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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 U n i v e r s i t y of Western O n t a r i o , 1971 M.Sc.(Kinesiology),  Simon F r a s e r 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  in THE FACULTY OF GRADUATE STUDIES (Department of A d u l t  We accept  Education)  t h i s t h e s i s as conforming  to the r e q u i r e d  standard  THE UNIVERSITY OF BRITISH COLUMBIA January 1980  ©  Anne S c o t t , 1980  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of B r i t i s h 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 B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5  Date  M a r c h 10. 1980  ABSTRACT  The purpose of t h i s study was  to a i d i n u n d e r s t a n d i n g the p r o c e s s  of change i n o c c u p a t i o n a l s e t t i n g s by examining f a c t o r s t h a t i n f l u e n c e an employee to change h i s performance of a t a s k . critical  F i v e f a c t o r s thought to be  to the change p r o c e s s were s e l e c t e d and t h e i r r e l a t i o n s h i p s to  both immediate examined.  and long-term changes i n employee performance l e v e l s were  The f a c t o r s s e l e c t e d were:  the task, h i s m o t i v a t i o n to change,  an i n d i v i d u a l ' s knowledge about  and h i s p e r c e p t i o n s of the r e s o u r c e s  a v a i l a b l e to do the task, the s t a n d a r d s r e q u i r e d f o r c o r r e c t and the r e i n f o r c e r s a s s o c i a t e d w i t h h i s performance. used to observe changes i n performance l e v e l s was r e c o r d s i n a h o s p i t a l department,  performance  The s p e c i f i c  task  a new method of k e e p i n g  c a l l e d Problem O r i e n t e d R e c o r d i n g  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 as f o l l o w s : performance would be more c l o s e l y l i n k e d  initial  to m o t i v a t i o n to change,  (POR).  changes i n increase  i n knowledge and the p e r c e i v e d presence of performance s t a n d a r d s than to the p e r c e i v e d a v a i l a b i l i t y o f r e s o u r c e s and r e i n f o r c e r s f o r c o r r e c t performance; and subsequent changes linked  i n performance would be more c l o s e l y  to the i n d i v i d u a l ' s p e r c e p t i o n s of the presence of performance  standards and 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 than to h i s m o t i v a t i o n to change and l o s s of  knowledge.  Four s p e c i a l l y c o n s t r u c t e d i n s t r u m e n t s were developed to measure the dependent  and independent v a r i a b l e s .  measured on a c h e c k - l i s t which i n d i c a t e d items i n randomly  Record-keeping b e h a v i o u r was the presence or absence of r e q u i r e d  selected patient-care records. ii  A paper and p e n c i l  recall  iii t e s t measured the p a r t i c i p a n t s ' knowledge of r e c o r d i n g p o l i c i e s , and format, and two and  procedures  a t t i t u d i n a l surveys measured t h e i r m o t i v a t i o n to change  t h e i r p e r c e p t i o n s of performance  s t a n d a r d s , r e s o u r c e s and  reinforcers.  An i n s e r v i c e e d u c a t i o n program p r o v i d e d the p a r t i c i p a n t s ,  62  p h y s i c a l and o c c u p a t i o n a l t h e r a p i s t s , w i t h an o p p o r t u n i t y to l e a r n Problem O r i e n t e d Recording.  about  The program c o n s i s t e d of seven 1-hour s e s s i o n s ;  f i v e s e s s i o n s were h e l d on c o n s e c u t i v e days and  the remaining  two were h e l d  one month l a t e r and a f t e r a f u r t h e r i n t e r v a l of t h r e e months. e x c e p t i o n of m o t i v a t i o n to change, which was  With the  measured once a t the b e g i n n i n g  of  the study, data c o l l e c t i o n on a l l v a r i a b l e s c o i n c i d e d w i t h the d e l i v e r y  of  the i n s e r v i c e program.  i n t r o d u c t i o n of POR, months l a t e r .  Thus, v a r i a b l e s were measured b e f o r e the  one month a f t e r i t s i n t r o d u c t i o n and a g a i n t h r e e  Changes i n each v a r i a b l e were c a l c u l a t e d  from the d i f f e r e n c e s  between s c o r e s a t b a s e l i n e and one month, and one month and The d a t a showed t h a t r e c o r d i n g behaviour d u r i n g the f i r s t month and months.  f o u r months.  s i g n i f i c a n t l y increased  s i g n i f i c a n t l y decreased d u r i n g the next  Knowledge a l s o s i g n i f i c a n t l y i n c r e a s e d d u r i n g the f i r s t month but  i t remained  a t t h a t new  level.  A s i m i l a r p a t t e r n was  observed f o r  t h e r a p i s t s ' p e r c e p t i o n s of standards f o r proper performance. at  the b e g i n n i n g of the implementation  were m o t i v a t e d  of POR  indicated  to change t h e i r r e c o r d - k e e p i n g p r a c t i c e s .  Data  that  Stepwise m u l t i p l e  observed 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 behaviour and  subsequent  d e c l i n e of recording behaviour.  f o r 33%  34% i n the  General h i e r a r c h i c a l  tests  confirmed  t h a t m o t i v a t i o n to change, knowledge and performance  accounted  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 i n i t i a l change o f  performance  collected  therapists  r e g r e s s i o n e q u a t i o n s showed t h a t the s e l e c t e d v a r i a b l e s accounted of  three  than r e s o u r c e s and r e i n f o r c e r s ; and performance  standards  standards,  resources loss  and  reinforcers  of performance.  a c c o u n t e d 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  Therefore,  the hypothesized  relationships  i n the  were  confirmed. The to  reach  to h e l p for  new  levels  the newly  inservice  acquired  maintenance are discussed  s u p e r v i s o r s and  m e n t and  that  the need  education  of performance but a d d i t i o n a l  them m a i n t a i n  ensuring  between  f i n d i n g s imply  educators,  to e s t a b l i s h  how  level.  including  programs.  activities Several  help are  employees necessary  recommendations  the need  for collaboration  the advantages of a s i t u a t i o n a l much k n o w l e d g e  a d e c i s i o n i s made t o r e m e d y p e r f o r m a n c e d e f i c i t s education  programs  has been  retained  t h r o u g h more  assessbefore  inservice  TABLE OF CONTENTS  Page ABSTRACT  1  1  LIST OF TABLES  ix  LIST OF FIGURES  xi  ACKNOWLEDGEMENT  xiii  Chapter 1.  2.  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  THE RELATED LITERATURE  9  PLANNED CHANGE  9  THE STUDY OF WORK BEHAVIOR Motivation  11 11  Content t h e o r i e s  12  A process theory  14  Behaviourism  15  Summary  16  TWO MODELS OF PERFORMANCE  17  A Model of Performance  17  A Performance A u d i t Model  19  AN EDUCATOR'S APPROACH TO CHANGE  21  A SUMMARY OF THE THEORETICAL CONSTRUCTS  26  v  vi Chapter  Page FACTORS AFFECTING PERFORMANCE CHANGE Studies  on Performance Change among P r o f e s s i o n a l s  Studies  on Employee Knowledge Change  . . .  28 31  A c q u i s i t i o n and r e t e n t i o n of knowledge  31  Immediate changes i n knowledge  33  O r g a n i z a t i o n a l F a c t o r s and Employee Performance A Summary of E m p i r i c a l F i n d i n g s 3.  28  DESIGN AND: RATIONALE FOR THE STUDY THE CONCEPTUAL FRAMEWORK  . . . .  34 35 38 38  The P r o c e s s of Change  39  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  39  Knowledge Motivation  40 t o change  41  Performance standards  43  Resources  43  Reinforcers  45  F o r c e s Promoting I n i t i a l Change  45  F o r c e s Promoting Maintenance of Change  46  THE VARIABLES AND  THEIR MEASUREMENT  The V a r i a b l e s  49 49  V a r i a b l e s of r e c o r d i n g behaviour  49  Knowledge v a r i a b l e s  50  Motivation variables  51  Performance standards  51  Resources  52  Reinforcers  52  vii Chapter  Page Measurement o f t h e V a r i a b l e s THE  52  HYPOTHESES  55  PROCEDURES The  56  Setting  Phases The  and P a r t i c i p a n t s  56  o f t h e S t u d y and D a t a C o l l e c t i o n  59  i n s e r v i c e program  60  Data c o l l e c t i o n The A n a l y s i s  60  of Data  62  4. INSTRUMENT DEVELOPMENT  64  FORMAT REVIEW AUDIT SHEET  64  CLINICAL  65  RECORD-KEEPING INVENTORY  RECORDING NEEDS SURVEY  69  RECORDING OPINIONS SURVEY  . . . . . . .  5. DATA ANALYSIS AND RESULTS  ; . . .  A C Q U I S I T I O N AND MAINTENANCE A C Q U I S I T I O N AND  OF RECORDING BEHAVIOUR  . . .  RETENTION OF KNOWLEDGE  72 76 76 81  MOTIVATION TO CHANGE  81  TASK-RELATED FACTORS  86  RELATIONSHIPS AMONG THE VARIABLES  . . . . .  87  Acquisition Hypothesis  89  Maintenance  91  Proportion Relative  Hypothesis of Explained Variance  Contribution  "Best" Motivation  o f Independent  t o Change V a r i a b l e  SUMMARY 6. D I S C U S S I O N AND CONCLUSIONS  91 Variables  . . . .  97 100 101 103  viii  Chapter  Page CHANGES IN RECORD-KEEPING PRACTICES  103  CHANGES IN PERSONAL ATTRIBUTES  105  Increased Knowledge of Recording  106  Knowledge R e t e n t i o n  108  M o t i v a t i o n t o Change  109  CHANGES IN ORGANIZATIONAL FACTORS  I l l  Departmental G u i d e l i n e s f o r Recording  7.  I l l  R e i n f o r c e r s and Resources  112  ACQUIRING AND MAINTAINING POR  114  SUMMARY AND IMPLICATIONS  119  SUMMARY  119  IMPLICATIONS  122  Theoretical Implications  123  P r a c t i c a l Implications  124  I m p l i c a t i o n s f o r F u r t h e r Research  126  BIBLIOGRAPHY  128  APPENDICES  133  A.  Formula f o r t e s t i n g hypotheses  134  B.  Explanatory note:  135  C.  Format A u d i t Review Sheet  136  D.  Data r e l a t i n g  to p i l o t  t e s t o f RNS  137  E.  Data r e l a t i n g to p i l o t  t e s t o f ROS  139  F.  R e g r e s s i o n d a t a : a c q u i s i t i o n and maintenance hypotheses  G.  R e g r e s s i o n d a t a : summary t a b l e s  regression r e s i d u a l score  . . .  144 157  LIST OF TABLES  Table  Page 1.  2.  Concepts and I m p l i c a t i o n s of M o t i v a t i o n and Behaviour Theories  16  P e r s o n a l and O r g a n i z a t i o n a l F a c t o r s I d e n t i f i e d i n Three Performance Models and Two M o t i v a t i o n T h e o r i e s  27  3.  F a c t o r s A f f e c t i n g Performance Change  37  4.  L o c a t i o n 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 T h e r a p i s t s by Country o f G r a d u a t i o n  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  . . . .  58  t o Number o f  Years s i n c e G r a d u a t i o n  59  7.  Format A u d i t Review Sheet Components and Items  66  8.  Means and Standard D e v i a t i o n s f o r the C l i n i c a l Record-Keeping Inventory ( P i l o t T e s t ) Means, Standard D e v i a t i o n s and t - t e s t s f o r A c q u i s i t i o n of Recording Scores  67 79  Means, Standard D e v i a t i o n s and t - t e s t s f o r Maintenance of Recording Scores  80  Means, Standard D e v i a t i o n s and t - t e s t s f o r Knowledge A c q u i s i t i o n and R e t e n t i o n Scores  83  Means and Standard D e v i a t i o n s f o r M o t i v a t i o n t o Change V a r i a b l e s  85  Means, Standard D e v i a t i o n s and t - t e s t s f o r Task-related Variables  88  General H i e r a r c h i c a l T e s t of the A c q u i s i t i o n Hypothesis  90  G e n e r a l H i e r a r c h i c a l Test o f t h e Maintenance Hypothesis  92  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 R e g r e s s i o n A n a l y s i s  93  9. 10.  11.  12.  13.  14.  15.  16.  ix  X Table 17.  18.  Page V a r i a n c e i n Increase i n R e c o r d i n g Components ( A c q u i s i t i o n Phase) Accounted f o r by M o t i v a t i o n , Knowledge and Task-related Variables  95  V a r i a n c e i n D e c l i n e i n R e c o r d i n g Components (Maintenance Phase) Accounted f o r by M o t i v a t i o n , Knowledge and Task-related Variables  96  LIST OF FIGURES  Figure  Page  1.  Cummings and Schwab's Model of Performance  17  2.  Rummler's Performance A u d i t Model  20  3.  C h a r t e r s and B l a k e l y ' s Model of I n s e r v i c e E d u c a t i o n  4.  Lewin's Model of the P r o c e s s of Change  40  5.  I n i t i a l Change of R e c o r d i n g Behaviour  47  6.  Subsequent Change of R e c o r d i n g Behaviour  48  7.  D e r i v a t i o n of Impetus V a r i a b l e  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 I n v e n t o r y Items  68  10.  R e c o r d i n g Needs Survey Items  69  11.  R e c o r d i n g Needs Survey Items R e l a t i n g to Importance  12.  Resources Items  73  13.  Performance Standards Items  74  14.  R e i n f o r c e r s Items  75  15.  A Comparison.of Performance Component Scores a t B a s e l i n e , One Month and Four Months  78  A Comparison of G e n e r a l , S p e c i f i c and T o t a l Knowledge Scores a t B a s e l i n e , One Month and Four Months  82  A Comparison of "Important," " I s P r e s e n t , " "Should be P r e s e n t " and "Gap" Scores w i t h the Response S c a l e . . . .  84  A Comparison of Resources, Performance Standards and R e i n f o r c e r s Scores w i t h Response S c a l e  86  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 Taskr e l a t e d V a r i a b l e s to I n c r e a s e i n POR Format  98  16.  17.  18.  19.  20.  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 Taskr e l a t e d V a r i a b l e s to Decrease in,POR Format xi  . . . .  . . . .  . .  23  71  99  xii Figure 21.  22.  Page D i s t r i b u t i o n of E x p l a i n e d V a r i a n c e Phase (Complete Record)  i n Acquisition  D i s t r i b u t i o n of Explained Variance Phase (Complete Record)  i n Maintenance  115  116  ACKNOWLEDGEMENTS  I w i s h t o thank the members of my d i s s e r t a t i o n committee: D a l e R u s n e l l , Dr. John C o l l i n s , Dr. Graham K e l s e y  Dr.  and Dr. George Szasz  f o r t h e i r continuous guidance, encouragement and support. In a d d i t i o n , I am g r a t e f u l t o t h e PTs and OTs o f Vancouver f o r t h e i r w i l l i n g n e s s t o p a r t i c i p a t e i n t h i s study, t o C h r i s I r v i n g f o r h e r assistance with the preparation Forsyth  for her preparation  of t h e graphs and f i g u r e s , and t o J u d i  of t h e f i n a l m a n u s c r i p t .  xiii  Chapter  1  INTRODUCTION TO THE STUDY  To change employee performance i s one f u n c t i o n of i n s e r v i c e i n health-care agencies.  T h i s f u n c t i o n has become p a r t i c u l a r l y  as h o s p i t a l s , c l i n i c s and treatment  important  c e n t r e s s t r i v e t o keep a b r e a s t of new  developments i n h e a l t h - c a r e d e l i v e r y and employees have t o a l t e r performance p a t t e r n s t o meet the r e s u l t i n g changes. of  education  existing  D e s p i t e the importance  t h i s f u n c t i o n , l i t e r a t u r e r e g a r d i n g the c o n t r i b u t i o n made by i n s e r v i c e  to changes i n performance i n h e a l t h - c a r e s e t t i n g s i s s c a r c e , and those items which do e x i s t r e f e r more t o i d e a l s and i n t e n t i o n s than t o s y s t e m a t i c s t u d i e s of a c t u a l change i n performance  on-the-job.  I n s e r v i c e e d u c a t i o n i s , of c o u r s e , not new, a l t h o u g h impact  and importance a r e .  i t s increased  The a c c r e d i t a t i o n b o d i e s t h a t r e q u i r e i t , the  h o s p i t a l f u n d i n g t h a t supports  i t , the p r a c t i t i o n e r ' s involvement  in i t ,  and  the many needs i t s e r v e s , r e p r e s e n t a s i g n i f i c a n t change i n the meaning  and  purpose of i n s e r v i c e e d u c a t i o n programs.  There i s every r e a s o n t o  suppose t h a t i n s e r v i c e w i l l c o n t i n u e t o e v o l v e as an i n t e g r a l p a r t of every h e a l t h - c a r e agency's mandate t o d e l i v e r h i g h q u a l i t y p a t i e n t c a r e .  The  o r g a n i z a t i o n a l arrangements f o r c o r r e l a t i n g i n s e r v i c e programs w i t h p e r f o r mance needs of s t a f f  seem l i k e l y t o show a c o r r e s p o n d i n g  growth i n s o p h i s -  t i c a t i o n , a l o n g w i t h an i n c r e a s e i n demand f o r proof of e f f e c t i v e n e s s . Such proof i s s c a r c e a t the p r e s e n t until  several issues are explored.  limited  time, and i s l i k e l y  One of the more c r i t i c a l  scope of the a d u l t e d u c a t o r ' s 1  t o remain so i s s u e s i s the  approach t o performance change.  2 C o n v e n t i o n a l program p l a n n i n g models ( H o s p i t a l Research and T r u s t , 1970)  are intended to prepare  Educational  employees to be a b l e to meet  performance demands; they do not adequately  address  new  the p r a c t i c a l i t i e s  t r a n s f e r r i n g , a p p l y i n g and m a i n t a i n i n g those newly a c q u i r e d s k i l l s knowledge i n the w o r k - s e t t i n g . may  proceed  w i t h impunity  to do a t a s k and  G i v e n t h i s narrow scope, a d u l t  and  educators  to f o c u s t h e i r a t t e n t i o n on an employee's  i g n o r e the r e a l i t i e s of on-the-job  I f the e f f e c t i v e n e s s of i n s e r v i c e i s judged  of  ability  change i n performance.  by the extent  to which i t  i n c r e a s e s 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 s u a l l y g a i n knowledge ( U n i v e r s i t y of Texas System S c h o o l of N u r s i n g ,  1975).  However, i f the e f f e c t i v e n e s s of i n s e r v i c e should be determined change i n performance, as suggested 1974;  D i c k i n s o n & Verner,  somewhat l i m i t e d .  And  1974;  by a c t u a l  by s e v e r a l s c h o l a r s ( C h a r t e r s & B l a k e l y ,  Hutchinson,  a d u l t educators may  1974), then t h i s approach i s find  i t necessary  modify t h e i r approach by i n c o r p o r a t i n g a d d i t i o n a l  to extend  or  concepts.  E m p i r i c a l s t u d i e s of change i n performance among p r o f e s s i o n a l s a r e a p r o f i t a b l e source of a d d i t i o n a l concepts ment of change.  modified,  B e r n s t e i n (1971),  suggested  and  isolated  five organizational barriers  t h a t the n o t i o n of " r e s i s t a n c e t o change" should  i n a s e r i e s of s t u d i e s done i n a St. L o u i s h o s p i t a l  1970), v a r i o u s o b s t a c l e s to and From those and  i d e a s about the manage-  For example, i n a study of a r o l e change among t e a c h e r s ,  Gross, G i a c q u i n t a and to change and  and new  be  (Coe,  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 .  other s t u d i e s (Davies, 1972;  Wolfe & Moe,  1973), i t appears  t h a t s u c c e s s f u l changes i n performance r e q u i r e changes i n both the employee and  the w o r k - s e t t i n g .  to be important  The p e r s o n a l a t t r i b u t e s most f r e q u e n t l y c o n s i d e r e d  and amenable t o change are a b i l i t y and m o t i v a t i o n .  the o r g a n i z a t i o n a l f a c t o r s c o n s i d e r e d most l i k e l y  Among  to i n f l u e n c e change,  3 r e i n f o r c e m e n t i s a key concept. to the  Other f a c t o r s a r e the r e s o u r c e s a v a i l a b l e  do the j o b , the presence of c l e a r l y d e f i n e d reward  s t a n d a r d s of performance,  system (pay), the d e s i g n of the t a s k and s u p e r v i s o r y b e h a v i o u r .  