lack of opportunity to p r a c t i c e Lack of feedback to r e i n f o r c e new s k i l l s Behaviour change not expected by supervisor Wolfe & Moe (1973) Lack of supervisor i n t e r e s t Lack of motivation to learn and apply new s k i l l s F l e i s c h e r (1974) Shortage of equipment Inappropriate performance standards F a c i l i t a t o r s Hammett, Bashook & Sandlow (1976) Increased knowledge Fernow, McColl, Mackie & Rendall (1977) Increased knowledge Peer support Favourable attitudes toward new idea Steckel (1976) Time o f f F l e x i b l e work assignments Recognition C l e a r l y defined performance standards Chapter 3 DESIGN AND RATIONALE FOR THE STUDY In the previous chapter several theories, models and p r a c t i c a l approaches to employee performance and performance change were reviewed. From that body of l i t e r a t u r e a framework for conceptualizing planned change i n the work-setting and several p o t e n t i a l b a r r i e r s and f a c i l i t a t o r s to change were i d e n t i f i e d . This chapter describes the conceptual frame-work used i n t h i s study to understand and explain employee performance change i n health-care agencies. * In addition, i t includes descriptions, d e f i n i t i o n s and measurements of the va r i a b l e s , the hypotheses to be tested and the procedures of the study. THE CONCEPTUAL FRAMEWORK Current understanding of human behaviour suggests that man i s an independent organism always surrounded by an environment with which he continously i n t e r a c t s . His behaviour at any given moment of time i s a function of i n t e r a c t i o n between himself and h i s environment (Lewin, 1938). Performance of a task i s one type of behaviour, consequently performance i s also a r e s u l t of an i n t e r a c t i o n between the performer and the s e t t i n g i n which the performance takes place. Based on t h i s , t h i s study proceeds on the understanding that a deliberate attempt to change an i n d i v i d u a l ' s performance requires changes to occur i n either the person, h i s environment, or some combination of both. 38 39 The Process of Change Change, by d e f i n i t i o n , i s a diff e r e n c e between two states; thus, a conceptual framework for understanding employee performance change should r e f l e c t the dynamic nature of the change process. One model that meets t h i s requirement i s Lewin's (1947) model of the process of change. This model, gr a p h i c a l l y depicted i n Figure 4, portrays change as a three-stage process (unfreezing, moving and refreezing) which i s governed by modifying the d r i v i n g and r e s t r a i n i n g forces. Lewin (1947) proposes that an e x i s t i n g l e v e l of performance i s maintained by a v a r i e t y of factors that are i n a state of balance. Those factors a r i s e from within the person and the environment. A del i b e r a t e attempt to increase performance l e v e l s involves a l t e r i n g the balance between the forces. This i s achieved by adding a new d r i v i n g force or strengthening an e x i s t i n g one. A s i m i l a r r e s u l t can be achieved by reducing the number or strength of the r e s t r a i n i n g forces. Upsetting the balance of forces w i l l allow the performance l e v e l to r i s e to a point where the forces are again i n balance. To maintain, or refreeze, the newly acquired performance l e v e l the balance between the forces must be s t a b i l i z e d . If s t a b i l i t y i s not achieved performance w i l l decline toward i t s previous l e v e l . When t h i s occurs the change attempt has been unsuccessful. Driving and Restraining Forces Dr i v i n g and r e s t r a i n i n g forces are key.concepts i n Lewin's model of planned change. As th e i r names imply, d r i v i n g forces are those which encourage change and r e s t r a i n i n g forces are those which hinder change. Obviously, an understanding of both types of forces i s a primary task of persons attempting to change a s p e c i f i c performance i n a given s e t t i n g . From the t h e o r e t i c a l and empirical l i t e r a t u r e reviewed, several concepts 40 REFREEZING RESTRAINING FORCES / I " PERFORMANCE UNFREEZING PRESENT J LEVEL OF • PERFORMANCE 4 DRIVING FORCES Figure 4 Levin's Model of the Process of Change appear to act either singly or combined to f a c i l i t a t e or hinder performance change among health-care professionals. These include the knowledge and motivation possessed by the performer, and the performance standards, resources and reinforcers provided by the organization. Knowledge. Possessing the necessary knowledge or s k i l l i s an obvious requirement for job performance. No matter how motivated a person i s or how suitable he appears to be for the job, he w i l l be unable to carry out the necessary actions without the required knowledge or s k i l l . Organizations recognize this when they stipulate an employee must have the appropriate qualifications for his job. Organizations also recognize that an employee may need additional knowledge or s k i l l when a new task i s introduced into his job or an existing task is extensively revised. They acknowledge the need for additional information by providing training and inservice education programs. In fact, in-house education programs are the major strategy used by organizations to help employees meet new performance requirements (Cummings & Schwab, 1973). Such programs a r e i n t e n d e d t o h e l p p a r t i c i -p a n ts overcome knowledge or s k i l l d e f i c i t s r e s u l t i n g from t a s k changes. Whether the program f o c u s e s on knowledge or on s k i l l depends on the n a t u r e of the new o r r e v i s e d t a s k . I f i t i s p r i m a r i l y a c o g n i t i v e t a s k as i t i s i n t h i s study, the f o c u s i s on knowledge. Thus i t appears t h a t , o r g a n i z a -t i o n s c o n s i d e r knowledge to be an i m p o r t a n t p a r t of new t a s k performance and they a t t e s t to i t s importance by p r o v i d i n g s t a f f w i t h o p p o r t u n i t i e s t o i n c r e a s e t h e i r e x i s t i n g knowledge. Based on t h e f o r e g o i n g , i t was assumed i n t h i s study t h a t knowledge i s a d e t e r m i n a n t of performance and, as such, i t i s one o f t h e d r i v i n g f o r c e s s u p p o r t i n g an e x i s t i n g l e v e l o f performance. Furthermore, i t was expected t h a t an i n c r e a s e i n t h i s d r i v i n g f o r c e would h e l p employees move t h e i r performance of an e x t e n s i v e l y r e v i s e d t a s k from an e x i s t i n g l e v e l to a new l e v e l . M o t i v a t i o n to change. M o t i v a t i o n t o change i s another f o r c e t h a t appears to be an important c o n t r i b u t o r t o the p r o c e s s of change. I t i s g e n e r a l l y agreed t h a t an employee must p o s s e s s some m o t i v a t i o n or i n t e r n a l " d r i v e " t o c a r r y out t h e r e q u i r e m e n t s o f h i s j o b . Thus, i t seems r e a s o n -a b l e t o c o n s i d e r m o t i v a t i o n as an e s s e n t i a l component of performance change. I t i s , however, d i f f i c u l t t o determine p r e c i s e l y from the m o t i v a t i o n l i t e r a t u r e which i n t e r n a l and e x t e r n a l events a r e more l i k e l y to a s s i s t changes i n performance l e v e l s as each t h e o r e t i c a l f o r m u l a t i o n approaches m o t i v a t i o n from a d i f f e r e n t p e r s p e c t i v e . T h i s d i f f i c u l t y may be overcome to some e x t e n t by examining r e p o r t s of d e l i b e r a t e attempts to change employee performance. S e v e r a l r e p o r t s , suggest t h a t an employee's p e r c e i v e d need c o n s t i t u t e s a m o t i v a t i o n a l f o r c e i n a change s i t u a t i o n . The r a t i o n a l e f o r assuming t h i s form of l i n k a g e i s 42 s u c c i n c t l y explicated by Leagans (1964) i n his attempt to b u i l d a f u n c t i o n a l concept of need. He states: (1) Needs represent an imbalance, lack of adjustment, or gap between the present s i t u a t i o n or status quo and a new or changed set of conditions assumed to be more desirable. (2) People's needs are i d e n t i f i e d by f i n d i n g the a c t u a l , the possible, and the valuable through s i t u a t i o n a l a n a l y s i s . (3) People have to recognize the gap between the ac t u a l , the possible, and the desirable, and place value on a t t a i n i n g the desirable before they become motivated to change. (Leagans, 1964, pp. 92-93) As well as describing the l i n k between motivation to change and perceived need, t h i s explanation suggests several ways to conceptualize an employee's motivation to change h i s performance. One concept i s "gap," that i s , an i n d i v i d u a l ' s awareness of a discrepancy between what i s and what should be. A second concept i s "importance." This r e f e r s to the value a person places on the attempted change. Importance may be p a r t i c u -l a r l y c r u c i a l when change i s introduced through some form of external mandate. A t h i r d concept, which may be l a b e l l e d "impetus," i s the combined e f f e c t s of gap and importance. The complex int e r a c t i o n s of perceptions involved i n motivation suggest that impetus may r e f l e c t a d i f f e r e n t aspect than that of i t s two constituent parts. Based on the foregoing r a t i o n a l e , i t was assumed i n t h i s study that motivation i s a determinant of performance and, as such, i t i s one of the d r i v i n g forces supporting an e x i s t i n g l e v e l of performance. Motivation to change was considered l i k e l y to be one of the forces influencing perfor-mance change. Moreover, i t was recognized that motivation to change may be composed of several i n d i v i d u a l elements which act either s i n g l y or i n combination to "push" performance l e v e l s up. A perceived discrepancy between what exi s t s and what should or might e x i s t i s a l i k e l y element and 43 another i s the importance attached to some future state. Thus, i t was expected that the presence of a motivation to change would contribute to r a i s i n g an employee's performance of a new or revised task. Performance standards. In addition to such personal a t t r i b u t e s as motivation to change and increased knowledge, reports of attempts to implement change frequently i d e n t i f y b a r r i e r s and f a c i l i t a t o r s to perfor-mance change that e x i s t i n the organizational s e t t i n g . Performance standards are thought :to be one important s i t u a t i o n a l factor that can either help or hinder employee performance change. If standards are present they probably help the change process; i f they are absent they probably act as a source of interference. Performance standards encompass a l l the d i r e c t i v e s a v a i l a b l e to the performer that specify expected l e v e l s of correct performance. The impor-tant point here i s that employees kriow what the standards and c r i t e r i a are. When they exist only i n the supervisor's head employees have to guess what they are and t h i s leads to uncertainty and confusion. It seems that an i d e a l s i t u a t i o n would exist when guidelines describing actions to be taken, procedures to be followed and standards to be met are av a i l a b l e i n written form to a l l employees. It was assumed i n t h i s study that performance standards contribute to employee performance and that the extent to which they are present or absent determines t h e i r status as either a d r i v i n g or re s t r a i n i n g force. Lack of written standards f o r a new task i s a res-s t r a i n i n g force and presence of such guidelines i s a d r i v i n g force. As performance standards were not present p r i o r to t h i s study, they were considered to be a r e s t r a i n i n g force. It was anticipated that provision of written standards would change t h e i r status to a d r i v i n g force. Resources. Resources are another s i t u a t i o n a l factor that has been 44 linked with the success or f a i l u r e of performance change i n a work-setting. And l i k e performance standards, the extent to which they are a v a i l a b l e determines whether they are classed as p o t e n t i a l b a r r i e r s or f a c i l i t a t o r s . Two resources appear to be important; they are materials and time. The type of materials necessary for performance and performance change obviously depends on the s p e c i f i c task. Books and printed matter were necessary materials f o r implementing the " c a t a l y t i c teaching r o l e " i n the Gross et a l . (1971) study, whereas a new drug-console unit and new drug reporting cards were e s s e n t i a l pieces of equipment i n an attempt to i n t r o -duce a new drug-dispensing method (Coe & B a r n h i l l , 1970). In the teacher-r o l e study, lack of materials was c i t e d as an obstacle to change; i n the drug-dispensing study the presence of the necessary equipment was thought to help the change process. The contribution of time to performance change seems to have been overlooked i n many change attempts, yet i t i s l i s t e d as a p o t e n t i a l source of task interference i n the performance audit model (Rummler, 1972). Its i n c l u s i o n appears to be reasonable because employees need a d d i t i o n a l time to carry out new or revised tasks. The extra time i s needed to "unlearn" old patterns and replace them with new ones. The time factor may be p a r t i c u l a r l y c r i t i c a l when employees f e e l t h e i r work schedules are already f u l l . This i s often the case i n health-care agencies. An assumption was made i n t h i s study that resources such as time and materials contribute to employee performance and that an ex i s t i n g l e v e l of performance i s maintained, i n part, by resources acting as a r e s t r a i n i n g force. An increase i n a v a i l a b i l i t y r e s u l t s i n a reduction of the r e s t r a i n i n g forces. As no attempt was made i n t h i s study to a l t e r work schedules i t was expected that resources would remain constant throughout the change process. 45-: Reinforcers. Reinforcers are the t h i r d and f i n a l o r g a n i z a t i o n a l -r e l a t e d factor included i n t h i s study. Reinforcers are those actions and events s p e c i f i c a l l y directed at the performer as he attempts to carry out the new task. Any member of the organization i s a p o t e n t i a l source of r e i n f o r c e r s but the persons considered more l i k e l y to be important sources are the employee's supervisor and members of h i s immediate work group. Reinforcing events and actions that appear to be important to health-care professionals include praise, encouragement, recognition and i n d i c a t i o n s of improvement i n professional status. It was assumed i n t h i s study that r e i n f o r c e r s are an e s s e n t i a l component of employee performance and an e x i s t i n g l e v e l of task performance i s maintained, i n part, by r e i n f o r c e r s acting as a r e s t r a i n i n g force. Thus, an improvement i n r e i n f o r c e r s constitutes a weakened r e s t r a i n i n g force. Forces Promoting I n i t i a l Change Implementation of change i s a three-stage process: (1) unfreezing an e x i s t i n g l e v e l of performance, (2) moving to a new l e v e l , and (3) refreezing at the new l e v e l . Inservice education i s one of the major' strategies used i n health-care agencies to help s t a f f unfreeze t h e i r e x i s t i n g l e v e l of task performance and move to a new l e v e l . An i n s e r v i c e educator's approach to performance change i s t h e o r e t i c a l l y sound, insofar as i t aims to promote i n i t i a l change i n per-formance l e v e l s . A successful educational a c t i v i t y , that i s , one r e s u l t i n g i n p a r t i c i p a n t s being more knowledgeable and more aware of the need to change, disturbs the balance of forces impinging on e x i s t i n g performance l e v e l s . Therefore, i t should provide s u f f i c i e n t impetus to move perfor-mance l e v e l s up despite the s i t u a t i o n a l b a r r i e r s that might continue to e x i s t . 46 At the p r e s e n t time, f o r m a l r e s e a r c h t e s t i n g t h i s assumption among p r o f e s s i o n a l s employed i n h e a l t h - c a r e a g e n c i e s i s s c a r c e . The p a u c i t y o f s t u d i e s i s p r o b a b l y due, i n p a r t , to the l o g i s t i c a l problems a s s o c i a t e d w i t h o b s e r v i n g and measuring a c t u a l performance o n - t h e - j o b . Those problems ar e p a r t i c u l a r l y d i f f i c u l t t o overcome when the performance under i n v e s t i -g a t i o n i n v o l v e s d i r e c t c a r e o f p a t i e n t s . There a r e , however, some t a s k s i n a h e a l t h - c a r e p r o f e s s i o n a l ' s d a i l y work t h a t do not i n v o l v e d i r e c t p a t i e n t c a r e , f o r example, k e e p i n g r e c o r d s , and those a c t i v i t i e s may be used to t e s t the e f f e c t s o f changing the d r i v i n g f o r c e s on i n i t i a l change i n performance l e v e l s . T h i s study used r e c o r d - k e e p i n g p r a c t i c e s to t e s t r e l a t i o n s h i p s among changes i n 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 , and a c q u i s i t i o n o f new performance l e v e l s . I t was h y p o t h e s i z e d t h a t a c q u i s i t i o n o f r e c o r d i n g b e h a v i o u r would be more c l o s e l y l i n k e d to the p r e s e n c e o f a m o t i v a t i o n to change, i n c r e a s e i n knowledge about t h e t a s k and the p r e s e n c e o f performance s t a n d a r d s t h a n to the a v a i l a b i l i t y of r e s o u r c e s and r e i n f o r c e r s f o r p r o p e r r e c o r d i n g . Those r e l a t i o n s h i p s a r e s c h e m a t i c a l l y r e p r e s e n t e d i n F i g u r e 5. F o r c e s Promoting Maintenance of Change Another c r i t i c a l d i m e n s i o n o f change i s the maintenance o r r e f r e e z i n g of new performance l e v e l s . C o n v e n t i o n a l i n s e r v i c e e d u c a t i o n programs do n o t appear t o make adequate p r o v i s i o n f o r t h e maintenance o f newly a c q u i r e d performance l e v e l s . As was p o i n t e d out p r e v i o u s l y , i n s e r v i c e e d u c a t o r s c o n c e n t r a t e on i n d u c i n g change i n the p e r s o n and tend to i g n o r e s i t u a t i o n a l events t h a t might be working a g a i n s t change. T h i s l i m i t e d approach appears t o be c r i t i c a l i n t h e maintenance phase where performance i s s u s c e p t i b l e t o a l l f o r c e s , b o t h p e r s o n a l and s i t u a t i o n a l . S u p e r v i s o r s u s u a l l y respond t o d e c l i n i n g performance l e v e l s among Figure 5 I n i t i a l Change of Recording Behaviour their staff by ordering more inservice education. Implicit in this response is a belief that loss of performance is primarily caused by loss of knowledge. This leads to the notion that the decline can be halted and reversed by giving the staff a refresher course. This belief and i t s response is not theoretically sound for at least two reasons. F i r s t , studies on rates of retention show that adults do not lose a significant amount of knowledge over a period of several months. And second, the Lewinian model of planned change posits that establishing a new balance of forces is the crucial determinant in maintaining a newly acquired performance level. Thus i t seems that, focusing on knowledge and ignoring other forces is an inappropriate response to correcting a decline in performance. Again, a lack of formal research relating to long term performance change in health-care agencies makes i t d i f f i c u l t to determine whether performance declines and, i f i t does, which forces are responsible for the decline. This study addressed those issues by testing relationships among changes in driving and restraining forces and maintenance of a newly acquired performance level. It was hypothesized that maintenance of record-ing behaviour would be more closely linked to the ava i l a b i l i t y of resources and reinforcers for proper recording and the presence of performance standards than to loss of knowledge and the presence of a motivation to change. Those relationships are schematically represented in Figure 6. TO m O O C TO n m o N E W LEVEL — O F P O R A O < > o z z o !* I— m O m o TO n m TO CO CO ~D —i m TO >• D > O Z n m CO o c TO o m O TO m o TO n m TO CO CO TO Z " " o O >*? TO ^ C o z n m iOTI z o < > • r— m O :DGE z :DGE • SUBSEQUENT LEVEL O F P O R Figure 6 Subsequent Change of Recording Behaviour THE VARIABLES AND THEIR MEASUREMENT This study was concerned with change of behaviour and i t s r e l a t i o n -ship to change of selected organizational and personal forces. Two phases of the change process were examined:, a c q u i s i t i o n of a new performance and maintenance of that new performance. The a c q u i s i t i o n phase covered the f i r s t month following the introduction of a new task, Problem Oriented Recording (POR) and the maintenance phase covered the following three months. The knowledge required to perform POR was presented i n an i n s e r v i c e education program. This section explains the v a r i a b l e s used to investigate the r e l a t i o n s h i p s among changes i n performance l e v e l s and changes i n the designated d r i v i n g and r e s t r a i n i n g forces. The Variables Two dependent v a r i a b l e s , a c q u i s i t i o n and maintenance of recording behaviour, and eleven variables associated with knowledge, motivation to change, performance standards, resources and r e i n f o r c e r s are described and defined i n the following paragraphs. Variables of recording behaviour. The c r i t i c a l and dependent variables were performance change, namely the a c q u i s i t i o n and maintenance of a new recording behaviour. The new recording behaviour was Problem Oriented Recording (POR) and the p a r t i c i p a n t s were physiotherapists (PTs) and occupational therapists (QTs). Recording behaviour r e f e r s to the format used by PTs and OTs to document t h e i r day-by-day int e r a c t i o n s with patients. This documentation i s entered into the PT/OT section of the patient-care record. A c q u i s i t i o n of recording behaviour r e f e r s to the change i n adherence to POR format observed before and immediately a f t e r the introduction of POR. I t was defined as the regression r e s i d u a l score obtained from a : 50 random sample for each PT/OT pa r t i c i p a n t of four of her patient-care records completed during the month preceding introduction of POR and a d i f f e r e n t set of four records completed during the month following introduction of POR. (An explanation of a regression r e s i d u a l score i s included i n Appendix A.) Maintenance of recording r e f e r s to the change i n adherence to POR format observed over three months. It was defined as the regression r e s i d u a l score obtained from a random sample of four records for each PT/OT pa r t i c i p a n t completed during the month immediately following i n t r o -duction of POR and a d i f f e r e n t set of records completed during the fourth month following introduction of POR. To permit a more de t a i l e d examination of changes i n recording behavior, the PT/OT record was sub-divided into the following f i v e components: data base, problem focus, treatment plan, follow-up and documentation. An a c q u i s i t i o n and maintenance score was obtained for each of those components. Knowledge v a r i a b l e s . Knowledge r e f e r s to the f a c t u a l knowledge possessed by the p a r t i c i p a n t s concerning recording p o l i c i e s , p r i n c i p l e s , procedure and format. Knowledge about record-keeping f a l l s into two categories, general and s p e c i f i c . The general knowledge category contains information dealing with the p r i n c i p l e s , p o l i c i e s and functions of any kind of patient-care recording, while the s p e c i f i c category contains i n f o r -mation r e l a t i n g to the format, terms and a p p l i c a t i o n of POR. Both types of knowledge were included i n t h i s i n v e s t i g a t i o n . Each knowledge v a r i a b l e was a change v a r i a b l e , namely a c q u i s i t i o n of general and s p e c i f i c knowledge, and retention of general and s p e c i f i c knowledge. A c q u i s i t i o n was the change observed before and one month a f t e r 51 the i n s e r v i c e program. It was defined as the regression r e s i d u a l score obtained from pretest versus posttest measures taken at the beginning of the i n s e r v i c e program and four weeks post-program. Retention was the change observed over three months. It was defined as the regression r e s i d u a l score obtained from posttest versus delayed posttest measures taken four weeks post-program and 18 weeks post-program. Motivation v a r i a b l e s . Motivation to change r e f e r s to the i n d i v i d u a l ' s perceptions of the need for change and the importance placed on the new performance. The motivation to change v a r i a b l e s , and the three v a r i a b l e s concerned with s i t u a t i o n a l factors which follow, are defined d i f f e r e n t l y from the preceding variables i n that they are concerned with p a r t i c i p a n t s ' perceptions of things and events, whereas the former are based on observable events. Four v a r i a b l e s representing d i f f e r e n t aspects of motivation to change were used. Two, l a b e l l e d "gap" and "leeway," were concerned with perceived discrepancies i n record-keeping, a t h i r d , l a b e l l e d "importance," re f e r r e d to the perceived importance attached to the objectives of an " i d e a l " record, and a fourth one, "impetus," was a combination of gap and importance. Those four variables were defined as follows: gap was the per-ceived dif f e r e n c e between the present recording system and how i t should be; leeway was the perceived estimated discrepancy between previous record-keeping practices i n the PT/OT department and expected p r a c t i c e s ; importance was the perceived importance of an " i d e a l " record; and impetus was a need to change generated by the combined e f f e c t s of gap and importance. Performance