As i n s e r v i c e e d u c a t o r s assume g r e a t e r r e s p o n s i b i l i t y f o r implementing changes i n the w o r k - s e t t i n g i t seems l i k e l y t h a t they w i l l need t o c o n s i d e r the  impact of some of those f a c t o r s . Another i s s u e t h a t cannot be ignored i s the d i f f e r e n c e between the  s h o r t - 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)  p o i n t s out: A change toward a h i g h e r l e v e l of group performance i s f r e q u e n t l y 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 r e t u r n s to the p r e v i o u s l e v e l . (p. 34) If  i n s e r v i c e e d u c a t i o n i s expected t o be more than a "shot i n the arm"  t h e r e i s a need to understand the dynamics  of b o t h a c q u i s i t i o n and  then  main-  tenance of new b e h a v i o u r s .  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 e d u c a t i o n i n h e a l t h - c a r e  facilities  and change i n employee performance i s o n l y b e g i n n i n g t o be u n d e r s t o o d . the  Of  few r e s e a r c h s t u d i e s r e p o r t e d , most have f o c u s e d e i t h e r on changes i n  p a r t i c i p a n t s ' knowledge (Parker, Sturm & P i e r c e , 1975; M a r g o l i s , Sheenan & Meyers, 1976) Barnhill,  or changes i n performance l e v e l s  1970).  (Davies, 1972;  The e n t i r e spectrum of change i n performance from  a c q u i s i t i o n of knowledge and s k i l l s  to t h e i r  initial  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 h e a l t h - c a r e s e t t i n g . of  Coe &  The  purpose  the p r e s e n t study i s to add t o a s m a l l but growing body of e m p i r i c a l  d a t a r e l a t i n g to change i n performance by a d d r e s s i n g c e r t a i n a s p e c t s of the  issues outlined  i n the p r e c e d i n g  paragraphs.  Those i s s u e s a r e the need  4 to broaden an a d u l t e d u c a t o r ' s approach t o change i n performance, and the need t o i d e n t i f y the d i f f e r e n c e s between immediate  and s u s t a i n e d  change  i n performance. • An u n d e r l y i n g assumption of t h i s study i s t h a t behaviour i s a f u n c t i o n of an i n t e r a c t i o n between a person and h i s environment  (Lewin, 1938) and  t h a t attempts t o change b e h a v i o u r r e q u i r e c o n s i d e r a t i o n of b o t h the person and t h e s i t u a t i o n . f a c t o r s such as:  From t h i s p o i n t of view i t may be argued t h a t (1) m o t i v a t i o n t o change,  personal  (2) amount o f knowledge  possessed about t h e t a s k , and s i t u a t i o n a l f a c t o r s such as (3) r e s o u r c e s , (4) performance s t a n d a r d s and (5) r e i n f o r c e r s f o r proper performance, c o n t r i b u t e t o changes i n employee performance.  Furthermore, the c o n t r i b u -  t i o n s of those f a c t o r s 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.  T h i s study attempts t o a i d i n under-  s t a n d i n g change i n performance through i n s e r v i c e e d u c a t i o n 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 o f performance,  (2) changes i n knowledge,  (3) i n d i v i d u a l m o t i v a t i o n t o change, and (4)  i n d i v i d u a l p e r c e p t i o n s of s e l e c t e d t a s k - r e l a t e d  factors.  THE FOCUS OF THE STUDY  H e a l t h - c a r e a g e n c i e s a c r o s s the c o n t i n e n t a r e making a c o n c e r t e d effort  t o improve the q u a l i t y of p a t i e n t - c a r e r e c o r d s and, i n many p l a c e s ,  i n s e r v i c e e d u c a t o r s a r e expected t o c o n t r i b u t e to t h i s e f f o r t .  During  the past decade, many a g e n c i e s and groups o f h e a l t h p r o f e s s i o n a l s have changed  t h e i r r e c o r d i n g systems t o the Problem O r i e n t e d Record  (POR).  T h i s sytem, d e v i s e d by Weed (1964), r e q u i r e s the h e a l t h - c a r e  to document, i n a new format, the c a r e g i v e n t o a p a t i e n t .  system worker  Instead of  the c o n v e n t i o n a l method of n a r r a t i v e r e c o r d - k e e p i n g , which a l l o w e d  5 p r a c t i t i o n e r s considerable  leeway i n r e c o r d i n g  s t y l e , POR r e q u i r e s  c l i n i c i a n s t o adhere c l o s e l y t o a d e f i n i t i v e s t r u c t u r e and format. changes i n format a r e s u f f i c i e n t l y g r e a t  t o warrant an e d u c a t i o n  The  program  f o r t h e i r proper implementation (Bashook, Sandlow & Hammett, 1975; Fernow, M c C o l l , Mackie & R e n d a l l , program i s t o i n f o r m  1977).  B a s i c a l l y , the purpose of a POR i n s e r v i c e  s t a f f of the i n t r o d u c t i o n of the new system and h e l p  them l e a r n the concepts and format. Physiotherapists  (PTs) and o c c u p a t i o n a l  t h e r a p i s t s (OTs) a r e among  those h e a l t h p r o f e s s i o n a l s c u r r e n t l y i n v o l v e d i n improving t h e i r keeping.  T h i s movement has been s t i m u l a t e d ,  a t t e n t i o n given to patient-care records but  record-  i n p a r t , by the i n c r e a s e d  throughout the h e a l t h - c a r e  industry,  the main impetus can be t r a c e d t o d i r e c t i v e s i s s u e d by t h e Canadian  C o u n c i l f o r H o s p i t a l A c c r e d i t a t i o n (CCHA) (1977) and t h e Canadian therapy A s s o c i a t i o n (CPA) (1976).  Both b o d i e s i s s u e d standards and g u i d e -  l i n e s f o r r e c o r d i n g , and encouraged t h e r a p i s t s t o improve t h e i r keeping.  A t the present  time n e i t h e r CCHA nor CPA i n s i s t  a l t h o u g h CPA recommends i t s use.  Nevertheless,  have chosen POR as t h e i r o f f i c i a l r e c o r d i n g I n s e r v i c e education  Physio-  record-  on t h e POR format,  many PT/OT departments  system.  i s used by many i n s t i t u t i o n s t o h e l p  employees  g a i n an u n d e r s t a n d i n g o f , and become competent i n u s i n g POR, but f o r m a l research  i n t o the e f f e c t i v e n e s s of those programs i s s c a r c e .  Occasionally  a r e p o r t , such as one by Hammett, Sandlow and Bashook (1976), demonstrates a change i n r e c o r d i n g p r a c t i c e s f o l l o w i n g a c a r e f u l l y designed  educational  program, but the g r e a t e r p o r t i o n of documentation on t h i s t o p i c i s concerned w i t h d e s c r i b i n g methods that should  be used t o e f f e c t  a r t i c l e s suggest, but f a i l t o c o n f i r m , education.  change.  Many of those  the importance of i n s e r v i c e  6 To change r e c o r d i n g any  behaviour i n any  stood and  p r a c t i c e s i s a s p e c i f i c example of changing  work s e t t i n g .  As  such, i t can be  i n s e r v i c e and  recognize and  continuing  education repeatedly  Leading  T h i s study i n v e s t i g a t e d change i n POR The  (Charters  urge e d u c a t o r s to  & Blakely,  1974;  these r e l a t i o n s h i p s , u s i n g  p r a c t i c e s among p h y s i c a l and  being r e f e r r e d to as " a c q u i s i t i o n , " the  1974).  as a s p e c i f i c  focus,  therapists.  phases of change,  second as  suggested t h a t i n i t i a l  factors, motivation  and  on u n d e r s t a n d i n g POR  change i n  should r i s e .  In the  that newly a c q u i r e d  recording  format.  Those  two  sufficient  from o r g a n i z a t i o n a l f o r c e s .  p r a c t i c e s would be v u l n e r a b l e  suggested  to pressure  Lack of r e s o u r c e s such as time and  l a c k of r e i n f o r c e r s f o r proper r e c o r d i n g  force  thus performance l e v e l s  second phase of change, maintenance, i t was recording  In  to change h i s  knowledge, were expected to e x e r t  to overcome o r g a n i z a t i o n a l b a r r i e r s to change and  the  "maintenance."  behaviour would be governed by a t h e r a p i s t ' s m o t i v a t i o n r e c o r d - k e e p i n g p r a c t i c e s and  motivation  Lessinger,  occupational  study made a d i s t i n c t i o n between two  the case of a c q u i s i t i o n , i t was  and  consultants  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  organizational factors  first  under-  u l t i m a t e l y c o n t r o l l e d by a c r i t i c a l examination of those f a c t o r s  shown to i n f l u e n c e change i n w o r k - r e l a t e d b e h a v i o u r . in  explained,  were expected to  materials, exert  s u f f i c i e n t f o r c e to d r i v e performance l e v e l s down.  THE  Accountability shrinking health-care sumes time and money.  SIGNIFICANCE OF  i s one dollar.  THE  STUDY  of the more p r e s s i n g Inservice  issues  i n times of  e d u c a t i o n i s expensive; i t con-  Both those commodities are becoming s c a r c e  i s t r a t o r s seek to h o l d down h e a l t h - c a r e  the  delivery costs.  as  Educational  admin-  7  activities  that f a i l  t o 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 p a t i e n t - c a r e  are a l u x u r y which n e i t h e r the h e a l t h system nor the h e a l t h p r o f e s s i o n a l can a f f o r d . little  A t the p r e s e n t time, the s p o t l i g h t o f a c c o u n t a b i l i t y  finds  evidence t o show t h a t i n s e r v i c e e d u c a t i o n 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 m o n i t o r i n g changes i n r e c o r d - k e e p i n g  p r a c t i c e s and d e t e r m i n i n g how much change r e l a t e s t o l e a r n i n g  activities  and how much t o c e r t a i n o r g a n i z a t i o n - r e l a t e d f a c t o r s , t h i s study p r o v i d e s some evidence of the extent t o which i n s e r v i c e programs c o n t r i b u t e t o changing In  employees' performance. a d d i t i o n to p r o v i d i n g p r a c t i c a l information, t h i s research p r o j e c t  c o n t r i b u t e s to t h e body of knowledge c o n c e r n i n g planned  performance change.  One n o t a b l e gap i n performance change r e s e a r c h i s a l a c k of l o n g i t u d i n a l data.  Many s t u d i e s c o n c e n t r a t e on s h o r t - t e r m changes i n performance and  i d e n t i f y c o n d i t i o n s t h a t a r e conducive a new performance l e v e l f a i l s  t o change.  On those o c c a s i o n s when  t o m a t e r i a l i z e , l a c k of f o l l o w - u p  j e o p a r d i z e s the s e a r c h f o r c a u s a t i v e f a c t o r s .  data  By u s i n g a m o d i f i e d  time-  s e r i e s e x p e r i m e n t a l d e s i g n w i t h a p r e t e s t , one-month p o s t t e s t and t h r e e months d e l a y e d p o s t t e s t , t h i s study addresses  the i s s u e of s h o r t - and  long-term changes i n performance.  THE  This i n i t i a l  ORGANIZATION OF THE THESIS  chapter has d e s c r i b e d the purpose of t h e study, i t s  c o n t r i b u t i o n t o the body of knowledge r e l a t i n g t o i n s e r v i c e e d u c a t i o n and planned  performance change, and the s p e c i f i c problem under  Chapter  2 reviews  the r e l e v a n t l i t e r a t u r e and Chapter  c o n c e p t u a l framework and study d e s i g n . in  Chapter  Instrument  investigation.  3 o u t l i n e s the  development i s d e t a i l e d  4 and the r e s u l t s a r e p r e s e n t e d and a n a l y s e d  i n Chapter  5.  8 Chapter and  6 d i s c u s s e s the f i n d i n g s  p r e s e n t s the  implications.  and  a final  Chapter  7 summarizes  the  study  Chapter 2  THE  RELATED LITERATURE  E m p i r i c a l s t u d i e s concerning i n t h e i r work-setting  performance change among p r o f e s s i o n a l s  suggest t h a t an i n d i v i d u a l i s l i k e l y  t o change h i s  performance when changes occur i n both t h e person and the o r g a n i z a t i o n a l f o r c e s t h a t impinge on the s p e c i f i c t a s k .  Social s c i e n t i s t s offer several  t h e o r i e s to e x p l a i n r e l a t i o n s h i p s among p e r s o n a l and  and o r g a n i z a t i o n a l f a c t o r s  to suggest ways by which change can be accomplished.  This  chapter  examines Lewin's (1947) model o f planned change, as i t appears t o be t h e most f r e q u e n t l y c i t e d ; work behaviour from t h e p e r s p e c t i v e motivation  t h e o r i s t s and a b e h a v i o u r i s t ;  of three  two models of performance  from those p e r s p e c t i v e s ; and an educator's approach t o change. the chapter c o n t a i n s  derived  In a d d i t i o n ,  reviews o f s e v e r a l e m p i r i c a l s t u d i e s on performance  change, knowledge change and the e f f e c t s o f o r g a n i z a t i o n a l f a c t o r s on p e r formance change among p r o f e s s i o n a l s w i t h i n and o u t s i d e  the h e a l t h - c a r e  industry.  PLANNED CHANGE  Lewin (1947), i n h i s pioneer  work on change, proposes t h a t any l e v e l  of performance i s determined by the combined e f f e c t s of f o r c e s o p e r a t i n g on an i n d i v i d u a l .  He assumes t h a t i n any s i t u a t i o n t h e r e a r e both d r i v i n g and  restraining forces.  D r i v i n g f o r c e s a r e 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 f o r c e s a r e those which work a g a i n s t pressure  from a s u p e r v i s o r  change.  For example,  and an i n d i v i d u a l ' s sense of achievement may a c t  as d r i v i n g f o r c e s i n a work s i t u a t i o n , and non-support from c o l l e a g u e s and 9  10 p o o r l y m a i n t a i n e d equipment may  a c t as r e s t r a i n i n g f o r c e s .  performance l e v e l i s s t a b l e when the sum  The  employee's  of the d r i v i n g f o r c e s equals the  sum  of the r e s t r a i n i n g f o r c e s . U s i n g the n o t i o n of opposing f o r c e s , Lewin (1947) i d e n t i f i e s phases of the change p r o c e s s : mance, (2) changing to a new  (1) u n f r e e z i n g l e v e l , and  the p r e s e n t  (3) r e f r e e z i n g at the new  Changing performance begins w i t h u n f r e e z i n g Hersey and and be  Blanchard  (1972) s t a t e :  l e v e l of  "The  aim  ing f o r c e s .  of u n f r e e z i n g  E i t h e r manoeuvre d i s t u r b s the e q u i l i b r i u m and  The  a t t e n t i o n to new  second stage,  b e l i e f s , a t t i t u d e s and  patterns  of b e h a v i o u r . i d e a s and  (Hersey & B l a n c h a r d , 1972;  educators o f t e n a s s i s t  t i o n phase.  Schein  (Schein & Kommers, 1972).  T h i s i s where new  behaviour  Trainers  s t a f f with opportunities  r e f r e e z i n g , i s the  and to  stabiliza-  b e l i e f s , a t t i t u d e s and b e h a v i o u r s are of the i n d i v i d u a l .  l e v e l of performance the f o r c e s o p e r a t i n g (1972) p o i n t out  integrated  To m a i n t a i n a  on the i n d i v i d u a l must be  new  changed.  t h a t change f o l l o w i n g t r a i n i n g programs  i s o f t e n s h o r t - l i v e d because e x i s t i n g f o r c e s a r e not changed. c a r e f u l a t t e n t i o n be p a i d to r e i n f o r c e m e n t refreezing  new  Once i n d i v i d u a l s are m o t i v a t e d  & Kommers, 1972).  f i n a l stage i n the change p r o c e s s ,  Blanchard  makes i t p o s s i b l e  knowledge.  i n t o the t o t a l performance p a t t e r n s  Hersey and  may  some r e s t r a i n -  are r e c e p t i v e to new  t h i s phase by p r o v i d i n g  a c q u i r e needed s k i l l s and The  Unfreezing  changing, i s concerned w i t h a c q u i s i t i o n of  to change they a c t i v e l y seek new patterns  information  level.  i s to m o t i v a t e  i n c r e a s i n g c e r t a i n d r i v i n g f o r c e s or d e c r e a s i n g  f o r i n d i v i d u a l s to pay  perfor-  the e x i s t i n g l e v e l .  make the i n d i v i d u a l or group ready to change" (p. 30). induced by  three  They recommend  as i t i s a p o w e r f u l f o r c e i n the  stage.  Lewin's approach to planned change i s recommended f o r use  in a  v a r i e t y of s e t t i n g s .  Hersey and Blanchard  (1972) s e l 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 f o r g u i d i n g the development of change s t r a t e g i e s i n b u s i n e s s and  i n d u s t r y , Longest  i n h e a l t h - c a r e a g e n c i e s , and  (1976) advocates  i t s use i n managing change  Schein and Kommers (1972) use t h i s approach  to r e - s t r u c t u r e e d u c a t i o n programs f o r p r o f e s s i o n a l s .  Those and  other  r e p o r t s a t t e s t to the v a l u e of v i e w i n g planned  change as a t h r e e - s t e p  p r o c e s s w i t h a l t e r a t i o n of f o r c e s as a c e n t r a l  concept.  The manager or change agent who change must be a b l e to i d e n t i f y and forces.  Reports of attempts  s e l e c t p o t e n t i a l d r i v i n g and  a t planned  used t o e s t a b l i s h " f o r c e s p r e s e n t " .  wishes to use the L e w i n i a n model of  change f r e q u e n t l y omit  the methods  As Haskew (1974) n o t e s , f o r c e s "seem  to emanate from i n t u i t i v e assumptions of the a n a l y s t s " (p. 58). apparent  restraining  This  weakness i n some uses of Lewin's t h e o r y might be overcome by  c o n s i d e r i n g t h e o r i e s and models t h a t p u r p o r t t o e x p l a i n the behaviour i n d i v i d u a l s i n the  work-place.  THE  STUDY OF WORK BEHAVIOUR  M o t i v a t i o n and behaviourism used  a r e among the more prominent t h e o r i e s  to e x p l a i n work-related behaviour.  a r e based  Those two  theoretical constructs  on d i f f e r e n t assumptions about the n a t u r e of man.  o r i e n t a t i o n c o n s i d e r s man  to be a p a s s i v e organism  e x t e r n a l environment.  The m o t i v a t i o n  to be a p u r p o s i v e , p r o b l e m - s o l v i n g b e i n g w i t h  freedom to make c h o i c e s i n each s i t u a t i o n . c o n s i d e r s man  of  A behaviouristic  orientation  governed by s t i m u l i s u p p l i e d by  the  Those two views g i v e r i s e to d i f f e r e n t p e r s p e c t i v e s  f o r understanding work-related  behaviour.  Motivation M o t i v a t i o n r e f e r s to the p r o c e s s by which behaviour  i s energized,  12 d i r e c t e d and  sustained  ( P o r t e r & Lawler,  t h r e e components of m o t i v a t e d  1968).  behaviour:  (1) the presence  f o r c e w i t h i n the i n d i v i d u a l t h a t " d r i v e s " him  one  of those  identifies  of an e n e r g e t i c  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 to r e i n f o r c e the behaviour.  This d e f i n i t i o n  (3) some form of feedback  A l l t h e o r i e s of m o t i v a t i o n d e a l w i t h a t  least  factors.  T h e o r i e s of m o t i v a t i o n a r e c l a s s i f i e d by S t e e r s and P o r t e r as e i t h e r " c o n t e n t " or " p r o c e s s " t h e o r i e s . s p e c i f y the e n e r g i z e r s of b e h a v i o u r s ; i d e n t i f y the c o g n i t i v e p r o c e s s e s (Luthans & K r e i t n e r , 1975). Content  theories.  d u a l - f a c t o r theory  Content  Thus, p r o c e s s  1968;  t h e o r i e s attempt  Herzberg,  to  purposeful direction  t h e o r i e s tend  Needs h i e r a r c h y theory  (Herzberg,  t h e o r i e s attempt t o  whereas, p r o c e s s  t h a t g i v e behaviour  (1975)  to be more complex.  (Maslow, 1943,  1965)  Mausner & Snyderman,  and  1959)  are examples of content t h e o r i e s . Maslow's needs h i e r a r c h y theory assumptions.  F i r s t , man  Second, those needs are  s e q u e n t i a l l y i n a h i e r a r c h i c a l form.  esteem, and  i s based on  i s a "wanting" a n i m a l , m o t i v a t e d  s a t i s f y c e r t a i n s p e c i f i c needs.  a r e , from lowest  (1943, 1965)  to h i g h e s t :  two  by a d e s i r e t o arranged  The needs c o n t a i n e d i n the h i e r a r c h y  p h y s i o l o g i c a l , s a f e t y , l o v e and  belonging,  s e l f - a c t u a l i z i n g needs.  Maslow contends t h a t behaviour l e v e l of u n s a t i s f i e d needs. such as hunger and  i s e n e r g i z e d by the next  higher  For example, when b a s i c p h y s i o l o g i c a l needs  t h i r s t are s a t i s f i e d ,  t h e i r importance d i m i n i s h e s  needs f o r p r o t e c t i o n a g a i n s t danger become the s t r o n g e s t m o t i v a t o r . p r o c e s s of i n c r e a s e d s a t i s f a c t i o n - decreased  and This  importance - i n c r e a s e d impor-  tance of next h i g h e r l e v e l r e p e a t s i t s e l f u n t i l the h i g h e s t l e v e l i s reached. McGregor (1960) d e s c r i b e s some i m p l i c a t i o n s of needs h i e r a r c h y theory  to changing employee performance.  He m a i n t a i n s t h a t management  f a c i l i t a t e motivational  l e v e l s by p r o v i d i n g  to s a t i s f y t h e i r h i g h e r  order  needs.  employees w i t h  T h i s can be achieved  people more freedom to d i r e c t t h e i r own  activities,  r e s p o n s i b i l i t y for planning  and  (4) a l l o w i n g  appraising  opportunities by:  (1) g i v i n g  (2) r e - o r g a n i z i n g  to encourage acceptance of r e s p o n s i b i l i t y , (3) u s i n g c o n s u l t a t i v e management p r a c t i c e s , and  can  work  p a r t i c i p a t i o n and employees t o take more  t h e i r own  contributions  to  organizational objectives. Dual-factor  theory  (Herzberg, 1968;  example of a content theory. behaviour but,  i n contrast  Herzberg et a l . , 1959)  I t a l s o focuses  on f a c t o r s t h a t  Using s e m i - s t r u c t u r e d  one  i n t e r v i e w s , Herzberg and  his  Job  Content a n a l y s i s r e v e a l e d  distinct  theory  of m o t i v a t i o n  i n c l u d e d the work i t s e l f , , advancement  life,  and  l e a d i n g 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 " ,  p e e r s , t e c h n i c a l s u p e r v i s i o n , company p o l i c y and  personal  sets  i s needed.  include status, interpersonal relationships with superiors, and  an  Those f i n d i n g s l e d Herzberg et a l . (1959) to conclude  s a t i s f a c t i o n f a c t o r s , or " m o t i v a t o r s " ,  Factors  or decreased  two  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 growth.  colleagues  s e t l e d to job s a t i s f a c t i o n w h i l e a d i f f e r e n t set l e d to  job d i s s a t i s f a c t i o n . that a two-factor  the  man.  c o l l e c t e d d a t a on events at work t h a t markedly i n c r e a s e d  of f a c t o r s :  energize  to Maslow's work, i t d e a l s w i t h the n a t u r e of  t a s k as w e l l as the n a t u r e of  individual's satisfaction.  i s another  working c o n d i t i o n s , job s e c u r i t y , and  subordinates  administration, salary.  The  are j o b c o n t e n t c h a r a c t e r i s t i c s w h i l e the hygiene f a c t o r s are j o b  motivators environ-  ment c h a r a c t e r i s t i c s . Implications  of d u a l - f a c t o r theory  f o r changing employee performance  14 stem from the h y p o t h e s i s e d dichotomy faction.  of j o b s a t i s f a c t i o n and j o b d i s s a t i s -  Because those a r e two d i s t i n c t  e n t i t i e s and not o p p o s i t e ends of  a continuum,  changes i n employee m o t i v a t i o n can o n l y be a c h i e v e d by  motivators.  M o t i v a t o r s a r e j o b content c h a r a c t e r i s t i c s ; t h e r e f o r e , i t i s  changes w i t h i n the j o b t h a t are l i k e l y (1968) recommends j o b enlargement A process theory.  to improve  performance.  as one means of i n c r e a s i n g  changing  Herzberg satisfaction.  Vroom's (1964) e x p e c t a n c y / v a l e n c e t h e o r y i s an  example of a p r o c e s s t h e o r y ; i t i s concerned w i t h r e l a t i o n s h i p s among v a r i a b l e s i n a dynamic s t a t e as they a f f e c t b e h a v i o u r .  Vroom (1964) d e f i n e s  m o t i v a t i o n as a "process governing c h o i c e s , made by persons or lower organisms,  among a l t e r n a t i v e forms of v o l u n t a r y 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 f a c e d w i t h a s e t o f a l t e r n a t i v e "first first  l e v e l outcomes."  The c h o i c e made by the i n d i v i d u a l among those  l e v e l outcomes i s determined  p o s s i b l e "second  l e v e l outcomes."  r e l a t i o n s h i p s i n t h i s model: expectancy.  by the expected r e l a t i o n s h i p of them to Three concepts are used  (1) v a l e n c e , (2) i n s t r u m e n t a l i t y , and  (3)  V a l e n c e r e f e r s to the s t r e n g t h of an i n d i v i d u a l ' s d e s i r e f o r  a p a r t i c u l a r outcome.  I n s t r u m e n t a l i t y i s the extent to which a f i r s t  outcome i s seen as l e a d i n g to the accomplishment And  to e x p l a i n the  expectancy  of a second  level  l e v e l outcome.  i s a momentary b e l i e f c o n c e r n i n g the l i k e l i h o o d  that a  p a r t i c u l a r a c t i o n w i l l be f o l l o w e d by a p a r t i c u l a r outcome. Simply s t a t e d , Vroom's e x p e c t a n c y / v a l e n c e model (1964) p r e d i c t s t h a t people w i l l choose tional force.  to behave i n whatever way  has the h i g h e s t m o t i v a -  For example, workers w i l l be m o t i v a t e d to i n c r e a s e 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 h i g h l y p r o d u c t i v e and i f they see some p o s i t i v e outcome a t t a c h e d to b e i n g a h i g h producer. From the expectancy/valence model, i t i s c l e a r t h a t an employee's  15 m o t i v a t i o n a l l e v e l i s h e a v i l y i n f l u e n c e d by h i s p e r s o n a l g o a l s , t h u s , attempts  t o change performance  of the importance  should be preceded by an a c c u r a t e  assessment  of an i n d i v i d u a l ' s g o a l s , h i s p e r c e p t i o n of r e l a t i o n -  s h i p s between o r g a n i z a t i o n a l o b j e c t i v e s and p e r s o n a l g o a l s , and h i s expectancy  t h a t o r g a n i z a t i o n a l o b j e c t i v e s can be  attained.  Behaviourism Behaviourism p r o v i d e s a d i f f e r e n t p e r s p e c t i v e f o r u n d e r s t a n d i n g f o r c e s o p e r a t i n g f o r and a g a i n s t change i n the w o r k - s e t t i n g (Campbell, 1971;  Gellerman, 1977;  Rummler, 1972).  Luthans & K r e i t n e r , 1975;  N i s b e r g , 1976;  Whereas m o t i v a t i o n a l t h e o r i s t s b e l i e v e t h a t  Nord,  the J.P.,  1969;  individuals  chose the p a t h they w i s h t o f o l l o w , b e h a v i o u r i s t s s u b s c r i b e t o the n o t i o n t h a t behaviour i s governed  by i t s consequences.  A c c o r d i n g t o Dubin  and  Okun (1973), " B e h a v i o u r i s t s concern themselves w i t h the o b s e r v a b l e s of b e h a v i o u r , namely s t i m u l i and r e s p o n s e s .  Strict behaviouristic  doctrine  a v o i d s any s p e c u l a t i o n about what i s g o i n g on i n the mind" (p. 4 ) . c u r r e n t a p p l i c a t i o n s of b e h a v i o u r i s m i n the work-place  are based  As  primarily  on S k i n n e r ' s operant l e a r n i n g t h e o r y , i t i s germane t o review b r i e f l y major concepts of t h a t Operant  the  theory.  l e a r n i n g i s concerned w i t h those b e h a v i o u r s t h a t are  emitted by the organism r a t h e r than e l i c i t e d by a known s t i m u l u s ( S k i n n e r , 1953).  Operant  b e h a v i o u r , as c o n c e i v e d by S k i n n e r , i s t h a t behaviour which  i s s t r e n g t h e n e d , maintained or weakened by i t s consequences.  Thus,  operant l e a r n i n g d e a l s w i t h the o b s e r v a b l e e f f e c t s of e n v i r o n m e n t a l consequences  on o b s e r v a b l e responses.  Consequences of b e h a v i o u r f a l l n e g a t i v e and n e u t r a l .  into three classes:  P o s i t i v e consequences  s t r e n g t h e n a response; n e g a t i v e consequences  positive,  a r e those events  that  d i m i n i s h a response;  and  n e u t r a l consequences a r e those events  t h a t have no n o t i c e a b l e e f f e c t on a  response. Reinforcement behaviour  i s a key concept  i n Skinner's  system.  To r e i n f o r c e  simply means t o 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 f u t u r e o c c u r r e n c e s  of t h a t behaviour.  Reinforce-  ment may be v e r b a l such as p r a i s e , or m a t e r i a l such as money, and i t can b scheduled  t o occur a f t e r every c o r r e c t response  or i n t e r m i t t e n t l y  (Costell  & Z a l k i n d , 1963). Summary T a b l e 1 summarizes the f o u r t h e o r i e s t h a t were d i s c u s s e d i n the previous section. work-related  I t p r e s e n t s the key concepts  and i m p l i c a t i o n s f o r  performance.  Table 1 Concepts and I m p l i c a t i o n s o f M o t i v a t i o n and Behaviour T h e o r i e s  Theory & Exponent  Key Concepts  Implications  Needs H i e r a r c h y (Maslow, 1943)  I n d i v i d u a l needs  Provide opportunities f o r employees t o s a t i s f y t h e i r h i g h e r order needs  Dual-factor (Herzberg, 1968)  Motivators Hygiene f a c t o r s  Re-design j ob (job enlargement)  Expectancy/ Valence (Vroom, 1964)  Expectancy Valence Instrumentality  A s s e s s importance of p e r s o n a l g o a l s , p e r c e p t i o n of r e l a t i o n s h i p between o r g a n i z a t i o n a l o b j e c t i v e s and p e r s o n a l g o a l s  Operant L e a r n i n g ( S k i n n e r , 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. t h i s section.  Two of those models w i l l be examined i n  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 h i s 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 i n Figure 1.  I t 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 m o t i v a t i o n ,  d i f f e r e n t i a t e d as f o l l o w s :  ability  i s an i n d i v i d u a l ' s " c u r r e n t  to perform some task or set of t a s k s " motivation  activity"  capacities  (Cummings & Schwab, 1973,  p. 8 ) ,  " r e f l e c t s e f f o r t or energy, a dynamic, o f t e n f l e e t i n g  i s t i c which determines how  vigorously  (Cummings & Schwab, 1973,  p.  are  and  character-  c a p a b i l i t i e s w i l l be employed i n some 8).  When d i s c u s s i n g the i n f l u e n c e of o r g a n i z a t i o n a l f a c t o r s on a b i l i t y component of t h i s model, Cummings and  the  Schwab note t h a t a t r a i n i n g  program i s o f t e n the major procedure used by an o r g a n i z a t i o n , to m a n i p u l a t e ability  l e v e l s of i t s employees.  the f o l l o w i n g elements:  I d e a l l y , the t r a i n i n g p r o c e s s  (1) i d e n t i f i c a t i o n of the s k i l l s  involves  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 r e c e i v e t r a i n i n g , (3) development, or s e l e c t i o n , of procedures t h a t 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 the r e q u i r e d  skills,  (4) implementation of p r o c e d u r e s , and  learn  (5) a p p r a i s a l  of r e s u l t s . The m o t i v a t i o n a l  component of t h i s model i s c o n s i d e r a b l y  than the a b i l i t y component.  An  individual's motivational  more complex  l e v e l i s shown as  a f u n c t i o n of s a t i s f a c t i o n w i t h g o a l s a t t a i n e d and w i t h g o a l a s p i r a t i o n s . Thus, " m o t i v a t i o n h i s e f f o r t and and  to perform depends on h i s p e r c e p t i o n  performance, and  between performance and  e x t r i n s i c outcomes" (Cummings & Schwab, 1973,  between the two m o t i v a t o r s and  types of outcomes appear to be hygiene f a c t o r s .  about l i n k s between valued  p. 48).  The  intrinsic difference  c l o s e l y r e l a t e d to Herzberg's  For example, a sense of accomplishment  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  and  working c o n d i t i o n s a r e i n c l u d e d among the e x t r i n s i c outcomes. Organizational  f a c t o r s t h a t may  i n d i r e c t l y influence  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  motivational  s u c c e s s f u l performance  are  t a s k d e s i g n , t a s k d e f i n i t i o n , m a n a g e r i a l b e h a v i o u r and the company's reward system.  D e c i s i o n s and a c t i o n s taken i n any of those areas can a l t e r  employee p e r c e p t i o n s of the l i n k s between m o t i v a t i o n , performance, outcomes and g o a l a t t a i n m e n t .  F o r example,  i f the r e q u i r e m e n t s and s t a n d a r d s f o r a  s p e c i f i c t a s k ( t a s k d e f i n i t i o n ) a r e ambiguous o r n o t s t a t e d employees  will  have d i f f i c u l t y p e r f o r m i n g " p r o p e r l y , " even though they a r e w e l l - m o t i v a t e d and c a p a b l e .  Companies can a v o i d t h i s s i t u a t i o n by i s s u i n g c l e a r l y  defined  g u i d e l i n e s f o r t a s k performance. In  summary, the model o f performance by Cummings and Schwab (1973)  suggests t h a t an i n d i v i d u a l ' s a b i l i t y and m o t i v a t i o n a r e the p r i m a r y determinants o f performance.  Organizational factors influence  i n a number of ways i n c l u d i n g d i r e c t indirect  i n f l u e n c e on m o t i v a t i o n  impact on a b i l i t y  (extrinsic  performance  (training  programs),  "hygiene" f a c t o r s ) and as a  mediator between those two d e t e r m i n a n t s and performance  (task design,  task  definition). A Performance A u d i t  Model  A performance a u d i t model, by Rummler of  (1972, 1976), i s an example  the a p p l i c a t i o n o f operant l e a r n i n g t h e o r y t o changing employee b e h a v i o u r .  Rummler's approach to u n d e r s t a n d i n g performance i s c o n s i d e r a b l y to  different  t h a t proposed by Cummings and Schwab (1973) i n t h a t i t i s p r i n c i p a l l y  concerned w i t h the d i r e c t , r a t h e r than t h e mediated, impact o f o r g a n i z a t i o n a l f o r c e s on employee performance.  He agrees t h a t 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 i g n o r e m o t i v a t i o n . The model c o n s i s t s o f a performance system and f i v e s e t s of v a r i a b l e s The c o n s t i t u e n t p a r t s o f the performance system a r e : or  (1) the j o b s i t u a t i o n  o c c a s i o n to perform, (2) the performer, (3) the b e h a v i o u r t h a t i s t o occur  (4) the consequences o f t h a t behaviour to the performer, and (5) feedback  20 of consequences to the performer.  This system i s graphically represented i n  Figure 2.  JOB  •  SITUATION  INDIVIDUAL-^RESPONSE—•CONSEQUENCES PERFORMER i  ( A c t i o n or  OF ACTION  D e c i s i o n by j  OR  DECISION T O  Performer)  PERFORMER  !  (+,-,9)  L  FEEDBACK  1  Figure 2 Rummler's Performance Audit Model Within this system Rummler (1976) i d e n t i f i e s f i v e sets of variables as potential sources of performance problems: (2) performance standards, (3) knowledge, back mechanisms.  (1) task interference,  (A) consequences, and (5) feed-  Task interference includes such factors as poor physical  working conditions; inadequate tools, time and support services; and competing tasks.  Performance standards refers to written p o l i c i e s guidelines  and procedures for doing a s p e c i f i c job or task.  The knowledge v a r i a b l e i s  concerned with an employee knowing what to do, how to do i t and when to do it.  Consequences are those external events that occur after the behaviour  has been emitted.  These events may a r i s e 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 h i s performance. and r e i n f o r c i n g .  This information should be s p e c i f i c , understandable  21 Rummler considerable  (1976) argues t h a t t h i s form o f performance a u d i t has  u t i l i t y f o r managers a t t e m p t i n g t o change l e v e l s o f s t a f f  performance.  I t encourages a s y s t e m a t i c  i n f l u e n c e performance l e v e l s .  Initially,  knowledge from d e f i c i e n c i e s of e x e c u t i o n . out,  this distinction i s particularly  considered  as a p p r o p r i a t e  examination o f key v a r i a b l e s  that  i t s e p a r a t e s d e f i c i e n c i e s of As Mager and P i p e  (1971) p o i n t  important when t r a i n i n g programs a r e  s o l u t i o n s to poor performance.  They argue t h a t  knowledge d e f i c i t s can be overcome by t r a i n i n g programs but e x e c u t i o n d e f i c i t s r e q u i r e changes i n e x t e r n a l c o n d i t i o n s and e v e n t s . b e l i e v e s t h a t as w e l l as b e i n g  useful for analysing  changes a r e  Thus, the performance a u d i t has p o t e n t i a l as a p l a n n i n g  w e l l as a d i a g n o s t i c  t o o l as  tool.  AN  In r e c e n t  (1976)  e x i s t i n g problems, the  a u d i t can be used t o p r e d i c t p o t e n t i a l problem areas b e f o r e introduced.  Rummler  EDUCATOR'S APPROACH TO CHANGE  years s e v e r a l attempts have been made to develop models of  i n s e r v i c e education  t h a t l i n k l e a r n i n g e x p e r i e n c e s 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 o f problems o l v i n g as a b a s i c framework (Brown & U h l , 1970; H o s p i t a l Research & Educational  T r u s t , 1970; C h a r t e r s  problem-solving  cycle are:  & B l a k e l y , 1974).  (1) r e c o g n i z e  a problem,  The b a s i c steps  i n the  (2) d e f i n e 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 p l a n , and (5) a s s e s s the outcomes. appropriate  Miller  (1967) b e l i e v e s the p r o b l e m - s o l v i n g  f o r the e d u c a t i v e  t i o n e r s d e l i v e r care t o t h e i r  p r o c e s s because i t p a r a l l e l s the way p r a c t i patients.  Under the a e g i s of the R e g i o n a l M e d i c a l model o f the c o n t i n u i n g  approach i s  education  Programs S e r v i c e  p r o c e s s was developed  (Charters  (RMPS) a & Blakely,  1974).  The RMPS model marks a s i g n i f i c a n t advance  i n t h e a r e a of i n s e r v i c e  and c o n t i n u i n g e d u c a t i o n i n t h a t i t p r o v i d e s e d u c a t o r s w i t h a t h e o r e t i c a l l y based, s y s t e m a t i c approach t o changing on-the-job performance o f h e a l t h - c a r e practitioners.  P r i o r to i t s development  c o n t i n u i n g e d u c a t i o n f o r h e a l t h man-  power tended to be s p o r a d i c , fragmented, n o n s e q u e n t i a l and l a c k i n g a c o n c e p t u a l base  (Hutchinson, 1974) .  The RMPS model as o u t l i n e d by C h a r t e r s and B l a k e l y through n i n e s t e p s .  T h i s model i s p r e s e n t e d i n F i g u r e 3.  (1974), proceeds The p r o c e s s b e g i n s  w i t h t h e educator c o l l e c t i n g , o r g a n i z i n g and a n a l y s i n g d a t a to determine the needs o f p r a c t i t i o n e r s . deficit.  The term "need" as used here means performance  D e f i c i t s may be found through r e c o r d a u d i t s , peer r e v i e w s ,  performance a p p r a i s a l , o b s e r v a t i o n , i n t e r v i e w s and q u e s t i o n n a i r e s .  A f t e r the  needs a r e determined they a r e ranked i n an o r d e r of p r i o r i t i e s which  reflect  the c u r r e n t o b j e c t i v e s of t h e i n s t i t u t i o n . The next s t e p , A n a l y s e t h e Nature o f the Need and D e f i n e t h e Problem, i s c r i t i c a l because a f a u l t y assumption about t h e cause o f performance deficit  i slikely  to l e a d t o an i n a p p r o p r i a t e remedy.  E d u c a t o r s a r e 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 l a c k o f knowledge from those caused by o r g a n i z a t i o n a l problems, and t o c o n c e n t r a t e t h e i r s k i l l s on t h e former. I f o r g a n i z a t i o n a l problems a r e found to be t h e cause of performance then the educator must seek other remedies.  deficits  The remaining s t e p s i n t h e  RMPS model d e a l e x c l u s i v e l y w i t h p l a n n i n g an e d u c a t i o n a l program f o r problems due t o l a c k of knowledge. The f o u r t h s t e p d e a l s w i t h d i a g n o s i n g t h e knowledge problem. key p o i n t s i n t h i s s t e p a r e :  (1) t h e d i a g n o s i s must be s p e c i f i c ,  Three  (2) c a r e -  f u l a t t e n t i o n should be g i v e n to t h e a f f e c t i v e domain, and (3) e f f o r t s t o b r i n g about performance change must i n c l u d e changes organizational  forces.  i n b o t h p e r s o n a l and  1. D e t e r m i n e  T  needs 9. N e x t steps Maintain  Within priorities select a  If s a t i s f i e d  results  need  If not s a t i s f i e d 3  #  Analyse need  re-examine  and  d e f i n e the p r o b l e m  T  If it is a l e a r n i n g p r o b l e m  // /  d i a g n o s e cause a n d cure  5.  ^  T I  Select a  learning  Plan and learning  I  //  corrective  experience V  prepare  8.  experience  Evaluate outcome  Implement corrective learning  experience  Figure 3 Charters and Blakely's Model of Inservice Education  24 The next p r e p a r i n g and  t h r e e s t e p s a r e concerned  planning,  implementing a c o r r e c t i v e l e a r n i n g e x p e r i e n c e .  B l a k e l y recommend t h a t the p r i n c i p l e s and o u t l i n e d by D i c k i n s o n and Verner are f o l l o w e d throughout The  with s e l e c t i n g ,  these  techniques  Charters  and  of a d u l t e d u c a t i o n  (1974), Knox (1974), and Gagne  as  (1970),  activities.  e i g h t h s t e p f o c u s e s on assessment of outcomes.  In a d d i t i o n to  e v a l u a t i n g the e f f e c t of the l e a r n i n g e x p e r i e n c e on the c l i e n t s , e v a l u a t i o n should encompass the p l a n n i n g and p r e p a r a t i o n of the program, s e t t i n g of o b j e c t i v e s , d i a g n o s i n g needs and The  f i n a l step addresses  s e t t i n g of g o a l s . the q u e s t i o n :  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.  I f they are not s a t i s f a c t o r y a s e r i e s of q u e s t i o n s  be c o n s i d e r e d . another  Is the performance d e f i c i t  remedy?  What were the p r o b a b l e  i n c o r r e c t l y diagnosed? Was  Is the d e f i c i t  the l e a r n i n g e x p e r i e n c e  sources of f a i l u r e ? caused  and  the need  steps.  or d e l i v e r e d ?  Answers to  I f the outcomes are  s t e p i s to ensure maintenance of the performance.  B l a k e l y do not s p e c i f y how  t h a t educators may of planned  Was  to t r y  by an a d m i n i s t r a t i o n problem?  i m p r o p e r l y planned  those q u e r i e s h e l p to determine the next f a c t o r y the next  s u f f i c i e n t l y important  should  t h i s should be c a r r i e d out but they  f i n d some ideas f o r a c c o m p l i s h i n g  satisCharters  suggest  t h i s t a s k i n the models  change (Schein & Kommers, 1972), d i s s e m i n a t i o n 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 i n n o v a t i o n s  (Rogers & Shoemaker,  1972). The RMPS model appears to have t h r e e major advantages f o r performance change i n h e a l t h - c a r e a g e n c i e s . and on-the-job  performance.  First,  Miller  i t integrates educational a c t i v i t i e s  (1967), one  of the f i r s t modern  critics  of c o n t i n u i n g m e d i c a l e d u c a t i o n programs, c o g e n t l y argues f o r t h i s form of  linkage.  He d e p l o r e s  relevance  t o a c t u a l performance needs.  method o f c o n t i n u i n g  educational  education  programs t h a t have l i t t l e He recommends a  "process-oriented"  where p r a c t i t i o n e r s a r e encouraged t o  i d e n t i f y c l i n i c a l problems and seek a p p r o p r i a t e s o l v e them.  immediate  By f i r m l y a n c h o r i n g e d u c a t i o n a l  c l i n i c a l p r a c t i c e t h e RMPS model meets t h a t  l e a r n i n g experiences to  activities  to t h e context of  requirement.  Second, t h e RMPS model d i s t i n g u i s h e s between performance problems caused by a p r a c t i t i o n e r ' s l a c k of knowledge o r s k i l l other The  and those caused by  f a c t o r s such as poor a d m i n i s t r a t i v e p o l i c i e s o r inadequate  need f o r t h i s k i n d o f d i f f e r e n t i a t i o n i s s t r e s s e d by many  consultants  including Lessinger  (1974) and F l e i s c h e r (1974).  resources.  health-care They p o i n t out  t h a t inadequate a n a l y s i s o f t h e p r o b a b l e causes of gaps between observed and  expected performance l e a d s  Lessinger  to inappropriate  corrective actions.  (1974) recommends the u s e o f Mager and P i p e ' s (1971) a n a l y s i s o f  performance problems.  T h i s system uses a s e r i e s o f q u e s t i o n s  d e f i c i e n c e s of knowledge from d e f i c i e n c i e s o f e x e c u t i o n . c o u l d he do i t i f h i s l i f e depended on i t ?  to d i s t i n g u i s h  F o r example,  A p o s i t i v e answer suggests t h a t  the problem i s not due to l a c k of knowledge.  One advantage o f t h e RMPS i s  t h a t i t encourages t h i s type of a n a l y s i s . The  t h i r d advantage o f t h e RMPS model concerns t h e expansion of t h e  r o l e and r e s p o n s i b i l i t i e s of i n s e r v i c e e d u c a t o r s .  Other models, such as  those recommended by the H o s p i t a l Research and E d u c a t i o n T r u s t King  (1970) and  (1976), s t a t e t h a t educators a r e a c c o u n t a b l e f o r an employee's  to perform and s u p e r v i s o r s  are responsible  ability  f o r maintenance of performance.  This e x p l i c i t d e l i n e a t i o n of r o l e s i s challenged  by D i c k i n s o n  and Verner  (1974) who s p e c i f y t h a t one o f the f u n c t i o n s of i n s e r v i c e s i s to " i n s u r e t h a t changes t h a t have been i n t r o d u c e d  i n t o the o r g a n i z a t i o n a r e adopted  26 and m a i n t a i n e d " by b l u r r i n g  (p. 182).  The RMPS model s u b s c r i b e s to the second  the d i s t i n c t i o n between s u p e r v i s o r and educator and s t r e s s i n g  the need f o r c o l l a b o r a t i o n .  By so d o i n g , i t extends  boundaries t o encompass assessment to  t h e educator's  and removal o f o r g a n i z a t i o n a l  barriers  change. In  summary, the RMPS model i s an e l a b o r a t i o n of the b a s i c  solving cycle. approach  problem-  I t p r o v i d e s educators and s u p e r v i s o r s w i t h a s y s t e m a t i c  t o l i n k i n g e d u c a t i o n a l a c t i v i t i e s w i t h observed performance  By emphasising of  position  performance  deficits.  i t s a t i s f i e s some concerns expressed by c r i t i c s  c o n t i n u i n g and i n s e r v i c e e d u c a t i o n .  A p p l i c a t i o n of t h i s model f o r c e s  educators t o expand t h e i r a c t i v i t i e s beyond t h e c l a s s r o o m and c o n s i d e r t h e i n f l u e n c e o f o r g a n i z a t i o n a l f a c t o r s on t h e performance  they a r e t r y i n g t o  change.  A SUMMARY OF THE THEORETICAL CONSTRUCTS  Two o b j e c t i v e s guided t h e review o f l i t e r a t u r e .  The f i r s t  was t o i d e n t i f y key concepts r e l a t i n g t o employee performance  and performance  change i n the work s e t t i n g from s e v e r a l t h e o r e t i c a l c o n s t r u c t s . accomplished by examining  T h i s was  l i t e r a t u r e on work behaviour i n t h e c o n t e x t of  m o t i v a t i o n , b e h a v i o u r i s m and i n s e r v i c e e d u c a t i o n . the r e s u l t s of t h a t  objective  T a b l e 2 a i d s i n comparing  examination.  The t a b l e l i s t s  the key concepts i d e n t i f i e d  i n needs h i e r a r c h y t h e o r y  (Maslow, 1943, 1965), d u a l - f a c t o r t h e o r y (Herzberg e t a l . , 1959), a model of performance  (Cummings & Schwab, 1973) based on expectancy/valence t h e o r y , a  performance  a u d i t model (Rummler, 1972, 1976) d e r i v e d from operant  learning  theory, and a model o f i n s e r v i c e e d u c a t i o n ( C h a r t e r s & B l a k e l y , 1974) based on a p r o b l e m - s o l v i n g c y c l e .  The concepts a r e c l a s s i f i e d  as e i t h e r p e r s o n a l  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 i n 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 i s recognized  as an important part of.the performance equation by behaviourists, inservice educators and motivation "process" theorists. Table 2 Personal and Organizational Factors I d e n t i f i e d i n 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 d e f i n i t i o n Supervision Compensation  Rummler (1976)  Knowledge  Task interference Performance standards Reinforcement Feedback  Charters & Blakely (1974)  Perceived needs Knowledge  Performance d e f i c i t s Learning experience Evaluation procedures Administrative policy Resources  28 The second o b j e c t i v e was to determine from e m p i r i c a l s t u d i e s of performance change which of the p r e v i o u s l y i d e n t i f i e d concepts were important t o a c t u a l performance change.  The r e s u l t s o f t h a t examination  a r e p r e s e n t e d i n the next s e c t i o n o f t h i s review.  FACTORS AFFECTING PERFORMANCE  CHANGE  For the purpose of t h i s review, s t u d i e s d e a l i n g w i t h f a c t o r s a f f e c t performance change a r e d i v i d e d  i n t o the f o l l o w i n g  that  categories:  performance change among p r o f e s s i o n a l s , employee knowledge change, and o r g a n i z a t i o n a l f a c t o r s and employee performance S t u d i e s on Performance Change among P r o f e s s i o n a l s Reports o f d e l i b e r a t e attempts t o change performance p a t t e r n s o f t e a c h e r s , nurses and p h y s i c i a n s i l l u s t r a t e some p e r s o n a l and o r g a n i z a t i o n a l f a c t o r s t h a t seem to h e l p or b l o c k the change p r o c e s s . Gross et a l . ( 1 9 7 1 ) , conducted an i n t e n s i v e case study of an attempt to implement  a new t e a c h i n g r o l e among a s m a l l group o f t e a c h e r s i n Cambrie.  The new r o l e , r e f e r r e d t o as " c a t a l y t i c teaching s t y l e .  t e a c h i n g , " i n v o l v e d a change i n  The dependent v a r i a b l e was degree o f implementation,  s p e c i f i c a l l y stated as:  the extent to which t e a c h e r r o l e performance, a t  a g i v e n p o i n t i n time, conformed  t o the new r o l e .  Systematic observation  of performance by a t r a i n e d o b s e r v e r , s e l f - a d m i n i s t e r e d i n t e r v i e w s were the main sources of d a t a . was i n t r o d u c e d t h e r e was l i t t l e  Seven months a f t e r the new r o l e  e v i d e n c e o f change.  behaving i n a c c o r d w i t h the t r a d i t i o n a l r o l e F a i l u r e to implement to f i v e c i r c u m s t a n c e s :  q u e s t i o n n a i r e s and  Teachers were  still  model.  the d e s i r e d performance change was a t t r i b u t e d  (1) l a c k of c l a r i t y about the new performance,  (2) l a c k o f c a p a b i l i t y t o 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 and  m a t e r i a l s , (4) i n c o m p a t i b i l i t y of o r g a n i z a t i o n a l arrangements,  (5) l a c k o f m o t i v a t i o n 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 Gross e t a l . (1971) noted  role,  t h a t performance change r e q u i r e s changes i n  p e r s o n a l f o r c e s , such as m o t i v a t i o n and knowledge, and changes i n o r g a n i z a t i o n a l f o r c e s such as r e s o u r c e s and working arrangements. A c o l l e c t i o n of case s t u d i e s of planned hospital Coe  (Coe, 1970) i n c l u d e s one r e l a t i n g  and B a r n h i l l  to performance change i n n u r s e s .  (1970) monitored the implementation  a new d r u g - d i s p e n s i n g nurses  change i n a S t . L o u i s  system on a. h o s p i t a l ward.  and s u s t a i n e d use of  The new method r e q u i r e d  to use a new p i e c e o f equipment, a d r u g - d i s p e n s i n g  drug-report  cards.  c o n s o l e , and new  Degree of a c c e p t a n c e o f t h e new system was measured by  p r e - and post-implementation  questionnaires.  A d d i t i o n a l data were o b t a i n e d  from o b s e r v a t i o n and i n t e r v i e w s . Nine months a f t e r the new d r u g - d i s p e n s i n g  system was i n t r o d u c e d ,  n u r s i n g s t a f f had r e v e r t e d t o the t r a d i t i o n a l method of d i s p e n s i n g Those authors  drugs.  a t t r i b u t e d f a i l u r e t o s u s t a i n the new method t o t h r e e  (1) l a c k o f p e r c e i v e d need t o change among s t a f f , system to f u l f i l l  factors:  (2) i n a b i l i t y of the new  e x p e c t a t i o n s , and (3) c o v e r t h o s t i l i t y o f s t a f f  toward  persons r e s p o n s i b l e f o r t h i s new method. E x p l a i n i n g those f i n d i n g s , Coe and B a r n h i l l  (1970) note t h a t the  new d i s p e n s i n g method was imposed by an o u t s i d e s o u r c e : a study done by the human e n g i n e e r i n g department.  i t r e s u l t e d from  Nursing  s t a f f d i d not  p e r c e i v e a need f o r i t ; they were happy w i t h the e x i s t i n g system. of p e r c e i v e d need was c o n s i d e r e d  t o be an important  This lack  f o r c e a g a i n s t the r e q u i r e d  change i n performance. S t u d i e s on attempts t o change r e c o r d - k e e p i n g  p r a c t i c e s of h e a l t h -  care personnel report varying  degrees o f s u c c e s s .  Hammett e t a l . (1976)  measured the use o f a new r e c o r d i n g method among 200 p h y s i c i a n s Reese H o s p i t a l , Chicago. (POMR), r e q u i r e d care.  system, Problem O r i e n t e d  Medical  Records  c l i n i c i a n s t o f o l l o w a s p e c i f i c format i n r e c o r d i n g  A f t e r an e x t e n s i v e  from 57% t o 72%.  The new  at Michael  education  patient  program, adherence t o POMR i n c r e a s e d  The study d i d not  i n c l u d e a c o n t r o l group;  the authors c l a i m the r e s u l t s p r o b a b l y r e f l e c t  the v a l u e  nevertheless,  of the education  program. I n i t i a l r e s u l t s from an on-going study o f POMR use a t Guy's H o s p i t a l , London, (Fernow e t a l . , 1977) attempts t o change p h y s i c i a n b e h a v i o u r .  provide  further insights into  The r e s e a r c h e r s  i n which feedback and a t t i t u d e s a f f e c t the use o f POMR. from 336 s e t s o f r e c o r d s At r e g u l a r  completed by 28 p h y s i c i a n s  i n v e s t i g a t e d ways Data were c o l l e c t e d  over a 12-week p e r i o d .  i n t e r v a l s , each p h y s i c i a n r e c e i v e d feedback i n the form o f a copy  of h i s r e s u l t s showing t h e e r r o r s he made, h i s monthly s c o r e and h i s i n r e l a t i o n s h i p to his colleagues'  scores.  Significant findings  score  include:  (1) use o f POMR by j u n i o r members o f a team i n c r e a s e d when s e n i o r members used i t , (2) no p o s i t i v e e f f e c t s o f feedback were demonstrated, and s c o r e s were b e t t e r f o r p h y s i c i a n s w i t h f a v o u r a b l e The  (3)  a t t i t u d e s toward POMR.  i n f l u e n c e o f o r g a n i z a t i o n a l f o r c e s on performance change i s  v i v i d l y demonstrated i n a r e p o r t o f t h e e f f e c t i v e n e s s o f a management t r a i n i n g program f o r nurses  (Davies,  appeared t o be the i m p o s i t i o n  1972).  The main cause o f the  o f a new i d e a by an o u t s i d e  agency.  problem The  management t r a i n i n g program r e s u l t e d from the recommendations o f a n a t i o n a l committee.  They decreed t h a t "management courses should  prepare s t a f f f o r t h e i r management r o l e s " (Davies, neither  1972,  be run p. 13).  i n order t o However,  the h o s p i t a l s nor the s t a f f were prepared f o r implementing change.  31 S e l e c t i o n of p a r t i c i p a n t s f o r the program was volunteered  (25%)  or were nominated by  h a l f the p o t e n t i a l l e a r n e r s had  the f o l l o w i n g :  senior s t a f f  no p r e p a r a t i o n  c o l l e c t e d from the q u e s t i o n n a i r e s , revealed  haphazard; t r a i n e e s e i t h e r  interviews  (75%)  acquired  skills,  l e d g e and  skill,  the t r a i n e e s who Studies  approximately  f o r the c o u r s e . and  on-the-job  Data  observations  (1) nominators of t r a i n e e s r a r e l y expected  p o s i t i v e behaviour change to r e s u l t from the course, u n w i l l i n g to p r o v i d e  and  opportunities  any  (2) s e n i o r s t a f f were  f o r nurses to p r a c t i c e t h e i r newly  (3) the t r a i n i n g program h e l p e d the l e a r n e r s to g a i n knowand  (4) c o l l e a g u e s  r a r e l y provided  feedback to r e i n f o r c e  d i d attempt to implement t h e i r new  skills.  on Employee Knowledge Change A primary o b j e c t i v e of i n s e r v i c e e d u c a t i o n  t h e i r knowledge and Dickinson  skills  & Verner, 1974;  (Campbell, A.B., K i n g , 1976;  1971;  increasing  (Abrahamson, 1968;  staff  A l t h o u g h the use  i n t o two  types,  Long, 1969), p u b l i s h e d  s t u d i e s are s c a r c e The  those r e p o r t i n g immediate a c q u i s i t i o n  and  available and  those d e a l i n g  w i t h the impact of l e a r n i n g on immediate changes i n knowledge.  Examples  follow:  A c q u i s i t i o n and  r e t e n t i o n of knowledge.  s i v e e v a l u a t i o n s t u d i e s i n the h e a l t h - c a r e researchers  one  of e v a l u a t i o n measures i s  subsequent r e t e n t i o n over a p e r i o d of s e v e r a l months, and  of both types  1973;  been a t t a i n e d i s through  p r o b a b l y r e f l e c t o n l y a minute p o r t i o n of e v a l u a t i o n e f f o r t s . studies f a l l  increase  Cooper & Hornback,  Medearis & P o p i e l , 1971), and  method of d e t e r m i n i n g whether t h i s o b j e c t i v e has e v a l u a t i o n of the l e a r n e r s .  