standards. Performance standards are the written guide-l i n e s describing c r i t e r i a and requirements for correct record-keeping. In t h i s study, the performance standards were contained i n a manual which was d i s t r i b u t e d to each therapist during the i n s e r v i c e program. The performance standards v a r i a b l e was defined as the extent to which a therapist perceived the p o l i c i e s and procedures for record-keeping to be c l e a r l y defined, r e a l i s t i c and understandable. I n i t i a l change i n t h i s v a r i a b l e was the change i n perceptions during the a c q u i s i t i o n of POR and subsequent change was the change i n perceptions during the maintenance phase. Resources• Resources are the materials and time a v a i l a b l e to per-form the new task. The resources v a r i a b l e was defined as the extent to which a therapist perceived resources for proper record-keeping to be a v a i l a b l e . I n i t i a l and subsequent changes i n resources were the changes i n perceptions during the a c q u i s i t i o n and maintenance phases r e s p e c t i v e l y . Reinforcers. Reinforcers are the events and actions that r e i n f o r c e an i n d i v i d u a l ' s attempt to record i n the required format. The r e i n f o r c e r s v a r i a b l e was defined as the extent to which a therapist perceived r e i n -forcers for proper recording to be present. I n i t i a l and subsequent changes i n r e i n f o r c e r s were the changes during the a c q u i s i t i o n and maintenance phases r e s p e c t i v e l y . Measurement of the Variables The s i x major sets of v a r i a b l e s , that i s , recording behaviour, knowledge, motivation to change, performance standards, resources and r e i n f o r c e r s , were measured by four s p e c i a l l y constructed instruments. A d e t a i l e d d e s c r i p t i o n of those instruments and t h e i r development i s presented i n Chapter 4 . This sub-section describes how each v a r i a b l e was measured on those instruments. Recording behaviour was measured on the Format Audit Review Sheet 53 (FRAS), a 23-item, present or absent c h e c k - l i s t which provided measures for each of f i v e components of the PT/OT record and a composite measure for the whole PT/OT record. A recording behaviour score was obtained by summing the number of items present i n four records randomly selected from a l l records completed by each therapist over a s p e c i f i e d time period. This procedure was c a r r i e d out on three d i f f e r e n t occasions to obtain a c q u i s i -t i o n and maintenance recording behaviour scores for each component of the record. Knowledge was measured on the C l i n i c a l Record-Keeping Inventory (CRKI), a paper and p e n c i l r e c a l l test containing 20 items grouped into 13 questions; 10 items related to general recording knowledge and 10 items to s p e c i f i c POR knowledge. The scoring system was two points f or a wholly correct answer, one point f or a p a r t i a l l y correct answer and zero for an incor r e c t or omitted answer. A score for s p e c i f i c and general knowledge was obtained by summing the points f or each subset of items. The CRKI was administered three times to obtain scores for a c q u i s i t i o n and retention of both types of knowledge. The four motivation to change variables were measured on the Record-ing Needs Survey (RNS), an instrument with a 6-point, Likert-type response scale. The RNS consisted of two sets of items; one set measured leeway and the other measured gap and importance. The fourth v a r i a b l e , impetus, was a hypothetical construct derived from gap and importance. Gap was calculated from responses given to seven statements describing the objects of an " i d e a l " record. P a r t i c i p a n t s indicated how true each statement was at the present time and how true i t should be; gap was the diffe r e n c e between those two responses. Importance was the summed responses to seven statements describing the " i d e a l " record. Leeway was the d i f f e r e n c e between two estimates 54 of record-keeping effectiveness: (1) the percentage of records in a department that the staff f e l t actually contained a factual record of patient-care, and (2) the percentage of records that could be reasonably expected to contain this information. Impetus was a resultant Euclidean vector of gap and importance. The derivation of this vector is shown in Figure 7. The performance standards, resources and reinforcers variables were measured on the Recording Opinions Survey (ROS), a 30-item instrument with a 5-point, Likert-type response scale. Items for each variable were randomly placed throughout the instrument. The ROS was administered three times to obtain measures of change in perceptions of each variable. A performance standards score was obtained by summing the responses to eight items (performance standards subset). A high score indicated standards were perceived as being more clearly defined. IMPORTANCE (Response Scale Units) Figure 7 Derivation of Impetus Variable 55 The r e s o u r c e s subset a l s o c o n t a i n e d e i g h t i t e m s , and a r e s o u r c e s s c o r e was o b t a i n e d by summing the r e s p o n s e s t o those i t e m s . A h i g h s c o r e i n d i c a t e d r e s o u r c e s were p e r c e i v e d as b e i n g r e a d i l y a v a i l a b l e . The r e i n f o r c e r s v a r i a b l e was measured by a 14-item subset on the ROS. A s c o r e was o b t a i n e d by summing the r e s p o n s e s to those i t e m s . A h i g h s c o r e i n d i c a t e d r e i n f o r c e r s were p e r c e i v e d as b e i n g p r e s e n t . THE HYPOTHESES At t h i s p o i n t , i t i s a p p r o p r i a t e to r e - s t a t e the g e n e r a l hypotheses which were drawn from t h e c o n c e p t u a l framework and p r e s e n t the r e s e a r c h hypotheses proposed f o r i n v e s t i g a t i o n . Two g e n e r a l hypotheses were f o r m u l a t e d . They were: (1) a c q u i s i t i o n of r e c o r d i n g b e h a v i o u r would be more c l o s e l y l i n k e d t o m o t i v a t i o n to change, i n c r e a s e i n knowledge and p r e s e n c e of performance s t a n d a r d s than to r e s o u r c e s and r e i n f o r c e r s f o r p r o p e r r e c o r d i n g ; and (2) maintenance of r e c o r d i n g would be more c l o s e l y l i n k e d t o t h e p r e s e n c e o f performance s t a n d a r d s , r e s o u r c e s and r e i n f o r c e r s than to l o s s o f knowledge and m o t i v a -t i o n t o change. For the purposes of s t a t i s t i c a l t e s t i n g the g e n e r a l hypotheses were r e - c a s t i n o p e r a t i o n a l form. In each h y p o t h e s i s , the v a r i a b l e s were grouped i n t o a p r i m a r y subset which c o n s i s t e d of the v a r i a b l e s e x p e c t e d to account f o r most change i n the dependent v a r i a b l e , and a secondary subset c o n t a i n i n g the v a r i a b l e s expected to account f o r l e a s t change. The r e l a t i o n s h i p between these two s e t s was e x p r e s s e d as the v a r i a n c e accounted f o r by adding the secondary s u b s e t . The r e s e a r c h hypotheses proposed f o r i n v e s t i g a t i o n were s t a t e d as f o l l o w s : (1) the a d d i t i o n a l v a r i a n c e i n a c q u i s i t i o n of r e c o r d i n g b e h a v i o u r 56 a c c o u n t e d f o r by r e s o u r c e s and r e i n f o r c e r s (secondary s u b s e t ) would n o t s i g n i f i c a n t l y i n c r e a s e the v a r i a n c e accounted f o r by i n c r e a s e i n know-l e d g e , m o t i v a t i o n to change and pr e s e n c e o f performance s t a n d a r d s ( p r i m a r y s u b s e t ) ; and (2) the a d d i t i o n a l v a r i a n c e i n maintenance o f r e c o r d i n g b e h a v i o u r accounted f o r by r e t e n t i o n o f knowledge and m o t i v a t i o n to change (secondary s u b s e t ) would n o t s i g n i f i c a n t l y i n c r e a s e t h e v a r i a n c e accounted f o r by the pr e s e n c e of performance s t a n d a r d s , r e s o u r c e s and r e i n f o r c e r s ( p r i m a r y s u b s e t ) . Each h y p o t h e s i s was t e s t e d f o r s i g n i f i c a n c e w i t h an a l p h a l e v e l e q u a l t o .05. The f o r m u l a used f o r t e s t i n g t h e hypotheses i s i n c l u d e d i n Appendix B. PROCEDURES T h i s s e c t i o n d e s c r i b e s t h e s e t t i n g , the p a r t i c i p a n t s , the phases of the stu d y and d a t a c o l l e c t i o n . I t c o n c l u d e s w i t h a d e s c r i p t i o n o f t h e a n a l y s i s o f d a t a . The S e t t i n g and P a r t i c i p a n t s The s t u d y was conducted i n f o u r p h y s i o t h e r a p y (PT) and two o c c u p a t i o n a l t h e r a p y (OT) departments l o c a t e d i n f o u r h o s p i t a l s i n t h e G r e a t e r Vancouver a r e a . A l l departments were u s i n g t r a d i t i o n a l r e c o r d i n g methods b e f o r e the p r o j e c t s t a r t e d . In each department the s u p e r v i s o r o f PT and OT had i n v e s t i g a t e d t h e u s e f u l n e s s o f POR and made t h e d e c i s i o n t o r e p l a c e her e x i s t i n g r e c o r d i n g methods w i t h POR. P e r m i s s i o n to c a r r y out the s t u d y , which i n c l u d e d examining p a t i e n t -c a r e r e c o r d s , was g r a n t e d by each h o s p i t a l a d m i n i s t r a t o r , and a C e r t i f i c a t e o f A p p r o v a l f o r Research I n v o l v i n g Human Subjects.was i s s u e d t o the i n v e s t i g a t o r by t h e B e h a v i o u r a l S c i e n c e s S c r e e n i n g Committee, U n i v e r s i t y of B r i t i s h Columbia. 57 Sixty-two therapists p a r t i c i p a t e d i n the study; 11 were occupational therapists and 51 were physiotherapists. This sample i s approximately 5% of the PT and OT population of B r i t i s h Columbia. Within the sample there were two males, both physiotherapists. D i s t r i b u t i o n of therapists by h o s p i t a l and department i s shown i n Table 4. With the exception of three persons, a l l s t a f f were employed on a permanent f u l l - t i m e b a s i s . The exceptions were three r e l i e f ' s t a f f who were working f u l l - t i m e s h i f t s throughout the duration of the project. Part-time employees, casual r e l i e f , s t a f f and therapists assigned to Extended Care Units (ECU) were not included i n the sample for the following reasons. Part-time and r e l i e f s t a f f were excluded because t h e i r terms of employment did not extend throughout the entire study. ECU s t a f f were not included because the records kept i n those units were not compatible with the recording system devised f o r the regular PT and OT departments. Table 4 Location of Pa r t i c i p a n t s Physio- Occupational Hospital t h e r a p i s t s Therapists Burnaby General 7 0 Shaughnessy 12 4 St. Paul's 16 0 Lions Gate L6 _7_ TOTAL 51 11 58 The majority of the p a r t i c i p a n t s had received t h e i r professional education i n either Canada (40%) or the United Kingdom (42%) . The remainder had graduated from PT or OT educational programs i n India, New Zealand, A u s t r a l i a , Europe and the United States. The d i s t r i b u t i o n of therapists by country of graduation i s shown i n Table 5. The average length of time since graduation was 10 years with a standard deviation of 8.1 years. Inspection of the data i n Table 6 shows t h i s mean value does not r e f l e c t the average therapist i n the sample as j u s t over h a l f of them (32) had been graduated le s s than 10 years. A median value of 8.2 years conveys a more r e a l i s t i c p i c t u r e of the t y p i c a l p a r t i c i p a n t . Table 5 D i s t r i b u t i o n of Therapists by Country of Graduation Country of Graduation United Kingdom Canada India Europe New Zealand A u s t r a l i a United States Number of Therapists 26 25 7 2 2 1 1 Relative frequency (%) 41.9 40.3 8.1 3.2 3.2 1.6 1.6 Cummulative frequency (%) 41.9 82.3 90.4 93.6 96.8 98.4 100.0 TOTAL 62 100.0 100.0 59 T a b l e 6 D i s t r i b u t i o n of T h e r a p i s t s A c c o r d i n g to Number of Y e a r s S i n c e G r a d u a t i o n Y e a r s s i n c e G r a d u a t i o n Number of T h e r a p i s t s R e l a t i v e f r e q u e n c y (%) Cummulative f r e q u e n c y (%) 1 - 3 14 22.7 22.7 4 - 6 13 20.9 43.6 7 - 9 5 8.0 51.6 10 - 12 15 24.2 75.8 13 - 15 3 4.8 80.6 16 - 18 3 4.8 85.4 19 - 21 2 3.2 88.6 22 - 24 3 4.8 93.4 25 or more 4 6.4 100.00 Note: Mean = 10.03 y e a r s , median = 8.2 y e a r s . The amount of time p a r t i c i p a n t s had worked i n t h e i r p r e s e n t h o s p i t a l was u n e v e n l y d i s t r i b u t e d through a range of one to 16 y e a r s . Over h a l f o f them (34) had been i n t h e i r p r e s e n t department f o r l e s s than 18 months; o n l y f i v e of the s t a f f (8%) had worked i n the same p l a c e f o r over f i v e y e a r s . A l l PT and OT departments i n the study o f f e r e d b o t h o u t p a t i e n t and i n p a t i e n t s e r v i c e s . E l e v e n t h e r a p i s t s spent the m a j o r i t y of t h e i r time t r e a t i n g o u t p a t i e n t s w h i l e 48 worked m a i n l y w i t h i n p a t i e n t s . Three of the s u p e r v i s o r s d i d not t r e a t p a t i e n t s . Phases of the Study and Data C o l l e c t i o n The i n v e s t i g a t i o n w a s - a l o n g i t u d i n a l , a n a l y t i c a l study u s i n g 60 i n d i v i d u a l PTs and OTs as the u n i t o f a n a l y s i s . The d e s i g n i n c l u d e d a p r e - , one month p o s t - and t h r e e months d e l a y e d p o s t t e s t i n g paradigm. Three d i m e n s i o n s , performance, knowledge and t a s k - r e l a t e d f o r c e s were measured a t each of those t h r e e s t a g e s . The m o t i v a t i o n a l d i m e n s i o n was measured i n the p r e - t e s t s t a g e o n l y . The i n s e r v i c e e d u c a t i o n program. An i n s e r v i c e e d u c a t i o n program d e a l i n g w i t h a l l a s p e c t s o f r e c o r d i n g , i n c l u d i n g t h e p o l i c i e s and p r o c e d u r e s e s t a b l i s h e d by t h e department s u p e r v i s o r s and t h e s p e c i f i c format o f POR, p r o v i d e d the i n s t r u c t i o n a l component of t h e study. The i n i t i a l l e a r n i n g e x p e r i e n c e c o n s i s t e d o f f i v e , one-hour s e s s i o n s h e l d on c o n s e c u t i v e days d u r i n g working h o u r s . S e s s i o n s were h e l d i n e i t h e r c o n f e r e n c e rooms or s m a l l a u d i t o r i u m s i n each h o s p i t a l i n an attempt to p r o v i d e a s u i t a b l e l e a r n i n g environment. A s i n g l e i n s t r u c t o r conducted a l l s e s s i o n s . The program was d e s i g n e d t o a l l o w a c t i v e p a r t i c i -p a t i o n o f the l e a r n e r s through d i s c u s s i o n and p r a c t i c e . D i d a c t i c i n s t r u c t i o n was used to p r e s e n t c o n c e p t s and p r i n c i p l e s o f POR. One month f o l l o w i n g t h i s i n t e n s i v e l e a r n i n g e x p e r i e n c e a one-hour s e s s i o n was h e l d i n each h o s p i t a l . The purpose o f t h i s f o l l o w - u p was t w o f o l d : (1) to c o l l e c t post-program d a t a , and (2) to a l l o w t h e r a -p i s t s an o p p o r t u n i t y t o d i s c u s s d i f f i c u l t i e s i n t h e i n t e r p r e t a t i o n o f POR format. No new m a t e r i a l or feedback was g i v e n a t t h i s time. A t h i r d s e s s i o n w i t h the same purpose was h e l d t h r e e months l a t e r . Data c o l l e c t i o n . The study extended over 6 1/2 months w i t h d a t a c o l l e c t i o n a t t h r e e p o i n t s i n time as can be seen i n F i g u r e 8. Data were c o l l e c t e d on f o u r socio-demographic c h a r a c t e r i s t i c s , m o t i v a t i o n to change, knowledge, r e c o r d i n g b e h a v i o u r , and p a r t i c i p a n t s ' p e r c e p t i o n s o f performance s t a n d a r d s , r e s o u r c e s and r e i n f o r c e r s . 61 D A T A C O L L E C T I O N Mot i va t i on K n o w l e d g e Resources Reinforcers S t a n d a r d s INSERVICE P R O G R A M ; D A T A COLLECT ION K n o w l e d g e Resources Reinforcers S t anda rds IRecord Audit J If Record |T^udit I I Record 0 1 2 3 4 5 6 7 8 9 10 11 21 22 23 24 25 26 W e e k f rom b e g i n n i n g of study in. e a ch hospi ta l Figure 8 Data Collection Socio-demographic information, including country of graduation, length of time since graduation, time employed in present hospital and type of patient service (inpatient or outpatient) was obtained from each participant at the beginning of the study. Data on four variables representing different aspects of motiva-tion to change were collected on the RNS. Therapists completed the RNS at the end of the introductory lecture on record-keeping. Knowledge data, both general and specific, were collected on the CRKI. This test was administered three times: (1) at the beginning of the inservice program (baseline), (2) one month later, and (3) after a further interval of three months. Data on recording behaviour, including the five components of POR format, were collected from three administrations of the FRAS. The D A T A COLLECT ION Mot iva t ion K n o w l e d g e Resources Reinforcers S t anda rds INSERVICE P R O G R A M D A T A COLLECT ION Know ledge Resources Reinforcers S t anda rds 11 21 22 23 24 25 26 W e e k from beg inn ing of study in each hospi ta l Figure 8 Data Collection Socio-demographic information, including country of graduation, length of time since graduation, time employed in present hospital and type of patient service (inpatient or outpatient) was obtained from each participant at the beginning of the study. Data on four variables representing different aspects of motiva-tion to change were collected on the RNS. Therapists completed the RNS a the end of the introductory lecture on record-keeping. Knowledge data, both general and specific, were collected on the CRKI. This test was administered three times: (1) at the beginning of the inservice program (baseline), (2) one month later, and (3) after a further interval of three months. Data on recording behaviour, including the five components of POR format, were collected from three administrations of the FRAS. The procedure used to c o l l e c t information was as follows. A l l patients d i s -charged during the month preceding the introduction of POR who had been treated for three or more days were l i s t e d according to therapist (62 l i s t s ) . From each l i s t , four patient-care records were randomly selected, obtained from the Medical Records department and audited. This process was repeated f o r a l l patients admitted and discharged during the s i x weeks immediately following the introduction of POR, and again for a s i x week period beginning four months a f t e r i t s introduction. Data on performance standards, resources and r e i n f o r c e r s were co l l e c t e d on the ROS. This instrument was administered to p a r t i c i p a n t s on three occasions: (1) at the beginning of the in s e r v i c e program, (2) one month l a t e r , and (3) a f t e r a further i n t e r v a l of three months. The Analysis of Data The data were analysed on the IBM 360 computer at the Uni v e r s i t y of B r i t i s h Columbia using the S t a t i s t i c a l Package for the S o c i a l Sciences (SPSS) program (Nie, H u l l , Jenkins, Steinbrenner & Bent, 1975). Demographic data were analysed by preparing one-way frequency d i s t r i b u t i o n s with d e s c r i p t i v e s t a t i s t i c s . The mean, standards deviation and range were calculated f o r a l l scores on the RNS, ROS, CRKI and FRAS. The s i g n i f i c a n c e of the gain, i n both knowledge and recording behaviour, between baseline and one month, and the s i g n i f i c a n c e of the loss between one and four months, were determined by t- t e s t s for paired c o r r e l a t i o n s (Guilford, 1965, p. 177). An alpha l e v e l equal to .05 was used to test f o r s i g n i f i c a n c e . Pearsonian c o r r e l a t i o n s were calculated for each subset of items on the RNS, ROS and FRAS. C o r r e l a t i o n c o e f f i c i e n t s f o r each subset of items on the RNS and FRAS were used to determine the degree of overlap between the s u b s e t s . M u l t i p l e r e g r e s s i o n a n a l y s i s was used to i n v e s t i g a t e t h e r e l a t i o n -s h i p s between r e c o r d i n g b e h a v i o u r change (dependent v a r i a b l e ) and the independent v a r i a b l e s . In a d d i t i o n to c a l c u l a t i n g the b e s t l i n e a r p r e -d i c t i o n e q u a t i o n , the r e g r e s s i o n program p r o v i d e d s t a t i s t i c s t h a t i n d i c a t e d (1) the r e l a t i v e s t r e n g t h of the r e l a t i o n s h i p , (2) the p r o p o r t i o n of v a r i a n c e i n the dependent v a r i a b l e e x p l a i n e d by t h e independent v a r i a b l e s ( c o e f f i c i e n t o f d e t e r m i n a t i o n ) , (3) the c o n t r i b u t i o n o f each v a r i a b l e t o the v a r i a t i o n i n the dependent v a r i a b l e , and (4) the i n f l u e n c e of each v a r i a b l e ( s t a n d a r d i z e d r e g r e s s i o n c o e f f i c i e n t s a l s o r e f e r r e d to as b e t a w e i g h t s ) . A g e n e r a l h i e r a r c h i c a l r e g r e s s i o n e q u a t i o n was used to t e s t the h y potheses. Chapter 4 INSTRUMENT DEVELOPMENT This study investigated r e l a t i o n s h i p s among: (1) a c q u i s i t i o n and maintenance of recording behaviour among physi c a l and occupational the r a p i s t s , (2) the i n d i v i d u a l ' s motivation to change h i s record-keeping p r a c t i c e s , (3) a c q u i s i t i o n and retention of new knowledge about POR and general p o l i c i e s and procedures for recording, and (4) selected task-related f a c t o r s . This chapter describes the development of the instruments to the v a r i a b l e s used i n the i n v e s t i g a t i o n . FORMAT REVIEW AUDIT SHEET A record audit i s the method most frequently used to monitor recording behaviour i n health-care agencies. Auditing records i s a r e l a t i v e l y new a c t i v i t y f o r therapists, consequently only a small number of audit forms are i n use. A s e l e c t i o n of audit forms was c o l l e c t e d from various sources but none was wholly su i t a b l e f o r t h i s study as they con-tained items which were not relevant or items which required subjective i n t e r p r e t a t i o n . Because of the lack of a su i t a b l e form, a Format Review Audit Sheet (FRAS) was developed. Three p r i n c i p l e s guided i t s construction: (1) the FRAS should r e f l e c t the concepts of POR by including items associated with data base, problem l i s t , treatment plan and progress notes, (2) a l l items must be objective, and (3) the items should p a r a l l e l the format s p e c i f i e d i n the departmental p o l i c y for record-keeping. The i n i t i a l version of the FRAS was developed and tested at the 64 U n i v e r s i t y Hospital, London, Ontario, where i t was used to audit over 100 records during a 15-month period. At the end of t h i s t e s t i n g , the audit form was judged to accurately r e f l e c t an i n d i v i d u a l ' s adherence to POR format by the Chief of Physiotherapy Services. The FRAS used i n the present study contains 23 items divided into f i v e components. The components are: (1) data base, (2) problem focus, (3) treatment plan, (4) follow-up, and (5) documentation. The d i s t r i b u t i o n of items i n those components i s outlined i n Table 7. The FRAS i s scored on a present or absent scale. A sample of the FRAS i s included i n Appendix C. CLINICAL RECORD-KEEPING INVENTORY The t h e r a p i s t s ' knowledge of recording procedures and POR format was measured by the C l i n i c a l Record-Keeping Inventory (CRKI), a paper and p e n c i l r e c a l l t e s t . As a suitable test did not previously e x i s t , a serie s of questions was'~ constructed and p i l o t - t e s t e d . Test items were generated from three sources: (1) the procedure manual for record-keeping adopted by each department, (2) guidelines f o r treatment and progress notes issued by the Canadian Physiotherapy Association (1976), and (3) standards f o r patient-care plans s p e c i f i e d i n the R e h a b i l i t a t i o n Services section of the Canadian Council Hospital A c c r e d i t a t i o n Manual (1977). F i f t e e n items were generated f o r the p i l o t t e s t , eight r e l a t i n g to general knowledge of recording p o l i c i e s and procedures, and seven r e l a t i n g to POR format. The CRKI underwent two separate p i l o t t e s t s . On the f i r s t occasion i t was administered to a group of 19 q u a l i f i e d therapists who were attending a U n i v e r s i t y c r e d i t course. This group completed the tes t twice, with one week between t e s t s , and received no i n s t r u c t i o n about record-keeping. Table 7 Format Review Audit Sheet Components and Items Component Item Possible score Data Base Problem Focus Treatment Plan Medical h i s t o r y S o c i a l h i s t o r y Physical findings Projected treatment Tot a l Data Base 16 Problem l i s t with: a) correct problem t i t l e s b) a l l problems numbered Problem number/title f o r : a) each treatment plan b) each progress Treatment plan for each problem Tot a l Problem Focus Frequency of treatment Duration of plan Expected response 20 Total Treatment Plan 12 Follow-up Documentation POR format (S.O.A.P.) used: a) i n one progress note b) i n a l l progress notes Discharge summary Diagnosis Source of r e f e r r a l Date of r e f e r r a l Patient i d e n t i f i c a t i o n on: a) assessment sheet b) a l l sheets A l l e n t r i e s : a) signed i n f u l l b) dated c) l e g i b l e T o t a l Follow-up 12 T o t a l Documentation 32 The mean scores (18.22 and 18.23) and standard deviations (7.93 and 7.92) showed v i r t u a l l y no change between the two t e s t s . Test-retest r e l i a b i l i t y for the t o t a l test was .90, with i n d i v i d u a l items ranging from .39 to 1.00. C o e f f i c i e n t alpha measures of r e l i a b i l i t y were .79 for the i n i t i a l test and .80 for the second t e s t . The second p i l o t t e s t of the CRKI was done to determine i t s s e n s i t i v i t y to r e f l e c t changes i n knowledge following i n s t r u c t i o n . It was administered twice to a new group of 25 p h y s i c a l and occupational therapy students who attended two, two-hour lectures on recording procedures and POR format as part of t h e i r course work. The CRKI was given before and immediately a f t e r the lectures which were spaced one week apart. Mean scores rose from 16.36 to 37.04 and standard deviations decreased from 5.80 to 3.88. The gain score was s i g n i f i c a n t at the .001 l e v e l of p r o b a b i l i t y . Data from both p i l o t t e s t s are presented i n Table 8. Table 8 Means and Standard Deviations for the C l i n i c a l Record-Keeping Inventory ( P i l o t Test) Group Pretest Mean S.D. Posttest Mean S.D. t a h t-prob Instruction 16.36 5.80 37.04 3.83 3.88 .001 (n = 25) No I n s t r u c t i o n 18.22 7.93 18.83 7.92 .61 .50 (n = 19) Note: Maximum possible score = 44. t - t e s t for differences between correlated p a i r s of means (Gui l f o r d , 1965, p. 184). t - p r o b a b i l i t y of .05 or le s s represents a gain s i g n i f i c a n t l y d i f f e r e n t from chance. 