i s to h e l p  One  f i e l d was  of the more comprehendone by a group of  a t the U n i v e r s i t y of Texas System S c h o o l of N u r s i n g  (1975).  T h i s group attempted to measure changes i n a t t i t u d e s , knowledge and mance, e i t h e r s i n g l y or i n combination, among nurses a t t e n d i n g  10  perforcontinuing  32 education courses. measure on-the-job g a t h e r i n g ) and  Even though the r e s e a r c h e r s had  to abandon attempts to  performance changes (due to d i f f i c u l t i e s  they e x p e r i e n c e d  i n data  some problems w i t h a t t i t u d i n a l measures,  t h e i r r e p o r t p r o v i d e s u s e f u l data on the e f f e c t i v e n e s s of i n s e r v i c e  and  c o n t i n u i n g e d u c a t i o n i n the area of knowledge change. Nurses a t t e n d i n g f i v e d i f f e r e n t c o u r s e s , r a n g i n g from a one-day to a s i x - d a y workshop, were measured f o r immediate and knowledge. end  For each c o u r s e ,  of the course and  paradigm enabled  long-term  t e s t s were a d m i n i s t e r e d  a t the b e g i n n i n g  a f t e r an i n t e r v a l of t h r e e months.  the r e s e a r c h e r s to e s t a b l i s h i n i t i a l  changes i n and  This evaluation  a c q u i s i t i o n and  sub-  sequent r e t e n t i o n of knowledge. The  r e s u l t s , summarized by Deets and  Blume (1977) show:  (1) p o s t -  t e s t and delayed p o s t t e s t knowledge s c o r e s were s i g n i f i c a n t l y h i g h e r pretest  s c o r e s i n two  courses,  than  (2) p o s t t e s t knowledge means were s i g n i f i -  c a n t l y h i g h e r than delayed p o s t t e s t means i n two  c o u r s e s , and  (3) delayed  p o s t t e s t knowledge s c o r e s were s i g n i f i c a n t l y h i g h e r than p o s t t e s t s c o r e s on one c o u r s e .  Thus, i t was  concluded  t h a t a c q u i s i t i o n of knowledge con-  s i s t e n t l y o c c u r r e d i n a l l courses but r e t e n t i o n v a r i e d . there was i n two  a s m a l l l o s s of knowledge which was  other i n s t a n c e s the d e c l i n e was  not  In two  statistically  s i g n i f i c a n t , and  i n the  cases significant, remaining  case knowledge i n c r e a s e d s i g n i f i c a n t l y d u r i n g the t h r e e months f o l l o w i n g the program. High r a t e s of r e t e n t i o n and knowledge are not w h o l l y u n u s u a l . s h i p between age  o c c a s i o n a l i n c r e a s e s i n newly a c q u i r e d In a p r o j e c t i n v e s t i g a t i n g the  and r e t e n t i o n , Jamieson (1972),  relation-  tested acquisition  and  r e t e n t i o n of a b i n a r y l e a r n i n g t a s k among 80 female s u b j e c t s r a n g i n g i n age  from 24 to 70 y e a r s .  He found  a s i g n i f i c a n t drop i n knowledge o c c u r r e d  i n the o l d e r age group but no  (52 to 70 years) a f t e r an i n t e r v a l of f o u r months  l o s s o c c u r r e d i n the younger age group (24 to 39 y e a r s ) . 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 i n c r e a s e s i n knowledge a f t e r  a three-month i n t e r v a l i s r e p o r t e d by Donegan, Reid and They e v a l u a t e d the l e a r n i n g and i n s i x , two-day workshops. t e s t , p o s t t e s t and  Eggers  (1976).  r e t e n t i o n of a n e s t h e s i o l o g i s t s p a r t i c i p a t i n g  The number of l e a r n e r s who  completed  delayed p o s t t e s t ranged from 68 to 37.  the p r e -  In a l l s i x work-  shops the mean knowledge s c o r e s on the immediate p o s t t e s t s were  significantly  i h i g h e r than p r e t e s t s c o r e s , and  i n f o u r workshops the s c o r e s three months  l a t e r were s i g n i f i c a n t l y h i g h e r than immediate p o s t t e s t s c o r e s . remaining t e s t and  two workshops, one group mean was one group mean was  h i g h e r f o r the delayed  lower but n e i t h e r was  statistically  Knowledge r e t e n t i o n s c o r e s from the Texas study Texas System School of N u r s i n g , (1976) underscore  the post-  significant.  ( U n i v e r s i t y of  1975), Jamieson (1972) and Donegan et a l .  the importance of measuring l e a r n i n g a f t e r an  i n t e r v a l of s e v e r a l months.  In  elapsed  Those s t u d i e s show t h a t d e c l i n e i n knowledge  should not be taken f o r granted.  I t i s p o s s i b l e f o r a d u l t l e a r n e r s to  m a i n t a i n newly a c q u i r e d knowledge a t a v e r y h i g h l e v e l f o r a t l e a s t months and,  i n some i n s t a n c e s , they may  Immediate changes i n knowledge. take i n i t i a l  even i n c r e a s e t h e i r knowledge. Educators  should not, of  r e p o r t , such as one by Wolfe and Moe  (1973),  Occasionally a  shows t h a t an  program can f a i l t o i n c r e a s e p a r t i c i p a n t s ' knowledge.  was  inservice  Those authors  e v a l u a t e d a h o s p i t a l s u p e r v i s o r y t r a i n i n g program.  w e l l - d e s i g n e d , had.face  the t r a i n e e s .  course,  l e a r n i n g f o r g r a n t e d , even though the m a j o r i t y of e v a l u a t i o n  s t u d i e s show p o s i t i v e r e s u l t s from l e a r n i n g e x p e r i e n c e s .  ducted and  three  validity  of content  and  format,  and  The  con-  program  satisfied  D e s p i t e i t s p o s i t i v e a s p e c t s , "the program had a b s o l u t e l y  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 o f t h e group exposed t o t h e program" (p. 7 4 ) . The r e s e a r c h e r s note t h a t t h e t r a i n i n g program and c o n t e n t r e c e i v e d l o w 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 supervisors.  T h i s l e d them t o s p e c u l a t e t h a t l a c k o f m o t i v a t i o n t o l e a r n  and a p p l y management concepts were, i n p a r t , r e s p o n s i b l e f o r t h e program failure. The Wolfe and Moe (1973) s t u d y i s u n u s u a l i n t h a t i t used a c o n t r o l , group i n the e x p e r i m e n t a l d e s i g n . demonstrating participants.  T y p i c a l l y , educators a r e content w i t h  t h e e f f e c t i v e n e s s o f t h e i r e f f o r t s by measuring o n l y t h e Two examples o f t h e more u s u a l form o f e v a l u a t i o n a r e p r o v i d e d  by P a r k e r e t a l . (1975) and M a r g o l i s e t a l . (1976). P a r k e r and h e r a s s o c i a t e s (1975) e v a l u a t e d a POMR workshop f o r nurses.  P r e - and p o s t - c o u r s e measures o f knowledge, u s i n g seven m u l t i p l e -  c h o i c e q u e s t i o n s , showed t h e nurses knowledge.  s i g n i f i c a n t l y i n c r e a s e d t h e i r POMR  From those r e s u l t s , t h e program was judged  t o be s u c c e s s f u l .  However, t h e a u t h o r s r e c o g n i z e d t h a t t h i s was a l i m i t e d measure and they concluded  t h a t 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 s h o u l d be a s s e s s e d  w i t h r e g a r d to whether h i g h post s c o r e s a r e 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 " ( P a r k e r e t a l . , 1975, p. 3 8 ) . In another POMR study ( M a r g o l i s e t a l . , 1976) t h e i s s u e o f t r a n s f e r r i n g s k i l l s t o t h e j o b was a g a i n o m i t t e d from the study d e s i g n . main o b j e c t i v e was t o determine workshop.  The  the e f f e c t i v e n e s s o f a s e l f - i n s t r u c t i o n  The p e d i a t r i c i a n s a t t e n d i n g t h i s workshop i n c r e a s e d t h e i r POMR  knowledge by 33%.  The a u t h o r s were s a t i s f i e d t h a t t h i s i n d i c a t e d a g a i n  i n knowledge and the a b i l i t y t o use POMR. O r g a n i z a t i o n a l F a c t o r s 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 t o account "f-orvjorganiza-  35 t i o n a l b a r r i e r s t o performance change i n h e a l t h - c a r e a g e n c i e s , examples of such e f f o r t s a r e s c a r c e .  specific  F l e i s c h e r (1974) uses anecdotes t o  i l l u s t r a t e o r g a n i z a t i o n a l o b s t a c l e s t o performance.  In one example he  d i s c u s s e s problems w i t h meeting c r i t e r i a e s t a b l i s h e d f o r m o n i t o r i n g myocardial  i n f a r c t i o n p a t i e n t s ; s t a f f were unable t o meet the c r i t e r i a  because t h e r e was a shortage procedures  acute  of h e a r t m o n i t o r s .  Inappropriate  were a l s o i n t e r f e r i n g w i t h s t a f f performance.  admitting  Thus, two  o r g a n i z a t i o n a l b a r r i e r s d e s c r i b e d by F l e i s c h e r a r e l a c k of r e s o u r c e s and l a c k o f c o o r d i n a t i o n between two p a r t s of the work f o r c e . of  i n t e r f e r e n c e were removed a f t e r they had been S t e c k e l (1976) p r o v i d e s a l i s t  s e l e c t e d by nurses  Both  sources  diagnosed.  of o r g a n i z a t i o n a l f a c t o r s that were  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  p r o v i d e s some  i n s i g h t i n t o the t h i n g s s t a f f p e r c e i v e as l i k e l y t o h e l p them improve t h e i r performance.  The l i s t  included:  (1) a three-day  weekend, (2)  o p p o r t u n i t y t o l e a v e work two hours e a r l y , (3) c h o i c e of p a t i e n t assignments, (4) o p p o r t u n i t y t o observe s u r g e r y ,  (5) o p p o r t u n i t y t o a t t e n d a c o n t i n u i n g  e d u c a t i o n workshop, (6) have a l e t t e r of recommendation p l a c e d i n p e r s o n n e l file,  (7) work on a p r o j e c t w i t h i n working time, and (8) have a day w i t h -  out c o m p l a i n t s . list  Systematic  was s u c c e s s f u l .  a p p l i c a t i o n of r e i n f o r c e r s s e l e c t e d from  this  Nurses improved t h e i r r e c o r d i n g of n u r s e - p a t i e n t  interactions substantially.  I n a d d i t i o n t o working out a l i s t  of r e i n -  f o r c e r s , nurses were asked t o i d e n t i f y t h e i r p e r s o n a l performance g o a l s . This process  of g o a l i d e n t i f i c a t i o n a l s o c o n t r i b u t e d t o performance change  as i t f o r c e d both nurses expected  and s u p e r v i s o r s t o c l e a r l y s p e c i f y what was  f o r "good" performance.  A Summary of E m p i r i c a l F i n d i n g s 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 o r g a n i z a t i o n a l f a c t o r s on were reviewed  i n an attempt  t o i d e n t i f y which p e r s o n a l and  f a c t o r s a r e important to r e a l - l i f e performance Table 3 aids  i n comparing  change among p r o f e s s i o n a l s .  identified  among t e a c h e r s (Gross et a l . , 1971), nurses 1972;  It  (Fernow et a l . , 1977;  (Coe & B a r n h i l l ,  1973)  and  1976).  r e q u i r e s changes i n p e r s o n a l and  of change.  and data from r e t e n t i o n s t u d i e s (Deets & Blume, 1977; 1972)  d e f i n e d performance  the  initial  change.  intro-  change,  Donegan et a l . ,  imply that l o s s of knowledge i s an u n l i k e l y  s u s t a i n e d performance  i s the  There i s some e v i d e n c e t o  suggest t h a t m o t i v a t i o n and i n c r e a s e d knowledge f a c i l i t a t e  Jamieson,  to  situational  they i n t e r a c t w i t h each o t h e r throughout  d u c t o r y and implementation phases  to  Davies,  However, i t i s not c l e a r which of those two dimensions  more important or how  table  1970;  i s obvious from those s t u d i e s t h a t a d e l i b e r a t e attempt  change employee performance factors.  Hammett et a l . ,  The  i n s t u d i e s of change  S t e c k e l , 1976), a d m i n i s t r a t i v e p e r s o n n e l (Wolfe & Moe,  physicians  1976;  situational  the r e s u l t s of t h a t i n v e s t i g a t i o n .  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  performance  A p p a r e n t l y , the presence of  barrier  clearly  standards i s one important s i t u a t i o n a l f a c t o r  r e i n f o r c e m e n t from p e e r s , c o l l e a g u e s and s u p e r v i s o r s i s another.  and Other  s i t u a t i o n a l f a c t o r s t h a t a f f e c t change i n c l u d e l a c k of r e s o u r c e s and a d m i n i s t r a t i v e support.  There i s l i t t l e evidence t o show whether those  f a c t o r s are e q u a l l y important i n both phases e f f e c t s v a r y w i t h each stage.  of change or whether  their  37 Table 3 F a c t o r s A f f e c t i n g Performance Change  Investigators  Barriers  Gross, G i a c q u i n t a & 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 n e c e s s a r y m a t e r i a l s Lack of m o t i v a t i o n to change I n c o m p a t a b i l i t y of o r g a n i z a t i o n arrangements  Coe & B a r n h i l l (1970)  Lack of p e r c e i v e d need to change Staff h o s t i l i t y I n a b i l i t y of new i d e a to f u l f i l l e x p e c t a t i o n s  Davies (1972)  Lack of o p p o r t u n i t y 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 s u p e r v i s o r  Wolfe & (1973)  Moe  Fleischer (1974)  Lack of s u p e r v i s o r i n t e r e s t Lack o f m o t i v a t i o n to l e a r n and a p p l y new  Shortage of equipment I n a p p r o p r i a t e performance standards  Facilitators  Hammett, Bashook & Sandlow (1976)  Increased knowledge  Fernow, M c C o l l , Mackie & R e n d a l l (1977)  Increased knowledge Peer support F a v o u r a b l e a t t i t u d e s toward new  Steckel (1976)  Time o f f F l e x i b l e work assignments Recognition C l e a r l y d e f i n e d performance standards  idea  skills  Chapter 3  DESIGN AND RATIONALE FOR THE STUDY  In the p r e v i o u s chapter s e v e r a l t h e o r i e s , models and p r a c t i c a l approaches  t o employee performance  From t h a t body o f l i t e r a t u r e a  and performance  change were reviewed.  framework f o r c o n c e p t u a l i z i n g planned  change i n the w o r k - s e t t i n g and s e v e r a l 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 .  T h i s c h a p t e r d e s c r i b e s t h e c o n c e p t u a l frame-  work used i n t h i s study to understand and e x p l a i n employee change i n h e a l t h - c a r e a g e n c i e s . * In a d d i t i o n , i t i n c l u d e s  performance descriptions,  d e f i n i t i o n s and measurements o f the v a r i a b l e s , the hypotheses  t o be t e s t e d  and the procedures o f the study.  THE CONCEPTUAL FRAMEWORK  C u r r e n t u n d e r s t a n d i n g of human behaviour suggests t h a t man i s an independent  organism always  continously interacts.  surrounded by an environment  w i t h which he  H i s behaviour a t any g i v e n moment of time i s a  f u n c t i o n of i n t e r a c t i o n between h i m s e l f and h i s environment Performance  of a t a s k i s one type of b e h a v i o u r , c o n s e q u e n t l y  (Lewin,  1938).  performance  i s a l s o 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 p l a c e .  Based on t h i s , t h i s study proceeds  on the u n d e r s t a n d i n g that a d e l i b e r a t e attempt performance  t o change an i n d i v i d u a l ' s  r e q u i r e s changes t o occur i n e i t h e r the person, h i s environment,  or some combination o f b o t h . 38  39 The P r o c e s s of Change Change, by d e f i n i t i o n ,  i s a d i f f e r e n c e between two  a c o n c e p t u a l framework f o r understanding should r e f l e c t  i s Lewin's  thus,  employee performance change  the dynamic n a t u r e of the change p r o c e s s .  meets t h i s requirement  states;  One model t h a t  (1947) model of the p r o c e s s of change.  T h i s model, g r a p h i c a l l y d e p i c t e d i n F i g u r e 4, p o r t r a y s change as a t h r e e stage p r o c e s s modifying  ( u n f r e e z i n g , moving and r e f r e e z i n g ) which i s governed  the d r i v i n g and  restraining  Lewin (1947) proposes maintained  forces.  t h a t an e x i s t i n g l e v e l of performance i s  by a v a r i e t y of f a c t o r s t h a t a r e i n a s t a t e of b a l a n c e .  f a c t o r s a r i s e from w i t h i n the person and attempt  by  the environment.  Those  A deliberate  to i n c r e a s e performance l e v e l s i n v o l v e s a l t e r i n g the b a l a n c e between  the f o r c e s .  T h i s i s achieved by adding a new  an e x i s t i n g one.  d r i v i n g f o r c e or s t r e n g t h e n i n g  A s i m i l a r r e s u l t can be achieved by r e d u c i n g the number  or s t r e n g t h of the r e s t r a i n i n g f o r c e s .  U p s e t t i n g the b a l a n c e of f o r c e s  w i l l a l l o w the performance l e v e l to r i s e to a p o i n t where the f o r c e s are again i n balance.  To m a i n t a i n , or r e f r e e z e , the newly a c q u i r e d performance  l e v e l the b a l a n c e between the f o r c e s 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 d e c l i n e toward i t s p r e v i o u s l e v e l . o c c u r s the change attempt  When t h i s  has been u n s u c c e s s f u l .  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 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 a r e key.concepts planned  change.  i n Lewin's model of  As t h e i r names imply, d r i v i n g f o r c e s a r e those which  encourage change and r e s t r a i n i n g f o r c e s a r e those which h i n d e r change. O b v i o u s l y , an u n d e r s t a n d i n g persons  of both types of f o r c e s i s a primary  t a s k of  a t t e m p t i n g t o change a s p e c i f i c performance i n a g i v e n s e t t i n g .  From the t h e o r e t i c a l and  e m p i r i c a l l i t e r a t u r e reviewed,  s e v e r a l concepts  40  REFREEZING RESTRAINING FORCES PRESENT J LEVEL OF • PERFORMANCE 4  /  I  " PERFORMANCE  UNFREEZING 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 r e i n f o r c e r s provided by the organization. Knowledge. obvious requirement i s or how  Possessing the necessary knowledge or s k i l l i s an for job performance.  No matter how motivated  a person  suitable he appears to be f o r 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 q u a l i f i c a t i o n s for h i s job. Organizations also recognize that an employee may knowledge or s k i l l when a new  need additional  task i s introduced into h i s job or an  existing task i s extensively revised.  They acknowledge the need f o r  additional information by providing t r a i n i n g and inservice education programs.  In f a c t , in-house education programs are the major strategy  used by organizations to help employees meet new  performance  requirements  (Cummings & Schwab, 1 9 7 3 ) . pants  the program  of  t h e new  in  this  tions  their  Based  existing  on  that  an  performance  t o be  generally "drive"  an  agreed  to carry  increase  Thus  o f new  staff  assumed  i n this  the nature  task  i t appears  providing  changes.  depends on  a cognitive  important part  i t was and,  level  i n this  as  as  that,  task  i t is  organiza-  performance  with opportunities  study that  s u c h , i t i s one  of performance.  driving  extensively  to change.  