68 1. Two methods are presently used to c o l l e c t and organize information i n the medical record: a) Name both methods. b) B r i e f l y describe the main di f f e r e n c e between the two methods. 2. State the primary function of a medical record (exclude l e g a l use). 3. The information accumulated i n medical records can be used by health-care professionals for a c t i v i t i e s other than d i r e c t patient-care: State two a c t i v i t i e s . 4. The Canadian Hospital A c c r e d i t a t i o n Manual (1977) s p e c i f i e d a standard for a PT/OT patient-care plan: a) L i s t three components of a current care plan. b) L i s t three a d d i t i o n a l components which the Manual expects to be i n the completed record. 5. State the primary l e g a l requirement which must appear i n either the medical record or the P o l i c i e s and Procedures Manual for a l l patients receiving physiotherapy. 6. When an in-patient i s receiving PT/OT services where must the therapist's record of treatment be kept? 7. State the correct sequence of the four basic components of Problem Oriented Recording. 8. L i s t four types of information that must be included i n an i n i t i a l data base (as s p e c i f i e d i n the p o l i c y manual of t h i s department). 9. Problem Oriented Recording uses a unique format for w r i t i n g progress notes: a) L i s t the elements of a progress note i n t h e i r correct sequence. b) State the type of information entered i n each element. 10. L i s t four types of information that must be included i n a treatment plan (as s p e c i f i e d i n the p o l i c y manual of t h i s department). 11. L i s t s i x problem t i t l e s which would be appropriate f o r i n c l u s i o n i n a PT/OT problem l i s t . 12. Complete t h i s statement: Every PT/OT entry i n the medical record must be 13. Many ho s p i t a l s have i n s t i t u t e d a procedure f o r monitoring medical records: a) Name the procedure. b) Define t h i s procedure. Figure 9 C l i n i c a l Record-Keeping Inventory Items 69 A number of r e v i s i o n s were made following the p i l o t t e s t s . One item with low r e l i a b i l i t y was discarded and a second item was removed as i t was c o r r e c t l y answered by a l l subjects on the pretest, i t was, there-fore, considered to be non-discriminating. Minor r e v i s i o n s i n wording were made to reduce ambiguity. The CRKI used i n t h i s study (Figure 9) contained 13 questions, seven r e l a t i n g to general knowledge of recording p o l i c i e s and procedures, and six r e l a t i n g to s p e c i f i c knowledge of POR format. RECORDING NEEDS SURVEY The Recording Needs Survey (RNS) i s designed to measure four facets of the therapists' motivation to change. I t consists of two sets of items. The f i r s t set, displayed i n Figure 10, contains seven statements, each one r e f l e c t i n g a c h a r a c t e r i s t i c of an " i d e a l " record. 1. The PT/OT record i s a f a c t u a l j o u r n a l of the current state of the patient. 2. The PT/OT record acts as an important communication device to other members of the patient-care team. 3. Therapists use PT/OT records to i d e n t i f y gaps i n t h e i r knowledge. 4. The PT/OT record provides perspective and o b j e c t i v i t y necessary i n planning and implementing treatment. 5. The PT/OT record provides data f o r c l i n i c a l studies and research. 6. The PT/OT record provides information f o r se t t i n g standards of patient care. 7. The PT/OT record provides an index of the q u a l i t y of patient care. Figure 10 Recording Needs Survey Items 70 The t h e r a p i s t r a t e s each statement on the RNS t h r e e t i m e s : how t r u e each one j i s a t t h e p r e s e n t time, how t r u e each one s h o u l d be, and how i m p o r t a n t each statement i s to him p e r s o n a l l y . A 6 - p o i n t , monotonic r a t i n g s c a l e , r a n g i n g from "never t r u e " to "always t r u e " i s a t t a c h e d t o t h e i s  t r u e and s h o u l d be t r u e s c a l e s ; a s i m i l a r r a t i n g s c a l e , r a n g i n g from "never i m p o r t a n t " to "always i m p o r t a n t " i s a t t a c h e d to the importance s c a l e . By s u b t r a c t i n g s h o u l d be t r u e from i s t r u e the p e r c e i v e d gap i n r e c o r d i n g p r a c t i c e s i s o b t a i n e d . An a p r i o r i assumption i s th e l a r g e r t h e d i f f e r e n c e , the l a r g e r the p e r c e i v e d need f o r change. T h i s i s c o n s i s t e n t w i t h the r a t i o n a l e used by Leagans (1964) to b u i l d a f u n c t i o n a l concept of need. As w e l l as b e i n g c o n c e p t u a l l y sound, measuring needs i n t h i s manner has another a t t r i b u t e ; i t uses an i n d i r e c t measure of need from two d i r e c t answers which p u r p o r t s to reduce the p o s s i b i l i t y o f s u b j e c t s g i v i n g the s o c i a l l y a c c e p t a b l e " r i g h t " answer ( P o r t e r , 1962). The importance a t t a c h e d to c h a r a c t e r i s t i c s of an " i d e a l " r e c o r d i s another f a c e t of m o t i v a t i o n to change. Responses to the items shown i n F i g u r e 11 p r o v i d e d a t a on t h i s a s p e c t of m o t i v a t i o n to change. The second p o r t i o n of t h e RNS c o n t a i n s two items d e s i g n e d to i d e n t i f y a p e r c e i v e d p o t e n t i a l d i s c r e p a n c y i n d e p a r t m e n t a l r e c o r d i n g p r a c t i c e s . The two items a r e s t a t e d as f o l l o w s : (1) From your own vantage p o i n t i n your department p l e a s e e s t i m a t e , from the p a s t y e a r , the p e r c e n t a g e of PT/OT r e c o r d s t h a t c o n t a i n a f a c t u a l r e c o r d of the c a r e g i v e n to the p a t i e n t . (2) Now e s t i m a t e the p e r c e n t a g e of r e c o r d s t h a t s h o u l d be r e a l i s t i c a l l y expected t o be a f a c t u a l r e c o r d of t h e c a r e g i v e n to the p a t i e n t . The d i f f e r e n c e between t h o s e two e s t i m a t e s i s a measure o f p e r c e i v e d d i s -c r e pancy or "leeway" i n r e c o r d i n g p r a c t i c e s . A c r i t i c a l l y i n t e r e s t i n g q u e s t i o n i s to determine the " b e s t " 1. The PT/OT record i s a f a c t u a l journal of the current state of the patient. How important i s such f a c t u a l i t y to you? 2. The PT/OT record acts as an important communication device to other members of the patient-care team. How important i s t h i s communication channel to you? 3. Therapists use PT/OT records to i d e n t i f y gaps i n t h e i r knowledge. How important i s such an assessment to you? 4. The PT/OT record provides perspective and o b j e c t i v i t y necessary i n planning and implementing treatment. How important i s t h i s perspective to you? 5. The PT/OT record provides data for c l i n i c a l studies and research. How important are such studies to you? 6. The PT/OT record provides information f o r se t t i n g standards of patient care. How important are such standards to you? 7 . The PT/OT record provides an index of the qu a l i t y of patient care. How important i s t h i s index to you? Figure 11 Recording Needs Survey Items Relating to Importance motivational predictor of changes i n recording behaviour. Possible predictors include "gap" alone, "importance" alone, a resultant vector of gap m u l t i p l i e d by importance (impetus), "leeway" alone, and some combination of those four v a r i a b l e s . Three of those measures can be calculated from the f i r s t portion of the RNS; the fourth, leeway, i s obtainable from the second portion. The RNS was p i l o t tested on a group of 49 physical and occupational therapists working i n f i v e Vancouver health-care agencies. The survey was administered twice with one week between t e s t s . Item-by-item data f o r various r e l i a b i l i t y tests ( t e s t - r e t e s t , highest c o r r e l a t i o n with any other 72 item, and squared multiple correlations) are presented i n Appendix D. Cronbach's alpha measures of r e l i a b i l i t y were used to assess the i n t e r n a l consistency of the three scales. Alpha values were: presently true - .82, should be true - .83, and importance - .81. RECORDING OPINIONS SURVEY The Recording Opinions Survey (ROS) i s designed to measure the ther a p i s t s ' perceptions of three task-related factors that p o t e n t i a l l y might act as r e s t r a i n i n g forces i n a change s i t u a t i o n . Those three factors are resources, performance standards, and /reinforcers. To develop t h i s instrument, a pool of statements was generated from interviews with thera-p i s t s , problems noted i n the l i t e r a t u r e and discussions with i n s e r v i c e educators and supervisors. The ROS consists of 30 statements; eight r e l a t i n g to resources, eight r e l a t i n g to performance standards, and 14 r e l a t i n g to r e i n f o r c e r s for proper recording. Figures 12, 13 and 14 display the item sets f o r each scale. Items f o r each v a r i a b l e are randomly d i s t r i b u t e d throughout the ROS. Therapists rate each statement on a 5-point, Likert-type scale, ranging from "strongly disagree" to "strongly agree." Choosing a method to monitor the presence or absence of task-rel a t e d f a c t o r s r a i s e s an i n t e r e s t i n g question. Should monitoring be done by a representative of the organization, an outside consultant or the persons involved i n the change process? Usually, t h i s task i s c a r r i e d out by a manager or a consultant. However, i t can be argued that employees are the best source of information as i t i s t h e i r behaviour which i s expected to change. L e a v i t t (1972) maintains that people behave i n accordance with t h e i r perceptions of the world. This view i s consistent with the general 73 1. On the whole, the patient's chart i s a v a i l a b l e when I go to write i n i t . 2. Therapists are too busy t r e a t i n g patients to be concerned with d e t a i l e d recording. 3. The record sheets used i n t h i s department are unsuitable and inadequate. 4. Therapists should set aside part of each day for recording. 5. The recording sheets are kept near the patients' charts. 6. Problem oriented recording takes more time than the old method. 7. Therapists i n t h i s department spend too much time recording. 8. Written records are an unnecessary d u p l i c a t i o n of verbal communication with other members of the patient-care team. Figure 12 Resources Items theory of behaviour espoused i n the present study, that i s , behaviour i s a r e s u l t of an i n t e r a c t i o n between a person and h i s environment. Thus for the purposes of t h i s project, the employees' perceptions are the method of choice for monitoring s i t u a t i o n a l f a c t o r s . The ROS was p i l o t tested on the same group of therapists c i t e d above (n = 49). Item-by-item s t a t i s t i c s f o r various r e l i a b i l i t y tests ( t e s t - r e t e s t , highest c o r r e l a t i o n with any other item, and squared multiple c o r r e l a t i o n s ) are presented i n Appendix E. Cronbach's alpha values were: resources - .59, performance standards - .72, and r e i n f o r c e r s - .80. 74 1. The standards for record-keeping required by t h i s department are d i f f i c u l t to a t t a i n . 2. The i n s t r u c t i o n a l manual (for recording) i s r e a d i l y a v a i l a b l e for reference. 3. Regular audits should be done to monitor the record-keeping of s t a f f i n t h i s department. 4. The procedures for recording are c l e a r l y stated i n the manual. 5. The p o l i c i e s and procedures for recording have been c l e a r l y explained. 6. The standards for record-keeping required by t h i s department are r e a l i s t i c . 7. Consistent recording i n t h i s department requires that the supervisor check each chart. 8. The expectations for recording are c l e a r l y defined. Figure 13 Performance Standards Items 75 1. Information contained i n the PT/OT patient-care record should be used for peer review. 2. A l l members of the patient-care team should read a l l components of the record. 3. Doctors r e g u l a r l y read the therapist's entries i n the patient-care record. 4. Detailed records are valuable only when they are read by a l l people caring f o r the patient. 5. Doctors r e g u l a r l y comment on the usefulness of the information written by the therapist. 6. Record-keeping habits should be part of the annual performance appraisal of the s t a f f . 7. Record-keeping has low p r i o r i t y with t h i s h o s p i t a l ' s administration. 8. Nurses r e g u l a r l y read the therapist's entries i n the patient-care record. 9. Problem oriented recording w i l l improve the professional status of therapists. 10. Nurses r e g u l a r l y comment on the usefulness of the information written by therapists. 11. Regular meetings should be held to discuss the problems of changing to a new recording system. 12. Detailed records are e s s e n t i a l for peer review. 13. Problem oriented recording improves the r e l i a b i l i t y of the information i n the record. 14. The q u a l i t y of care that therapists give t h e i r patients p a r a l l e l s the q u a l i t y of t h e i r record-keeping . Figure 14 Reinforcers Items Chapter 5 DATA ANALYSIS AND RESULTS The change i n r e c o r d - k e e p i n g p r a c t i c e s o f 62 t h e r a p i s t s was measured over 26 weeks. D u r i n g t h a t time, d a t a were c o l l e c t e d on v a r i o u s f o r c e s t h a t f a c i l i t a t e or h i n d e r t h e p r o c e s s of change. S p e c i f i c a l l y , the s i x v a r i a b l e s i n v e s t i g a t e d were: (1) a c q u i s i t i o n and maintenance of r e c o r d i n g b e h a v i o u r , (2) a c q u i s i t i o n and r e t e n t i o n of knowledge, (3) m o t i v a t i o n to change, (4) r e s o u r c e s , (5) performance s t a n d a r d s , and (6) r e i n f o r c e r s f o r p r o p e r r e c o r d i n g . In t h i s c h a p t e r the d a t a a r e p r e s e n t e d and a n a l y s e d . I n i t i a l l y , d a t a r e l a t e d t o each v a r i a b l e were examined. The second p o r t i o n of t h e c h a p t e r d e a l s w i t h an e x a m i n a t i o n of t h e hypotheses and observed r e l a t i o n -s h i p s among independent v a r i a b l e s and changes i n r e c o r d i n g b e h a v i o u r . ACQUISITION AND MAINTENANCE OF RECORDING BEHAVIOUR The major dependent v a r i a b l e s i n t h i s s t u d y were a c q u i s i t i o n and maintenance of r e c o r d i n g b e h a v i o u r . As w e l l as o b t a i n i n g a s c o r e f o r the t o t a l r e c o r d , s e p a r a t e s c o r e s were c a l c u l a t e d f o r each of f i v e components of the r e c o r d . Those components were d a t a base, problem f o c u s , treatment p l a n , f o l l o w - u p and documentation. An a n a l y s i s o f the b a s e l i n e s c o r e s r e v e a l e d t h a t a p p r o x i m a t e l y h a l f (48.6%) of FRAS items were p r e s e n t i n the r e c o r d p r i o r t o the i n t r o d u c t i o n o f POR. The major c o n t r i b u t o r s to t h i s s c o r e were d a t a base and docu-m e n t a t i o n i t e m s . Together, t h o s e two s u b s e t s accounted f o r 92% of t h e items 77 present i n the t o t a l record. Figure 15 presents a comparison of the contribution of each component at baseline, one month and four months. It i s obvious from an examination of t h i s Figure that there were major d e f i c i t s i n three components of the record, problem focus, treatment plan and follow-up, when therapists recorded i n the conventional manner. Aft e r the introduction of POR and the i n s e r v i c e educational program which accompanied i t , a l l parts of the record showed an improvement with the greatest gain occurring i n problem focus. At t h i s point (one month) 77% of FRAS items were present. Four months l a t e r , adherence to the new POR format had declined to 71%. The greater portion of t h i s l o s s was among items r e l a t i n g to problem focus, treatment plan and follow-up. Tables 9 and 10 present means, standard deviations and s i g n i f i c a n c e t e s t s for t o t a l recording behaviour and each component during the a c q u i s i t i o n and maintenance phases of t h i s study. As Table 9 shows, gains occurred i n a l l components and i n each instance the gain was s i g n i f i c a n t l y greater than chance. From those r e s u l t s , i t was concluded that therapists acquired the new recording behaviour. Examination of maintenance data (Table 10) shows that, i n terms of the t o t a l record, the newly acquired l e v e l of recording was not maintained. The lo s s score of 5.5% was s i g n i f i c a n t at the .002 l e v e l . This o v e r a l l decline was due to s i g n i f i c a n t decreases i n treatment plan and problem focus items. Small losses occurred i n data base, follow-up and docu-mentation areas but those losses were not s t a t i s t i c a l l y s i g n i f i c a n t . From those r e s u l t s , i t was concluded that therapists had maintained recording behaviour i n three components (data base, follow-up and documentation) but had not maintained a l l t h e i r acquired l e v e l of recording i n treatment plan and problem focus. 78 D= Documentation DB= Data Base P= Problem Focus T= Treatment Plan F= Follow-up INSERVICE Figure 15 A Comparison of Performance Component Scores at Baseline, One Month and Four Months Table 9 Means, Standard Deviations and t-test s for A c q u i s i t i o n of Recording Scores Component MPS Baseline Mean S.D. 1 month b c Mean S.D. Difference t-value d.f. t-prob Data Base 16 11.11 4.1 14.36 3.1 3.25 6.22 52 ,000 Problem Focus 20 1.98 4.7 15.62 5.9 13.64 14.58 52 ,000 Treatment Plan 12 .28 1.2 2.64 3.6 2.36 5.12 52 ,000 Follow-up 12 1.32 1.6 6.28 4.1 4.96 8.96 52 ,000 Documentation 32 30.02 3.3 31.57 1.2 1.55 4.00 52 ,000 Tota l Record 92 44.72 9.58 70.47 13.1 25.75 16.19 52 ,000 Maximum possible score, ^ t - t e s t s f o r correlated means. "A t - p r o b a b i l i t y of .05 or les s represents a change s i g n i f i c a n t l y d i f f e r e n t from chance. T a b l e 10 Means, Standard D e v i a t i o n s and t - t e s t s f o r Maintenance of R e c o r d i n g Scores Component MPS 1 month Mean S.D. 4 months b c Mean S.D. D i f f e r e n c e t - v a l u e d . f . t-prob Data Base 16 14.36 3.1 14.21 2.8 - .15 .40 52 ,688 Problem Focus 20 15.70 5.9 13.60 6.4 -2.09 2.52 52 .015 Treatment P l a n 12 2.58 3.6 ,94 2.0 -1.64 4.80 52 .000 Fol l o w - u p 12 6.40 4.1 5.66 3.' - .74 1.31 52 .195 Documentation 32 31.64 1.1 31.30 1.8 - .34 1.46 52 ,515 T o t a l Record 92 70.68 13.17 65.72 11.8 -4.96 3.28 52 ,002 Maximum p o s s i b l e s c o r e , ^ t - t e s t s f o r c o r r e l a t e d means. Q A t - p r o b a b i l i t y of .05 or l e s s r e p r e s e n t s a change s i g n i f i c a n t l y d i f f e r e n t from chance. N o n - s i g n i f i c a n t . ACQUISITION AND RETENTION OF KNOWLEDGE An analysis of responses to the knowledge tests showed that before the i n s e r v i c e program the p a r t i c i p a n t s knew more about general recording procedures (42.5%) than s p e c i f i c information r e l a t i n g to POR (27.5%). It i s c l e a r from an examination of scores at baseline, one month and four :.. months (Figure 16) that substantial gains occurred during the i n i t i a l phase of the study with the greater gain occurring i n the s p e c i f i c knowledge area. Figure 16 also demonstrates a small decline i n general knowledge and a very small increase i n s p e c i f i c knowledge occurred between the one-month and four-month post i n s e r v i c e follow-up. Table 11 presents means, standard deviations and s i g n i f i c a n c e tests for the t o t a l knowledge test and i t s two subsets during both phases of the study. The maximum score f e a s i b l e for the t o t a l test was 40, with each subset contributing 20 points. As Table 11 reveals, the gains i n general and s p e c i f i c knowledge i n the a c q u i s i t i o n phase were highly s i g n i f i c a n t , with a s t a t i s t i c a l p r o b a b i l i t y l e v e l less than .001. The minimum changes i n knowledge i n the maintenance phase were not s i g n i f i c a n t . From these r e s u l t s , i t was concluded that therapists had acquired and retained knowledg about recording practices and format. MOTIVATION TO CHANGE Analysis of responses to items on the RNS revealed that therapists were aware of deficiences i n t h e i r e x i s t i n g recording system and p r a c t i c e s . For example, they f e l t that approximately 50% of the c h a r a c t e r i s t i c s of an " i d e a l " record were being met but they f e l t almost a l l the c h a r a c t e r i s t i c s should be met. Figure 17 presents a comparison of responses to the " i d e a l " record items. As t h i s Figure shows, therapists not only perceived a 82 «/5 <D U) O c <D u k_ <D a. to U J o u to LU o Specific Total General lOOi 80 60 40 3 20 O W -o X BASE | lmth INSERVICE 4 mths Figure 16 A Comparison of General, S p e c i f i c and Total Knowledge Scores at Baseline, One Month and Four Months Table 11 Means, Standard Deviations and t - t e s t s for Knowledge A c q u i s i t i o n and Retention Scores A c q u i s i t i o n Baseline 1 month Test MPSb Mean S.D. Mean S.D. Difference c t-value d.f t-prob^ General knowledge 20 8.49 4.2 14.14 3.6 5.64 12.84 58 .000 S p e c i f i c knowledge 20 5.49 4.4 16.83 3.4 11.34 18.29 58 .000 Tota l test 40 13.93 7.4 30.97 5.8 17.03 19.81 58 .000 Retention 1 month 3 4 months General knowledge 20 14.04 3.6 13.60 3.5 - .44 1.42 51 * .161 S p e c i f i c knowledge 20 16.83 3.3 17.00 3.1 .17 .52 51 .606* Tot a l test 40 30.87 5.6 30.60 5.3 - .27 .55 51 .585 Sli g h t d i f f e r e n c e s i n means, standard deviations and number of subjects occur because of subj ect drop-out during the 4-month l i f e t i m e of the study. b Maximum possible score. t - t e s t s f o r correlated means. ^ A t - p r o b a b i l i t y of .05 or less represents a change s i g n i f i c a n t l y difference from chance. * Non-significant. 84 I ^ 1 | PRESENTLY TRUE j J | SHOULD BE TRUE 2 3 3 j IMPORTANT 37.1 4 36.1 1 1 I 1 1 1 7 14 21 28 35 42 NEVER RARELY SOMETIMES FREQUENTLY USUALLY ALWAYS Figure 17 A Comparison of "Important," "Is Present," "Should be Present" and "Gap" Scores with the Response Scale considerable gap existed between present and "ideal" recording but they also f e l t the "ideal" characteristics were important. Table 12 presents means and standard deviations for the raw scores and calculated values for variables reflecting motivation to change. The possible range of scores on the "presently true," "should be true" and "important" scales was 7 to 42, with a mid-point of 24. The range for the estimates was 0 to 100%. As Table 12 demonstrates, the present level of factual recording was estimated to be just less than 60%. It is obvious from the range of responses (10% to 90%) that the group held widely divergent views on the present state of record-keeping. Those views became more cohesive when they estimated the percentage of records that could be r e a l i s t i c a l l y expected to contain a factual account of patient care. The estimated expected level was 88% and the responses ranged from 70% to 90%. 85 Table 12 Means and Standard Deviations f o r Motivation to Change Variables RNS Probes 3 Mean S.D. Range Min. Max. MPSb Presently true 23.39 5.52 9 37 42 Should be true 37.11 3.71 25 42 42 Important 36.16 4.09 24 42 42 Estimate present % 57.72 19.39 10 90 100 Estimate expected %^ 88.26 8.44 70 99 100 e Variables Gap 13.73 5.63 4 27 35 Impetus 39.00 4.84 26 49 55 Leeway (%) 30.54 20.48 10 99 100 Importance 36.16 4.09 24 42 42 'Recording Needs Survey questions. 'Maximum possible score. 'Estimate of present l e v e l of f a c t u a l recording. Estimate of expected l e v e l of f a c t u a l recording. 'Variables derived from RNS probes. The di f f e r e n c e between the estimates showed that therapists perceived there was a 30% de f i c i e n c y i n departmental recording p r a c t i c e s . Results from the RNS demonstrated that therapists perceived a need fo r changing t h e i r recording p r a c t i c e s . They estimated a r e l a t i v e l y large d e f i c i t existed i n the o v e r a l l practices of t h e i r departments and, when 86 asked to examine the objectives of an "ideal" record, they f e l t there was substantial room for improvement. Furthermore, they attached considerable importance to those objectives. From those results i t was concluded that a motivational force to change, as measured by the RNS, was present in the physical and occupational therapists in this study. resources, performance standards and reinforcers are graphically represented in Figure 18. A summary of means, standard deviations and significance tests for i n i t i a l and subsequent scores are presented in Table 13. Scores for resources and standards subsets range from a minimum possible of 8 to a maxi-mum possible of 40. Minimum and maximum scores for the reinforcers subset is 14 and 70. TASK-RELATED FACTORS I n i t i a l and subsequent responses to task-related items about PERFORMANCE STANDARDS RESOURCES REINFORCERS Strongly Disagree I Disagree j Neutral Agree Strongly Agree Figure 18 A Comparison of Resources, Performance Standards and Reinforcers Scores with Response Scale 87 Before an attempt was made to change t h e i r recording behaviour, the s t a f f ' s a t t i t u d e s toward a l l three f a c t o r s tended to be negative. In terms of the resources subset, t h i s response indicated the therapists f e l t resources were adequate. This r e s u l t i s somewhat unexpected as lack of time and unsuitable forms are c i t e d by therapists i n general elsewhere as a major reason for poor record-keeping. With respect to performance  standards, i t appears that therapists f e l t the e x i s t i n g standards were not c l e a r l y defined, r e a l i s t i c or understandable. Responses to the r e i n - forcers scale showed that s t a f f f e l t p o s i t i v e r e i n f o r c e r s for proper recording were low. The mean value, which was six points below the "neutral" point of the scale, indicated that therapists f e l t there was considerable room f o r increasing p o s i t i v e reinforcement for t h e i r recording e f f o r t s . As can be seen i n Table 13, the l e v e l s of resources and r e i n f o r c e r s remained v i r t u a l l y stable throughout the study. This lack of change indicated that no major re-organization of resources or increases i n r e i n f o r c e r s had occurred during the introduction and implementation of POR. There was, however, a s i g n i f i c a n t change i n performance standards. One month a f t e r changes i n recording were introduced, s t a f f f e l t that the departmental requirements for record-keeping were more sharply focused. An almost i d e n t i c a l score at the four-month point indicated t h i s improve-ment did not decay with time. RELATIONSHIPS AMONG THE VARIABLES With respect to the c e n t r a l issue of the study, the r e l a t i o n s h i p s among the v a r i a b l e s , regression equations showed that the major hypotheses were supported. A d d i t i o n a l equations were solved to determine the'amount of variance i n recording behaviour explained by the independent v a r i a b l e s Table 13 Means, Standard Deviations and t-tests for Task-related Variables Baseline 1 month 3 Variable MPSb Mean S.D. Mean S.D. Difference t-value d.f. t-prob^ Resources 40 21 . 9 3 2 .5 21 .98 2 .8 .05 .13 56 .894* Reinforcers 70 35 . 25 4 . 2 36 . 30 4 .7 1.05 2 .04 56 . 056* Performance 40 21 . 19 3 .5 23 .95 3 .0 2 .75 7 .05 56 .000 ' -Standards 1 month 3 4 months Resources 40 21 . 83 2 .8 21 .65 2.9 .17 .54 51 . 589* Reinforcers 70 36 . 27 4 . 7 35 . 31 4 . 5 .96 1.68 51 . 100* Performance 40 23 .85 3 . 2 23 .87 3 .0 .02 .05 51 . 962* Standards Slight differences i n means-, standard deviations and number of subjects occur because of subject dropout during the 4-month l i f e t i m e of the study. "Maximum possible score, t - t e s t s for correlated means. t - p r o b a b i l i t y of . 05 or l e s s represents a change s i g n i f i c a n t l y d i f f e r e n t from chance. Non-significant. 89 and the r e l a t i v e contribution of each independent v a r i a b l e to t h i s explained variance. Those findings are presented i n t h i s section. A c q u i s i t i o n Hypothesis The a c q u i s i t i o n hypothesis proposed that i n i t i a l changes i n recording behaviour would be more c l o s e l y linked to motivation to change, increase i n knowledge and presence of performance standards than to resources and r e i n -forcers for proper recording. Data presented i n Table 14 show- that i n the complete record and i n a l l i t s components the variance accounted for by the primary subset (motivation, knowledge and standards) was greater than that accounted for by the secondary subset (resources and r e i n f o r c e r s ) . The data also show that i n the complete record and four components adding the second subset to the f i r s t did not s i g n i f i c a n t l y increase the amount of variance accounted f o r . The four components where the a d d i t i o n a l variance explained by resources and r e i n f o r c e r s was not s i g n i f i c a n t at the .05 l e v e l or better were treatment plan, problem focus, follow-up and documentation. In the data base component, there was only a marginal d i f f e r e n c e between the 2 variance accounted for by the primary subset (R = .18) and the secondary 2 subset (R = .17). The addition of resources and r e i n f o r c e r s i n t h i s component was s i g n i f i c a n t at the .05 l e v e l . From these data, i t was con-cluded that i n the complete record and i n four of i t s components, documenta-t i o n , problem focus, treatment plan and follox^-up, the change i n recording behaviour that occurred during the introduction of POR was more c l o s e l y linked to changes i n knowledge, motivation to change and changes i n the c l a r i t y of performance standards than to resources and r e i n f o r c e r s f or proper recording. Thus, the a c q u i s i t i o n hypothesis was confirmed. Further-more, with the exception of data base, the r e l a t i o n s h i p proposed i n the a c q u i s i t i o n hypothesis occurred i n a l l components of recording behaviour. Table 14 General H i e r a r c h i c a l Test of the A c q u i s i t i o n Hypothesis Documentation Data Base Problem Focus Treatment Plan Follow-up Complete Record To t a l variance explained by a l l independent v a r i a b l e s .27 .35 .32 .38 .27 .33 Variance accounted f o r by Knowledge, Motivation and Standards .23 .18 .20 .34 .15 .21 A d d i t i o n a l variance accounted for by Resources and Reinforcers .04 .17 .11 .04 .11 .12 . F r a t i o .58* 2.78 1.83* .66* 1.69* 2.01* a An F r a t i o greater than 2.58 i s s i g n i f i c a n t at the .05 l e v e l with 4 and 44 degrees of freedom. JL Non-significance indicates support of the hypothesis; namely, that the addition of the second subset does not s i g n i f i c a n t l y increase the amount of variance explained by the f i r s t subset. Note: Data f o r each regression equation i s presented i n Appendix F. 91 Maintenance Hypothesis The second hypothesis proposed that maintenance of recording behaviour would be more c l o s e l y linked to resources, r e i n f o r c e r s and performance standards than to l o s s of knowledge and motivation to change. Table 15 presents data from regression equations solved to investigate the maintenance hypothesis. Inspection of t h i s Table shows that i n the complete record and a l l f i v e components the variance accounted for by the primary subset (resources, r e i n f o r c e r s and standards) i s not s i g n i f i c a n t l y increased by the addition of the secondary subset (knowledge and motivation). Curiously, i n the follow-up component, the s i z e of the r e l a t i o n s h i p of the two subsets i s reversed. But i n a l l s i x instances, addition of motivation and knowledge to the variance already explained by resources, r e i n f o r c e r s and standards did not reach a s i g n i f i c a n c e l e v e l of .05 or better. From those r e s u l t s , i t was concluded that the decline i n recording behaviour during the maintenance phase of changing behaviour was more c l o s e l y linked to resources, r e i n f o r c e r s f or proper recording and the presence of performance standards than to loss of knowledge and motivation to change. Thus, the maintenance hypothesis was confirmed. Furthermore, the r e l a t i o n s h i p proposed i n the maintenance hypothesis occurred i n a l l components of recording behaviour. Proportion of Explained Variance Step-wise multiple regression equations were solved to determine the proportion of variance i n each component of recording performance explained by the independent v a r i a b l e s . Table 16 displays the independent v a r i a b l e s attempted i n the analysis of a c q u i s i t i o n and maintenance of performance. Summary s t a t i s t i c s showing l i n e a r dependence of recording performance on the independent v a r i a b l e s are presented i n Tables 17 (acquisition) and 18 Table 15 General H i e r a r c h i c a l Test of the Maintenance Hypothesis Documentation Data Problem Treatment Follow-up Complete Base Focus Plan Record To t a l variance explained by a l l independent v a r i a b l e s .38 .40 .34 .16 .12 .34 Variance accounted for by Resources, Reinforcers and Standards .32 .31 .21 .14 .03 .23 A d d i t i o n a l variance accounted for by Motivation and Knowledge .06 .09 .13 .02 .09 .11 SL F r a t i o .96* 1.16* 1.44* .15* .75* 1.14* An F r a t i o greater than 2.31 i s s i g n i f i c a n t at the .05 l e v e l with 6 and 44 degrees of freedom. * Non-significance indicates support of the hypothesis; namely, that the addition of the second subset does not s i g n i f i c a n t l y increase the amount of variance explained by the f i r s t subset. Note: Data f o r each regression equation i s presented i n Appendix F. 93 Table 16 V a r i a b l e s Attempted i n the A c q u i s i t i o n and Maintenance Regression A n a l y s i s A c q u i s i t i o n Phase VARIABLES Maintenance Phase Basel i n e - I month ( r e s i d u a l ) B a s e l i n e - 1 month ( r e s i d u a l ) B a s e l i n e Recording Performance Documentation Data base j Problem focus Treatment p l a n Follow-up Knowledge General S p e c i f i c M o t i v a t i o n to Change Gap Important Leeway Impetus Performance Standards 1 month - 4 months ( r e s i d u a l ) 1 month - 4 months ( r e s i d u a l ) B a s e l i n e B a s e l i n e Baseline - 1 month (gain) Standards Standards change 1 month 1 month - 4 months (gain) B a s e l i n e B a s e l i n e (gain) - 1 month Resources Resources Resources change R e i n f o r c e r s 1 month 1 month - 4 months (gain) B a s e l i n e Baseline (gain) - 1 month Re i n f o r c e r s R e i n f o r c e r s change 1 month 1 month - 4 months (gain) 94 (maintenance). Two sets of data are displayed i n each table. One set deals with the proportion of variance explained by a l l v a r i a b l e s ; the second set, l a b e l l e d "maximum," deals with explained variance at the point of maximum p r e d i c t i v i t y of the regression equation. Inspection of a c q u i s i t i o n data for a l l v a r i a b l e s shows that each component of recording performance has a degree of l i n e a r dependence on the independent v a r i a b l e s . The strongest r e l a t i o n s h i p e x i s t s i n treatment plan, where 38% of i t s variance i s explained. The amount of variance i n other components i s 35% i n data base, 32% i n problem focus and 27% i n both follow-up and documentation. Data associated with maximum p r e d i c t i v i t y i n i n i t i a l change of performance show that each component has a unique set of predictors. For example, gap, s p e c i f i c knowledge and standards have p r e d i c t i v e power i n acquiring changes i n treatment plan while leeway and resources are pr e d i c t i v e of changing recording i n data base. Variables associated with the remaining components of the record are shown in Table 17. Inspection of maintenance data for a l l variables (Table 18) shows that the change i n each component of recording performance has at le a s t some degree of l i n e a r dependence on the independent v a r i a b l e s . The strongest r e l a t i o n s h i p occurs i n data base where the j o i n t l y operating v a r i a b l e s explain 41% of the v a r i a t i o n . The proportion of explained variance i n documentation and problem focus i s 38% and 34% re s p e c t i v e l y . Explained variance i n treatment plan (16%) and follow-up (12%) i s considerably lower. Data associated with maximum p r e d i c t i v i t y i n the decline of perfor-mance show that each component has a unique set of pred i c t o r s . However, i t i s obvious that r e i n f o r c e r s and resources are powerful predictors because they appear, either i n combination or separately, i n a l l components. Table 17 Variance i n Increase i n Recording Components (Acquisition Phase) Accounted for by Motivation, Knowledge and Task-related Variables Component Mul t i p l e R R Square Standard Error a b A l l Max A l l Max A l l Max A l l Max A l l Max Variables i n Equation at Maximum Data Base Problem Focus Treatment Plan Follow-up .59 .38 ,62 .52 ,52 .40 Documentation .52 .33 ,35 .15 .84 .85 1.04 3.67 .56 .48 .32 .23 .96 .91 1.27 3.01 ,38 .27 ,27 .16 ,27 .11 .86 .83 1.68 5.06 97 .92 ,99 2.62 .19 .03 .28 .03 ,12 .004 .47 .06 .85 .82 1.02 2.58 .45 .09 Leeway Resources Sp e c i f i c knowledge Standards change Resources Reinforcers Gap S p e c i f i c knowledge Standards Standards Standards change Reinforcers Gap Standards Variance explained by a l l v a r i a b l e s . b Variance at point of maximum p r e d i c t i v i t y of regression equation. Note: Data f o r each regression equation i s presented i n Appendix G. Table 18 Variance i n Decline i n Recording Components (Maintenance Phase) Accounted for by Motivation, Knowledge and Task-related Variables M u l t i p l e R R Squa :re Standard Error F P Component A l l a M b Max A l l Max A l l Max A l l Max A l l Max Variables i n Equation at Maximum Data Base .64 .54 .41 .29 9.73 .71 1.90 5.62 .07 .002 Resources Resources change Standards Problem Focus .58 .43 .34 .16 .81 .79 1.14 4.90 .21 .01 Resources change Reinforcers Treatment Plan .40 .25 .16 .06 .67 .64 .65 2.96 .76 .09 Resources Follow-up .35 .16 .12 .03 .94 .87 .44 1.20 .93 .27 Reinforcers Documentation .62 .60 .38 .36 .84 .79 1.17 5.71 .11 .001 Reinforcers Reinforcers change General Knowledge Gap Variance explained by a l l v a r i a b l e s . Variance at point of maximum p r e d i c t i v i t y of regression equation. Note: Data f o r each regression equation i s presented i n Appendix G. 97 By contrast, general knowledge and gap appear i n only one component (documentation). P r e d i c t i v e v a r i a b l e s for each component are shown i n Table 18. Relative Contribution of Independent Variables In addition to providing an o v e r a l l p i c ture of the strength of the r e l a t i o n s h i p between dependent and independent v a r i a b l e s , regression solu-tions provide d e t a i l e d information on the r e l a t i v e c ontribution of each independent v a r i a b l e . This information i s contained i n the c o e f f i c i e n t of 2 determination (R ). Figures 19 and 20 g r a p h i c a l l y display the r e l a t i v e contribution of each set of independent v a r i a b l e s to each component of performance. Examination of those figures shows that the contribution of motiva-t i o n , knowledge and task-related v a riables d i f f e r s among components of performance. In the i n i t i a l change i n recording ( a c q u i s i t i o n ) , motivation to change was the main contributor to three components: documentation, data base and treatment plan (Figure 19); standards was the major c o n t r i -butor to problem focus and follow-up. Increases i n knowledge, both general and s p e c i f i c , contributed a s u b s t a n t i a l portion of explained variance i n only two components. They were problem focus and treatment plan. With the exception of data base, where resources s u b s t a n t i a l l y contributed to i t s a c q u i s i t i o n , r e i n f o r c e r s and resources were r e l a t i v e l y minor contributors to a l l components. Recording performance declined i n the maintenance phase and resources were the main contributor to t h i s decline i n three components: data base, problem focus and treatment plan. Reinforcers dominated the documentation component, and motivation to change contributed a major portion of explained variance to follow-up (Figure 20). Changes i n knowledge contributed nothing Knowledge 3% Motivation 14% Standards 5% Resources 2% inforcers 3% owledge 3% Motivation 14% Standards 4 % esources 11% einforcers 3% DOCUMENTATION COMPONENT Explained Variance 27% DATA BASE COMPONENT Explained Variance 35% Knowledge 8 % Motivation 5% Standards 9% Resources 6% inforcers 4% PROBLEM FOCUS COMPONENT Explained Variance 32% Knowledge 10% Motivation 13% Standards 117a Resources 3% inforcers 1% TREATMENT PLAN COMPONENT Explained Variance 38% Knowledge 1% Motivation 7% Standards 12% Reinforcers 7% FOLLOW UP COMPONENT Explained Variance 27% F i g u r e 19 C o n t r i b u t i o n of M o t i v a t i o n , Knowledge and T a s k - r e l a t e d V a r i a b l e s t o I n c r e a s e i n POR Format Reinforcers 2% Reinforcers 26% 'Resources 1% Standards 1% ivation 5% Knowledge 5% DOCUMENTATION COMPONENT Explained Variance 38% Resources 22% Standards 8% Motivation 6% Knowledge 3% DATA BASE COMPONENT Explained Variance 41% Reinforcers 6% ,Resources 15% Standards 1% 'Motivation 8% Knowledge 4% PROBLEM FOCUS COMPONENT Explained Variance 34% Reinforcers 5% Resources 7% Standards 3% 'Motivation 1% TREATMENT PLAN COMPONENT Explained Variance 16% FOLLOW UP COMPONENT Explained Variance 12% F i g u r e 20 C o n t r i b u t i o n o f M o t i v a t i o n , Knowledge and T a s k - r e l a t e d V a r i a b l e s t o Decrease i n POR Format 100 toward explained variance i n treatment plan and follow-up and only minor amounts i n the other three components. Data r e l a t i n g to r e l a t i v e contribution of v a r i a b l e s to explained variance further support the hypotheses. Motivation and standards are e s s e n t i a l aspects of acquiring a new behaviour but are far le s s important than r e i n f o r c e r s and resources i n i t s sustained p r a c t i c e . "Best" Motivation to Change Variable One of the subsidary questions addressed i n t h i s study concerns the "best" motivation-to-change predictor. Data presented i n the preceding sections c l e a r l y demonstrate that motivation to change i s an important force i n acquiring a new behaviour. For example, the f o u r f o l d measure of motivation to change used i n t h i s study accounts for one-third of explained variance i n t o t a l performance a c q u i s i t i o n , with contributions to each component ranging from 52% (documentation) to 16% (problem focus). I t s impact on decline of a newly acquired behaviour i s considerably weaker but i t s t i l l accounts for 21% of t o t a l explained variance. One method of i d e n t i f y i n g the "best" motivation to change v a r i a b l e i s through examination of standardized regression c o e f f i c i e n t s or beta weights. Since beta weights are p a r t i a l regression c o e f f i c i e n t s they may be used as measures of the influence of each independent v a r i a b l e upon performance with adjustments made for a l l other independent v a r i a b l e s (Nie et a l . , 1975, p. 322). Regression equations using a c q u i s i t i o n of performance, gap, leeway, importance and impetus yielded the appropriate beta weights. Those data show that a change i n impetus, a resultant vector of gap and importance, would introduce the greatest change i n performance. Furthermore, a change i n leeway, the estimated diffe r e n c e between present and expected recording p r a c t i c e s , would introduce the l e a s t change i n 101 performance. From those r e s u l t s , i t was concluded that the "best" motivation to change predictor was a combination of a perceived gap i n performance and the importance attached to an " i d e a l " performance. SUMMARY The introduction and continued use of a new recording format was measured over 6 1/2 months. Various personal and organizational variables were measured i n conjunction with measurements of recording behaviour. Those variables were motivation to change, knowledge about recording procedures and p r a c t i c e s , and employee perceptions r e l a t i n g to the resources a v a i l a b l e f or the task, the c l a r i t y of performance standards and the presence of r e i n f o r c e r s for proper recording. With the exception of motivation to change, which was measured once, a l l variables were measured at three points i n time: baseline, one month and four months. Changes between base-l i n e and one month represented performance a c q u i s i t i o n ; changes between one month and four months represented performance maintenance. In the a c q u i s i t i o n phase, highly s i g n i f i c a n t changes occurred i n recording behaviour and knowledge. A small s i g n i f i c a n t change was noted i n performance standards and no change occurred i n the l e v e l of resources or r e i n f o r c e r s . P r i o r to the introduction of the new recording format, employees demonstrated a motivation to change. Regression analysis showed that a c q u i s i t i o n of performance was strongly influenced by an increase i n knowledge, a motivation to change and the presence of performance standards. Resources and r e i n f o r c e r s exerted considerably l e s s influence. In the maintenance phase, 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 loss of recording behaviour occurred. There was no change i n the three task-related factors and knowledge did not decline. Regression analysis showed that 102 maintenance of performance was s t r o n g l y i n f l u e n c e d by r e s o u r c e s , r e i n f o r c e r s and performance s t a n d a r d s . Loss of knowledge and m o t i v a t i o n to change p l a y e d r e l a t i v e l y minor r o l e s i n the observed d e c l i n e i n performance. Chapter 6 DISCUSSION AND CONCLUSIONS The r e s u l t s presented i n the previous chapter provide some support for asserting that an in s e r v i c e education program helps s t a f f to acquire a new work-related task but further actions are required to help s t a f f continue p r a c t i c i n g the new task. S p e c i f i c a l l y , the findings show that physiotherapists and occupational therapists changed t h e i r recording s t y l e to more c l o s e l y match the required POR format when they perceived a need for change, increased t h e i r knowledge of POR and other general recording procedures and f e l t the expectations f o r record-keeping were more c l e a r l y defined. Moreover, they achieved t h i s change even though they f e l t the r e i n f o r c e r s f o r proper recording were low and some i n s u f f i c i e n c i e s existed i n the time and materials a v a i l a b l e f o r t h i s task. Three months l a t e r , therapists had not forgotten how to use POR nor did they f e e l the r e i n -f o r c e r s , resources or performance standards had altered i n any way, yet t h e i r use of POR declined. This chapter presents a discussion of those r e s u l t s under four major headings: changes i n record-keeping p r a c t i c e s , changes i n personal a t t r i b u t e s , changes i n organizational f a c t o r s , and acquiring and main-tainin g performance change. CHANGES IN RECORD-KEEPING PRACTICES The findings show that PTs and OTs increased t h e i r o v e r a l l recording of POR items by approximately 30% i n the a c q u i s i t i o n phase. This 103 increase i s twice as large as that found by Hammett et a l . (1976) i n t h e i r study of physicians and t h e i r use of POR. However, i t should be noted that the baseline scores for those physicians (57%) was considerably higher than the PT/OT baseline score (49%) observed here. In f a c t , both groups attained a somewhat si m i l a r implementation l e v e l (72% f o r physicians i n the Hammett study and 77% for the PTs and OTs i n t h i s study). Unfortunately, the majority of reports describing POR implementation do not specify the amount of implementation so i t i s d i f f i c u l t to determine whether the amount observed here i s usual or unusual. Thus, i t i s t e n t a t i v e l y con-cluded that the l e v e l of implementation attained by PTs and OTs i s within an acceptable range. Implementation was not uniform across the components of the record. For example, documentation items increased by 5% while problem focus items increased by 69%. Between those two extremes, increase of 19% (treatment plan), 21% (data base) and 42% (follow-up) were registered. The increase was s i g n i f i c a n t i n a l l components at the .001 l e v e l . In part, the lack of uniformity i s a function of the number of items recorded before POR was o f f i c i a l l y adopted and the maximum number possible i n any one component. For example, therapists were already recording 94% of documentation items and 69% of data base items before POR was introduced, therefore only a small amount of change was possible i n those two components. The data do not provide a ready explanation for the wide v a r i a t i o n s observed among the remaining parts of the record. I t would appear that therapists experienced most d i f f i c u l t y with treatment plan items and l e a s t d i f f i c u l t y with problem focus items. Possibly the nature of the treatment plan items might be responsible for some of those d i f f i c u l t i e s as two items dealt with the duration of the plan and the expected response of the 105 patient. Therapists may be unwilling or unable to state how long a p a r t i c u l a r treatment plan w i l l be used and what response they expect from a patient. C e r t a i n l y t h i s type of commitment i s seldom seen i n PT/OT records elsewhere i n Canada although i t i s an accepted part of payment-for-service contracts i n the United States. Therapists did not wholly maintain t h e i r i n i t i a l gains i n POR format. Results from the audit done during the fourth month showed a 6% decline of POR items i n the complete record. This los s was s t a t i s t i c a l l y s i g n i f i c a n t at the .002 l e v e l . However, the observed decline was not uniform across the components. Documentation and data base remained v i r t u a l l y at the acquired l e v e l , problem focus and treatment plan showed s i g n i f i c a n t losses and the change i n follow-up was not s i g n i f i c a n t l y d i f f e r e n t from chance. Here again, lack of comparable data from other studies makes i t impossible to determine whether t h i s amount of loss i s usual or not but the researcher's experience with other implementation programs suggests that the decline was less than normal. One of the major purposes of t h i s study was to examine the e f f e c t s of various forces on the a c q u i s i t i o n and maintenance of POR. Those r e s u l t s w i l l be more f u l l y discussed a f t e r changes i n personal and organizational factors have been examined. CHANGES IN PERSONAL ATTRIBUTES The personal a t t r i b u t e s monitored i n t h i s study were knowledge of recording procedures and motivation to change. Before discussing .the findings r e l a t e d to each of those v a r i a b l e s , i t i s germane to point out that motivation to change was measured once, at the