to  of the  knowledge  driving  Furthermore,  f o r c e would  revised  that  help  t a s k from an  i t was  employees  existing  move  level  difficulty  deliberate  suggest  internal  that  attempts an  and  essential  external  l e v e l s as  may  each  Thus,  component  to  from  The  It i s  or  internal  i t seems r e a s o n -  the  change.  motivation  e v e n t s a r e more l i k e l y  theoretical  that  of performance  formulation  to  assist  approaches  perspective. be  o v e r c o m e t o some e x t e n t by  to change employee p e r f o r m a n c e .  employee's  a change s i t u a t i o n .  as an  to determine p r e c i s e l y  from a d i f f e r e n t  This  i s another f o r c e  t o the p r o c e s s of change.  out the requirements of h i s j o b .  i n performance  motivation  t o change  a n e m p l o y e e m u s t p o s s e s s some m o t i v a t i o n  i s , however, d i f f i c u l t  changes  Motivation  important c o n t r i b u t o r  to consider motivation  l i t e r a t u r e which  in  existing  o f an  skill  task  level.  appears  able  an  from  partici-  knowledge.  the foregoing,  Motivation  of  an  to i t s importance by  supporting  a new  resulting  If i t i s primarily  a determinant of performance  expected  It  task.  knowledge t o be  they a t t e s t  their  deficits  f o c u s e s on k n o w l e d g e o r on  or revised  consider  forces  are intended to help  s t u d y , t h e f o c u s i s on k n o w l e d g e .  increase  is  programs  overcome knowledge or s k i l l  Whether  and  Such  perceived rationale  need  constitutes  f o r assuming  examining Several  reports  reports,  a motivational  this  form  force  of linkage i s  42 s u c c i n c t l y e x p l i c a t e d by Leagans concept  of need.  He  (1964) i n h i s attempt to b u i l d a  functional  states:  (1) Needs r e p r e s e n t an imbalance, l a c k of adjustment, or gap between the p r e s e n t s i t u a t i o n or s t a t u s quo and a new or changed s e t of c o n d i t i o n s assumed to be more d e s i r a b l e . (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 , p o s s i b l e , and the v a l u a b l e through s i t u a t i o n a l a n a l y s i s .  the  (3) People have to r e c o g n i z e the gap between the a c t u a l , the p o s s i b l e , and the d e s i r a b l e , and p l a c e v a l u e on a t t a i n i n g the d e s i r a b l e b e f o r e they become m o t i v a t e d to change. (Leagans, 1964, pp. 92-93) As w e l l as d e s c r i b i n g the l i n k between m o t i v a t i o n to change and p e r c e i v e d need, t h i s e x p l a n a t i o n suggests  s e v e r a l ways to c o n c e p t u a l i z e  an employee's m o t i v a t i o n to change h i s performance.  One  concept  i s "gap,"  t h a t i s , an i n d i v i d u a l ' s awareness of a d i s c r e p a n c y between what i s and what should be. v a l u e a person  A second concept  i s "importance."  p l a c e s on the attempted change.  l a r l y c r u c i a l when change i s i n t r o d u c e d through mandate.  A t h i r d concept, which may  e f f e c t s of gap and  importance.  i n v o l v e d i n m o t i v a t i o n suggest than t h a t of i t s two  The  be l a b e l l e d  T h i s r e f e r s to the  Importance may  some form of e x t e r n a l "impetus," i s the combined  t h a t impetus may  reflect a different  aspect  constituent parts.  m o t i v a t i o n i s a determinant  of performance and,  assumed i n t h i s study t h a t as such,  i t i s one  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 of performance. considered l i k e l y  mance change.  particu-  complex i n t e r a c t i o n s of p e r c e p t i o n s  Based on the f o r e g o i n g r a t i o n a l e , i t was  change was  be  to be one  Moreover, i t was  of  the  M o t i v a t i o n to  of the f o r c e s i n f l u e n c i n g p e r f o r -  r e c o g n i z e d t h a t m o t i v a t i o n to change may  be  composed of s e v e r a l i n d i v i d u a l elements which a c t e i t h e r 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 e x i s t s and what should or might e x i s t  is a likely  element  and  43 another  i s the importance  expected  a t t a c h e d to some f u t u r e s t a t e .  Thus, i t was  t h a t the presence o f a m o t i v a t i o n to change would c o n t r i b u t e t o  r a i s i n g an employee's performance Performance s t a n d a r d s .  o f a new or r e v i s e d  task.  In a d d i t i o n t o such p e r s o n a l a t t r i b u t e s as  m o t i v a t i o n to change and i n c r e a s e d knowledge, r e p o r t s o f attempts t o implement change f r e q u e n t l y 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 t o p e r f o r mance change t h a t e x i s t i n the o r g a n i z a t i o n a l s e t t i n g . a r e thought :to be one important h i n d e r employee performance  s i t u a t i o n a l f a c t o r t h a t can e i t h e r h e l p or  change.  I f standards a r e p r e s e n t they p r o b a b l y  h e l p the change p r o c e s s ; i f they a r e absent of  Performance standards  they p r o b a b l y a c t as a source  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  t h a t s p e c i f y expected  l e v e l s of c o r r e c t performance.  The impor-  t a n t p o i n t here i s t h a t employees kriow what the standards and c r i t e r i a a r e . When they e x i s t o n l y i n the s u p e r v i s o r ' s head employees have t o guess what they a r e and t h i s l e a d s to u n c e r t a i n t y and c o n f u s i o n .  I t seems t h a t an  i d e a l s i t u a t i o n would e x i s t when g u i d e l i n e s d e s c r i b i n g a c t i o n s to be taken, procedures  t o be f o l l o w e d and standards to be met a r e a v a i l a b l e i n w r i t t e n  form t o a l l employees.  I t was assumed i n t h i s study t h a t  standards c o n t r i b u t e t o employee performance they a r e p r e s e n t or absent determines restraining force.  performance  and t h a t the e x t e n t to which  t h e i r s t a t u s as e i t h e r a d r i v i n g or  Lack of w r i t t e n standards f o r a new t a s k i s a r e s -  s t r a i n i n g f o r c e and presence of such g u i d e l i n e s i s a d r i v i n g f o r c e . performance  As  standards were not p r e s e n t p r i o r t o t h i s study, they were  c o n s i d e r e d t o be a r e s t r a i n i n g f o r c e .  I t was a n t i c i p a t e d t h a t  of w r i t t e n standards would change t h e i r s t a t u s t o a d r i v i n g Resources.  Resources  a r e another  provision  force.  s i t u a t i o n a l f a c t o r t h a t has been  44 l i n k e d w i t h the success or f a i l u r e of performance change i n a w o r k - s e t t i n g . And l i k e performance s t a n d a r d s , determines  the extent to which they a r e a v a i l a b l e  whether they a r e c l a s s e d 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 r e s o u r c e s appear to be important; The  type o f m a t e r i a l s n e c e s s a r y  they a r e m a t e r i a l s and time.  f o r performance and performance change  o b v i o u s l y depends on the s p e c i f i c t a s k .  Books and p r i n t e d matter were  n e c e s s a r y m a t e r i a l s f o r implementing t h e " c a t a l y t i c t e a c h i n g r o l e " i n the Gross e t a l . (1971) study, whereas a new drug-console  u n i t and new drug  r e p o r t i n g cards were e s s e n t i a l p i e c e s o f equipment i n an attempt t o i n t r o duce a new d r u g - d i s p e n s i n g method  (Coe & B a r n h i l l , 1970).  In the t e a c h e r -  r o l e study, l a c k o f m a t e r i a l s was c i t e d as an o b s t a c l e t o change; i n the drug-dispensing  study the presence  of t h e n e c e s s a r y  equipment was  thought  to h e l p the change p r o c e s s . The overlooked  c o n t r i b u t i o n o f time t o performance change seems to have been 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 t a s k i n t e r f e r e n c e i n the performance a u d i t model (Rummler, 1972). I t s i n c l u s i o n appears to be r e a s o n a b l e because employees need a d d i t i o n a l to c a r r y out new or r e v i s e d t a s k s .  The e x t r a time i s needed t o " u n l e a r n "  o l d p a t t e r n s and r e p l a c e them w i t h new ones.  The time f a c t o r 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 full.  time  T h i s i s o f t e n the case i n h e a l t h - c a r e An assumption was made i n t h i s study  are already  agencies. t h a t r e s o u r c e s such as time and  m a t e r i a l s c o n t r i b u t e to employee performance and t h a t an e x i s t i n g l e v e l o f performance i s m a i n t a i n e d , force.  i n p a r t , by r e s o u r c e s a c t i n g as a r e s t r a i n i n g  An i n c r e a s e i n a v a i l a b i l i t y r e s u l t s i n a r e d u c t i o n 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  expected  t h a t r e s o u r c e s would remain c o n s t a n t throughout  i t was  the change p r o c e s s .  45-:  Reinforcers.  Reinforcers  related factor included  are the t h i r d and  organizational-  Reinforcers  are those a c t i o n s  and  events s p e c i f i c a l l y d i r e c t e d at the performer as he  attempts to c a r r y  out  the new  task.  Any  r e i n f o r c e r s but are  the  i n t h i s study.  final  member of the o r g a n i z a t i o n  the persons c o n s i d e r e d  employee's s u p e r v i s o r  R e i n f o r c i n g events and  and  i s a p o t e n t i a l source of  more l i k e l y to be  important  sources  members of h i s immediate work group.  a c t i o n s t h a t appear t o be  important to  p r o f e s s i o n a l s i n c l u d e p r a i s e , encouragement, r e c o g n i t i o n and  health-care indications  of improvement i n p r o f e s s i o n a l s t a t u s . I t was  assumed i n t h i s study t h a t 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 t a s k  performance  i s m a i n t a i n e d , i n p a r t , by r e i n f o r c e r s a c t i n g as a r e s t r a i n i n g f o r c e .  Thus,  an improvement i n r e i n f o r c e r s c o n s t i t u t e s a weakened r e s t r a i n i n g f o r c e . F o r c e s Promoting I n i t i a l Change Implementation of change i s a t h r e e - s t a g e an e x i s t i n g l e v e l of performance, r e f r e e z i n g at the new  level.  (2) moving to a new  Inservice education  s t r a t e g i e s used i n h e a l t h - c a r e  agencies to h e l p  e x i s t i n g l e v e l of t a s k performance and An  process:  (1)  l e v e l , and  i s one  (3)  of the major'  s t a f f unfreeze  move to a new  unfreezing  their  level.  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, i n s o f a r as formance l e v e l s .  i t aims to promote i n i t i a l  A successful educational  change i n p e r -  a c t i v i t y , t h a t 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 b e i n g more knowledgeable and  more aware of the need to  change, d i s t u r b s the b a l a n c e of f o r c e s impinging on e x i s t i n g performance levels.  Therefore,  mance l e v e l s up exist.  i t should  provide  sufficient  impetus to move p e r f o r -  d e s p i t e the s i t u a t i o n a l b a r r i e r s t h a t might c o n t i n u e to  46 At  the present time, formal research  professionals studies with are  and m e a s u r i n g  particularly involves  difficult direct  care,  to  the e f f e c t s  test  performance  to the l o g i s t i c a l  actual  performance  care of patients.  f o r example,  daily  of changing the d r i v i n g  forces  i n driving  and r e s t r a i n i n g  levels.  b e h a v i o u r would  Forces  increase  than to the a v a i l a b i l i t y relationships  Promoting Maintenance critical  new p e r f o r m a n c e  appear  t o make a d e q u a t e levels.  concentrate  on i n d u c i n g  events  might  all  that  be c r i t i c a l forces,  on i n i t i a l  investi-  some  tasks  direct may b e u s e d  change i n  acquisition  of recording  to the presence of a motivation to  t h e t a s k and t h e p r e s e n c e o f p e r f o r m a n c e o f r e s o u r c e s and r e i n f o r c e r s  f o r proper  represented i n Figure  Conventional inservice  5.  change  i n t h e maintenance and  out p r e v i o u s l y ,  o f newly  inservice  change.  This  limited  phase where performance  do n o t  acquired educators  i n t h e p e r s o n and t e n d t o i g n o r e  against  or refreezing  e d u c a t i o n programs  f o r the maintenance  A s was p o i n t e d  usually  o f new  o f Change  be w o r k i n g  Supervisors  relationships  and a c q u i s i t i o n  are schematically  provision  both personal  to test  d i m e n s i o n o f change i s t h e maintenance  levels.  performance  to  linked  i n knowledge about  Those  forces,  I t was h y p o t h e s i z e d t h a t  be more c l o s e l y  Another of  under  problems  levels.  among c h a n g e s  recording.  Those  k e e p i n g r e c o r d s , and t h o s e a c t i v i t i e s  record-keeping practices  standards  associated  do n o t i n v o l v e  study used  change,  problems  There a r e , however,  work t h a t  among  The p a u c i t y o f  on-the-job.  This  performance  assumption  t o o v e r c o m e when t h e p e r f o r m a n c e  a health-care professional's  patient  this  i n health-care agencies i s scarce.  i s p r o b a b l y due, i n p a r t ,  observing  gation in  employed  testing  situational  approach  appears  i s susceptible to  situational.  respond  to declining  performance  levels  among  Figure 5 I n i t i a l Change of Recording Behaviour their s t a f f by ordering more inservice education.  Implicit i n this  response i s a b e l i e f that loss of performance i s primarily caused by loss of knowledge.  This leads to the notion that the decline can be halted and  reversed by giving the s t a f f a refresher course. This b e l i e f and i t s response i s not t h e o r e t i c a l l y sound for at least two reasons.  F i r s t , studies on rates of retention show that adults do not  lose a s i g n i f i c a n t 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 i s the c r u c i a l determinant i n maintaining  acquired performance l e v e l .  a newly  Thus i t seems that, focusing on knowledge and  ignoring other forces i s an inappropriate response to correcting a decline i n performance.  Again, a lack of formal research r e l a t i n g to long term performance change i n 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 f o r the decline.  This study addressed those issues by t e s t i n g r e l a t i o n s h i p s among  changes i n driving and r e s t r a i n i n g forces and maintenance of a newly acquired performance l e v e l .  It was  hypothesized  that maintenance of record-  ing behaviour would be more c l o s e l y linked to the 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 for proper recording and the presence of performance standards change.  than to loss of knowledge and the presence of a motivation to Those r e l a t i o n s h i p s are schematically represented  i n Figure 6.  TO  m O  O  C  o  n  TO n  TO  m o  NEW  LEVEL  O F POR  < >  o  z  o !  * I—  m  O  m  —i m  oO  >*?  n  c CO ~D  Z""  oTO  TO ^  Co  m  TO  TO CO  o  TO >•  D > O Z  n  m  •SUBSEQUENT  <  > O  •  z  o  r— m  :DGE  m  z  n  m O  iOTI  o  z  CO  TO CO  A O  m  m  —  CO TO  TO  z Figure 6 Subsequent Change of Recording  Behaviour  LEVEL POR  OF  THE  This ship  VARIABLES AND  study was  THEIR MEASUREMENT  concerned w i t h change of behaviour and  to change of s e l e c t e d  organizational  and  personal forces.  of the change p r o c e s s were examined:, a c q u i s i t i o n of a new and  maintenance of t h a t new  the  f i r s t month f o l l o w i n g  Recording  (POR)  months.  The  and  performance.  the  The  This  to perform POR  section explains  task,  was  Problem O r i e n t e d  the v a r i a b l e s used to  investigate  changes i n  the  restraining forces.  dependent v a r i a b l e s , a c q u i s i t i o n and  b e h a v i o u r , and  eleven v a r i a b l e s associated  defined  i n the  following  Variables  maintenance of  behaviour.  behaviour.  O r i e n t e d Recording occupational  (POR)  and  therapists  The  new  The  c r i t i c a l and  recording  dependent  behaviour was  format used by PTs  i s entered i n t o the PT/OT s e c t i o n of the p a t i e n t - c a r e A c q u i s i t i o n of r e c o r d i n g  (PTs)  This  and  OTs  to  documentation  record.  behaviour r e f e r s to the change i n adherence  format observed b e f o r e and defined  Problem  (QTs).  document t h e i r day-by-day i n t e r a c t i o n s w i t h p a t i e n t s .  I t was  maintenance  the p a r t i c i p a n t s were p h y s i o t h e r a p i s t s  Recording behaviour r e f e r s to the  to POR  and  paragraphs.  of r e c o r d i n g  recording  to  r e i n f o r c e r s are d e s c r i b e d  v a r i a b l e s were performance change, namely the a c q u i s i t i o n and of a new  recording  w i t h knowledge, m o t i v a t i o n  change, performance s t a n d a r d s , r e s o u r c e s and  POR.  inservice  Variables Two  and  three  p r e s e n t e d i n an  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 d e s i g n a t e d d r i v i n g and  phases  a c q u i s i t i o n phase covered  i n t r o d u c t i o n of a new  knowledge r e q u i r e d  Two  performance  the maintenance phase covered the f o l l o w i n g  e d u c a t i o n program.  The  its relation-  immediately a f t e r the  as the r e g r e s s i o n  introduction  r e s i d u a l s c o r e o b t a i n e d from a  of :  50  random sample f o r each PT/OT p a r t i c i p a n t of f o u r of her p a t i e n t - c a r e r e c o r d s completed d u r i n g the month p r e c e d i n g  i n t r o d u c t i o n of POR  and  a different  set of f o u r r e c o r d s completed d u r i n g the month f o l l o w i n g i n t r o d u c t i o n of POR.  (An e x p l a n a t i o n of a r e g r e s s i o n r e s i d u a l s c o r e i s i n c l u d e d i n  Appendix  A.)  Maintenance of r e c o r d i n g r e f e r s to the change i n adherence to format observed  over  t h r e e months.  r e s i d u a l score obtained  I t was  d e f i n e d as the r e g r e s s i o n  from a random sample of f o u r r e c o r d s f o r each  PT/OT p a r t i c i p a n t completed d u r i n g the month immediately d u c t i o n of POR  and  behavior,  sub-divided  of changes i n r e c o r d i n g  i n t o the f o l l o w i n g f i v e  data base, problem f o c u s , treatment  documentation. of those  POR.  a more d e t a i l e d examination  the PT/OT r e c o r d was  components:  following intro-  a d i f f e r e n t s e t of r e c o r d s completed d u r i n g the f o u r t h  month f o l l o w i n g i n t r o d u c t i o n of To permit  POR  plan, follow-up  An a c q u i s i t i o n and maintenance s c o r e was  and  obtained  f o r each  components.  Knowledge v a r i a b l e s . possessed  Knowledge r e f e r s to the f a c t u a l knowledge  by the p a r t i c i p a n t s c o n c e r n i n g  procedure and  format.  c a t e g o r i e s , g e n e r a l and  recording p o l i c i e s ,  Knowledge about r e c o r d - k e e p i n g specific.  The  falls  into  terms and  Each knowledge v a r i a b l e was of g e n e r a l  and  knowledge.  