beginning of the change attempt, therefore i t i s not a "change" v a r i a b l e . By contrast, knowledge 106 was measured three times, thus i t i s a "change" v a r i a b l e . Increased Knowledge of Recording Ph y s i c a l and occupational therapists had a better understanding of general recording p o l i c i e s and procedures (42%) p r i o r to the introduction of the new recording system than they had of POR format, concepts and d e f i n i t i o n s (28%). One month following the i n s e r v i c e program, t h e i r POR knowledge surpassed t h e i r general recording knowledge (84% to 71%). The i n s e r v i c e program was expected to help the s t a f f acquire new knowledge so i t i s tempting to accept those r e s u l t s as proof of i t s e f f i c a c y . However, several a l t e r n a t i v e explanations are possible and those must be considered before reaching such a conclusion. According to Campbell and Stanley (1966), eight classes of extraneous v a r i a b l e s may, i f not controlled i n the experimental design, confound the e f f e c t of an experimental treatment. Those threats to i n t e r n a l v a l i d i t y are contemporary h i s t o r y , maturation processes, pre-te s t i n g procedures, measuring instruments, s t a t i s t i c a l regression, d i f f e r e n t i a l s e l e c t i o n of subjects, d i f f e r e n t i a l experimental m o r t a l i t y and selection-maturation i n t e r a c t i o n s . To control f or some of those extraneous v a r i a b l e s a non-equivalent co n t r o l group was established f or the s p e c i f i c purpose of answering the question: Did the i n s e r v i c e program (independent variable) produce a change i n knowledge (dependent var i a b l e ) ? The non-equivalent control group consisted of 19 PTs and OTs who were attending a r e h a b i l i t a t i o n seminar course. They completed the CRKI twice, with a one week i n t e r v a l between t e s t s , and received no i n s t r u c t i o n i n record-keeping p r a c t i c e s . Giving both groups the same t e s t (CRKI) insured against mistaking the e f f e c t s of pretesting and instrumentation for the main e f f e c t s of the i n s e r v i c e program. But, the control group took the 107 test at a d i f f e r e n t period to time so contemporary h i s t o r y was not t o t a l l y c o n trolled for. To determine whether a major event r e l a t i n g to recording of POR occurred during the study a regular check was made of professional journals and other hospital-wide i n s e r v i c e programs. No events were noted so i t seems reasonable to conclude that contemporary h i s t o r y did not sub-s t a n t i a l l y confound the experimental treatment. Maturation processes within the group were con t r o l l e d for by giving the pretest and subsequent posttests at the same time of day. This manoeuvre was expected to hold any fatigue f a c t o r constant. However, the time of day was not the same for each group. The experimental group completed the test i n the early afternoon whereas the c o n t r o l group took the test i n the early evening. Also, the time gap was not the same between pretest and posttest; the experimental group had a five-week gap and the c o n t r o l group had a one-week gap. Because of those d i s s i m i l a r i t i e s the confounding e f f e c t s of maturation processes cannot be e n t i r e l y ruled out; there i s a s l i g h t p o s s i b i l i t y that those e f f e c t s may mask the r e a l t r e a t -ment e f f e c t s . As both groups remained i n t a c t throughout the t e s t i n g period d i f f e r e n t i a l m o r tality did not occur. S i m i l a r l y , s t a t i s t i c a l regression was not an issue as subjects were not selected on the basis of extreme scores. Isaac and Michael (1971) maintain that the main threat to i n t e r n a l v a l i d i t y i n the non-equivalent co n t r o l group design a r i s e s from i n t e r a c t i o n between such v a r i a b l e s as s e l e c t i o n and maturation, s e l e c t i o n and h i s t o r y , or s e l e c t i o n and t e s t i n g . They argue that without random s e l e c t i o n there i s always the p o s s i b i l i t y a c r i t i c a l d i f f e r e n c e e x i s t s between the two groups that can contaminate the posttest data. C e r t a i n l y , i t can be argued 108 i n the present study that the control group might have been more ready to learn because they were enrolled i n a U n i v e r s i t y course. For t h i s i n t e r -action to present a substantial threat to i n t e r n a l v a l i d i t y i t would be necessary to show an increase i n c o n t r o l group posttest scores. This did not m a t e r i a l i z e ; the scores between the tests remained v i r t u a l l y the same. Afte r examining the major sources of contamination, i t i s concluded that the i n s e r v i c e education program was mainly responsible for the observed increase i n knowledge. Thus, i t i s judged to be successful, insofar as i t helped therapists gain a greater understanding of a l l aspects of recording. Knowledge Retention The knowledge test was repeated four months a f t e r the i n s e r v i c e program and the r e s u l t s show that therapists retained a l l t h e i r newly acquired recording knowledge. This r e s u l t i s s i m i l a r to the findings of other researchers who have investigated the long-term e f f e c t s of educa-t i o n a l programs. For example, Deets and Blume (1977) found that nurses retained a s i g n i f i c a n t amount of newly acquired materials f o r at l e a s t three months a f t e r they had attended a continuing education workshop. Donegan et a l . (1976) reported s i m i l a r findings from four programs for anesthesiologists, and Jamieson (1972) found that housewives i n the 24 to 39 age group retained newly acquired material for at l e a s t four months. The findings of the present study add to the growing body of empirical data r e l a t i n g to rates of knowledge retention among adults. Furthermore, they lend support to the notion that i n s e r v i c e educators can expect p a r t i c i -pants i n t h e i r programs to r e t a i n a very high portion of newly acquired knowledge over several months. The high l e v e l of knowledge retention may have been due, i n part, 109 to the i n s t r u c t i o n a l technique used throughout the i n s e r v i c e program. A workshop format was used because i t i s i n accord with two fi r m l y established p r i n c i p l e s of the adult learning process. F i r s t , learning i s an act i v e process, and therefore the most suitable technique i s one that encourages act i v e p a r t i c i p a t i o n (Verner & Booth, 1964; Hutchinson, 1974; Knowles, 1970). Second, retention i s enhanced when adults are given the opportunity to immediately apply the newly learned material (Verner & Booth, 1964). The format used i n t h i s study met those conditions; i t encouraged active p a r t i c i p a t i o n by emphasizing discussion and keeping d i d a c t i c presentations at a minimal l e v e l , and i t made pro v i s i o n f o r immediate a p p l i c a t i o n by including r e a l and simulated problems for the s t a f f to solve. It was thought that those actions would a s s i s t the PTs and OTs to gain and r e t a i n a s u b s t a n t i a l amount of new knowledge. Motivation to Change The second personal a t t r i b u t e expected to be important i n deter-mining performance change was motivation to change. Motivation i s the end product of a serie s of complex i n t e r a c t i o n s among several v a r i a b l e s . Depending on which motivational t h e o r i s t one reads, those v a r i a b l e s might include p h y s i o l o g i c a l and psychological needs, i n t r i n s i c f e e l i n g s of s a t i s f a c t i o n , and e x t r i n s i c events such as the company's reward system, the value attached to a p a r t i c u l a r outcome, the expectation that a p a r t i c u l a r a c t i o n w i l l lead to a desired outcome, and a b e l i e f that achieving one goal w i l l lead to another goal. Faced with the obvious complexity of measuring an i n d i v i d u a l ' s motivation to change his s t y l e of recording, i t was decided to approach the concept through a multiple measure. The development of t h i s f o u r - f o l d measure was based on two assumptions. F i r s t , i t was assumed that a perceived d e f i c i t between 110 a p r e s e n t and expected s t a t e a c t s as a m o t i v a t i o n a l f o r c e . T h i s assump-t i o n i s c l o s e l y r e l a t e d t o Leagans' (1966) concept of need and C o f f e y and Golden's (1973) concept of t e n s i o n between the i n d i v i d u a l and h i s s u r r o u n d i n g f i e l d . The second assumption was t h a t the importance a t t a c h e d to a p a r t i c u l a r gap or p e r c e i v e d d e f i c i t a c t s as a m o t i v a t i o n a l f o r c e . The f o u r - f o l d measure of m o t i v a t i o n to change c o n t a i n s two measures of d e f i c i e n c y : leeway and gap. E s s e n t i a l l y , leeway p r o v i d e s a g l o b a l v iew of p e r c e i v e d d e f i c i t as i t measures the e x t e n t t o which the e n t i r e d e p a r t m e n t a l r e c o r d i n g system f u l f i l l e d the most b a s i c r e q u i r e m e n t of r e c o r d i n g , t h a t i s , f a c t u a l r e c o r d i n g of p a t i e n t c a r e . Gap i s much more s p e c i f i c ; i t f o c u s e s on the c o n t e n t s of a r e c o r d . S t a f f were asked t o compare c u r r e n t c o n t e n t w i t h " i d e a l " c o n t e n t . I t c o u l d be argued t h a t t h o s e two measures o v e r l a p p e d . I f t h i s were the case the v a r i a b l e s would be h i g h l y c o r r e l a t e d . I n s p e c t i o n of s i m p l e c o r r e l a t i o n c o e f f i c i e n t s show a moderate amount of o v e r l a p ( r = .60). T h i s f i n d i n g s u g g e s t s t h a t f u t u r e r e s e a r c h e r s may f i n d i t p r o f i t a b l e t o combine the g l o b a l and s p e c i f i c a s p e c t s of d e f i c i t . The t h i r d measure of m o t i v a t i o n t o change d e a l s w i t h the i s s u e of importance. T h i s measure a l s o f o c u s e d on the c o n t e n t of a p a t i e n t - c a r e r e c o r d . In e s s e nce, s t a f f were asked t o s t a t e how i m p o r t a n t each " i d e a l " o b j e c t i v e was t o them. I t i s i n t e r e s t i n g to note t h a t importance has low c o r r e l a t i o n s w i t h b o t h leeway ( r = .17) and gap ( r = .28). Those low> c o r r e l a t i o n s i n d i c a t e t h a t importance has m i n i m a l o v e r l a p w i t h b o t h d e f i c i e n c y measures. T h i s f i n d i n g i s noteworthy because i t tends t o con-f i r m an o b v ious but o f t e n f o r g o t t e n a s p e c t of change, t h a t i s , acknow-ledgement of a gap by s t a f f does not imply a s t r o n g d e s i r e to reduce i t . The f o u r t h measure of m o t i v a t i o n , impetus, i s a h y p o t h e t i c a l v a r i a b l e c o n s t r u c t e d from two d i r e c t l y measured v a r i a b l e s . The c o n s t r u c -t i o n of impetus was based on the n o t i o n t h a t a p e r c e i v e d d e f i c i t combined w i t h the importance of the d e f i c i t might more a c c u r a t e l y i n d i c a t e a s t a t e of t e n s i o n between the i n d i v i d u a l and h i s s u r r o u n d i n g f i e l d and, as such, i t might be the " b e s t " i n d i c a t o r of a m o t i v a t i o n to change. Indeed, t h e r e i s some e v i d e n c e t o support t h i s n o t i o n as a n a l y s i s of the b e t a w e i g h t s show t h a t an i n c r e a s e i n impetus would c r e a t e the g r e a t e s t change i n t o t a l a c q u i s i t i o n of POR. The r e s u l t s r e p o r t e d f o r each m o t i v a t i o n v a r i a b l e a r e s u f f i c i e n t l y p o s i t i v e t o c o n c l u d e t h a t the s t a f f p o s s e s s e d m o t i v a t i o n t o change p r i o r t o the i n t r o d u c t i o n o f POR. CHANGES IN ORGANIZATIONAL FACTORS The p r e s e n c e of c e r t a i n o r g a n i z a t i o n a l f o r c e s was e x p e c t e d t o i n f l u e n c e a c q u i s i t i o n and maintenance of r e c o r d i n g b e h a v i o u r . The f o r c e s examined i n t h i s s t u d y were performance s t a n d a r d s , r e s o u r c e s and r e i n -f o r c e r s f o r p r o p e r r e c o r d i n g . B e f o r e c o n s i d e r i n g t h e r e l a t i o n s h i p s among th o s e f o r c e s and performance change, i t i s n e c e s s a r y t o e s t a b l i s h how the s t a f f f e l t about each f a c t o r and i f t h e i r p e r c e p t i o n s changed throughout the i m p l e m e n t a t i o n of POR. D e p a r t m e n t a l G u i d e l i n e s f o r R e c o r d i n g The d e p a r t m e n t a l g u i d e l i n e s f o r r e c o r d i n g c o n t a i n e d the s t a n d a r d s f o r p r o p e r performance t h a t the s u p e r v i s o r s had e s t a b l i s h e d p r i o r t o the i m p l e m e n t a t i o n of POR. The p r e s e n c e of t h o s e s t a n d a r d s was expected t o p l a y a key r o l e i n a l t e r i n g r e c o r d i n g b e h a v i o u r because, as performance e x p e r t s (Mager & P i p e , 1971; N i s b e r g , 1976; Rummler, 1976) p o i n t out, workers need t o know what i s expected of them. 112 The f i n d i n g s a t b a s e l i n e show t h a t PTs and OTs f e l t the e x i s t i n g g u i d e l i n e s were not c l e a r l y d e f i n e d or r e a d i l y u n d e r s t a n d a b l e . T h i s r e s u l t i s h a r d l y s u r p r i s i n g as none of the f o u r departments s t u d i e d had a d e t a i l e d r e c o r d - k e e p i n g p o l i c y manual nor had t h e y e s t a b l i s h e d an a u d i t i n g system to m o n i t o r r e c o r d i n g p r a c t i c e s . T h e r a p i s t s ' p e r c e p t i o n s of t h e performance s t a n d a r d s changed d u r i n g the f i r s t month of the POR program and remained unchanged a t t h a t new l e v e l throughout the next t h r e e months. A t the end of t h e f i r s t month they f e l t the d e p a r t m e n t a l g u i d e l i n e s f o r c o r r e c t r e c o r d - k e e p i n g were more s h a r p l y f o c u s e d . The change from b a s e l i n e to one month was s m a l l but s t a t i s t i c a l l y s i g n i f i c a n t . The p e r c e i v e d i n c r e a s e d c l a r i t y o f d e p a r t m e n t a l r e q u i r e m e n t s f o r r e c o r d - k e e p i n g was p r o b a b l y due to t h e i n s e r v i c e program, where s t a n d a r d s were e x p l i c i t l y d e s c r i b e d , and to the d i s t r i b u t i o n o f a manual c o n t a i n i n g a l l the r e q u i r e d p r o c e d u r e s to each s t a f f member. While i t i s n o t known whether PTs o r OTs r e a d t h e i r copy o f the manual, i t i s c o n s i d e r e d to be a l i k e l y p o s s i b i l i t y . I t i s noteworthy t h a t t h e mean v a l u e s f o r the performance s t a n d a r d s v a r i a b l e d i d not r i s e above the m i d - p o i n t of th e s c a l e . T h i s s u g g e s t s t h a t s t a f f were not i n w h o l e h e a r t e d agreement w i t h the c l a r i t y or s u i t -a b i l i t y o f the r e q u i r e d s t a n d a r d s . As performance s t a n d a r d s a r e c o n s i d e r e d to be an i n t e g r a l p a r t of any worker's j o b performance, t h i s a pparent l a c k of s a t i s f a c t i o n w a r r a n t s c l o s e r e x a m i n a t i o n by f u t u r e r e s e a r c h e r s . R e i n f o r c e r s and Resources Two o r g a n i z a t i o n a l f a c t o r s were expected to a c t as b a r r i e r s to change. Those were i n a d e q u a t e r e i n f o r c e r s and i n s u f f i c i e n t r e s o u r c e s f o r p r o p e r r e c o r d i n g . The f i n d i n g s show t h a t t h e r a p i s t s f e l t r e i n f o r c e r s f o r p r o p e r r e c o r d i n g were low. T h i s r e s u l t comes as no s u r p r i s e as PTs and OTs elsewhere repeatedly complain that no-one ever reads t h e i r records. "No-one" usually r e f e r s to physicians and nurses working on the same team but i t might also include the department supervisor and other members of h o s p i t a l management. Ce r t a i n l y , i n the h o s p i t a l s studied, no mechanisms existed f o r regular auditing of PT/OT records so i t seems l i k e l y that supervisors were not i n a p o s i t i o n to either praise or c r i t i c i z e s t a f f members for t h e i r record-keeping p r a c t i c e s on a regular basis. The low l e v e l of r e i n f o r c e r s perceived to e x i s t at the beginning of the study persisted throughout the implementation of POR. This lack of change indicates that even when therapists switched from one recording s t y l e to another they received no encouragement from any outside source. The consequences of t h i s lack of reinforcement w i l l be discussed i n a l a t e r section. I t was somewhat su r p r i s i n g to f i n d that the s t a f f perceived resources such as time and materials were adequate. The r e s u l t was unexpected because a previous study done by McGregor (1972) showed that PTs and OTs f e l t too much of t h e i r time was spent on recording. Also, interviews with s t a f f i n many locations p r i o r to the present study revealed that therapists were unhappy with the amount of time needed f o r recording and often f r u s t r a t e d with poorly designed recording forms. Perhaps the context i n which the issue of a v a i l a b i l i t y of resources was examined explains the d i s p a r i t y of responses. P h y s i c a l and occupational therapists i n t h i s study expressed t h e i r f e e l i n g s while t r y i n g to improve t h e i r record-keeping p r a c t i c e s , whereas the other groups were surveyed i n a "no-change" s i t u a t i o n . It could be argued that therapists involved i n change might experience some form of dissonance i f t h e i r actions are at variance with t h e i r b e l i e f s so they reduce the c o n f l i c t by changing t h e i r b e l i e f s . The surveyed groups 114 would probably not experience t h i s c o n f l i c t because they were not required to take action. During the implementation of POR, therapists f e l t the resources did not change. This r e s u l t was not surp r i s i n g as no attempt was made to increase the time a v a i l a b l e f o r record-keeping or to change the recording forms. ACQUIRING AND MAINTAINING POR To t h i s point, i t has been established that therapists possessed a motivation to change, gained and retained knowledge about recording procedures and POR format, perceived an improvement, which pe r s i s t e d , i n the c l a r i t y of departmental requirements f o r recording, f e l t resources were j u s t adequate, and f e l t r e i n f o r c e r s were low and stable. How did those factors influence the a c q u i s i t i o n and maintenance of POR? The findings show that the j o i n t combination of a motivation to change, increased knowledge and improved performance standards (primary subset) added s i g n i f i c a n t l y more variance to a c q u i s i t i o n of POR than perceived l e v e l s of r e i n f o r c e r s and resources (secondary subset). This indicates that PTs and OTs implemented POR when they were motivated to change, gained a d d i t i o n a l knowledge of recording procedures and when they perceived an improvement i n the c l a r i t y of departmental requirements f o r proper record-keeping. Implementation was not s i g n i f i c a n t l y affected by the low l e v e l s of r e i n f o r c e r s and the presence of just adequate resources (as perceived by the s t a f f ) . The pattern observed i n the complete record (Figure 21) also occurred i n each POR component (Figure 19, p. 98) and, with the exception of data base, the addition of the secondary subset did not s i g n i f i c a n t l y increase the variance explained by the primary subset. 115 Figure 21 Distribution of Explained Variance in Acquisition Phase (Complete Record) A somewhat different picture emerged after an interval of three months. The findings show that the newly acquired recording behaviour had declined to some extent and the joint contribution of resources, rein-forcers and performance standards (the primary subset in the maintenance phase) added significantly more variance to the loss than motivation to change and loss of knowledge (secondary subset). This indicates that decline in POR was more closely associated with persistent low levels of reinforcers, lack of change in the available resources and lack of further improvement in departmental requirements for proper record-keeping. Problem oriented recording loss was not significantly affected by i n i t i a l levels of motivation to change and retained knowledge. 116 The pattern observed in the complete record as may be seen in Figure 22 occurred in four components, the exception was follow-up where the pattern was reversed, as may be seen in Figure 20, p. 99 . It i s useful to identify combinations of factors that help staff acquire and subsequently lose new behaviour patterns, but i t is more useful to know which factor i s the most potent. Three lines of evidence converge to suggest that motivation to change is the major factor influencing acquisition. Motivation to change accounted for one-third of explained change in overall POR implementation, and also contributed the most to change in three POR components: data base, documentation and treatment plan. Furthermore, in data base and documentation, motivation to change accounted for almost twice as much change as increased knowledge and improved performance standards combined. Figure 22 Distribution of Explained Variance in Maintenance Phase (Complete Record) 117 Motivation to change played a key r o l e i n promoting a c q u i s i t i o n but, with the exception of one component, i t had a minor part i n the subsequent decline of POR format. The findings i n the maintenance phase show that two f a c t o r s share the r e s p o n s i b i l i t y f or loss of POR. Those factors are persistent low l e v e l s of r e i n f o r c e r s and lack of change i n a v a i l a b l e resources. Together they account for s l i g h t l y more than two-t h i r d s of explained loss of POR i n the o v e r a l l record with each c o n t r i -buting almost equally to the loss. In those i n d i v i d u a l components where a s i g n i f i c a n t l o s s occurred, problem focus and treatment plan, the l e v e l of resources was the primary contributor to explained change. In two com-ponents where the loss of POR was not s i g n i f i c a n t resources was the major contributor i n one (data base) and r e i n f o r c e r s i n the other (documentation). Neither contributed much to loss i n follow-up where motivation to change was the primary contributor. Before concluding t h i s discussion of a c q u i s i t i o n and maintenance of POR, i t i s necessary to speculate b r i e f l y on the variance i n perfor-mance change that was unaccounted for by the selected forces. Variance explained by the f i v e selected forces i n the two phases of change was 33% and 34% r e s p e c t i v e l y ; thus, over 60% of observed change was not accounted for by those forces. Obviously, there were other personal and organizational-related forces f a c i l i t a t i n g and hindering the change process. In looking for l i k e l y sources of influence, i t might be u s e f u l to consider the impact of the i n s e r v i c e program on s t a f f a t t i t u d e s . The i n s e r v i c e program was intended to act as the unfreezing event and, as such, i t was designed to create a major impact on both at t i t u d e s and knowledge. This impact was achieved i n several ways. For example, the program was given a high p r o f i l e by holding f i v e sessions on 118 consecutive days instead of the more usual once-a-week scheduling, and the sessions were held i n a conference room rather than the PT/OT department. Those actions were expected to help s t a f f r e a l i z e that t h i s was a serious attempt to introduce a new recording method and not the usual run-of-the-m i l l i n s e r v i c e program. Other actions and a c t i v i t i e s associated with the i n s e r v i c e program that may have helped to induce p o s i t i v e a t t i t u d e s toward recording included showing a video tape of Lawrence Weed explaining the philosophy, concepts and usefulness of POR (Weed presents the material i n a humorous fashion); discussing with the s t a f f the impact of better c l i n i c a l data on the future growth of both professions; and allowing the medical records l i b r a r i a n to share the learning experience. This l a t t e r a c t i o n probably helped the s t a f f to r e a l i z e they were doing something new and important. If the s t a f f were ready to engage i n the change process, and the motivational measurements indicated they were, i t seems reasonable to propose that the i n s e r v i c e program boosted t h e i r a t t i t u d e s toward change. As w e l l as increasing t h e i r e x i s t i n g motivation, the program may have aroused a sense of p r o f e s s i o n a l pride and induced a f e e l i n g of challenge. Taken together, those a t t i t u d i n a l changes may be responsible for some of the variance unaccounted for by selected v a r i a b l e s . The implications of t h i s observation for further research, along with other issues that have been i d e n t i f i e d i n the course of t h i s discussion, w i l l be more f u l l y explored i n the next chapter. Chapter 7 SUMMARY AND IMPLICATIONS This chapter draws together the previous six chapters through a summary of the presented material. Implications with respect to theory, p r a c t i c e and further research complete the chapter. SUMMARY Formal research r e l a t i n g to the impact of ins e r v i c e education on employee performance change i n health-care agencies i s scarce, yet "i n s e r v i c e " remains a primary strategy for implementing change. From the few a v a i l a b l e studies, i t appears that educational programs probably contribute to short-term changes i n employee performance but they have s u b s t a n t i a l l y l e s s impact on the long-term maintenance of those changes. Performance consultants and change t h e o r i s t s suggest that educational a c t i v i t i e s are u n l i k e l y to produce permanent change because they are limi t e d to inducing changes i n the employee, whereas a successful change attempt requires a l t e r a t i o n s i n both the person and his environment. The purpose of t h i s study was to investigate r e l a t i o n s h i p s among i n i t i a l and subsequent changes i n a work-related behaviour and concommitant changes i n selected personal and organizational f a c t o r s . The s p e c i f i c behaviour was a new method of recording patient-care, c a l l e d "Problem Oriented Recording (POR)" and the p a r t i c i p a n t s were 62 ph y s i c a l therapists (PTs) and occupational therapists (OTs) located i n four h o s p i t a l s i n the Greater Vancouver area. The personal and organizational v a r i a b l e s selected 119 120 for study were: (1) motivation to change, changes i n (2) knowledge, (3) performance standards, (4) resources, and (5) r e i n f o r c e r s f or proper recording. The dependent v a r i a b l e , recording performance, was divided into f i v e components: data base, problem focus, treatment plan, follow-up and documentation. The hypothesized r e l a t i o n s h i p s among the dependent and independent v a r i a b l e s were as follows: a c q u i s i t i o n of recording behaviour i s more c l o s e l y linked to motivation to change, increase i n knowledge and presence of performance standards than to resources and r e i n f o r c e r s f or proper recording; and maintenance of recording i s more c l o s e l y linked to the presence of performance standards, resources and r e i n f o r c e r s than to loss of knowledge and motivation to change. Two research hypotheses were proposed and tested for s i g n i f i c a n c e . 