A c q u i s i t i o n was  contains  f u n c t i o n s of  k i n d of p a t i e n t - c a r e r e c o r d i n g , w h i l e the s p e c i f i c c a t e g o r y  of knowledge were i n c l u d e d i n t h i s  two  g e n e r a l knowledge c a t e g o r y  i n f o r m a t i o n d e a l i n g w i t h the p r i n c i p l e s , p o l i c i e s and  mation r e l a t i n g to the format,  principles,  any  contains  a p p l i c a t i o n of POR.  Both  infor-  types  investigation. a change v a r i a b l e , namely a c q u i s i t i o n  s p e c i f i c knowledge, and  r e t e n t i o n of g e n e r a l and  the change observed  b e f o r e and  specific  one month a f t e r  51 the i n s e r v i c e program.  I t was  d e f i n e d as the r e g r e s s i o n r e s i d u a l  score  o b t a i n e d from p r e t e s t v e r s u s p o s t t e s t measures taken at the b e g i n n i n g of the i n s e r v i c e program and change observed  f o u r weeks post-program.  over t h r e e months.  I t was  R e t e n t i o n was  the  d e f i n e d as the r e g r e s s i o n  r e s i d u a l s c o r e o b t a i n e d from p o s t t e s t v e r s u s delayed p o s t t e s t measures taken f o u r weeks post-program and 18 weeks post-program. Motivation variables.  M o t i v a t i o n to change r e f e r s to the  i n d i v i d u a l ' s p e r c e p t i o n s of the need f o r change and on the new  performance.  v a r i a b l e s concerned  the importance  The m o t i v a t i o n to change v a r i a b l e s , and  the t h r e e  w i t h s i t u a t i o n a l f a c t o r s which f o l l o w , are d e f i n e d  d i f f e r e n t l y from the p r e c e d i n g v a r i a b l e s i n t h a t they a r e concerned p a r t i c i p a n t s ' p e r c e p t i o n s of t h i n g s and on o b s e r v a b l e  placed  events, whereas the former  with are  based  events.  Four v a r i a b l e s r e p r e s e n t i n g d i f f e r e n t a s p e c t s of m o t i v a t i o n to change were used.  Two,  labelled  "gap"  and  "leeway," were concerned  perceived discrepancies i n record-keeping, a t h i r d , l a b e l l e d r e f e r r e d to the p e r c e i v e d importance " i d e a l " r e c o r d , and a f o u r t h one,  with  "importance,"  a t t a c h e d to the o b j e c t i v e s of an  "impetus,"  was  a combination  of gap  and  importance. Those f o u r v a r i a b l e s were d e f i n e d as f o l l o w s :  gap was  c e i v e d d i f f e r e n c e between the p r e s e n t r e c o r d i n g system and how leeway was  i t should  be;  the p e r c e i v e d estimated d i s c r e p a n c y between p r e v i o u s r e c o r d -  keeping p r a c t i c e s i n the PT/OT department and was  the p e r -  the p e r c e i v e d importance  to change generated  expected  of an " i d e a l " r e c o r d ; and  by the combined e f f e c t s of gap and  Performance s t a n d a r d s .  practices;  importance  impetus was  a need  importance.  Performance standards a r e the w r i t t e n g u i d e -  l i n e s d e s c r i b i n g c r i t e r i a and requirements  for correct  record-keeping.  In t h i s study, was  the performance standards  distributed  i n a manual which  to each t h e r a p i s t d u r i n g the i n s e r v i c e program.  performance standards therapist perceived  v a r i a b l e was  d e f i n e d as the extent  the p o l i c i e s and  c l e a r l y defined, r e a l i s t i c v a r i a b l e was  were c o n t a i n e d  and  to which a  procedures f o r r e c o r d - k e e p i n g  understandable.  the change i n p e r c e p t i o n s  subsequent change was  The  to  be  I n i t i a l change i n t h i s  d u r i n g the a c q u i s i t i o n of POR  and  the change i n p e r c e p t i o n s d u r i n g the maintenance  phase. Resources• form the new  Resources a r e the m a t e r i a l s and  task.  The  r e s o u r c e s v a r i a b l e was  which a t h e r a p i s t p e r c e i v e d r e s o u r c e s available.  I n i t i a l and  i n perceptions  time a v a i l a b l e to  d e f i n e d as the e x t e n t  f o r proper  record-keeping  to  be  subsequent changes i n r e s o u r c e s were the changes  d u r i n g 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.  R e i n f o r c e r s a r e 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 r e c o r d i n the r e q u i r e d format. v a r i a b l e was  to  per-  d e f i n e d as the extent  f o r c e r s f o r proper  The r e i n f o r c e r s  to which a t h e r a p i s t p e r c e i v e d  r e c o r d i n g to be p r e s e n t .  I n i t i a l and  rein-  subsequent changes  i n r e i n f o r c e r s were the changes d u r i n g 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 V a r i a b l e s The  s i x major s e t s of v a r i a b l e s , that i s , r e c o r d i n g  knowledge, m o t i v a t i o n  to change, performance s t a n d a r d s ,  r e i n f o r c e r s , were measured by f o u r s p e c i a l l y c o n s t r u c t e d A d e t a i l e d d e s c r i p t i o n of those presented  i n Chapter 4 .  measured on those Recording  instruments  and  behaviour,  resources  and  instruments.  t h e i r development i s  T h i s s u b - s e c t i o n d e s c r i b e s how  each v a r i a b l e  was  instruments. behaviour was  measured on the Format A u d i t Review Sheet  53 (FRAS), a 23-item, p r e s e n t or absent c h e c k - l i s t which p r o v i d e d measures f o r each of f i v e components of the PT/OT r e c o r d and a composite measure f o r the whole PT/OT r e c o r d .  A r e c o r d i n g behaviour s c o r e was  o b t a i n e d by summing  the number of items p r e s e n t i n f o u r r e c o r d s randomly  s e l e c t e d from a l l  r e c o r d s completed by each t h e r a p i s t over a s p e c i f i e d  time p e r i o d .  procedure was  c a r r i e d out on t h r e e d i f f e r e n t o c c a s i o n s to o b t a i n  t i o n and maintenance  This acquisi-  r e c o r d i n g behaviour s c o r e s f o r 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 t e s t c o n t a i n i n g 20 items grouped 13 q u e s t i o n s ; 10 items r e l a t e d to s p e c i f i c POR  knowledge.  into  to g e n e r a l r e c o r d i n g knowledge and 10  The s c o r i n g system was  items  two p o i n t s f o r a w h o l l y  c o r r e c t answer, one p o i n t f o r a p a r t i a l l y c o r r e c t answer and zero f o r an i n c o r r e c t or o m i t t e d answer.  A s c o r e f o r s p e c i f i c and g e n e r a l knowledge  o b t a i n e d by summing the p o i n t s f o r each subset of items.  was  The CRKI was  a d m i n i s t e r e d t h r e e times to o b t a i n s c o r e s f o r a c q u i s i t i o n and r e t e n t i o n of both types of knowledge. The f o u r m o t i v a t i o n to change v a r i a b l e s were measured on the Recordi n g Needs Survey scale.  The RNS  (RNS), an instrument w i t h a 6 - p o i n t , L i k e r t - t y p e c o n s i s t e d of two  response  s e t s o f items; one s e t measured leeway  the o t h e r measured gap and importance.  The f o u r t h v a r i a b l e , impetus, was  h y p o t h e t i c a l c o n s t r u c t d e r i v e d from gap and importance.  Gap was  P a r t i c i p a n t s i n d i c a t e d how  time and how responses.  t r u e each statement was  t r u e i t should be; gap was Importance  the " i d e a l " r e c o r d .  was  "ideal"  at the p r e s e n t  the d i f f e r e n c e between those  the summed responses to seven statements  Leeway was  a  calculated  from responses g i v e n to seven statements d e s c r i b i n g the o b j e c t s of an record.  and  the d i f f e r e n c e between two e s t i m a t e s  two describing  54 of record-keeping effectiveness:  (1) the percentage of records i n a  department that the s t a f f f e l t a c t u a l l y contained a factual record of patient-care, and  (2) the percentage of records that could be reasonably  expected to contain this information. vector of gap and importance.  Impetus was a resultant Euclidean  The derivation of t h i s vector i s shown i n  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. placed throughout the instrument.  Items for each variable were randomly  The ROS was administered three times to  obtain measures of change i n 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 c l e a r l y defined.  IMPORTANCE (Response Scale Units)  Figure 7 Derivation of Impetus Variable  55 The s c o r e was score  obtained  indicated The  ROS. high  resources  A  by  resources  contained  hypotheses  this  by  of  to  proposed  standards, to  and  reinforcers  resources  and  conceptual  subset  those  being  high  available. on  the  items.  A  present.  the  general  f r a m e w o r k and  more c l o s e l y presence  f o r proper linked  reinforcers  They were:  linked  of  present  the  acquisition  to motivation  r e c o r d i n g ; and to the  than  (1)  to  performance standards  presence  to l o s s  the  purposes  of  statistical  testing  than  (2) m a i n t e n a n c e of  of  performance  o f k n o w l e d g e and  the  re-cast  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 ,  grouped  into  which  account  f o r most  containing  adding The  follows:  a primary  subset  change i n the  the v a r i a b l e s  relationship by  A  motiva-  change. For  for  to  resources  investigation.  i n c r e a s e i n k n o w l e d g e and  r e c o r d i n g w o u l d be more c l o s e l y  tion  the  were f o r m u l a t e d .  w o u l d be  items.  14-item  responses  a  HYPOTHESES  for  general hypotheses  resources  the  a  and  readily  were p e r c e i v e d as  w h i c h were drawn f r o m  recording behaviour  change,  being  measured by  summing  reinforcers  those  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  research hypotheses Two  to  were p e r c e i v e d as  THE  At  eight items,  the responses  v a r i a b l e was  obtained  indicated  also  summing  reinforcers  s c o r e was  score  subset  the  secondary  two  the v a r i a b l e s  to account  s e t s was  and  for least  expressed  as  a  were expected  secondary  change.  were  to  subset  The  the v a r i a n c e  accounted  subset.  r e s e a r c h hypotheses (1) t h e  the v a r i a b l e s  dependent v a r i a b l e ,  expected  between these  c o n s i s t e d of  general 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  additional variance in acquisition  of  recording  as  behaviour  56 accounted  f o r by resources  significantly ledge,  change  accounted  (secondary  accounted  subset)  (primary  an a l p h a  hypotheses  subset)  would n o t  f o r b y i n c r e a s e i n know-  o f performance  standards  (primary  i n maintenance o f r e c o r d i n g  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 t o would n o t s i g n i f i c a n t l y  f o rby t h e presence  reinforcers with  t o change and presence  and (2) t h e a d d i t i o n a l v a r i a n c e  behaviour  (secondary  i n c r e a s e the v a r i a n c e accounted  motivation  subset);  and r e i n f o r c e r s  level  of performance  subset). equal  standards,  Each h y p o t h e s i s  t o .05.  i s i n c l u d e d i n Appendix  increase the variance  The f o r m u l a  r e s o u r c e s and  was t e s t e d f o r s i g n i f i c a n c e used  f o rtesting the  B.  PROCEDURES  This of  the study  analysis The  section describes the setting, and d a t a  with  a description  of the  S e t t i n g and P a r t i c i p a n t s study  occupational Greater  was c o n d u c t e d  therapy  Vancouver  methods b e f o r e  i n four physiotherapy  (OT) d e p a r t m e n t s  area.  ( P T ) a n d two  located i n four hospitals i n the  A l l departments were u s i n g  the project started.  traditional  In each department  recording  the supervisor of  a n d OT h a d 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 a n d made t h e d e c i s i o n t o  replace her existing Permission care  r e c o r d i n g methods w i t h  to carry out the study,  r e c o r d s , was g r a n t e d  of Approval  f o rResearch  by each h o s p i t a l  British  Columbia.  POR. which  i n c l u d e d examining p a t i e n t -  a d m i n i s t r a t o r , and a  I n v o l v i n g Human S u b j e c t s . w a s  investigator by the Behavioural of  I t concludes  t h e phases  of data.  The  PT  collection.  the participants,  Sciences  Screening  Certificate  issued to the  Committee, U n i v e r s i t y  57 Sixty-two  therapists participated  t h e r a p i s t s and 51 were p h y s i o t h e r a p i s t s .  i n the study; 11 were o c c u p a t i o n a l T h i s sample i s a p p r o x i m a t e l y  5% of the PT and OT p o p u l a t i o n of B r i t i s h Columbia. t h e r e were two males, both p h y s i o t h e r a p i s t s .  W i t h i n the sample  D i s t r i b u t i o n of t h e r a p i s t s  by h o s p i t a l and department i s shown i n T a b l e 4. With the e x c e p t i o n of t h r e e persons, permanent f u l l - t i m e b a s i s .  a l l s t a f f were employed on a  The e x c e p t i o n s were t h r e e r e l i e f '  were working f u l l - t i m e s h i f t s throughout  staff  who  the d u r a t i o n of the p r o j e c t .  P a r t - t i m e employees, c a s u a l r e l i e f , s t a f f and t h e r a p i s t s a s s i g n e d to Extended Care U n i t s reasons.  (ECU) were not i n c l u d e d i n the sample f o r the f o l l o w i n g P a r t - t i m e and r e l i e f  employment d i d not extend  s t a f f were excluded  throughout  i n c l u d e d because the r e c o r d s kept  because t h e i r terms of  the e n t i r e study.  ECU s t a f f were not  i n those u n i t s were not compatible  the r e c o r d i n g system d e v i s e d f o r the r e g u l a r PT and OT departments.  Table 4 L o c a t i o n of P a r t i c i p a n t s  Physiotherapists  Hospital  Burnaby General  Occupational Therapists  7  0  Shaughnessy  12  4  St. P a u l ' s  16  0  L i o n s Gate  L6  _7_  51  11  TOTAL  with  58 The m a j o r i t y of the p a r t i c i p a n t s had r e c e i v e d t h e i r  professional  e d u c a t i o n i n e i t h e r Canada (40%) or the U n i t e d Kingdom (42%) . remainder  had graduated  from PT or OT e d u c a t i o n a l programs i n I n d i a ,  Zealand, A u s t r a l i a , Europe and the U n i t e d S t a t e s .  The average l e n g t h of time s i n c e g r a d u a t i o n was s t a n d a r d d e v i a t i o n of 8.1  years.  New  The d i s t r i b u t i o n of  t h e r a p i s t s by c o u n t r y of g r a d u a t i o n i s shown i n T a b l e  5. 10 y e a r s w i t h a  I n s p e c t i o n of the d a t a i n T a b l e 6 shows  t h i s mean v a l u e does not r e f l e c t the average  t h e r a p i s t i n the sample as  j u s t over h a l f of them (32) had been graduated median v a l u e o f 8.2  The  l e s s than 10 y e a r s .  y e a r s conveys a more r e a l i s t i c p i c t u r e of the  A typical  participant.  Table 5 D i s t r i b u t i o n of T h e r a p i s t s by Country  Country of Graduation  Number of Therapists  of G r a d u a t i o n  Relative frequency (%)  Cummulative frequency (%)  U n i t e d Kingdom  26  41.9  41.9  Canada  25  40.3  82.3  India  7  8.1  90.4  Europe  2  3.2  93.6  New  2  3.2  96.8  Australia  1  1.6  98.4  United States  1  1.6  100.0  62  100.0  100.0  Zealand  TOTAL  59 Table  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 Number o f Y e a r s S i n c e G r a d u a t i o n  Years s i n c e Graduation  Number  of  to  Relative  Therapists  frequency  Cummulative frequency (%)  (%)  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  4  6.4  100.00  25  o r more  Note:  The  Mean = 10.03  amount o f  time  y e a r s , m e d i a n = 8.2  participants  h o s p i t a l was  unevenly  distributed  half  them  (34)  had  been  months; o n l y  five  of  the  and  OT  departments  five  of  through  in their  staff  had  (8%)  worked  in their  a range of  present had  years.  one  department  worked  i n the  present  t o 16  years.  for less  than  same p l a c e  for  Over 18 over  years. All  inpatient treating  PT  services.  outpatients while  supervisors Phases  Eleven  of The  d i d not  the  Study  i n the  study  t h e r a p i s t s spent 48  worked m a i n l y  o f f e r e d both the m a j o r i t y  with  outpatient of  inpatients.  their  and  Data  Collection  investigationwas-alongitudinal,analytical  study  time  Three of  treat patients.  using  and  the  60 individual pre-,  P T s a n d OTs a s t h e u n i t  one month p o s t -  Three dimensions,  and t h r e e months d e l a y e d  a t each of those  measured  i n the p r e - t e s t stage inservice  dealing with procedures format  provided  initial  conference  attempt  pation  was  POR  a suitable  twofold:  collection collected  hours.  concepts  on f o u r  held  The s t u d y i n time  data,  performance standards,  resources  and  i n an  single  instructor partici-  Didactic of  POR. a onefollow-up thera-  i n the interpretation of given  at this  over  time.  6 1/2 m o n t h s w i t h  characteristics,  and p a r t i c i p a n t s ' reinforcers.  A  third  later.  a s c a n b e s e e n i n F i g u r e 8.  and  sessions  were h e l d i n  (2) t o a l l o w  t h r e e months  extended  socio-demographic  knowledge, r e c o r d i n g behaviour,  one-hour  to allow active  and p r i n c i p l e s  to discuss d i f f i c u l t i e s  points  specific  i n each h o s p i t a l A  program  study.  The purpose o f t h i s  post-program  t h e same p u r p o s e was  at three  was  and  intensive learning experience  i n each h o s p i t a l .  collection.  Sessions  designed  No new m a t e r i a l o r f e e d b a c k was  session with Data  component o f t h e  d i s c u s s i o n and p r a c t i c e .  following this  an opportunity  format.  s u p e r v i s o r s and t h e  T h e p r o g r a m was  (1) t o c o l l e c t  education  the p o l i c i e s  l e a r n i n g environment.  to present  held  inservice  consisted of five,  days d u r i n g working  used  s e s s i o n was  pists  An  of recording, including  of the l e a r n e r s through  One m o n t h hour  program.  the i n s t r u c t i o n a l  a l l sessions.  i n s t r u c t i o n was  p o s t t e s t i n g paradigm.  The m o t i v a t i o n a l d i m e n s i o n  rooms o r s m a l l a u d i t o r i u m s  to provide  conducted  included a  only.  learning experience  on c o n s e c u t i v e  either  stages.  e s t a b l i s h e d by t h e department  The held  three  education  a l l aspects  o f POR,  The d e s i g n  p e r f o r m a n c e , knowledge and t a s k - r e l a t e d f o r c e s were  measured  The  of analysis.  motivation  perceptions of  data  Data  were  to change,  61  DATA COLLECTION Motivation Knowledge Resources Reinforcers Standards  DATA COLLECTION Knowledge Resources Reinforcers Standards  INSERVICE  PROGRAM;  I  Record Audit  0  1  2  3  J  If  Record  |T^udit  4  5  6  8  7  9  I  10  I  Record  11 21 2 2 2 3 2 4 2 5 2 6  W e e k f r o m b e g i n n i n g o f s t u d y in. e a c h h o s p i t a l  Figure 8 Data C o l l e c t i o n Socio-demographic information, including country of graduation, length of time since graduation, time employed i n present h o s p i t a l and type of patient s e r v i c e (inpatient or outpatient) was obtained from each participant at the beginning of the study. Data on four v a r i a b l e s representing d i f f e r e n t aspects of motivat i o n to change were c o l l e c t e d on the RNS.  Therapists completed the RNS at  the end of the introductory l e c t u r e on record-keeping. Knowledge data, both general and s p e c i f i c , were c o l l e c t e d on the CRKI.  