1. The a d d i t i o n a l variance i n a c q u i s i t i o n of recording behaviour accounted for by resources and r e i n f o r c e r s would not s i g n i f i c a n t l y increase the variance accounted for by increase i n knowledge, motivation to change and presence of performance standards. 2. The a d d i t i o n a l variance i n maintenance of recording behaviour accounted for by retention of knowledge and motivation to change would not s i g n i f i c a n t l y increase the variance accounted for by the presence of performance standards, resources and r e i n f o r c e r s . An alpha l e v e l equal to .05 was used to test for s i g n i f i c a n c e . The study design was a modified time-series experimental design with measurements of a l l v a r i a b l e s except motivation occurring three times: before the introduction of POR (baseline), one month l a t e r and again three months l a t e r . Motivation to change was measured at baseline only. Four instruments were developed to measure the dependent and independent v a r i a b l e s . Knowledge was measured by the C l i n i c a l Record Keeping Inventory (CRKI), a 13-item, short answer r e c a l l t e s t . The Recording 121 Needs Survey (RNS), a 7-item survey with a 6-point, Likert-type r a t i n g scale, was used to determine motivation to change. Therapists' perceptions of performance standards, r e i n f o r c e r s and resources for proper recording were measured by the Recording Opinions Survey (ROS), a 20-item, a t t i t u d e survey with a 5-point, Likert-type scale. Recording performance was measured by the Format Review Audit Sheet (FRAS), a 23-item c h e c k l i s t with a 2-point scale. The CRKI, RNS and ROS were tested for r e l i a b i l i t y p r i o r to the study. The FRAS was judged by users i n other centres to be a stable instrument. POR was introduced into four PT and two OT departments through an in s e r v i c e education program. The program consisted of f i v e hours of i n s t r u c t i o n spread over f i v e consecutive working days. Af t e r t h i s intensive program, two 1-hour sessions were held; the f i r s t a f t e r an i n t e r v a l of one month and the second three months l a t e r . E s s e n t i a l l y , those sessions were non-instructional; they were used to administer the CRKI and ROS, and to c l a r i f y any procedural problems ra i s e d by the s t a f f . Data on record-keeping were c o l l e c t e d from 744 patient-care records. Four sets of patient-care notes (PT/OT section) for each month preceding the three measurement points were selected randomly for each of 62 thera-p i s t s and scored f or the use of POR format i n the complete record and i n each of the following f i v e sub-divisions of the record: data base, problem focus, treatment plan, follow-up notes and documentation. Several types of data analysis were ca r r i e d out including regression r e s i d u a l scores for changes i n knowledge and recording performance, gain scores for changes i n performance standards, resources and r e i n f o r c e r s , r e l i a b i l i t y estimates for each subset of items on the RNS, ROS and FRAS, and t - t e s t s (correlated means) for changes i n knowledge and recording 122 performance d u r i n g the a c q u i s i t i o n phase and the maintenance phase. M u l t i p l e r e g r e s s i o n a n a l y s i s was used to i n v e s t i g a t e the r e l a t i o n s h i p s between changes i n r e c o r d i n g performance i n each of the f i v e components and changes i n the independent v a r i a b l e s . A g e n e r a l h i e r a r c h i c a l r e g r e s s i o n p r o c e d u r e was used to t e s t b o t h hypotheses which were c o n f i r m e d . The s i g n i f i c a n t f i n d i n g s were t h e s e : PTs and OTs a c q u i r e d the new r e c o r d i n g b e h a v i o u r and the a c q u i s i t i o n was more c l o s e l y a s s o c i a t e d w i t h m o t i v a t i o n to change, a p e r c e i v e d improvement i n department r e q u i r e m e n t s f o r r e c o r d - k e e p i n g and i n c r e a s e s i n knowledge than w i t h p e r c e i v e d low l e v e l s of r e i n f o r c e r s and j u s t adequate l e v e l s o f r e s o u r c e s f o r p r o p e r r e c o r d i n g and, a f t e r an i n t e r v a l o f t h r e e months, t h e r a p i s t s l o s t 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 amount of the newly a c q u i r e d r e c o r d i n g b e h a v i o u r . T h i s l o s s was more c l o s e l y l i n k e d to p e r s i s t e n t low l e v e l s of r e i n f o r c e r s and l a c k of change i n r e s o u r c e s and d e p a r t m e n t a l r e q u i r e m e n t s than to m o t i v a t i o n to change and h i g h l e v e l s o f r e t a i n e d knowledge. Other noteworthy f i n d i n g s were t h a t : t h e r a p i s t s p e r c e i v e d a r e l a t i v e l y l a r g e d e f i c i t t o e x i s t between t h e i r c u r r e n t r e c o r d s and an " i d e a l " r e c o r d ; they a t t a c h e d c o n s i d e r a b l e importance to an " i d e a l " r e c o r d ; and they r e t a i n e d a l l the knowledge g a i n e d i n the i n s e r v i c e program f o r a t l e a s t t h r e e months. R e i n f o r c e r s were p e r c e i v e d as low throughout the s t u d y . Resources were p e r c e i v e d to be j u s t adequate and remained so. D epartmental r e q u i r e m e n t s improved i n the a c q u i s i t i o n phase and showed no f u r t h e r change. IMPLICATIONS T h i s s t u d y i d e n t i f i e d a s e t o f c o n d i t i o n s t h a t was of c r i t i c a l importance i n e x p l a i n i n g why performance of a w o r k - r e l a t e d t a s k i n c r e a s e d and s u b s e q u e n t l y d e c l i n e d . T h e o r e t i c a l , p r a c t i c a l and r e s e a r c h i m p l i c a t i o n s 123 t h a t f l o w from the f i n d i n g s a r e c o n s i d e r e d i n t h i s c o n c l u d i n g s e c t i o n . T h e o r e t i c a l I m p l i c a t i o n s One of the b a s i c r e s e r v a t i o n s about the s o l e r e l i a n c e on i n s e r v i c e e d u c a t i o n as a means of implementing l o n g - l a s t i n g change i s t h a t i t f o c u s e s on changing the p e r s o n and i g n o r e s changing the w o r k - s e t t i n g . One of t h e purposes of t h i s study was to p l a c e an i n s e r v i c e program w i t h i n a b r o a d e r framework of change and thus i d e n t i f y f o r e d u c a t o r s and s u p e r v i s o r s a d d i t i o n a l c o n c e p t s t h a t i n f l u e n c e a d e l i b e r a t e attempt to change performance. The framework s e l e c t e d f o r t h i s t a s k was Lewin's model of change (Lewin, 1947). The f i n d i n g s showed t h a t the L e w i n i a n model of change was a s u i t a b l e model f o r p r e d i c t i n g changes i n r e c o r d i n g b e h a v i o u r . A c c o r d i n g t o t h a t model, performance l e v e l s r i s e when a net change o c c u r s i n the f o r c e f i e l d s u r r o u n d i n g the t a r g e t b e h a v i o u r and t h e y f a l l when the new f o r c e f i e l d i s not s t a b i l i z e d . A net change i s a c h i e v e d by s t r e n g t h e n i n g or a d d i n g d r i v i n g f o r c e s , r e d u c i n g or removing r e s t r a i n i n g f o r c e s , or making changes to b o t h s e t s of f o r c e s . A new b a l a n c e i s a c h i e v e d by s t a b i l i z i n g the f o r c e s a c t i n g on the new l e v e l . I m p l i c i t i n the s t a b l i z a t i o n phase i s the need to c o n s i d e r the f o r c e s t h a t remained c o n s t a n t throughout the e n t i r e change p r o c e s s . In the p r e s e n t s t u d y , knowledge and m o t i v a t i o n were s t r e n g t h e n e d , the r e s t r a i n i n g i n f l u e n c e of i n a d e q u a t e department r e q u i r e m e n t s was r educed and performance l e v e l s r o s e . T h i s i m p l i e s a n e t change o c c u r r e d i n the f o r c e f i e l d . F o l l o w i n g t h o se i n i t i a l changes no f u r t h e r change o c c u r r e d i n any of the s e l e c t e d 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 and performance l e v e l s d e c l i n e d . T h i s i m p l i e s a s t a b l e rearrangement of the f o r c e f i e l d was n o t a c h i e v e d . Throughout the e n t i r e p r o c e s s two r e s t r a i n i n g f o r c e s , r e i n f o r c e r s and r e s o u r c e s remained c o n s t a n t and t h e se were shown 124 to be p r i n c i p a l l y responsible for performance decline. Both performance outcomes were consistent with predictions derived from Lewin's model, therefore, i t was concluded that t h i s model of change was appropriate for understanding changes i n recording performance. The r e s u l t s l e f t l i t t l e doubt that changes i n personal a t t r i b u t e s contributed s u b s t a n t i a l l y to i n i t i a l changes i n performance and lack of change i n the work-setting was mainly responsible f o r i t s subsequent decline. Those findings emphasize the necessity for a conceptual frame-work to account for the i n t e r a c t i o n between the performer and the perfor-mance se t t i n g . I t i s argued here that conventional models of i n s e r v i c e education do not provide such a framework; they are performer-oriented and not context-oriented and, as such, they focus on i d e n t i f y i n g and meeting the learning needs of s t a f f . Thus, the t y p i c a l i n s e r v i c e education model accounts for j u s t one portion of the requirements f o r on-the-job performance change. The RMPS model recognizes the need to integrate the performer and h i s work-setting but i t lacks the conceptual c l a r i t y of the Lewinian model i n the area of maintenance of r e s u l t s . The r e s u l t s of t h i s study i n d i c a t e that i n s e r v i c e education helps s t a f f to unfreeze and move, i t does not help them to refreeze. Therefore, i t seems that Lewin's model of change i s more appropriate for implementing long-l a s t i n g changes i n work-re l a t e d behaviour than an educator's approach to change. P r a c t i c a l Implications Three p r a c t i c a l implications emerged from t h i s study that may be of u t i l i t y to i n s e r v i c e educators and supervisors concerned with implementing new performance requirements. The f i r s t deals with the need for shared r e s p o n s i b i l i t y , the second focuses on the importance of a s i t u a t i o n a l analysis and the t h i r d r e f e r s to the advantages of evaluation. 125 The f i r s t idea to emerge from t h i s attempt to implement long-term changes into recording p r a c t i c e s i s that, i n a given s i t u a t i o n , the supervisor and the educator must share the r e s p o n s i b i l i t y for introducing permanent change i n s t a f f performance. Collaboration i s e s s e n t i a l because each has a unique contribution to make to the change process. The educator has the s k i l l s to help s t a f f become knowledgeable and enthusiastic and the supervisor has the power and p o s i t i o n to give or withhold the necessary r e i n f o r c e r s , resources and requirements. The pattern of change observed i n the introduction and implementation of POR implied that the outcome might have been more successful i f the educator and supervisor had acted i n unison. The second idea of considerable importance that emerged from t h i s study i s that constraints are bound to e x i s t i n the work-place therefore a deliberate e f f o r t should be made to i d e n t i f y them before the change program i s i n i t i a t e d . Educators are very f a m i l i a r with the importance of determining learning needs; the findings of t h i s study suggest that a s i t u a t i o n a l a nalysis i s equally important. For example, the major con-s t r a i n t s to sustained use of POR were persistent low l e v e l s of r e i n f o r c e r s and lack of change i n such things as time and materials. Post-hoc analysis showed those conditions existed before the change program began and they remained constant. Those data suggest that educators and supervisors might be i n a better p o s i t i o n to manage change when they have i d e n t i f i e d p o t e n t i a l obstacles. Just as an assessment of learning needs helpstto determine required personal changes so a s i t u a t i o n a l analysis helps to determine the necessary organizational changes. A t h i r d idea emerged from the findings that could be of considerable u t i l i t y to supervisors: the c r i t i c a l importance of evaluation with respect 126 to planning c o r r e c t i v e actions. Supervisors t y p i c a l l y assume that poor performance can be remedied by further i n s e r v i c e education. In many instances t h i s assumption may be wrong. Ce r t a i n l y , the findings i n the present study implied that another i n s e r v i c e program would have done l i t t l e to halt the d e c l i n i n g p r a c t i c e of POR. The important point here i s that the evidence to support t h i s i m p l i c a t i on came from the delayed posttests. Those tests showed that the s t a f f had not forgotten any of th e i r acquired knowledge. Without those evaluative measures, the super-v i s o r would have lacked information e s s e n t i a l for the planning of appropriate c o r r e c t i v e actions. Of course, the importance of evaluation i s not new; every program planning manual and text stresses the need for i t and most educators, no doubt, subscribe to the concept. I t i s , however, d i f f i c u l t to e l i c i t much evidence of i t s p r a c t i c e . I t i s argued here that supervisors need evaluative material and i t i s the educator's responsi-b i l i t y to provide i t . Implications f o r Further Research This study posed and answered some questions about performance change i n health-care agencies; however, i t also stimulated a set of ad d i t i o n a l issues that require further i n v e s t i g a t i o n . One of those issues concerns the g e n e r a l i z a b i l i t y of the findings. After a l l , PTs and OTs are only two of many groups of health-care p r a c t i t i o n e r s attempting to implement new recording systems. Doctors, nurses and s o c i a l workers, to name a few, are equally involved i n recording the care they give to patients. A d i r e c t o r of nursing services, for example, might be very interested i n knowing whether s i m i l a r or a d d i t i o n a l forces influence the intro d u c t i o n and implementation of a new recording system. Further i n v e s t i g a t i o n i s needed to c l a r i f y t h i s issue. 127 An issue of concern to h o s p i t a l administrators that was not addressed i n t h i s study i s the cost involved i n POR implementation programs. In terms of s t a f f time, the most obvious costs occur during the i n t r o -ductory phase when weekly i n s e r v i c e time i s increased from one hour to f i v e hours. Even though the r e s u l t s of t h i s study suggest that an intensive i n s e r v i c e program exerts a powerful influence on a c q u i s i t i o n of POR format, other types of learning a c t i v i t i e s should be investigated. However, costs of d e l i v e r y cannot be studied i n i s o l a t i o n . Common sense d i c t a t e s that costs of a c q u i s i t i o n r i s e when performance i s not maintained and an expensive program may prove to be cheaper i n the long run. 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APPENDICES 133 APPENDIX A Residual Regression Score A r e s i d u a l regression score i s the extent to which a p a r t i c u l a r i n d i v i d u a l ' s score d i f f e r s from the regression l i n e of a l l scores. The use of a r e s i d u a l score to define change i s s t a t i s t i c a l l y more defensible than a gain score f o r the following reasons: 1. It provides a s t a r t i n g point which i s common to a l l subjects. 2. It i s independent of and uncorrelated with i n i t i a l status. Thus, when i t i s correlated with outside v a r i a b l e s , c o r r e l a t i o n i s with gain defined as independent of i n i t i a l status rather than a mixed function, an unknown part of which i s i n i t i a l status. 3. The r e s i d u a l gain score does not assume a zero point of measurement. 135 APPENDIX B Formula f or Testing Hypotheses (incremental variance due to and X^)/M F = :  variance /(N - k - 1) res Where: X. and X_ are the secondary subset: 4 5 M i s the number of independent variables i n the subset for which the s i g n i f i c a n c e test i s being made; variance i s the unexplained variance; res N i s the number of cases; and k i s the number of independent v a r i a b l e s . (Nie et a l . , 1975, p. 339) APPENDIX C 136 FORMAT REVIEW AUDIT SHEET Date of Audit; Therapist: Record Items' Documentation Base 1 month 4 months Data Base Problem Focus Treatment Plan Follow-up Location: PRESENT = Diagnosis Source of r e f e r r a l Date of r e f e r r a l Patient I. D. on face sheet Patient I. D. on a l l continuation sheets A l l entries signed by therapist A l l entries dated A l l entries l e g i b l e Medical h i s t o r y S o c i a l h i s t o r y P hysical findings Projected treatment Correct problem wording A l l problems numbered Problem n o . / t i t l e for a l l treatment plans Problem n o . / t i t l e for a l l progress notes Treatment plan for each problem Frequency of treatment s p e c i f i e d Duration of plan s p e c i f i e d Expected response of patient s p e c i f i e d SOAP format used i n one progress note SOAP format used i n a l l progress notes Discharge summary 137 APPENDIX D Data r e l a t i n g to p i l o t test of RNS M e a n s , s t a n d a r d d e v i a t i o n s a n d r e l i a b i l i t y c o e f f i c i e n t s f o r i t e m s m e a s u r i n g c h a r a c t e r i s t i c s o f a n " i d e a l " r e c o r d ( f i g u r e s b a s e d o n p i l o t t e s t i n g a m o n g 4 9 s u b j e c t s ) M e a n S . D . T e s t -r e t e s t H i g h e s t r w i t h a n y o t h e r i t e m S q u a r e d m u l t i p l e C h a r a c t e r i s t i c C o d e P r e P o s t P r e P o s t r P r e P o s t c o r r e l a t i t T h e P T / O T r e c o r d i s a f a c t u a l j o u r n a l o f t h e c u r r e n t s t a t e o f t h e p a t i e n t P r e s e n t l y S h o u l d b e I m p o r t a n t t r u e t r u e 4 . 3 5 5 . 6 7 5 . 4 5 4 . 3 7 5 . 6 5 5 . 3 7 . 9 7 . 5 5 . 7 4 . 8 6 . 5 6 . 8 1 . 7 5 . 5 6 . 5 7 . 5 4 . 4 6 . 6 1 . 4 9 . 6 0 . 5 4 . 5 1 . 5 1 . 4 6 T h e P T / O T r e c o r d a c t s a s a n i m p o r t a n t c o m m u n i c a t i o n d e v i c e t o o t h e r m e m b e r s o f t h e p a t i e n t - c a r e t e a m P r e s e n t l y S h o u l d b e I m p o r t a n t t r u e t r u e 3 . 3 9 5 . 3 7 4 . 9 0 3 . 5 4 5 . 2 1 4 . 8 5 1 . 2 0 . 8 8 1 . 0 6 1 . 1 1 . 7 7 . 9 9 . 4 5 . 5 1 . 5 3 . 3 5 . 6 1 . 5 5 . 4 5 . 7 4 . 7 4 . 4 4 . 5 5 . 5 2 T h e r a p i s t s u s e P T / O T r e c o r d s t o i d e n t i f y g a p s i n t h e i r k n o w l e d g e P r e s e n t l y S h o u l d b e I m p o r t a n t t r u e t r u e 3 . 1 6 4 . 5 1 4 . 5 7 3 . 3 9 4 . 6 2 4 . 6 7 1 . 0 3 1 . 2 8 1 . 3 4 1 . 1 3 1 . 1 3 1 . 1 0 . 6 9 . 6 8 . 6 5 . 5 1 . 8 5 . 8 5 . 5 6 . 8 5 . 8 5 . 6 1 . 7 9 . 7 8 T h e P T / O T r e c o r d p r o v i d e s p e r s p e c t i v e a n d o b j e c t i v i t y n e c e s s a r y i n p l a n n i n g a n d i m p l e m e n t i n g t r e a t m e n t P r e s e n t l y S h o u l d b e I m p o r t a n t t r u e t r u e 4 . 2 0 5 . 3 3 5 . 3 9 4 . 2 7 5 . 4 2 5 . 3 3 1 . 0 0 . 8 3 . 8 4 . 9 9 . 6 5 . 7 2 . 5 5 . 4 8 . 4 8 . 5 5 . 6 0 . 6 0 . 4 9 . 6 3 . 7 1 . 6 0 . 7 1 . 6 4 T h e P T / O T r e c o r d p r o v i d e s d a t a f o r c l i n i c a l s t u d i e s a n d r e s e a r c h P r e s e n t l y S h o u l d b e I m p o r t a n t t r u e t r u e 3 . 0 2 5 . 0 8 4 . 7 8 3 . 2 8 5 . 0 2 4 . 6 2 1 . 3 4 1 . 0 1 1 . 1 6 1 . 1 2 1 . 0 6 1 . 2 5 . 5 5 . 4 7 . 7 3 . 5 4 . 5 3 . 5 3 . 5 8 . 7 8 . 7 8 . 5 9 . 6 3 . 5 5 T h e P T / O T r e c o r d p r o v i d e s i n f o r m a t i o n f o r s e t t i n g s t a n d a r d s o f p a t i e n t c a r e P r e s e n t l y S h o u l d b e I m p o r t a n t t r u e t r u e 3 . 8 8 5 . 2 5 5 . 4 4 3 . 6 9 5 . 1 9 5 . 2 3 1 . 3 3 . 8 4 . 7 4 1 . 3 2 . 9 1 . 8 8 . 5 8 . 5 6 . 6 0 . 6 3 . 5 6 . 6 0 . 6 3 . 7 6 . 7 6 . 7 2 . 7 8 . 7 5 T h e P T / O T r e c o r d p r o v i d e s a n i n d e x o f t h e q u a l i t y o f p a t i e n t c a r e P r e s e n t l y S h o u l d b e I m p o r t a n t t r u e t r u e 3 . 4 8 5 . 2 3 5 . 3 2 3 . 7 1 5 . 1 7 5 . 0 8 1 . 3 8 . 8 0 . 7 5 1 . 1 7 1 . 0 6 1 . 0 5 . 5 5 . 6 3 . 7 8 . 6 3 . 7 9 . 7 9 . 6 3 . 9 1 . 9 1 . 6 0 . 8 2 . 8 1 APPENDIX E Data Relating to P i l o t Test of ROS 1. Performance standard items. 2. Resources items. 3. Reinforcer items. M e a n s , s t a n d a r d d e v i a t i o n s a n d r e l i a b i l i t y c o e f f i c i e n t s f o r i t e m s m e a s u r i n g p e r f o r m a n c e s t a n d a r d s ( f i g u r e s b a s e d o n p i l o t t e s t i n g a m o n g 4 9 s u b j e c t s ) P e r f o r m a n c e s t a n d a r d i t e m s M e a n P r e P o s t S.D. P r e P o s t T e s t -r e t e s t c H i g h e s t r w i t h a n y o t h e r i t e m P r e P o s t S q u a r e d m u l t i p l e c o r r e l a t i o n T h e s t a n d a r d s f o r r e c o r d - k e e p i n g r e q u i r e d b y t h i s d e p a r t m e n t a r e d i f f i c u l t t o a t t a i n T h e i n s t r u c t i o n a l m a n u a l ( f o r r e c o r d i n g ) i s r e a d i l y a v a i l a b l e f o r r e f e r e n c e R e g u l a r a u d i t s s h o u l d b e d o n e t o m o n i t o r t h e r e c o r d - k e e p i n g o f s t a f f i n t h i s d e p a r t m e n t T h e p r o c e d u r e s f o r r e c o r d i n g a r e c l e a r l y ' s t a t e d i n t h e m a n u a l T h e p o l i c i e s a n d p r o c e d u r e s f o r r e c o r d i n g h a v e b e e n c l e a r l y e x p l a i n e d ' T h e s t a n d a r d s f o r r e c o r d - k e e p i n g r e q u i r e d b y t h e d e p a r t m e n t a r e r e a l i s t i c C o n s i s t e n t r e c o r d i n g i n t h i s d e p a r t m e n t r e q u i r e s t h a t t h e s u p e r v i s o r c h e c k e a c h c h a r t T h e e x p e c t a t i o n s f o r r e c o r d i n g a r e c l e a r l y d e f i n e d 2 . 8 0 2 . 6 5 1 . 1 4 . 9 5 3 . 5 2 3 . 4 0 1 . 4 5 1 . 0 5 3 . 7 3 3 . 6 5 . 8 9 . 8 0 3 . 1 7 3 . 5 6 . 8 9 . 8 2 3 . 5 3 3 . 4 7 . 8 4 . 8 9 3 . 5 5 3 . 6 4 . 8 9 . 8 0 2 . 2 7 2 . 3 3 1 . 0 7 . 9 7 3 . 2 2 3 . 4 5 1 . 0 3 . 8 7 . 6 1 . 6 6 . 7 2 . 6 0 . 6 9 . 7 4 . 4 9 . 5 6 . 4 6 . 6 4 . 3 9 . 6 4 . 5 6 . 4 6 . 4 1 . 5 6 . 5 6 . 5 3 . 5 2 . 7 3 . 6 1 - . 4 5 . 5 2 . 7 3 . 4 8 . 4 6 . 5 9 . 6 2 . 6 8 . 5 2 . 5 1 . 7 3 M e a n s , s t a n d a r d d e v i a t i o n s a n d r e l i a b i l i t y c o e f f i c i e n t s f o r i t e m s m e a s u r i n g r e s o u r c e s ( f i g u r e s b a s e d o n p i l o t t e s t i n g a m o n g 4 9 s u b j e c t s ) T e s t - H i g h e s t r w i t h S q u a r e d M e a n S . D . r e t e s t a n y o t h e r i t e m m u l t i p l e R e s o u r c e i t e m s P r e P o s t P r e P o s t r P r e P o s t c o r r e l a t i o n O n t h e w h o l e , t h e p a t i e n t ' s c h a r t i s a v a i l a b l e w h e n I g o t o w r i t e i n i t T h e r a p i s t s a r e t o o b u s y t r e a t i n g p a t i e n t s t o b e c o n c e r n e d w i t h d e t a i l e d r e c o r d i n g T h e r e c o r d s h e e t s u s e d I n t h i s d e p a r t m e n t a r e u n s u i t a b l e a n d I n a d e q u a t e T h e r a p i s t s s h o u l d s e t a s i d e p a r t o f e a c h d a y f o r r e c o r d i n g T h e r e c o r d i n g s h e e t s a r e k e p t n e a r t h e p a t i e n t s ' c h a r t s P r o b l e m o r i e n t e d r e c o r d i n g t a k e s m o r e t i m e t h a n t h e o l d m e t h o d T h e r a p i s t s i n t h i s d e p a r t m e n t s p e n d t o o m u c h t i m e r e c o r d i n g W r i t t e n r e c o r d s a r e a n u n n e c e s s a r y d u p l i c a t i o n o f v e r b a l c o m m u n i c a t i o n w i t h o t h e r m e m b e r s o f t h e p a t i e n t - c a r e t e a m 4 . 0 0 3 . 8 8 . 7 7 . 7 3 2 . 5 9 2 . 5 6 1 . 0 2 1 . 0 3 2 . 8 7 2 . 6 9 1 . 1 8 1 . 0 8 3 . 9 8 4 . 0 0 3 . 8 6 3 . 7 6 2 . 4 3 2 . 4 0 1 . 5 5 1 . 6 7 . 9 5 . 8 4 . 8 7 . 8 8 3 . 4 5 3 . 1 8 1 . 1 9 1 . 0 3 . 8 4 . 7 6 . 5 0 . 6 6 . 7 1 . 7 7 . 8 0 . 7 6 . 5 8 . 7 6 . 6 3 . 4 9 . 3 4 . 3 1 . 4 4 . 5 6 . 4 1 . 2 9 . 2 8 . 2 2 . 3 1 . 3 7 . 4 5 . 3 8 - . 4 4 - . 4 9 . 4 2 - . 3 1 . 4 0 . 5 4 . 5 0 . 3 4 . 3 8 . 4 8 . 5 5 . 3 4 M e a n a , s t a n d a r d d e v i a t i o n s a n d r e l i a b i l i t y c o e f f i c i e n t s f o r i t e m s m e a s u r i n g r e i n f o r c e r s f o r p r o p e r r e c o r d i n g ( f i g u r e s b a s e d o n p i l o t t e s t i n g a m o n g 4 9 s u b j e c t s ) R e l n f o r c e r i t e m s M e a n P r e P o s t S . D . P r e P o s t T e s t -r e t e s t r H i g h e s t r w i t h a n y o t h e r i t e m P r e P o s t S q u a r e d m u l t i p l e c o r r e l a t i o n I n f o r m a t i o n c o n t a i n e d i n t h e P T / O T p a t i e n t - c a r e r e c o r d s h o u l d b e u s e d f o r p e e r r e v i e w A l l m e m b e r s o f t h e p a t i e n t - c a r e t e a m s h o u l d r e a l a l l c o m p o n e n t s o f t h e r e c o r d D o c t o r s r e g u l a r l y r e a d t h e t h e r a p i s t ' s e n t r i e s i n t h e p a t i e n t - c a r e r e c o r d D e t a i l e d r e c o r d s a r e v a l u a b l e o n l y w h e n t h e y a r e r e a d b y a l l p e o p l e c a r i n g f o r t h e p a t i e n t D o c t o r s r e g u l a r l y c o m m e n t o n t h e u s e f u l n e s s o f t h e i n f o r m a t i o n w r i t t e n b y t h e t h e r a p i s t R e c o r d - k e e p i n g h a b i t s s h o u l d b e p a r t o f t h e a n n u a l p e r f o r m a n c e a p p r a i s a l o f t h e s t a f f R e c o r d - k e e p i n g h a s l o w p r i o r i t y w i t h t h i s h o s p i t a l ' s a d m i n i s t r a t i o n N u r s e s r e g u l a r l y r e a d t h e t h e r a p i s t ' s e n t r i e s i n t h e p a t i e n t - c a r e r e c o r d P r o b l e m o r i e n t e d r e c o r d i n g w i l l I m p r o v e t h e p r o f e s s i o n a l s t a t u s o f t h e r a p i s t s N u r s e s r e g u l a r l y c o m m e n t o n t h e u s e f u l n e s s o f t h e i n f o r m a t i o n w r i t t e n b y t h e r a p i s t s R e g u l a r m e e t i n g s s h o u l d b e h e l d t o d i s c u s s t h e p r o b l e m s o f c h a n g i n g t o a n e w r e c o r d i n g s y s t e m D e t a i l e d r e c o r d s a r e e s s e n t i a l f o r p e e r r e v i e w P r o b l e m o r i e n t e d r e c o r d i n g i m p r o v e s t h e r e l i a b i l i t y o f t h e i n f o r m a t i o n i n t h e r e c o r d T h e q u a l i t y o f c a r e t h a t t h e r a p i s t s g i v e t h e i r p a t i e n t s p a r a l l e l s t h e q u a l i t y o f t h e i r record-keeping 3 . 8 3 3 . 6 3 3 . 8 3 3 . 9 6 2 . 2 0 2 . 1 8 2 . 9 6 3 . 1 2 2 . 1 6 2 . 1 2 3 . 9 4 3 . 9 2 2 . 1 4 2 . 2 0 2 . 8 4 2 . 5 4 3 . 5 5 3 . 5 9 2 . 4 1 2 . 3 7 3 . 5 3 3 . 6 1 3 . 6 1 3 . 4 5 3 . 6 9 3 . 8 0 2 . 3 1 2 . 3 5 . 7 1 . 9 7 1 . 0 0 1 . 0 8 1 . 1 0 1 . 0 1 1 . 2 7 1 . 1 8 . 9 6 1 . 0 4 . 7 5 . 8 6 1 . 0 2 . 9 6 . 9 9 . 9 4 . 9 8 . 9 3 . 9 6 . 9 5 . 9 4 . 8 1 . 8 9 . 9 6 1 . 0 8 . 7 4 1 . 0 6 . 9 5 . 6 3 . 4 8 . 7 1 . 6 5 . 7 2 . 6 4 . 8 7 . 7 9 . 6 4 . 7 9 . 3 9 . 7 2 . 4 4 . 7 6 . 6 1 . 6 7 . 5 2 . 4 4 . 7 3 . 4 6 . 7 3 . 5 2 . 3 8 . 6 5 . 5 2 . 7 9 . 4 4 . 7 9 . 5 6 - . 5 1 - . 4 9 . 6 5 . 7 8 . 4 5 . 7 8 . 4 1 . 6 1 . 6 7 . 3 8 . 4 5 - . 4 4 . 3 5 . 4 9 . 5 4 . 6 7 . 4 1 . 6 1 . 5 1 . 5 8 . 7 6 . 4 9 . 7 4 . 4 4 . 6 0 . 4 4 . 4 9 APPENDIX F Regression data: acquisition and maintenance hypotheses IS » * » * » « * » » * » * • • » » * » » * * • * M U L T I P L E R E G R E S S I O N • * * • » # » « « » » • * VARIABLE REGRESSION LIST 1 LIST l) DEPENDENT VARIABLE.. RESIDP1 COMPLETE RECORD IN ACQUISITION PHASE < VARIABLEISI ENTERED ON STEP NUMBER 1 RESIDGK4 GENERAL KNOWLEDGE CHANGE BASE TO 1MTH RESI0SK4 NIMP NCHNG SPECIFIC KNOWLEDGE CHANGE BASE TO IMPORTANCE GAP 1MTH NSCHNG MTIMP TPRl LEEWAY IMPETUS STANDARDS BASELINE TPRC1 STANDARDS CHANGE BASE TO 1MTH MULTIPLE R 0.45867 R SQUARE 0.21038 AOJUSTEO R SQUARE 0.03965 ANALYSIS OF VARIANCE DF REGRESSION 8. RESIDUAL 37. SUM OF SQUARES 7.09612 26.63429 MEAN SQUARE 0.88701 0.71985 F 1.23223 P 0.3082 STANDARD ERROR 0.84844 ~ .'•»••••-- VAHlABLtb IN IMt EQUATION VARIABLES NOT IN THE EQUATION • VARIABLE 8 BETA STD ERROR B F VARIABLE BETA IN PARTIAL TOLERANCE f RES IDGK4 0.2 367790 RESI0SK4 -0.1795607 0.21096 -0.19920 0.17331 0.14872 1. 867 1.458 TINFl -0.16069 -0.16795 TINFCl 0.14688 0.15585 0.86259 0.88897 1.045 0.896 NIMP -0.4066062 NCHNG -0.1149242 NtCHNG -0.9 454236E-02 -1.91894 -0.74711 -0.22359 0.33467 0.12407 0.00809 1.476 0.858 1.366 TRRl 0.21659 0.19184 TRRCl -0.34362 -0.32432 0.61947 0.70341 1.375 4.232 HTIMP 0.4356699 TPRl 0.7912815E-01 TPRC1 0.9731250E-01 2.43338 0.31435 0.33131 0.35062 0.04629 0.05791 1.544 2.922 2.824 I CONSTANT 1 -2.392366 VARIABLEISI ENTERED ON STEP NUMBER 2.. TRRCl REINFORCERS CHANGE BASE TG 1MTH TINFl TINFCl TRRl RESOURCES BASELINE RESOURCES CHANGE BASE TO 1MTH REINFORCERS BASELINE MULTIPLE R 0.57625 ANALVSIS OF VARIANCE DF SUN OF SQUARES MEAN SQUARE F P R SQUARE 0.33206 AOJUSTEO R SQUARE 0.08918 STANDARO ERROR 0.82627 REGRESSION RESIOUAL 12. 33. 11.20064 22.52976 0.93339 0.68272 1.36716 0.2304 • VARIABLES IN THE EQUATION VARIABLES NOT IN THE EQUATION VARIABLE B BETA STO ERROR B F VARIABLE BETA IN PARTIAL TOLERANCE F RESIDGK4 0.2383606 RESIDSK4 -0.2693459 NIMP -0.6881043 0.21237 -0.29881 -3.24744 0.17749 0.15295 0.35614 1.803 3.101 3.733 NCHN6 -0.2066253 NtCHNG -0.1310931E-01 MTIMP 0.7241325 -1.34325 -0.31003 4.04456 0.13010 0.00877 0.37599 2.522 2.236 3.709 TPRl 0.7967712E-01 TPRCl 0.134 6623 TRRCl -0.6818585E-01 0.31653 0.45916 -0.30699 0.05706 0.06566 0.04322 1.950 4.219 2.489 TINFl -0.4598062E-01 TINFCl 0.30158T4E-01 TRRl 0.2288751E-01 -0.13676 0.10355 0.11187 0.06250 0.05295 0.04338 0.541 0.3 24 0.278 1 CONSTANT) -1.941188 ~ — • • * » * * * * • * * » * • » » » » * » » » * M U L T I P L E R E G R E S S I O N * * * • • • • • • * * * * VARIABLE LIST 1 REGRESSION LIST 2) > DEPENDENT VARIABLE.. RESIDPL1 DOCUMENTATION IN ACQUISITION PHASE VARIABLE!SI ENTERED ON STEP NUMBER 1 RESIDGK4 GENERAL KNOWLEDGE CHANGE BASE TO 1MTH RESIDSK4 SPECIFIC KNOWLEDGE CHANGE BASE TO 1NTH NIMP IMPORTANCE NCHNG GAP NtCHNG LEEWAY KTINP IMPETUS TPR1 STANDARDS BASELINE TPRCI STANDARDS CHANGE BASE TO 1MTH MULTIPLE R 0.48211 ANALYSIS OF VARIANCE DF SUM OF SQUARES MEAN SQUARE F P R SQUARE 0.2 3243 REGRESSION 8. 7.59102 0.94888 1.40053 0.2287 ADJUSTED R SQUARE 0.06647 RESIDUAL 37. 25.06795 0.67751 STANDARD "ERROR 0.B2311 VARIABLES IN THE EQUATION VARIABLES NOT IN THE EQUATION —r-VARIABLE B BETA STD ERROR B F VARIABLE BETA IN PARTIAL TOLERANCE F RES IDGK4 -0.2119090 -0.19188 0.16814 1.588 TINF1 -0.0 5898 -0.06253 0.86259 0.141 RESIDSK4 0.54845 88 E- 01 0.06747 0.14428 0. 172 TINFC1 0.10170 0.10945 0.88897 0.436 NlMP 0.6134266 2. 94211 0.32468 3.569 TRR1 0.18472 0.16595 0.61947 1.019 NCHNG 0.2 782380 1.83822 0.12037 5.343 TRRC1 -0.05298 -0.05071 0.70341 0.093 NtCHNG -0.2102478E-02 -0.05053 0.00785 0. 072 WTIHP -0.6680432 -3.79199 0.34015 .3.857 TPR1 -0.6114T08E-01 -0.2468 7 0.04491 1.854 TPRC1 -0.2 884668E-01 -0.09981 0.05618 0.264 • CONSTANT) 1.477252 VARIABLEISl ENTERED ON STEP NUMBER 2 TRRC1 REINFORCERS CHANGE BASE TO 1MTH TINF1 RESOURCES BASELINE TINFC1 RESOURCES CHANGE BASE TO 1MTH TRR1 REINFORCERS BASELINE MULTIPLE R 0.52015 ANALYSIS OF VARIANCE DF SUM OF SQUARES MEAN SQUARE F P R SQUARE 0.2 7056 REGRESSION 12. " ' " 8.83624 0.73635 1.02002 0.4539 ADJUSTEO R SQUARE 0.00531 RESIDUAL 33. 23.82273 0.72190 STANOARO ERROR 0.84965 VARIABLES IN THE EQUATION VARIABLES NOT IN THE EQUATION VARIABLE B BETA STO ERROR B F VARIABLE BETA IN PARTIAL TOLERANCE F RESIDGK4 -0.2200478 -0.19925 0.18251 1.454 RESIDSK4 0.2 443471E-01 0.02755 0.15728 0.024 NINP 0.6067469 2.91007 0.36621 2.745 NCHNG T . 2 776940 1.83463 0.13379 4.308 NICHNG 0.1766901E-03 0.00425 0.00901 0.000 UTIMP -0.6772203 -3.84408 0.38662 3.068 TPR1 -0.8451950E-01 -0.34123 0.05867 2.075 TPRCI -0.3512628E-01 -0.12154 0.06752 0. 271 TRRC1 0.1064459 E-01 0.04870 0.04444 0.057 TINF1 -0.110 8636E-01 -0.03351 0.06427 0.030 TINFC1 0.3329539E-01 0.11618 0.05445 0.374 TRR1 0.4879212E-01 0.24237 0.04461 1.196 1 CONSTANT! 1.027310 " " • * • • * • * » » » • » * * » * * • * * * * • M U L T I P L E R E G R E S S I O N * * • * * * » • • * • * » V A R I A B L E L I S T 1 R E G R E S S I O N L I S T 3 D E P E N D E N T V A R I A B L E . . R E S I D P N I OATA B A S E I N A C Q U I S I T I O N P H A S E s. V A R I A B L E ! S I E N T E R E D ON S T E P N U M B E R 1 . . R E S I 0 G K 4 G E N E R A L K N O W L E D G E C H A N G E B A S E TO 1HTH R E S I D S K 4 N I M P NCHNG S P E C I F I C K N O W L E D G E C H A N G E B A S E TO I M P O R T A N C E GAP I N T H NtCHNG H T I M P TPRl L E E W A Y IMPETUS STANDARDS B A S E L I N E T P R C I S T A N D A R O S C H A N G E B A S E T O 1 H T H M U L T I P L E R S Q U A R E A D J U S T E O R 0 . 4 2 7 1 2 0 . 1 8 2 4 3 R S Q U A R E 0 . 0 0 5 6 6 A N A L Y S I S O F V A R I A N C E D F R E G R E S S I O N 8 . R E S I D U A L 3 7 . SUM O F S Q U A R E S 6 . 5 7 8 3 8 2 9 . 4 8 0 9 3 M E A N S Q U A R E 0 . 8 2 2 3 0 0 . 7 9 6 7 8 F , 1 . 0 3 2 0 2 P 0 . 4 3 0 1 S T A N D A R D E R R O R 0 . 8 9 2 6 3 — r 1— V A R I A B L E S I N T H E E Q U A T I O N — — — — — — — — — — V A R I A B L E S NOT I N T H E E Q U A T I O N V A R I A B L E B B E T A STD E R R O R B F V A R I A B L E B E T A I N P A R T I A L _ T O L E R A N C E __£_-R E S I O G K 4 R E S I D S K 4 0 . 2 0 7 5 9 3 7 - 0 . 2 7 2 4 8 3 6 0 . 1 7 8 8 9 0 . 1 8 2 3 4 - 0 . 2 9 2 3 7 0 . 1 5 6 4 6 1 . 2 9 6 3 . 0 3 3 TINFl - 0 . 3 1 2 2 0 - 0 . 3 2 0 6 8 TINFCl 0 . 1 0 8 4 8 0 . 1 1 3 1 2 0 . 8 6 2 5 9 0 . 8 8 8 9 7 4 . 1 2 6 0 . 4 6 7 NIMP NCHNG NtCHNG - 0 . 3 6 5 0 6 9 9 - 0 . 1 4 0 6 0 1 1 - 0 . 6 2 5 5 9 1 7 E - 0 2 - 1 . 6 6 6 3 5 0 . 3 5 2 1 0 - 0 . 8 8 4 0 2 0 . 1 3 0 5 3 - 0 . 1 4 3 0 9 0 . 0 0 8 5 1 1 . 0 7 5 1 . 1 6 0 0 . 5 4 0 T R R 1 T R R C 1 0 . 0 9 4 1 6 0 . 0 8 1 9 6 - 0 . 3 1 1 1 6 - 0 . 2 8 8 6 2 0 . 6 1 9 4 7 0 . 7 0 3 4 1 0 . 2 4 3 3 . 2 7 1 WTIMP T P R 1 TPRCI 0 . 3 8 8 2 4 3 1 0 . 7 5 3 9 0 4 6 E - 0 1 0 . 1 0 4 9 9 3 5 2 . 0 9 7 2 9 0 . 3 6 8 8 8 0 . 2 8 9 6 7 0 . 0 4 8 7 0 0 . 3 4 5 7 3 0 . 0 6 0 9 3 1 . 1 0 8 2 . 3 9 7 2 . 9 7 0 I CONSTANT 1 - 1 . 7 2 8 7 3 6 V V A R I A B L E I S I E N T E R E D O N STEP NUMBER 2 . . T R R C 1 R E I N F O R C E R S C H A N G E B A S E TO 1 M T H -TINFl TINFCl T R R 1 R E S O U R C E S B A S E L I N E R E S O U R C E S CHANGE B A S E T O 1MTH R E I N F O R C E R S B A S E L I N E MULTIPLE R 0 . 5 8 9 0 6 A N A L Y S I S OF V A R I A N C E D F SUN O F S Q U A R E S M E A N S Q U A R E _ E. P R S Q U A R E A D J U S T E D S T A N O A R O 0 . 3 4 6 9 9 R S Q U A R E 0 . 1 0 9 5 3 E R R O R 0 . 8 4 4 7 2 R E G R E S S I O N R E S I O U A L 1 2 . 3 3 . 1 2 . 5 1 2 2 8 2 3 . 5 4 7 0 3 1 . 0 4 2 6 9 0 . 7 1 3 5 5 1 . 4 6 1 2 6 0 . 1 8 8 8 V A R I A B L E S N O T I N T H E E Q U A T I O N " " V A K I A D L C J I N Infc C U U A I 1 U N — — — — — — — V A R I A B L E B B E T A STO E R R O R B F V A R I A B L E B E T A I N P A R T I A L T O L E R A N C E f R E S I D G K 4 R E S I D S K 4 N I M P 0 . 1 4 2 6 2 3 8 - 0 . 3 1 9 2 4 5 3 - 0 . 6 9 9 2 2 7 0 0 . 1 2 2 9 0 0 . 1 6 1 4 5 - 0 . 3 4 2 5 4 0 . 1 5 6 3 7 - 3 . 1 9 1 5 9 0 . 3 6 4 0 9 0 . 6 1 8 4 . 1 6 8 3 . 6 8 8 NCHNG NtCHNG UTIHP - 0 . 2 4 5 3 0 6 6 - 0 . 1 4 4 3 7 5 7 E - 0 1 0 . 7 3 7 27 3 3 - 1 . 5 4 2 3 5 0 . 1 3 3 0 1 - 0 . 3 3 0 2 3 0 . 0 0 8 9 6 3 . 9 8 2 7 5 0 . 3 8 4 3 8 3 . 4 0 1 2 . 5 9 5 3 . 6 7 9 tPRl T P R C I T R R C 1 0 . 6 9 4 4 6 3 1 E - 0 1 0 . 1 2 4 3 2 5 6 - 0 . 7 5 7 4 2 5 4 E - 0 1 0 . 2 6 6 8 3 0 . 0 5 8 3 3 0 . 4 0 9 3 9 0 . 0 6 7 1 2 - 0 . 3 2 9 8 1 0 . 0 4 4 1 9 1 . 4 1 7 3 . 4 3 1 2 . 5 3 8 TINFl T I N F C 1 T R R 1 - 0 . 1 2 9 3 1 4 8 - 0 . 2 3 7 6 3 1 6 E - 0 1 - 0 . 6 9 7 9 5 7 7 E - 0 3 - 0 . 3 7 1 9 8 " 0 . 0 6 3 9 0 - 0 . 0 7 8 9 1 0 . 0 5 4 1 3 - 0 . 0 0 3 3 0 0 . 0 4 4 3 5 4 . 0 9 6 0 . 1 9 3 0 . 0 0 0 ( C O N S T A N T I 1 . 4 4 3 2 9 5 \ » * » * « » * » * » » » • • * * • • » * * * « M U L T I P L E R E G R E S S I O N * * » » * » * » * * » • * VARIABLE REGRESSION LIST 1 LIST 4 j ? DEPENDENT VARIABLE.. RESI0PP1 PROBLEM FOCUS IN ACQUISITION PHASE 1 VARIABLEISI ENTERED ON STEP NUMBER 1 RESIDGK4 GENERAL KNOWLEDGE CHANGE BASE TO 1MTH RESI0SK4 NIMP NCHNG SPECIFIC KNOWLEDGE CHANGE BASE IMPORTANCE GAP TO 1NTH NSCHNG MTIMP TPRl LEEHAY IMPETUS STANDARDS BASELINE ~ T P R C l STANDARDS CHANGE BASE TO 1HTH MULTIPLE R SQUARE ADJUSTED R 0.44963 0.20216 R SQUARE 0.02966 ANALYSIS OF VARIANCE DF REGRESSION 8. RESIOUAL 37. SUM OF SQUARES 8.91965 35 . 20 1 27 MEAN SQUARE 1.11496 0.95139 F 1.17193 P 0. 3417 STANDARD ERROR 0.97539 ._ VARIABLES — — - — VARIABLES NOT IN THE EQUATION VARIABLE B BETA STD ERROR B F VARIABLE BETA IN PARTIAL TOLERANCE F RES IDGK4 RESIDSK4 0.2326114 -0.3055672 0.18121 -0.29640 0. 19924 0.17097 1.363 3. 194 TINFl TINFCl -0.17356 -0.18047 0.19411 0.20490 0.86259 0.88897 1.212 1.578 NIMP NCHNG NSCHNG -0.2083535 -0.4 899345 E-01 -0.7401272E-02 -0. 85S76 -0.27848 -0.15304 0.38475 0.14263 0.00930 0.293 0.118 0.633 TRRl TRRCl 0.22292 0.19643 -0.28109 -0.26393 0.61947 0.70341 1.445 2.696 MTIMP TPRl TPRCl 0.2267474 0.4759315E-01 0.1444023 1.10135 0.16532 0.42987 0.40308 0.05321 0.06658 0. 316 0.800 4.704 • CONSTANT! -1.847459 — ... .. ! VARIABLEISI ENTERED ON STEP NUMBER 2.. TRRCl REINFORCERS CHANGE BASE TO 1MTH TINFl TINFCl TRRl RESOURCES BASELINE ~ " RESOURCES CHANGE BASE TO 1HTH REINFORCERS BASELINE MULTIPLE R SOU ARE' R 0.56203 l\ 1 1 K n g - ANALYSIS OF VARIANCE DF SUN OF SQUARES MEAN SQUARE ** " H | l / M n t ADJUSTED STANDARD R SQUARE 0.06711 ERROR 0.95638 KCUttlMUN RESIDUAL 12. 33. 13.93699 30.18393 1.16142 0.91466 1.26977 P 0.2815 VARIABLES IN THE EQUATION VARIABLES M O T lu T U C VARIABLE R ES IDfiK4 B A 9 94 40m BETA STD ERROR B F VARIABLE . * w \ &Mot.cd nui i n inc BETA IN PARTIAL EQUATION TOLERANCE F RESI0SK4 NIMP NCHNG -0.4075002 -0.4770277 —A -1 WinyiCf 0.17907 -0.39527 -1.96843 0.20544 0.17704 0.41222 1.252 5.298 1.339 1 NSCHNG MTIMP TPRl U * ft 3 3OcO f -0.969 2771E-02 0.4955886 -""H 7t~l *l/,AAt, f-Wl -0. 77205 -0. 20043 2.42026 A—1 - tfTTg 0.15059 0.01015 0.43519 0.814 0.913 1.297 TPRCl TRRCl u I 7 0 0 jolrU 1 0.1 76236B -0.5 576984E-01 0. 14578 0.52463 -0.21954 0.06604 0.07600 0.05003 0.07235 0.06129 0.05022 0.404 5.378 1.243 '0.424 0.786 0.647 TTNFTT —=0.4709845E-0I -0. 1224 t r TINFCl TRRl fCONSTANT 0.5432401E-01 0.4038013E-01 1 — 1 f x j t a i a 0.16309 0.17257 i i I4PI I V 1.60001S -p-M U L T I P L E R E G R E S S * • • • • • * * * • * • • * • * * * • • * * • DEPENDENT VARIABLE.. • RES ID PCI TRETSTMETfT-Pt~AN I N_AT^WsTTTdTTPl(ASE VARIABLEISI ENTERED ON STEP NUMBER I. O N • • • * • • VARIABLE LIST REGRESSION LIST RESIDGK4 RESIDSK4 NIMP NCHNG "Ti'tCHN'6 HTIMP TPRl TPRCl GENERAL KNOWLEDGE CHANGE BASE TO 1MTH SPECIFIC KNOWLEOGE CHANGE BASE TO-IMTH IMPORTANCE GAP XEEWAV IMPETUS STANDARDS BASELINE STANOAROSCHANGEBASE TO IMTH MULTIPLE ft OTS8127 R SQUARE 0.33788 ADJUSTED R SQUARE 0.19471 STANDARD ERROR 0.83790" ANALVSTT~OF VARIANCE DF REGRESSION 8. RESIDUAL 37. SUM OF SQUARES 13.25578 25.9768 5 MEAN SQUARE 1.65697 0 . 70208 2.36010 P 0. 0367 VARIABLES IN THE EQUATION — VARIABLES NOT IN THE EQUATION VARIABLE B BETA STD ERROR B VARIABLE BETA IN PARTIAL TOLERANCE RESI0GK4 RESIDSK4 0.1403752 0 . 2 22 5601 NIMP NCHNG NtCHNG "WTlMP TPRl TPRCl 0.11597 0.22894 -0.4219617 -1.84649 -0.8135747E-01 -0.49041 -0.1087491E-01 -0.23847 2.24649 0.35461 0.17116 0.14687 0.673 2.296 0.4337741 0.9626757E-01 -0.2338914E-02 ICONSTANT) -2.214434 -0.00738 0.33052 0.12253 0.00799 0.34627 0.04571 0.05719 TINFl TINFCl 1.630 0.441 1.853 1.569 4.435 0.002 TRRl TRRCl -0.03316 0.17862 -0.0 3785 0.20697 -0.12716 0.05651 0.86259 0.88897 -0.12300 0.05825 0.61947 0.70341 0 . 0 5 2 J 1.6111 0.553 0.123 VARIABLEISI ENTERED ON STEP NUMBER 2. MULTIPLE R 0.61541 -R-SQUARE— 0737873 ADJUSTED R SQUARE 0.15281 STANDARD ERROR ' 0.85942 TRRCl REINFORCERS CHANGE BASE TO IMTH TINFl RESOURCES BASELINE TINFCl RESOURCES CHANGE BASE TO IMTH TRRl REINFORCERS BASELINE ANALYSIS OF VARIANCE DF REGRESSION 12. RESIDUAL 33. SUM OF SQUARES 14.85847 24.37416 MEAN SQUARE 1.23821 0.73861 1.67640 0.1181 VARIABLES IN THE EQUATION — VARIABLE B BET* STO ERROR B VARIABLE VARIABLES NOT IN. THE EQUATION --BETA IN PARTIAL TOLERANCE RESI0GK4 RES I0SK4 NIMP "NCHNG NSCHNG WTIMP "TPRl TPRCl TRRCl TINFl TINFCl TRRl  (CONSTANT) 0.1739373 0.1913979 -0.4636028 ~=0;9796532E-01" -0.1012851E-01 0.4851118 0.133 2185 0.1S113 81E-01 -0.1 7603 80E-04 0.14370 0.19688 -2.02871 -0.59052 -0.22210 2.51236 ~OT4"049966E;;0r 0.703 S785E-01 -0.2375626E-01 -3. 386809 0.49073" 0.04771 -0.00007 0.11169" 0.22399 -0.10767 0.18461 0.15909 0.37043 0.13533 0.00912 0.39107 TJ705535 -0.06829 0.04495 0.06501" 0.05508 0.04512 0.888 1.447 1.566 0.524 1.234 1.539 "T7039 0.049 0.000 0.388 1.632 0.277 00 • » * » » * » * » * » « » « W — : •» ....^r... - „ * * » » * • * * • M U L T I P L E R E G R E S S I O N • * * * * • * • « * » * » VARIABLE REGRESSION LIST 1 LIST 6 ucrcnucni r « l « t L C . K t i l U C i l FOLLOW UP IN ACQUISITION PHASE VARIABLE!SI ENTERED ON STEP NUMBER 1.. RESIDGK4 GENERAL KNOWLEDGE CHANGP RAtc TD I M T U RESIDSK4 NIMP NCHNG SPECIFIC KNOWLEDGE CHANGE BASE IMPORTANCE GAP TO INTH NtCHNG WTIMP TPRl LEEWAY IMPETUS STANOARDS BASELINE TPRCI STANDARDS CHANGE BASE TO 1MTH MULTIPLE R 0.39166 R SQUARE 0.15340 ADJUSTED R SQUARE -0.02965 ANALYSIS OF VARIANCE OF REGRESSION 8. RESIDUAL 37. SUM OF SQUARES 6.47613 35.74122 MEAN SQUARE 0.80952 0.96598 F 0.83803 P 0.5755 J INHUMRU C H I U J K UtVOCW " VARIABLE B in inc EUUAIIUN — BETA ST0 ERROR B F VARIABLE -- VARIABLES NOT IN THE BETA IN PARTIAL EQUATION TOL ERANCE c RESIDGK4 0.2244739E-01 RES IDSK4 -0.3663669E-01 UIM0""" "'"" " ' ' A 4a<taAli 0.01788 -0.03633 0.20077 0.17228 0.013 0.045 TINFl TINFCl 0.00229 0.00231 0.01680 0.01722 0.86259 0 . 8811*97 t a.ooa N I P I P 0.2888814 NCHNG 0.1379729 NtCHNG -0.653S875E-02 UTTHP H^~"^  A9>. * TT 1.21863 0.80174 -0.13825 0.38769 0.14372 0.00937 0.555 0.922 0. 487 TRR1 TRRCl -0.13997 -0.11973 -0.26203 -0.23885 0.61947 0.70341 0.011 0.524 2.178 wit nr , J U V O J f f TPRl 0.1067644 TPRCI 0.10395 80 -1.54587 0.37912 0.31637 0.40616 0.05362 0.06709 0.581 3.965 2.401 IUJNSTANTI -2.660146 _ ... . •- , VARIABLEISI ENTEREO ON STEP NUMBER 2.. TRRCl REINFORCERS CHANGE BASE TO 1MTH TINFl TINFCl TRR1 RESOURCES BASELINE RESOURCES CHANGE BASE TO 1MTH REINFORCERS BASELINE MULTIPLE R 0.51534 1) C A I I A D C « -v * c c -» ANALYSIS OF VARIANCE OF SUN OF SQUARES MEAN SQUARE c " »UUAKc 0.Z6557 ADJUSTED R SQUARE -0.00149 STANOARO ERROR 0.96931 KcbKESSION RESIDUAL 12. 33. 11.21183 31.00551 0.93432 0.93956 0.99442 P 0.4748 VARIABLES IN THE EQUATION — VARIABLES NOT IN TMF VARIABLE B DCCirtf^ lfA\ ' A dCAalAlr—iST— BETA STD ERROR B F VARIABLE • »-»« • nut. tr *I IVUI »n InC BETA IN PARTIAL IIUATIQN — ——— TOLERANCE f RESIDSK4 -0.9274774E-01 NIMP -0.3459978E-O1 NCHNG 0.?l5flOi.77P-711 0.06777 -0.09197 -0. 14596 ~ A I X A A C — 0.20822 0.17943 0.41779 0.167 0.267 0.007 • • v. £, 3uV*r f f c w X NXCHNG -0.1426844E-01 HTIMP 0.6012761E-01 T A D t X—. . . : 0*14995 -0.30162 0.30019 0.15263 0.01028 0.44108 0.029 1.925 0.019 • riw u i i g w » Q.63336 TPRCI 0.1796887 0.54684 TRRCl -0.1070705 -0.43088 TINFl K. 7fllU.nOC.ni «-'iieA-»i— 0.06694 0.07702 0.05070 7.101 5.'442 4.459 TINFCl 0.4339229E-02 TRR1 -0.8565798E-01 i Murftuv 4 . X—' - * -0.01332 -0.37424 0.07332"" 0.06212 0.05089 0. 077 0.005 2.833 • uiniMnii —£. c.9 it) f£ : _—. VO * » * * * * • » » • * * * * * * » • * * » » * M U L T I P L E D E P E N D E N T V A R I A B L E . . R T S T D T * C O M P L E T E R E C O R D I N T S A T N T T N A M E ^ P T T A S E R E G R E S S I O N » • * * * » * » » * VARIABLE LIST 1 REGRESSION LIST 1 VARIABLEISI ENTERED ON STEP NUMBER I.. TRRC2 T PR 2 TPRC2 TINF2 T TNF C 2 TRR2 REINFORCERS CHANGE 1 TO 4NTHS STANDARDS 1 M T H " " ~ " " " STANDARDS CHANGE 1 TO 4MTHS RESOURCES 1MTH RESOURCES CHANGE 1 TO 4NTHS REINFCRCERS 1MTH MULTIPLE R 0.48140 R SQUARE 0.23175 ADJUSTED R SQUARE 0.11356" STANDARO ERROR 0.74023 ANALYSIS OF VARIANCE REGRESSION TTESIDOAX" OF 6. SUM OF SQUARES 6.4462 5 39. 21.36948 MEAN SQUARE 1.07437 0.54794 F 1 .96077 P 0.0951 V A R I A B L E TRRC2 "TPR2 VARIABLES IN THE EQUATION STD ERROR-B~ — VARIABLES NOT IN THE EQUATION -0.1S23232E-01 "~0T228649lE-0r -0.1877771E-01 0. 51903 84E-01 TPRC2 TINF2  TINFC2 0.6496012E-01 TRR2 0.5885273E-01 (CONSTANTI -3.813737 BETA -0.09589 0.08664 -0.06991 0.18110 0.03467 0.05305 0.04599 0.04815 0. 18991 0.35070 0. 277 0.186 0. 167 1. 162 VARIABLE RES IDGK3 VARIABLE (SI ENTERED ON STEP NUMBER 2.. 0.05986 0.03219 RESI0GK3 RESIDSK3 NIMP NCHNG RESICSK3 NIMP NCHNG 1.178 3.342 BETA IN 0.14857 -6.06675 0.05287 -0.00156 PARTIAL TOLERANCE WTIMP NtCHNG 0.05997 0.17488 0.16435 -0.06888 0.05852 -0.00171 0.94003 0.0 6565 0.18226 0.81812 0.94122 0.91610 0.92086 0.83449 1.055 0.181 0.131 o.oool 0.164 1.306 WTIMP NSCHNG GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS SPECIFIC KNOWLEDGE CHANGE 1 TO 4HTHS IMPORTANCE GAP I MPETUS ~~ — LEEWAY MULTIPLE R 0.57908 R SQUARE 0.33534 ADJUSTED R SQUARE—0 .09364 STANDARD ERROR 0.74850 ANALYSIS OF VARIANCE REGRESSION RESIOUAL DF 12. 33. SUM OF SQUARES 9.32760 16.48813 MEAN SQUARE 0.77730 0.56025 F 1.38743 P Q« 2208 VARIABLES IN THE EQUATION VARIABLE TRRC2 rPRz TPRC2 TINF2 VARIABLES NOT IN THE EQUATION " T T N F C l — TRR2 RESIDGK3 RESI0SK3 NIMP NCHNG WTIMP NtCHNG (CONSTANTI -0.86066 10E- 02 ""071/310847^01 0.6979419E-02 0.458 62 85E-01 0.86137676-01 0.5261569E-01 0.2 081708 -0.7857571E-01 -0.4471942 -0.1925295 BETS -0. 04526 0.04967 0.02599 0.16002 0.4874138 0.6681994E-02 -3. 634206 0.25183 0.31353 0.16042 -0.07199 -2.32407 -1.37827 ~STD~ERR0R~B~ 0.03771 0.05568 0.05342 0.05170 V A R I A B L E BETA IN PARTIAL TOLERANCE 2.99789 0.17402 0.06555 0.03946 0.20253 0.18278 0.35937 0.13089 0.052 0.055 0.017 0. 787 0.38138 0.00852 1.727 1.778 1.056 0.185 1.548 2. 164 O 1.633 0.615 DEPENDENT V A R I A B L E . . M U L T I P L E R E G R E S S I O N * * * » » * » • » • * • » R E S I O P L 2 V A R I A B L E I S I E N T E R E D O N S T E P N U M B E R D O C U M E N T A T I O N I N M A I N T N E N A N C E P H A S E V A R I A B L E L I S T 1 R E G R E S S I O N L I S T 2 1 . . T R R C 2 R E I N F O R C E R S C H A N G E 1 T O 4 M T H S T P R 2 S T A N D A R D S I M T H T P R C 2 S T A N D A R D S C H A N G E 1 T O 4 H T H S T I N F 2 R E S O U R C E S I M T H T I N F C 2 T R R 2 R E S O U R C E S C H A N G E 1 T O 4 M T H S R E I N F O R C E R S I M T H M U L T I P L E R R S Q U A R E A D J U S T E D R S Q U A R E S T A N D A R D E R R O R 0 . 5 4 9 8 6 0 . 3 0 2 3 5 0.I9502 -0.83917 A N A L Y S I S O F V A R I A N C E R E G R E S S I O N RE St DUAL D F 6 . S U N O F S Q U A R E S 1 1 . 9 0 2 4 1 3 9 . 27.463 7 4 M E A N S Q U A R E 1 . 9 8 3 7 4 0 . 7 0 4 2 0 F 2 . 81 701 P 0 . 0 2 2 5 V A R I A B L E T R R C 2 " T P R 2 T P R C 2 T I N F 2 — g-- 0 . 1 0 3 3 9 1 3 V A R I A B L E S I N T H E E Q U A T I O N B E T A " V A R I A B L E S N O T I N T H E E Q U A T I O N — : TINFC2 TRR2 I C O N S T A N T I 0 . 6 8 7 0 4 4 I E - O F - 0 . 5 5 3 82 2 8 E - 0 1 0 . 4 1 3 8 5 3 0 E - 0 1 0 . 2 0 0 80 9 4 E - 0 1 0 . 7 8 3 6 1 1 2 E - 0 1 - 5 . 3 1 8 1 8 9 - 0 . 4 5 7 0 7 " 0 7 2 1 8 8 4 - 0 . 1 7 3 3 3 0 . 1 2 1 3 8 0 . 0 4 9 3 5 0 . 3 9 2 5 1 S T D E R R O R B 0.03930 0.06014 0.05213 0.05458 0 . 0 6 7 8 6 0 . 0 3 6 5 0 6 . 9 2 0 1 . 3 0 5 1 . 1 2 9 0 . 5 7 5 VARIABLE RESI0GK3 0 . 0 8 8 4 . 6 1 0 R E S I 0 S K 3 N I M P N C H N G W T I M P N S C H N G B E T A I N 0 . 2 0 8 0 3 0 . 0 4 7 5 9 - 0 . 0 9 6 7 6 - 0 . 1 3 8 8 9 P A R T I A L T O L E R A N C E 0.24147 - 0 . 1 3 9 1 7 - 0 . 0 8 1 6 1 0 . 0 5 1 5 3 - 0 . 1 1 2 3 1 - 0 . 1 5 9 1 6 JB.94003 - 0 . 1 5 9 8 9 - 0 . 0 8 9 2 5 0 . 8 1 8 1 2 0 . 9 4 1 2 2 0 . 9 1 6 1 0 0 . 9 2 0 8 6 0 . 8 3 4 4 9 ^ 2 . 3 5 3 . 0 . 1 0 1 0 . 4 8 6 0 » 9 8 8 0 . S 9 7 0 . 3 0 5 V A R I A B L E I S I E N T E R E D O N S T E P N U M B E R 2 . R E S I D G K 3 G E N E R A L K N O W L E D G E C H A N G E 1 T O 4 M T H S R E S I 0 S K 3 S P E C I F I C K N C W L E O G E C H A N G E 1 T O 4 M T H S N I M P I M P O R T A N C E N C H N G G A P " S T T N P N S C H N G IMPETUS LEEWAY M U L T I P L E R R S Q U A R E ADJUSTED R S Q U A R E S T A N D A R D E R R O R 0.61945 0.3 8371 0.15961 0.85742 A N A L Y S I S O F V A R I A N C E D F R E G R E S S I O N 1 2 . R E S I D U A L 3 3 7 S U N O F S Q U A R E S 1 5 . 1 0 5 3 2 2 4 . 2 6 0 8 4 M E A N S Q U A R E 1 . 2 5 8 7 8 0 . 7 3 5 1 8 F I ' T l 2 2 1 V A R I A B L E S I N T H E E Q U A T I O N V A R I A B L E S N O T I N T H E E Q U A T I O N — V A R I A B L E T R R C 2 ~ T P R 2 T P R C 2 T I N F 2 T I N F C 2 T R R 2 R E S I 0 G K 3 " R E S I D S K 3 N I M P N C H N G B -0.1006983 0.35820 84 E-Ol -0.3448708E-01 0.4152705E-01 0 . 1 5 8 8 0 5 0 E - 0 1 0 . 1 0 3 5 0 0 6 0 . 3 8 8 7 5 1 0 0 . 3 9 1 4 9 9 1 E - 0 1 0 . 1 6 2 5 5 2 1 0 . 2 7 0 5 2 7 6 E - 0 1 ' BETA - 0 . 4 4 5 1 6 0 . 1 1 4 1 0 - 0 . 1 0 7 9 3 0 . 1 2 1 8 0 0 . 0 3 9 0 3 0 . 5 1 8 4 3 0 . 2 5 1 8 2 0 7 0 3 0 1 5 0 . 7 1 0 1 2 0 . 1 6 2 7 9 W T I M P - 0 . 1 7 6 4 7 5 0 - 0 . 9 1 2 4 0 " N S C H N G 0 . 4 0 3 7 4 5 6 E - 0 3 0 . 0 0 8 8 4 I C O N S T A N T I - 4 . 8 3 7 4 0 4 " S T D EftRW~fi" . 0 4 3 2 0 . 0 6 3 7 8 . 0 6 1 2 0 . 0 5 9 2 3 . 0 7 5 0 9 . 0 4 5 2 1 . 2 3 2 0 0 . 2 0 9 3 8 . 4 1 1 6 7 1 1 4 9 9 4 V A R I A B L E B E T A I N P A R T I A L T O L E R A N C E 5 . 4 3 4 0 . 3 1 5 0 . 3 1 8 0 . 4 9 2 0 . 0 4 5 5 . 2 4 2 2 . 8 0 8 0 . 0 3 5 0 . 1 5 6 0 . 0 3 3 4 3 6 8 8 0 0 9 7 6 0 . 1 6 3 0 . 0 0 2 s * » « * » • * * * M U L T I P L E R E G R E S S I 0 N » # * • * * » • * » * * * VARIABLE REGRESSION LIST 1 LIST 3 < DEPENDENT VARIABLE.. RES IDPN2 OAT A BASE IN MAINTENANCE PHASE VARIABLE! SI ENTERED ON STEP NUMBER 1 TRRC2 REINFGRCERS CHANGE 1TO4MTHS TPR2 TPRC2 T INF 2 STANDAROS INTH STANDAROS CHANGE RESOURCES 1MTH 1 TO 4MTHS TINFC2 TRR2 RESOURCES CHANGE REINFGRCERS 1MTH 1 TO 4MTHS MULTIPLE R 0.56074 R SQUARE 0.31443 ANALYSIS OF VARIANCE OF SUM REGRESSION 6. OF SQUARES 9 . 26 3 21 MEAN SQUARE 1.54387 F 2.98116 P 0.0171 ADJUSTEO R SQUARE O.Z0896 STANDARD ERROR 0.71964 RESIDUAL 39. 20.19712 0.51787 - 1/ AD IA QJ CC EQUATION —————— VARIABLE 6 BETA STD ERROR B F VARIABLE BETA IN PARTIAL TOLERANCE F TRRC2 -O.2269812E-01 -0.11599 0.03370 0.454 RES I0GK3 0.13805 0.16166 0.94003 1.020 TPR2 0.65725 90E-01 TPRC2 0.3903O52E-O1 TINF2 0.1052284 0.24200 0.14120 0.35677 0.05157 0.04471 0.04681 1.624 0.762 5.054 RESIDSK3 NIMP NCHNG -0.09004 -0.11512 -0.10190 -0.09836 -0.13488 -0.11780 0.81812 0.94122 0.91610 0.371 0.704 0.535 TINFC2 0.4184266E-01 TRR2 0.3410128E-01 (CONSTANTI -5.094254 0.11887 0.19745 0.05819 0.03130 0. 517 1. 187 WTIMP NSCHNG -0.12793 0.11142 -0.14827 0.12293 0.92086 0.83449 0.854 0.583 VARIABLEISI ENTEREO ON STEP NUMBER 2.. RESI0GK3 GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS ' ~ ~ RESI0SK3 NIMP NCHNG SPECIFIC KNGWLEOGE CHANGE 1 TO IMPORTANCE GAP 4MTHS WTIMP NSCHNG IMPETUS LEEWAY MULTIPLE R 0.63897 R SQUARE 0.40828 ANALYSIS OF VARIANCE DF SUM REGRESSION 12. OF SQUARES 12.02813 MEAN SQUARE 1.00234 F 1.89749 P 0.0721 ADJUSTED R SQUARE 0.19311 STANDARD ERROR 0.72681 RESIDUAL 33. 17.43220 0.52825 — ~ . VARIABLES IN THE EQUATION -- VARIABLES NOT IN THE EQUATION VARIABLE B BEI A STD ERROR B F VARIABLE BETA IN PARTIAL TOLERANCE F TRRC2 -0.1346543E-01 ——»•(. ________________—jy|->«e'ji-c—M * -0. 06881 0.03662 0.135 l PKZ 0 • 514 62 56E- 01 TPRC2 0.426S308E-01 TINF2 0.9431734E-01 0.18948 0.15445 0.31977 0.05407 0.05187 0.05020 0.906 0.677 3.529 TINFCZ 0.7381417E-01 TRR2 0.5717873E-01 RES IDGK3 0.199S758 0.20969 0.33108 0.14944 0.06 365 0.03832 0.19666 1.345 2.227 1.030 RESIDSK3 -0.1460514 NIMP -0.6097075E-01 NCHNG -0.5267700E-01 -C.13001 -0.30789 -0.36643 0.17749 0.34896 0.12710 0.677 0.031 0. 172 WTIMP 0.4226101E-01 NSCHNG 0.1150453E-01 I CONSTANT I -4. 440823 0.25257 0.29113 0.37032 0.00827 0.013 1.933 - — - - -Ul * * • » * * » » • * * » • * * * * • * • * • * M U L T I P L E R E G R E S S I O N * » » * « • • » * » * * • VARIABLE LIST 1 . REGRESSION LIST 4 j DEPENDENT VARIABLE.. RES IDPP2 PROBLEM FOCUS IN MAINTENANCE PHASE! '- ^ VARIABLE! SI ENTERED ON STEP NUMBER 1.. TRRC2 REINFORCERS CHANGE 1 TO 4NTHS TPR2~"STANDARDS I M T H ' ~ ~ TPRC2 STANDARDS CHANGE 1 TO 4HTHS • TINF2 RESOURCES IMTH TINFC2 RESOURCES CHANGE 1 TO 4MTHS TRR2 REINFORCERS IMTH MULTIPLE R 0.45708 ANALVSIS OF VARIANCE OF SUM OF SQUARES MEAN SQUARE F R SQUARE 0.20892 REGRESSION 6; 6.88762 1.14794 1.71664 0. ADJUSTED R SQUARE 0.08722 I RfcTIBUAT" 397 26.07973 0.66871 STANDARD ERROR 0.81775 VARIABLES IN THE EQUATION — — — — — — VARIABLES NOT IN THE EQUATION — VARIABLE B BETA STO ERROR B F VAR IABLE BETA IN PARTIAL TOLERANCE F TRRC2 -0.4343331E-02 -0.02098 0.03830 0.013 RES IDGK3 0.15693 0.17107 0.94003 lc l 4 6 TPR2 TPRC2 TINF2 ~0.1015504^01 -0.2 685926E-01 0.430 8508E-0I 0.03535 -0.09186 0.13809 0.05861 0.05080 0.05319 0.030 0. 280 0.656 RESIDSK3 NIMP NCHNG -0.11590 -0.11786 0.16002 0.17454 0.11660 0.12548 0.81812 0.94122 0.91610 -0.535 1.194 0.608 TINFC2 TRR2 • CONSTANT! 0.1059702 0.472 5198E-01 -2.913380 0.28457 0.25864 0.06613 0.03556 2.568 1.765 WTIMP NSCHNG 0.19609 0.21156 0.17409 0.17880 0.92086 0.83449 . 1.780 1.255 . — VARIABLEISI ENTERED ON STEP NUMBER 2 RESI0GK3 GENERAL KNOWLEDGE CHANGE 1 TO ' »MTHS RESIDSK3 NIMP NCHNG SPECIFIC KNOWLE OGE CH AN G E l 10 IMPORTANCE GAP 4MTHS "•' WTIMP NSCHNG IMPETUS LEEWAY MULTIPLE R SQUARE R 0.5 8183 0.33853 ANALVSIS OF VARIANCE OF REGRESSION 12. SUM OF SQUARES 11. 16042 MEAN SQUARE 0.93003 F 1.40740 P 0.?117 ADJ USTED STANOARO ERROR 0.81291 RESIDUAL 33. 21.80694 0.66082 VARIABLES IN THE EQUATION — VARIABLES NOT IN THE EQUATION VAMIABLt U BETA SID ERROR B F VARIABLE BETA IN PARTIAL TOLERANCE F TRRC2 ~--~y p_ -0.13533 34E-01 A" D l i ' U ' l l C ' i l l 0.06538 0.04095 0.109 TPRC2 TINF2 u.o #4eZ 75e-02 -O.2147779E-02 0.3 257965E-0I ' 0.03044 -0.00735 0.10442 0.06047 0.05802 0.05615 0.021 0.001 0.337 TINFC2 TRR2 RES IDGK3 0.1250275 0.1756468E-01 0.2460479 A I ifci'it t ' t t ~ '• 0.33575 0.09614 0.17416 0.07119 0.04286 0.21996 3.084 0. 168 1.251 NIMP NCHNG —Uti49M13 -0.-6006032 -0.2262727 -0. 12591 -2.86710 -1.48790 0. 19851 0.39029 0.14215 0. 568 2.368 2.534 • u n r NSCHNG I CONSTANT1 0.6686648 0.16942 59E-03 -2.849606 3.77772 0.00405 0.41419 0.00925 2.606 0.000 » » » * * • » • • • * * » » » » » * * • » * « M U L T I P L E R E G R E S S I O N • * * * » • » • * • * * • / DEPENDENT VARIABLE.. RES~IDPC2 TREATMENT PLAN IN MAINTENANCE PHASE VARIABLEISI ENTERED ON STEP NUMBER 1.. TRRC2 REINFGRCERS CHANGE 1 TO 4NTHS VARIABLE LIST 1 REGRESSION LIST 5 T P R 2 S T A N D A R D S IMTH TPRC2 STANDARDS CHANGE I TO 4MTHS TINF2 RESOURCES IMTH "TINFCT" TRR2 RESOURCES CHANGE 1 TO 4MTHS REINFORCERS IMTH MULTIPLE R R SQUARE , 0.37*3* <• 0.14013 ADJUSTED R SQUARE STANOARD ERROR 0.00784 0.64843 ANALYSIS OF VARIANCE REGRESSION DF 6. RESIDUAL ~397 SUN OF SQUARES 2.67228 16.3977TT MEAN SQUARE 0.44538 F 1.05928 P 0.4032 0.42046 V A R I A B L E TRRC2 ~Twnr TPRC2 TINF2 VARIABLES IN THE EQUATION B — — VARIABLES NOT IN THE EQUATION BETA STD ERROR B 0.2516236E-01 -0.176 52 7 IE-01" -0.4005107E-01 -0.7676901E-02 0.15982 -0.08079 -0.18009 -0.03235 0.03037 0.04647 0.0402 8 0.04218 0.686 0. 144 0.9 89 0.033 VARIABLE RES IDGK3 RESI0SK3 NIMP NCHNG BETA IN -0.06255 0.02030 0.01021 -0.07196 PARTIAL TOLERANCE -0.06540 0.01980 0.01068 -0.07427 0.94003 0.81812 0.94122 0.91610 0.163 0.015 0.004 _____ TINFC2 TRR2 I CONSTANTI -0.50931 75E-01 0.2100786E-01 -0.1975326 -0.17983 0.15119 0.05243 0.02820 0.944 0.555 HTIMP NSCHNG -0.0 25 53 -0.12013 -0.02642 -0.11834 0.92086 0.83449 0.027 0.540 VARIABLEISI ENTERED ON STEP NUMBER 2, RESIDGK3 RESI0SK3 NIMP NCHNG HTIMP NSCHNG GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS SPECIFIC KNCWLEQGE CHANGE 1 TO 4MTHS IMPORTANCE GAP IMPETUS LEEWAY MULTIPLE R R SQUARE ADJUSTED ft SQUARE STANOARO ERROR 0.39718 0.15775 -0.148S2 0.69765 ANALYSIS OF VARIANCE REGRESSION RESIDUAL VARIABLES IN THE EQUATION OF 12. 33. SUM OF SQUARES 3.00827 16.06179 MEAN SQUARE 0.25069 F 0.51506 P 0.8897 0.48672 VARIABLES NOT IN THE EQUATION — VARIABLE "BETA STD ERTfflJTT VARIABLE BETA IN PARTIAL TOLERANCE TRRC2 " TPR2 TPRC2 TINF2 0.2300041E-01 -=07202B502E-0r -0.3642314E-01 -0.7 039374E-02 0. 14609 -0.09283 -0.16378 -0.02966 0.03515 0.05190 0.04979 0.04819 0.428 0.153 0.535 0.021 TINFC2 TRR2 RESI0GK3 U.ES"Iff5IO~ NIMP NCHNG -0.5997427E-01 0.1943691E-01 -0.4 2203 96E-01 "OV5070796E-Or 0.7177293E-01 0. 21949 89E-01 wrtMp NSCHNG I CONSTANTI -0.6923914E-01 -0.33191 29E-02 -0.1827519 -0.21176 0.13988 -0.03928 0.05611 0.45049 0.18978 -0.51433 -0.10440 0.06110 0.03678 0.18877 0.17037 0.33496 0.12200 0.35547 0.00794 0.963 0.279 0.050 0.089 0. 046 0.032 0.038 0.175 \ -• * * • * • * * • * • • • • • • * • * * * * • M U L T I P L E R E G R E S S I 0 N * * * * * * * * * * * * * V A R I A B L E R E G R E S S I O N L I S T 1 L I S T b) D E P E N D E N T V A R I A B L E . . R E S I D P S 2 F O L L O W U P I N M A I N T E N A N C E P H A S E V A R I A B L E I S I E N T E R E D ON S T E P N U M B E R I . . T R R C 2 R E I N F O R C E R S C H A N G E 1 T O 4 M T H S T P R 2 T P R C 2 T I N F 2 S T A N D A R D S I M T H S T A N D A R D S C H A N G E 1 R E S O U R C E S I M T H TO 4 M T H S T I N F C 2 T R R 2 R E S O U R C E S C H A N G E 1 R E I N F O R C E R S I M T H TO 4 M T H S M U L T I P L E R 0 . 1 8 3 0 4 R S Q U A R E 0 . 0 3 3 5 0 A N A L Y S I S O F V A R I A N C E D F SUN R E G R E S S I O N 6 . O F S Q U A R E S 1 . 1 5 2 3 1 M E A N S Q U A R E 0 . 1 9 2 0 5 F 0 . 2 2 5 3 2 P 0 . 9 6 6 1 A u i u i i t u K S Q U A R E - 0 . 1 1 5 1 9 S T A N D A R D E R R O R 0 . 9 2 3 2 3 R E S I D U A L < . . . 3 9 . 3 3 . 2 4 2 1 1 0 . 8 5 2 3 6 : - V A R I A B L E S I N T H E E Q U A T I O N V A R I A B L E S NOT I N T H E V A R I A B L E B T R R C 2 0 . 2 1 0 3 7 8 4 E - 0 2 B E T A 0 . 0 0 9 9 5 S T D E R R O R B 0 . 0 4 3 2 4 F 0 . 0 0 2 VAR I A B L E R E S I D G K 3 B E T A I N 0 . 0 0 2 6 5 P A R T I A L 0 . 0 0 2 6 1 T O L E R A N C E 0 . 9 4 0 0 3 F 0 . 0 0 0 T P R 2 0 . 2 0 4 7 0 6 1 E - 0 1 T P R C 2 - 0 . 4 S 3 T 6 2 9 E - 0 2 T I N F 2 - 0 . 4 5 8 1 6 2 9 E - 0 2 0 . 0 6 9 7 6 - 0 . 0 1 5 1 9 - 0 . 0 1 4 3 8 0 . 0 6 6 1 7 0 . 0 5 7 3 5 0 . 0 6 0 0 5 0 . 0 9 6 0 . 0 0 6 0 . 0 0 6 R E S I 0 S K 3 N I M P N C H N G 0 . 0 6 3 4 6 0 . 0 4 2 8 6 0 . 0 3 6 4 0 0 . 0 5 8 3 9 0 . 0 4 2 3 0 0 . 0 3 5 4 3 0 . 8 1 8 1 2 0 . 9 4 1 2 2 0 . 9 1 6 1 0 0 . 1 3 0 0 . 0 6 8 0 . 0 4 8 T I N F C 2 0 . 2 4 1 4 3 2 4 E - 0 1 T R R 2 0 . 2 1 9 0 7 7 1 E - 0 1 ( C O N S T A N T 1 - 1 . 1 8 2 4 3 4 0 . 0 6 3 4 8 0 . 1 1 7 4 0 0 . 0 7 4 6 6 0 . 0 4 0 1 5 0 . 1 0 5 0 . 2 9 8 W T I M P N S C H N G 0 . 0 6 8 2 5 0 . 1 9 5 6 7 0 . 0 6 6 6 2 0 . 1 8 1 8 1 0 . 9 2 0 8 6 0 . 8 3 4 4 9 0 . 1 6 9 1 . 2 9 9 V A R I A B L E I S I E N T E R E D O N S T E P N U M B E R 2 . . R E S I D G K 3 G E N E R A L K N O W L E D G E C H A N G E 1 TO 4 M T H S — — • R E S I D S K 3 N I M P N C H N G S P E C I F I C K N O W L E D G E I M P O R T A N C E G A P C H A N G E 1 T O 4 M T H S W T T M P N S C H N G " T M P E T U S L E E W A Y M U L T I P L E R 0 . 3 5 1 8 7 R S Q U A R E 0 . 1 2 3 8 1 A N A L Y S I S O F V A R I A N C E D F SUM R E G R E S S I O N 1 2 . O F S Q U A R E S 4 . 2 5 8 4 1 M E A N S Q U A R E 0 . 3 5 4 8 7 F 0 . 3 8 8 5 9 P 0 . 9 5 8 1 A D J U S T E D R S Q U A R E - 0 . 1 9 4 8 0 S T A N D A R D E R R O R 0 . 9 5 5 6 2 R E S I D U A L 3 3 . 3 0 . 1 3 6 0 1 0 . 9 1 3 2 1 — , 3 n l _ V A R I A B L E S I N T H E E Q U A T I O N VAR I A M F S M n T IM T H E E Q U A T I O N I I I B I I B I g H V A N ! A B I E B T R R C 2 - 0 . 5 4 3 8 8 9 3 E - 0 2 B E T A - 0 . 0 2 5 7 2 S T D E R R O R B 0 . 0 4 8 1 4 F 0 . 0 1 3 V A R I A B L E B E T A I N P A R T I A L T O L E R A N C E F I K K * O . Z 2 Z 1 8 1 0 E - 0 1 T P R C 2 0 . 2 5 8 4 3 7 5 E - 0 1 T I N F 2 0 . 3 9 9 0 0 5 1 E - 0 2 0 . 0 7 5 7 1 " 0 . 0 8 6 5 3 0 . 0 1 2 5 2 0 . 0 7 1 0 9 0 . 0 6 8 2 1 0 . 0 6 6 0 1 0 . 0 9 8 0 . 1 4 4 0 . 0 0 4 T I N F C 2 0 . 2 6 9 5 1 8 4 E - 0 1 T R R 2 0 . 9 6 5 6 4 2 7 E - 0 2 R E S I 0 G K 3 - 0 . 4 9 5 1 1 6 6 E - 0 1 ' B f t " * ft iTkt^L A • A"e>iV»"*i"«£T 0 . 0 7 0 8 6 0 . 0 5 1 7 6 - 0 . 0 3 4 3 1 0 . 0 8 3 6 9 0 . 0 5 0 3 8 0 . 2 5 8 5 7 0 . 1 0 4 0 . 0 3 7 0 . 0 3 7 R E S I D S K 3 0 . 1 0 5 9 8 4 2 N I M P - 0 . 5 7 4 4 8 6 0 N C H N G - 0 . 2 3 2 0 0 2 7 0 . 0 8 7 3 2 - 2 . 6 8 4 9 3 - 1 . 4 9 3 5 9 0 . 2 3 3 3 6 0 . 4 5 8 8 1 0 . 1 6 7 1 1 0 . 2 0 6 1 . 5 6 8 1 . 9 2 7 W T I M P 0 . 6 1 9 1 3 8 9 N S C H N G 0 . 7 5 1 9 9 6 8 E - 0 2 1 C O N S T A N T ) - 1 . 3 7 4 2 9 9 3 . 4 2 4 5 8 0 . 1 7 6 1 2 0 . 4 8 6 9 1 0 . 0 1 0 8 8 1 . 6 1 7 0 . 4 7 8 U l APPENDIX G Regression data: summary tab! REGRESSION SUMMARY TABLES FILE TOTAL (CREATION DATE = 06/22/78) 03/15/80 PAGE WITH NEW LABELS * * * * * * * * * * * * * * * * * * * * * * * DEPENDENT VARIABLE.. RETl~D~PT" H U L T I P L E R E G R E S S I O N * * * * * * * * * * * * * COMPLETE RECORD IN ACQUISITION PHASE VARIABLE LIST 1 REGRESSION LIST 1 SUMMARY TABLE VARIABLE MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R "TRIO TINFl TPRCl RESIDSK4— RESI0GK4 TPRl nrKRXT TINFCl NCHNG "NJJCHNG NIMP MTIMP {CONSTANT! RE INFOftC E l i T ^ S l L T N l E RESOURCES BASELINE STANOARDS CHANGE BASE TO IMTH SPECIFIC"KNOWLEDGECHANGEBASETO IMTH GENERAL KNOWLEDGE CHANGE BASE TO IMTH STANCARDS BASELINE REINFORCERS CHANGE BA^EnrirrMTfl RESOURCES CHANGE BASE TO IMTH GAP "LEEWAY" " ' " - ' IMPORTANCE IMPETUS 0.26247 0.33142 0.3777 5 0 . 40 537 0.43697 0.45244 0.06889 0.10984 0.14270 0.16432 0.19095 0.20471 0746193 0.4702 8 0.47989 0.50644 0.50694 0.57625 0.21338 0.22116 0.230 30 0.25648 0.25699 0.33206 0.06869 0.04095 0.03286 0.02163 0.02662 0.01376 0.2624 7 -0. 16047 0.13555 •0.02947 0.17865 0.13074 0.00868 0. 00778 0.00913 0.02619 0.00050 0.07508 -0.04943 0.04594 0.11608 -0.11921 0.08174 0.12236 B 0.2288751E-01 -0.4598062E-01 0. 1348623 -0.26 93 459 0.2383606 0.7967 712E-01 -0.6818 585E-01 0.3015874E-01 -0.2066253 -0.1310931E-01 -0.6881043 0.7241325 BETA 0.11187 -0.13676 0.45916 -0.29881 0.21237 0.31653 -0.30699 0.10355 -1.34325 -1.941188 -0.31003 -3.24744 4.04456 R E G R E S S I O N S U M M A R Y T A B L E S FILE TOTAL I CREATION OATE = 06/22/781 03/15/80 P A G E WITH NEW LABELS * * * * * * * * * * * * * * * * * * * * * * * M U L T I P L E D E P E N D E N T V A R I A B L E . . R E S I D P T I D O W M E N T A T T C T N I N A C Q U I S I T I O N P H A S E S U M M A R Y T A B L E R E G R E S S I O N * * * * * * * * * * * * * VARIABLE LIST 1 REGRESSION LIST 2 VARIABLE i MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R B BETA | NCHNG TPRl i RESIDGK4 GAP STANDARDS BASELINE GENERAL KNOWLEDGE CHANGE 8ASE TO IMTH 0.24563 0.32725 0.37174 0.06036 0.10709 0.13819 0.06036 0.04673 0.03110 0.24569 -0.22530 -0.17241 0.2775322 -0.8450509E-01 -0. 2204216 1.83356 -0.34118 -0.19958 TINFCl WTIMP NIMP RESOURCES CHANGE BASE TO IMTH INPE TUS IMPORTANCE 0.39594 0.41513 0.48645 0.15677 0.17233 0.23664 0.01858 0.01556 0.06430 0.16 510 0.03099 -0.05849 0.3310614E-01 -0.6756498 0.605322 5 0.11552 -3.83517 2.90324 TRRl TPRCI TRRCl REINFORCERS BASELINE STANDARDS CHANGE BASE TO IMTH RE INFORCERS CHANGE BASE TO IMTH 0.51409 0.51818 0.51903 0.26428 0.26852 0.269 39 0. 0 2 765 0.00423 0.00087 -0.01523 0.10910 -0.10679 0.4854401E-01 -0.3529457E-01 0.1037015E-01 0.24113 -0.12212 0.04745 TINFl RESIDSK4 (CONSTANT 1 RESOURCES BASELINE SPECIFIC KNOWLEDGE CHANGE BASE TO IMTH 0.51961 0. 52015 0.27000 0.2 7055 0.00061 0.00055 -0.03512 -0.02 730 -0. 1137 503E-01 0.2476095E-01 1.040787 -0.03438 0 .02792 I—' U l CO R E G R E S S I O N S U M M A R Y T A B L E S F I L E T O T A L ( C R E A T I O N D A T E 0 3 / 1 5 / 8 0 P A G E 0 6 / 2 2 / 7 8 1 W I T H N E W L A B E L S u I I i T r o i P R E G R E S S I O N * * * * * * * * * * * * * V A R I A B L E L I S T 1 * * * * * * * * * * * * * * * * * * * * * * * M U L T I P L E R E G R E S S I U N R E G R E S S I O N L I S T 3 DEPENDENl VARIABLE.. TJTETICrpNl f A T A - B T S E ~ n r ; A C Q U I S I T I O N P H A S E S U M M A R Y T A B L E VARIABLE TINFl NSCHNG TINFCl -RESTDSX4— TRRl TPRCI TRRCT ~ ~ TPRl RES I D G K 4 ~NlNP~~ ~~~~ WTIMP NCHNG ICONSTANTI RESOURCES B A S E L I N E ' L E E W A Y R E S O U R C E S C H A N G E B A S E T O I M T H S P E C I F I C K N O W L E D G E C H A N G E B A S E T O I M T H R E I N F O R C E R S B A S E L I N E S T A N D A R D S C H A N G E B A S E TO I M T H R E I N F O R C E R S TJT7ffZB4~ 0.38169 0.42106 0. 4 4 3 8 9 0 . 4 6 8 9 0 0 . 4 8 7 7 9 0 . 1 4 5 6 9 0 . 1 7 7 2 9 0 . 1 9 7 0 4 0 . 2 1 9 8 7 0 . 2 3 7 9 4 0 . 0 6 5 6 9 0 . 0 3 1 6 0 0 . 0 1 9 7 5 0 . 0 2 2 8 3 0 . 0 1 8 0 7 C H A N G E B A S E TO I M T H S T A N O A R D S B A S E L I N E G E N E R A L K N O W L E D G E C H A N G E B A S E T O T M P O R T A N C E I M P E T U S G A P '  I M T H " 0 7 5 0 1 5 1 0 . 5 1 4 9 7 0 . 5 2 3 2 3 0 . 5 2 3 4 3 0 . 5 2 8 8 5 0 . 5 8 9 0 6 0 . 2 5 1 5 1 0 . 2 6 5 1 9 0 . 2 7 3 7 7 0 . 2 7 3 9 8 0 . 2 7 9 6 9 0 . 3 4 6 9 9 0 . 0 1 3 5 8 0 . 0 1 3 6 8 0 . 0 0 8 5 8 0 . 0 0 0 2 1 0 . 0 0 5 7 0 0 . 0 6 7 3 1 M U L T I P L E R R S Q U A R E R S Q C H A N G E S I M P L E R "OTO _"OTJO 0T08000 ^0T2T28 4 - 0 . 2 1 6 1 7 0 . 0 1 9 2 4 - 0 . 1 4 8 6 3 0 . 1 2 4 3 7 0 . 1 0 7 8 8 - 0 . 0 4 2 0 0 0 . 1 1 0 5 2 0 . 1 0 8 7 5 - 6 . 0 1 0 7 4 - 0 . 0 4 9 9 2 - 0 . 1 1 9 9 8 B - 0 . 1 2 9 3 1 4 8 - 0 . 1 4 4 3 7 5 7 E - 0 1 - 0 . 2 3 7 6 3 1 6 E - 0 1 - 0 . 3 1 9 2 4 5 3 - 0 . 6 9 7 9 5 7 7 E - 0 3 0 . 1 2 4 3 2 5 6 - 0 . 7 5 7 4 2 5 4 E - 0 1 0 . 6 9 4 4 6 3 1 E - 0 1 0 . 1 4 2 6 2 3 8 - 0 . 6 9 9 2 2 7 0 0 . 7 3 7 2 7 3 3 - 0 . 2 4 5 3 0 6 6 1 . 4 4 3 2 9 5 B E T A - 0 . 3 7 1 9 8 - 0 . 3 3 0 2 3 - 0 . 0 7 8 9 1 - 0 . 3 4 2 5 4 - 0 . 0 0 3 3 0 0 . 4 0 9 3 9 - 0 . 3 2 9 8 1 0 . 2 6 6 8 3 0 . 1 2 2 9 ( B „ . - 3 . 1 9 1 5 9 3 . 9 8 2 7 5 - 1 . S 4 2 3 5 REGRESSION SUMMARY TABLES 03/15/80 PAGE 7 FILE TOTAL 1 CREATION DATE = 06/22/781 WITH NEW LABELS * * * * * * * * * * * * * * * * * * * * * * * M U L T I P L E R E G R E S S I 0 N * * * * * * * * * * * * * VARIABLE REGRESSION LIST 1 LIST 4 J DEPENDENT V A R I A B L E . . RESI0PP1 PROBLEM FOCUS IN ACQUISITION PHA SE SUMMARY TABLE VARIABLE MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R B BETA TPRCl TRRl RESIDSK4 S T A N C A H O S CHANGE BASE TO IMTH 0.28424 REINFORCERS BASELINE 0.35174 SPECIFIC KNOWLEDGE CHANGE BASE TO IMTH 0.42905 0.08079 0.12372 0.18408 0.08079 0.04293 0.06036 0.28424 0.13910 -0.11478 0.1762 368 0.4038013E-01 -0.4075002 0.52463 0.17257 -0.39527 TINFl RESIDGK4 TINFCl RE S O URCE S BAS E L I N E " 0 . 47651 GENERAL KNCWLEOGE CHANGE B A S E TO IMTH 0.49506 RESOURCES CHANGE BASE TO IMTH 0.51076 0.22706 0.24508 0.260 88 0.04298 0.01802 0.01580 -0.18857 0.11850 0.13413 -0.4709845E-01 0.2298623 0.5432401E-01 -0.12248 0.17907 0.16309 TRRCl TPRl NCHNG REINFORCERS C H A N G E B A S E T O I M T H 0.51545 STANDARDS BASELINE 0.52006 GAP 0.5252 0 0.26568 0.27046 0.275 83 0.00481 0.00478 0.00537 0.01394 -0.07108 0.09309 -0.5576984E-01 0.4196836E-01 -0.1358 267 -0.2195* 0.14578 -0.77205 "~""N ACTING NIHP WTI MP LEEWAY 0.53642 IMPORTANCE i 0.53758 IMPETUS 0.56203 0.287 75 0.28900 0.31588 0.01191 0.00125 0.02688 -0.11997 0.03675 0.06608 -0.9692771E-02 -0.4770277 0. 4955 886 -6.20043 -1.96843 2.42026 ( C O N S T A N T ! -1.666818 O j REGRESSION SUMMARY TABLES ' FILE TOTAL I CREATION DATE 03/15/80 PAGE 06/22/781 WITH NEW LABELS * * * * * * * * * * * * * * * * * * * * * * * M U L T I P L E R E G R E S S I O N D E P E N D E N T V A R I A B L E . . R E S I D P C 1 Wi?A~TTtrNT~PLAN I N A T T Q T J T S I T J W W A S -* * * * * * * * * * * * * VARIABLE LIST 1 REGRESSION LIST 5 SUMMARY TABLE VARIABLE MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R B BETA TPRl RESIDSK4 NCHNG STANDARDS BASELINE SPECIFIC KNOWLEDGE CHANGE BASE TO IMTH GAP 0.32958 0.44468 0.51542 0.10862 0.19774 0.26566 0.10862 0.08912 0.06792 0.32958 0.28163 0.27181 0. 1332185 0.1913979 -0.9796 532E-01 0.49073 0.19688 -0.59052 —NSCHNG TINFCl RES IDGK4 XEEW AY -RESOURCES CHANGE BASE TO IMTH GENERAL KNOWLEDGE CHANGE BASE TO IMTH 0. 5455 8 0.56373 0.57267 0.29766 0.31779 0.32795 0.03200 0.02013 0.01016 0.03 876 0.07597 0.20084 -0.1012851E-01 0. 7035 785E-01 0. 1739373 -0.2 2210 0.2 2399 0.14370 TINFl TRRCl TRRl RESOURCES BASELINE REINFORCERS CHANGE BASE TO IMTH REINFORCERS BASELINE 0.57993 0.58853 0.59090 0.33632 0.34637 0.34917 0.00836 0.01005 0.00280 -0.02815 0.08253 0.17749 0.4049966E-01 -0.1760 380E-04 -0.2375626E-01 0.11169 -0.00007 -0,10767 N 1 W WTIMP TPRCI IMPORTANCE IMPETUS STANDARDS CHANGE BASE TO IMTH 0.59136 0.61466 0.61541 0.34971 0.37781 0.37873 0.00054 0.02810 0.00092 0.09926 0.20406 -0.08884 -0.4636028 0.4851118 0.1511381E-01 -2.02 871 2.51236 0.04771 (CONSTANT) -3.386 809 REGRESSION SUMMARY TABLES FILE TOTAL (CREATION OATE = 06/22/781 WITH NEW LABELS 03/15/80 PAGE * * * * * * * * * * * * * * * * * * * * * * * M U L T I P L E DEPENDENT VARIABLE.. RESIDPS1 FOLLOW UP IN ACQUISlTToTTPHASE R E G R E S S I O N * * * * * * * * * * * * * VARIABLE LIST 1 REGRESSION LIST 6 J SUMMARY TABLE VARIABLE MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R B BETA TPRl TPRCl TRRCl . _ NtCHNG NCHNG STANDARDS BASELINE STAN CARDS CHANGE BASE TO IMTH REINFORCERS CHANGE BASE TO IMTH 0.18297 0.33943 0.39674 0.03348 0.11522 0.15741 0.03348 0.08174 0.04219 0.18297 0.12 578 -0.11013 0.1764047 0. 1774498 -0. 1056 200 0.62641 0.54002 -0.42505 REINFORCERS BASELINE LEEWAY GAP 0.43670 0.44989 0.50107 0.19070 0.20240 0.25107 0.03330 0.01170 0.04867 0.03905 -0.08 702 0.09412 -0.8521264E-01 -0.1422609E-01 0.3812211E-01 -0.3722? -0.30073 0.22152 WTIMP RESIDSK4 RES IDGK4 '—TIN FIT" (CONSTANT) IMPETUS SPECIFIC KNOWLEDGE CHANGE BASE TO IMTH GENERAL KNOWLEDGE CHANGE BASE TO IMTH 0.50696 0.51074 . 0.51318 0.25701 0.26086 0.26336 0.00594 0.00385 0.00250 0.04743 0.02612 0.02941 0. 2381206E-01 -0.8715064E-01 0. 8171376E-01 0.11888 -0.08642 0.06508 RESOURCES BASELINE 0.51510 0.26533 0.00197 -0.03703 0.1825 759E-01 -2.559745 0.04854 REGRESSION SUMMARY TABLES 03/15/80 PAGE 12 FILE TOTAL (CREATION DATE = Ob/22/181 WITH NEW LABELS * * * * * * * * * * * * * * * * * * * * * * * MU L T I P L E R E G R E S S I 0 N * * * * * * * * * * * * * VARIABLE LIST 1 REGRESSION LIST 1 J DEPENDENT VARIABLE.. RESIDP2 COMPLETE RECORD IN MAINTENANCE PHASE SUMMARY TABLE VARIABLE MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R B BETA TRRZ TI NFC2 RESIDGK3 REINFGRCERS IMTH RESOURCES CHANGE 1 TO 4MTHS GENERAL KNOWLEDGE CHANGE 1 TC 4MTHS 0.34294 0.44879 0.47085 0.11760 0.20141 0.22170 0. 11760 0.08380 0.02029 0.34 294 0.32022 0.10 242 0.5261569E-01 0.8613 767E-01 0.20 61708 0.31353 0.25183 0.16042 TTNF7 RESIDSK3 NSCHNG RESOURCES IMTH SPECIFIC KNOWLEDGE CHANGE 1 TO 4MTHS LEEWAY 0.49440 0.50561 0.51961 0.24443 0.25564 0.26999 0.02273 0.01121 0.01435 0.21472 -0.05247 -0.04201 0.4586 285E-01 -0.7857571E-01 0.6681994E-0 2 0.16002 -0.07199 0.17402 NCHNG WTIMP NIMP GAP IMPETUS IMPORTANCE 0.54188 0.54729 0.57626 0.29363 0.29953 0.33208 0.02364 0.00590 0.03255 -0.00 65 7 0.08617 0.07569 -0.1925 295 0.4874138 -0. 4471942 -1.37827 2.99789 -2.3 2407 TPR2 1 TRRC2 TPRC2 STANDARDS IMTH REINFORCERS CHANGE 1 TO 4MTHS STANDARDS CHANGE 1 TO 4MTHS 0. 57807 0.57878 0.57908 0.33417 0.33499 0.33534 0.00209 0.00083 0.00034 0.19176 0.03553 0.02041 0. 1310847E-01 -0.8606610E-02 0.6979419E-02 0.04967 -0.04526 0.0 2599 (CONSTANT) -3.634206 Co ; REGRESSION SUMMARY TABLES 03/15/80 PAGE 13 i FILE TOTAL (CREATION DATE = 06/22/781 WITH NEW LABELS ! * * * * * * * * * * * * * * * * * * * * * * * H U L T I P L E R E G R E S S I 0 N * * * * * * * * * * * * * VARIABLE LIST 1 REGRESSION LIST ? J DEPENDENT VARIABLE.. RES IDPL2 DOCUMENTATION IN MAINTNENANCE PHASE SUMMARY TABLE -s. VARIABLE MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R B BETA TRRC2 TRR2 RESI0GK3 REINFORCERS CHANGE 1 TO 4HTHS REINFORCERS IMTH GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS 0.26512 0.50839 0.55251 0.07029 0.25846 0.30527 0.07029 0. 18817 0.04681 -0 . 26512 0.25015 0.22278 -0. 1005 980 0.1027386 0.3899 860 -0.44472 0.51462 0.25262 NCHNG TINF2 TPR2 GAP RESOURCES IMTH STANDARDS IMTH 0.5982 5 0.60813 0.61096 0.35790 0.36982 0.37327 0.05263 0.01192 0.00344 -0.17957 0.06 546 0.2036 8 0.2554162E-01 0.4131524E-01 0.3573621E-01 0.15370 0.12118 0.11383 TPRC2 RESIDSK3 TINFC2 STANDARDS CHANGE 1 TO 4MTHS SPECIFIC KNOWLEDGE CHANGE 1 TO 4MTHS RESOURCES CHANGE 1 TO 4MTHS 0.61441 0.61603 0.61663 0.37750 0.37949 0.38023 0.00423 0.00199 0.00074 -0.10258 -0.01520 0.25715 -0.3403258E-01 0.3982017E-01 0.1511911E-01 -0.10651 0.03067 0.03716 WTIMP NIMP (CONSTANT1 IMPETUS IMPORTANCE 0.61691 0.61942 0.38058 0.38368 0.00035 0.00310 -0.09904 -0.04348 -0.1698047 0.1563882 -4.807172 -0.87791 0.68319 -O REGRESSION SUMMARY TABLES FILE TOTAL (CREATION DATE = 06/22/78) 03/15/80 PAGE 14 WITH NEW LABELS * * * * * * * * » * * * * * * * * * * * * * * M U L T I P L E DEPENDENT V A R I A B L E . . R E G R E S S I O N * * * * * * * * * * * * * RESIDPN2 DATA BASE IN MAINTENANCE PHASE-VARIABLE "TTNFTJ2" TPR2 TINF2 RESTDSK3-RESI0GK3 TRR2 WTTHP NSCHNG NCHNG — T P f t C 2  TRRC2 NIMP (CONSTANT) RESOURCES CHANGE 1 TO 4MTHS STANDARDS IMTH RESOURCES IMTH "SPECIFIC"KNOWLEDGECHANGE1TO 4MTHS GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS REINFORCERS IMTH IMPETUS LEEWAY GAP STANDARDS CHANGE 1 T O 4 M T H S " REINFORCERS CHANGE 1 TO 4MTHS IMPORTANCE SUMMARY TABLE MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R 0.35463 0.44519 0.53506 0.54632 0.56056 0.57727 0.59094 0.61910 0.62883 0.63661 0.43854 0.63897 0.12576 0.19819 0.28628 0.29846 0.31423 0.33324 0.349 21 0.383 29 0.39542 0.46527 0.40773 0.40828 0. 12576 0.07243 0.08809 0.01218 0.01577 0.01901 0.01597 0.03408 0.01214 6.00984 0.00247 0.00055 0.35463 0.31583 0.30904 -0.11819 0.09396 0.28 28 9 -0.12418 -0.08087 -0.09268 6.25140 0.04971 -0.12252 VARIABLE LIST 1 REGRESSION LIST 3 B 0.7381417E-01 0.5146256E-01 0.9431734E-01 -0.1460514 0.1995 758 0.S717873E-01 0.4226 101E-01 0.1150453E-01 -0. 5267 700E-01 0.4269308E-01 -0.1346543E-01 -0.6097 075E-01 ^.440823 BETA 0.20969 0.18948 0.31977 -0.13001 0.14944 0.33108 0.25257 0.29113 -0.36643 0.15445 -0.06881 -0.3Q78S ON FILE TOTAL (CREATION DATE * 06/22/78)WITHNEWLABELS * * * * * * * * * * * * * * * * * * * * * * * M U L T I P L E R E G R E S S I O N * * * * * * * * * * * * * VARIABLE LIST 1 • REGRESSION LIST 4 < , DEPENDENT VARIABLE.. RESIDPP2 PROBLEM FOCUS IN MAINTENANCE PHASE SUMMARY TABLE VARIABLE MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R B BETA TINFCZ TRR2 WTIMP RESOURCES CHANGETHTO 4MTHS REINFORCERS IMTH IMPETUS 0.36113 0.43095 0.46464 0.13042 0.18572 0.21589 0.13042 0.05530 0.03017 0.36113 0.26783 0.19289 0. 1250275 0. 1756468E-01 0.66 86648 0.33575 0.09614 3.77772 — T I N F 2 RESIDGK3 RESI0SK3 "RESOURCESIMTH GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS SPECIFIC KNOWLEDGE CHANGE 1 TO 4MTHS 0.48570 0.50999 0.52335 0.23591 0.26009 0.27390 0.02002 0.02419 0.01380 0.23171 0.11560 -0.07381 0.3257965E-01 0.2460479 -0.1496 215 0.10442 0.17416 -0.12591 TPRC2 NtCHNG ' NCHNG STANDARDS CHANGE 1 TO 4MTHS LEEWAY GAP 0.52938 0.53371 0.53732 0.280 24 0.28484 0.28871 0.00635 0.00460 0.00387 -0.01143 -0.03239 0.09648 -0.2147779E-02 0.1694259E-03 -0.2262727 -0.00735 0.00405 -1 .4 879.C NIMP ' TRRC2 TPR2 IMPORTANCE REINFORCERS CHANGE 1 TO 4MTHS STANDARDS IMTH 0.57964 0.58147 0.58183 0.33598 0.33811 0.33853 0.04727 0.00213 0.00042 0.15781 0.02357 0.12256 -0. 6006 032 0. 1353334E-01 0.8746 275E-02 -2.86 710 0.06538 0.03044 (CONSTANT) -2.849606 •I ON' ON • REGRESSION SUMMARY TABLES 03/15/80 PAGE 16 N. FILE TOTAL (CREATION DATE * 06/22/781 WITH NEW LABELS * * * * * * * * * * * * * * * * * * * * * * * M J L T I P L E R E G R E S S I 0 N * * * * * * * * * * * * * VARIABLE LIST 1 REGRESSION LIST 5 J DEPENDENT VARIABLE.. RESI0PC2 TREATMENT PLAN IN MAINTENANCE PHASE SUMMARY TABLE \ VARIABLE MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R B BETA TINFC 2 TRR2 TPRC2 RESOURCES CHANGE 1 TO 4NTHS REINFORCERS IMTH STANCAROS CHANGE 1 TO 4MTHS 0.25116 0.29916 0.34735 0.06308 0.08950 0.12065 0.06308 0.02641 0.03116 -0.25116 0.13838 -0.17426 -0.5997427E-01 0.1943691E-01 -0.3642314E-01 -0.21176 0.13988 -0.16378 TRRC2 NtCHNG TPR2 REINFORCERS CHANGE1TO4MTHS LEEWAY STANOARDS IMTH 0.36989 0.38332 0.38770 0.136 82 0.146 93 0.15031 0.01616 0.01011 0.00338 0.21 610 -0.07585 -0.07382 0. 230D041E-01 -0.3319129E-02 -0.2028502E-01 0.14609 -0.10440 -0.09283 RESIDSK3 NIMP RESIDGK3 SPECIFIC KNOWLEDGE CHANGE 1 TO 4MTHS IMPORTANCE GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS 0.39080 0.39332 0.39504 0.15272 0.154 70 0.15606 0.00241 0.00198 0.00136 0.05 376 0.06326 -0.09569 0.5070796E-01 0.7177293E-01 -0.4220396E-01 0.05611 0.45049 -0.0392 8 ~"~TIiNF2 MTIMP NCHNG RESOURCES I M T H ~ IMPETUS GAP 0.39588 0.39613 0.39718 0.15672 0.15692 0.15775 0.00066 0.00020 0.00083 -0.06664 0.03231 -0.05433 -0.7039374E-02 -0.6923914E-01 0.2194989E-01 -0.02966 -0.51433 0.18978 IC0N5TANT) -0.1827519 1 ON REGRESSION SUMMARY TABLES 03/15/80 PAGE 17 FILE TOTAL (CREATION DATE = 06/22/781 WITH NEW LABELS * * * * * * * * * * * * * * * * * * * * * * * M U L T I P L E DEPENDENT VARIABLE.* RESIDPS2 FOLLOW UP IN MAINTENANCE PHASE R E G R E S S I O N * * * * * * * * * * * * * VARIABLE LIST 1 REGRESSION LIST 6 SUMMARY TABLE VARIABLE MULTIPLE R R SQUARE RSQ CHANGE SIMPLE R B BETA TRR2 NSCHNG TINFC2 REINFORCERS IMTH LEEWAY RESOURCES CHANGE 1 TO 4MTHS 0.16292 0.22317 0.24612 0.02654 0.04981 0.06057 0.02654 0.02326 0.01077 0.16292 0.11131 0.07426 0.9348286E-02 0.7463105E-02 0. 2942610E-01 0.05010 0.17479 0.07736 NCHNG TPR2 WTIMP GAP STANDARDS IMTH IMPETUS 0.27157 0.27572 0. 2790 7 0.073 75 0.07602 0.07788 0.01318 0.00227 0.00186 0.04828 0.13848 0.08 891 -0.2326 871 0.2U0493E-01 0.6212709 -1.49800 0.07192 3.43638 NIMP RESIDSK3 TPRC2 IMPORTANCE SPECIFIC KNOWLEDGE CHANGE 1 TO 4MTHS STANDARDS CHANGE 1 TO 4MTHS 0.33921 0.34397 0.35015 0.11506 0.11832 0.12261 0.03719 0.00325 0.00429 0.06050 0.07906 0.05420 -0.5766 891 0. 1020015 0.2561242E-01 -2.69523 0.08404 0,08575 RESIDGK3 TRRC2 (CONSTANT 1 GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS REINFORCERS CHANGE 1 TO 4MTHS 0.35136 0.35173 0.12346 0.12371 0.00085 0.00026 -0.00 888 0.06347 -0.4916640E-01 -0.4486310E-02 -1.242397 -0.03407 -0.02122 CTN CO 

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