This test was administered three times:  (1) at the beginning of  the inservice program (baseline), (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. Data on recording behaviour, including the f i v e components of POR format, were c o l l e c t e d from three administrations of the FRAS.  The  DATA COLLECTION Motivation  Knowledge Resources  Reinforcers  Standards  INSERVICE  PROGRAM  DATA COLLECTION Knowledge Resources Reinforcers Standards  11 21 2 2 2 3 24 25 2 6 W e e k f r o m b e g i n n i n g o f s t u d y in e a c h h o s p i t a l  Figure 8 Data C o l l e c t i o n Socio-demographic information, including country of graduation, length of time since graduation, time employed i n 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 d i f f e r e n t aspects of motivat i o n 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 s p e c i f i c , were collected on the CRKI.  This test was administered three times:  (1) at the beginning of  the inservice program (baseline), (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. Data on recording behaviour, including the f i v e components of POR format, were collected from three administrations of the FRAS.  The  procedure charged  used to c o l l e c t  i n f o r m a t i o n was as f o l l o w s .  A l l patients dis-  d u r i n g t h e month p r e c e d i n g t h e i n t r o d u c t i o n of POR who had been  t r e a t e d f o r t h r e e or more days were l i s t e d lists).  From each l i s t ,  according to t h e r a p i s t  f o u r p a t i e n t - c a r e r e c o r d s were randomly s e l e c t e d ,  o b t a i n e d from the M e d i c a l Records department and a u d i t e d . was r e p e a t e d  f o r a l l p a t i e n t s admitted  weeks immediately  (62  This  process  and d i s c h a r g e d d u r i n g t h e s i x  f o l l o w i n g the i n t r o d u c t i o n of POR, and a g a i n f o r a s i x  week p e r i o d b e g i n n i n g  f o u r months a f t e r i t s i n t r o d u c t i o n .  Data on 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 were c o l l e c t e d on the ROS. on t h r e e o c c a s i o n s :  T h i s instrument was a d m i n i s t e r e d (1) a t the b e g i n n i n g  to p a r t i c i p a n t s  of the i n s e r v i c e program, (2)  one month l a t e r , and (3) a f t e r a f u r t h e r i n t e r v a l of t h r e e months. The A n a l y s i s of Data The data were a n a l y s e d on the IBM 360 computer a t the U n i v e r s i t y of B r i t i s h Columbia u s i n g t h e S t a t i s t i c a l Package f o r t h e S o c i a l (SPSS) program ( N i e , H u l l , J e n k i n s , S t e i n b r e n n e r  & Bent, 1975).  Demographic data were a n a l y s e d by p r e p a r i n g one-way 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 The mean, standards  Sciences  frequency  statistics.  d e v i a t i o n and range were c a l c u l a t e d f o r a l l  s c o r e s on the RNS, ROS, CRKI and FRAS.  The s i g n i f i c a n c e of the g a i n , i n  both knowledge and r e c o r d i n g behaviour,  between b a s e l i n e and one month,  and  the s i g n i f i c a n c e o f the l o s s between one and f o u r months, were  determined  by t - t e s t s f o r p a i r e d c o r r e l a t i o n s  ( G u i l f o r d , 1965, p. 177).  An a l p h a l e v e l equal to .05 was used t o t e s t f o r s i g n i f i c a n c e . P e a r s o n i a n c o r r e l a t i o n s were c a l c u l a t e d f o r each subset of items on t h e 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 o f  items on the RNS and FRAS were used t o determine the degree of o v e r l a p  between the  subsets.  Multiple ships  regression  between r e c o r d i n g  independent v a r i a b l e s .  behaviour In  diction  equation,  (1)  r e l a t i v e strength  the  variance  i n the  (coefficient the  variation  variable  of  the  hypotheses.  A  addition  regression of  i n the  general  used  to  to  investigate  calculating  relationship,  (3)  explained the  dependent v a r i a b l e , regression  the  (dependent v a r i a b l e )  program p r o v i d e d  the  determination),  was  change  dependent v a r i a b l e  (standardized  weights).  analysis  by  the  statistics  (2)  the  the  contribution and  (4)  the  coefficients also  hierarchical regression  best  relation-  and  the  linear that  proportion  independent of  indicated of  variables  each v a r i a b l e  influence referred  e q u a t i o n was  pre-  to  used  of as to  to  each beta test  the  Chapter  4  INSTRUMENT DEVELOPMENT  T h i s study i n v e s t i g a t e d 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 r e c o r d i n g behaviour among p h y s i c a l and o c c u p a t i o n a l therapists, practices,  (2) the i n d i v i d u a l ' s m o t i v a t i o n to change h i s r e c o r d - k e e p i n g (3) a c q u i s i t i o n and r e t e n t i o n of new  knowledge about POR  g e n e r a l p o l i c i e s and procedures f o r r e c o r d i n g , and related factors.  and  (4) s e l e c t e d t a s k -  T h i s c h a p t e r d e s c r i b e s the development of the i n s t r u m e n t s  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 r e c o r d a u d i t i s the method most f r e q u e n t l y used t o monitor recording behaviour i n h e a l t h - c a r e agencies. r e l a t i v e l y new  Auditing records i s a  a c t i v i t y f o r t h e r a p i s t s , c o n s e q u e n t l y o n l y a s m a l l number  of a u d i t forms are i n use. v a r i o u s sources but none was  A s e l e c t i o n of a u d i t forms was  collected  w h o l l y s u i t a b l e f o r t h i s study as they  t a i n e d items which were not r e l e v a n t or items which r e q u i r e d interpretation. A u d i t Sheet  con-  subjective  Because of the l a c k of a s u i t a b l e form, a Format Review  (FRAS) was  developed.  (1) the FRAS s h o u l d r e f l e c t  Three p r i n c i p l e s guided i t s c o n s t r u c t i o n :  the concepts of POR  a s s o c i a t e d w i t h d a t a base, problem  list,  (2) a l l items must be o b j e c t i v e , and format s p e c i f i e d  from  by i n c l u d i n g  items  treatment p l a n and p r o g r e s s n o t e s ,  (3) the items should p a r a l l e l  the  i n the departmental p o l i c y f o r r e c o r d - k e e p i n g .  The i n i t i a l v e r s i o n of the FRAS was 64  developed and  t e s t e d at the  U n i v e r s i t y H o s p i t a l , London, O n t a r i o , where i t was used t o a u d i t over 100 r e c o r d s d u r i n g a 15-month p e r i o d .  A t the end of t h i s t e s t i n g , the a u d i t  form was judged t o a c c u r a t e l y r e f l e c t an i n d i v i d u a l ' s adherence  t o POR  format by the C h i e f of P h y s i o t h e r a p y S e r v i c e s . The FRAS used i n the p r e s e n t study c o n t a i n s 23 items d i v i d e d f i v e components.  The components a r e :  (3) treatment p l a n ,  (1) d a t a base,  (2) problem f o c u s ,  (4) f o l l o w - u p , and (5) documentation.  of items i n those components i s o u t l i n e d on a p r e s e n t or absent s c a l e .  i n T a b l e 7.  into  The d i s t r i b u t i o n  The FRAS i s scored  A sample of the FRAS i s i n c l u d e d i n  Appendix C.  CLINICAL RECORD-KEEPING INVENTORY  The t h e r a p i s t s ' knowledge o f r e c o r d i n g procedures and POR format was measured by t h e C l i n i c a l Record-Keeping pencil r e c a l l test.  I n v e n t o r y (CRKI), a paper and  As a s u i t a b l e t e s t d i d not p r e v i o u s l y e x i s t , a s e r i e s  of q u e s t i o n s was'~ c o n s t r u c t e d and p i l o t - t e s t e d . from t h r e e s o u r c e s : each department,  T e s t items were generated  (1) t h e procedure manual f o r r e c o r d - k e e p i n g adopted by  (2) g u i d e l i n e s f o r treatment and p r o g r e s s n o t e s i s s u e d by  the Canadian P h y s i o t h e r a p y A s s o c i a t i o n patient-care plans s p e c i f i e d  (1976), and (3) s t a n d a r d s f o r  i n the R e h a b i l i t a t i o n S e r v i c e s s e c t i o n of the  Canadian C o u n c i l H o s p i t a l A c c r e d i t a t i o n Manual (1977). generated f o r the p i l o t  F i f t e e n items were  t e s t , e i g h t r e l a t i n g t o g e n e r a l knowledge of  r e c o r d i n g p o l i c i e s and p r o c e d u r e s , and seven r e l a t i n g t o POR format. The CRKI underwent two s e p a r a t e p i l o t i t was a d m i n i s t e r e d t o a group a U n i v e r s i t y c r e d i t course.  of 19 q u a l i f i e d  tests.  On the f i r s t o c c a s i o n  t h e r a p i s t s who were a t t e n d i n g  T h i s group completed  the t e s t t w i c e , w i t h one  week between t e s t s , and r e c e i v e d no i n s t r u c t i o n about r e c o r d - k e e p i n g .  Table 7 Format Review A u d i t Sheet Components and Items  Component  Data Base  Item  Possible score  Medical history Social history Physical findings P r o j e c t e d treatment  16  T o t a l Data Base Problem Focus  Problem l i s t w i t h : a) c o r r e c t problem t i t l e s b) a l l problems numbered Problem n u m b e r / t i t l e f o r : a) each treatment p l a n b) each p r o g r e s s Treatment p l a n f o r each problem  Treatment Plan  Followup  T o t a l Problem Focus  20  T o t a l Treatment  12  Frequency of treatment D u r a t i o n of p l a n Expected response Plan  POR format (S.O.A.P.) used: a) i n one p r o g r e s s note b) i n a l l p r o g r e s s notes D i s c h a r g e summary  Documentation  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 a) assessment sheet b) a l l s h e e t s  T o t a l Follow-up  12  T o t a l Documentation  32  on:  A l l entries: a) signed i n f u l l b) dated c) l e g i b l e  The mean s c o r e s (18.22 and  18.23) and  standard d e v i a t i o n s (7.93  showed v i r t u a l l y no change between the two f o r the t o t a l t e s t was  tests.  f o r the second The  .90, w i t h i n d i v i d u a l items r a n g i n g from .39  second p i l o t  t e s t of the CRKI was  twice t o a new  s t u d e n t s who  attended  two,  to 3.88.  probability.  The  test  It  and  to 37.04 and  The CRKI was  gain score  was  Data from both p i l o t  standard  was  o c c u p a t i o n a l therapy  two-hour l e c t u r e s on r e c o r d i n g procedures  a f t e r the l e c t u r e s which were spaced  s c o r e s r o s e from 16.36 5.80  1.00.  done t o determine i t s  group of 25 p h y s i c a l and  as p a r t of t h e i r course work.  immediately  f o r the i n i t i a l  changes i n knowledge f o l l o w i n g i n s t r u c t i o n .  administered  format  to  test.  s e n s i t i v i t y to r e f l e c t  POR  7.92)  Test-retest r e l i a b i l i t y  C o e f f i c i e n t a l p h a measures of r e l i a b i l i t y were .79 .80  and  given before  one week a p a r t .  t e s t s are presented  and  Mean  d e v i a t i o n s decreased  s i g n i f i c a n t a t the .001  and  from  l e v e l of  i n Table  8.  Table 8 Means and Standard D e v i a t i o n s f o r the C l i n i c a l Record-Keeping Inventory ( P i l o t T e s t )  Pretest  Posttest  Group  Mean  S.D.  Mean  S.D.  t  Instruction (n = 25)  16.36  5.80  37.04  3.83  3.88  No I n s t r u c t i o n (n = 19)  18.22  7.93  18.83  7.92  .61  Note:  1965,  p.  t-test 184).  Maximum p o s s i b l e s c o r e =  a  .05  h  .001  .50  44.  f o r d i f f e r e n c e s between c o r r e l a t e d p a i r s of means  t - p r o b a b i l i t y of d i f f e r e n t from chance.  t-prob  or l e s s r e p r e s e n t s a g a i n  (Guilford,  significantly  68 1.  Two methods a r e p r e s e n t l y used t o c o l l e c t and o r g a n i z e i n f o r m a t i o n i n the m e d i c a l r e c o r d : a) Name both methods. b) B r i e f l y d e s c r i b e t h e main d i f f e r e n c e between the two methods.  2.  S t a t e t h e primary f u n c t i o n o f a m e d i c a l  3.  The i n f o r m a t i o n accumulated i n m e d i c a l r e c o r d s can be used by h e a l t h care p r o f e s s i o n a l s f o r a c t i v i t i e s other than d i r e c t p a t i e n t - c a r e : S t a t e two a c t i v i t i e s .  4.  The Canadian H o s p i t a l 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 f o r a PT/OT p a t i e n t - c a r e p l a n : a) L i s t t h r e e components of a c u r r e n t c a r e p l a n . b) L i s t t h r e e a d d i t i o n a l components which the Manual expects t o be i n the completed r e c o r d .  5.  S t a t e t h e primary l e g a l requirement which must appear i n e i t h e r t h e m e d i c a l r e c o r d o r the P o l i c i e s and Procedures Manual f o r a l l p a t i e n t s r e c e i v i n g physiotherapy.  6.  When an i n - p a t i e n t i s r e c e i v i n g PT/OT s e r v i c e s where must t h e t h e r a p i s t ' s r e c o r d of treatment be kept?  7.  S t a t e t h e c o r r e c t sequence of the f o u r b a s i c components of Problem Oriented Recording.  8.  L i s t f o u r types o f i n f o r m a t i o n t h a t must be i n c l u d e d i n an i n i t i a l d a t a base (as s p e c i f i e d i n t h e p o l i c y manual of t h i s department).  9.  Problem O r i e n t e d Recording uses a unique format f o r w r i t i n g p r o g r e s s notes: a) L i s t t h e elements of a p r o g r e s s note i n t h e i r c o r r e c t sequence. b) S t a t e t h e type o f i n f o r m a t i o n entered i n each element.  record  (exclude  legal use).  10.  L i s t f o u r types of i n f o r m a t i o n t h a t must be i n c l u d e d i n a treatment p l a n (as s p e c i f i e d i n t h e 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 a p p r o p r i a t e 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: must be  13.  Many h o s p i t a l s have i n s t i t u t e d a procedure f o r m o n i t o r i n g records: a) Name t h e procedure. b) D e f i n e t h i s procedure.  Every PT/OT e n t r y i n the m e d i c a l  Figure 9 C l i n i c a l Record-Keeping Inventory  Items  record  medical  69 A number of r e v i s i o n s were made f o l l o w i n g the p i l o t  tests.  One  item w i t h low r e l i a b i l i t y was d i s c a r d e d and a second item was removed as i t was c o r r e c t l y answered by a l l s u b j e c t s on the p r e t e s t , i t was, t h e r e fore, considered  t o be n o n - d i s c r i m i n a t i n g .  Minor r e v i s i o n s i n wording were  made t o reduce ambiguity. The  CRKI used i n t h i s study  ( F i g u r e 9) c o n t a i n e d  13 q u e s t i o n s ,  r e l a t i n g t o g e n e r a l knowledge o f r e c o r d i n g p o l i c i e s and procedures,  seven  and s i x  r e l a t i n g t o s p e c i f i c knowledge o f POR format.  RECORDING NEEDS SURVEY  The Recording  Needs Survey (RNS) i s designed  of the t h e r a p i s t s ' m o t i v a t i o n The  first  t o change.  t o measure f o u r f a c e t s  I t c o n s i s t s o f two s e t s of items.  s e t , d i s p l a y e d i n F i g u r e 10, c o n t a i n s 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 r e c o r d i s a f a c t u a l j o u r n a l of the c u r r e n t s t a t e of the p a t i e n t .  2.  The PT/OT r e c o r d a c t s as an important communication d e v i c e t o other members of the p a t i e n t - c a r e team.  3.  T h e r a p i s t s use PT/OT r e c o r d s t o i d e n t i f y gaps i n t h e i r knowledge.  4.  The PT/OT 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 and 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 and implementing treatment.  5.  The PT/OT 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 and r e s e a r c h .  6.  The PT/OT 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 standards of p a t i e n t c a r e .  7.  The PT/OT r e c o r d p r o v i d e s of p a t i e n t c a r e .  an index  of the q u a l i t y  F i g u r e 10 Recording  studies  Needs Survey Items  70 The true  e a c h one  important scale, true  recording  to  need.  be  "never  important"  the  larger  rationale w e l l as  another  being  attribute;  acceptable The  another  Figure  11  identify  second  practices.  The  two  three  rating  t r u e from An  i t u s e s an to reduce  to  6-point,  need  scale, the  on  this  potential items  the  f o r change.  are  and  This  measure of need  rating  the  is  from  "never  scale.  perceived i s the  how  gap  in  larger  the  i s consistent concept  in this from  of  manner  two  direct  subjects giving  the  ( P o r t e r , 1962).  to  characteristics  to change. aspect the  to  a functional  of  how  monotonic  importance  assumption  possibility  be,  ranging  i s t r u e the  a priori  indirect  answer  times:  should  c o n c e p t u a l l y sound, m e a s u r i n g needs  p o r t i o n of  a perceived  A  b y Leagans ( 1 9 6 4 ) t o b u i l d  "right"  data  RNS  t r u e e a c h one  i s attached  perceived  of m o t i v a t i o n  provide  the  "always t r u e " i s attached  similar  be  importance attached  facet  The  the  used  answers which p u r p o r t s  is  a  how  on  personally.  t r u e " to  practices i s obtained.  As  socially  time,  true scales;  "always  statement  i s t o him  s u b t r a c t i n g should  difference, the  from  should  By  with  statement  ranging  and  r a t e s each  jis at the present  each  important"  has  therapist  Responses  of m o t i v a t i o n  RNS  contains  discrepancy s t a t e d as  two  of to to  an  "ideal"  the  items  record shown i n  change.  items  i n departmental  designed  to  recording  follows:  (1) F r o m y o u r own v a n t a g e p o i n t i n y o u r d e p a r t m e n t p l e a s e e s t i m a t e , f r o m t h e p a s t y e a r , t h e p e r c e n t a g e o f 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 care given to the p a t i e n t . (2) Now e s t i m a t e t h e p e r c e n t a g e o f 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 e x p e c t e d t o be a f a c t u a l r e c o r d o f t h e c a r e g i v e n the p a t i e n t . The  d i f f e r e n c e between those  crepancy  or A  two  "leeway" i n r e c o r d i n g critically  interesting  estimates  to  i s a measure of p e r c e i v e d  practices. question  i s to determine the  "best"  dis-  1.  The PT/OT r e c o r d i s a f a c t u a l j o u r n a l of the c u r r e n t s t a t e of t h e p a t i e n t . How important i s such f a c t u a l i t y to you?  2.  The PT/OT r e c o r d a c t s as an important communication to other members o f the p a t i e n t - c a r e team. How important i s t h i s communication channel to you?  3.  T h e r a p i s t s use PT/OT r e c o r d s t o 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 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 and 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 and implementing treatment. How important i s t h i s p e r s p e c t i v e t o you?  5.  The PT/OT r e c o r d p r o v i d e s data f o r c l i n i c a l research. How important a r e such s t u d i e s t o you?  6.  The PT/OT 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 of p a t i e n t c a r e . How important a r e such standards t o you?  7.  The PT/OT r e c o r d p r o v i d e s an index of the q u a l i t y o f p a t i e n t care. How important i s t h i s index t o you?  device  s t u d i e s and  standards  F i g u r e 11 Recording  Needs Survey Items R e l a t i n g t o Importance  m o t i v a t i o n a l p r e d i c t o r o f changes i n r e c o r d i n g behaviour. p r e d i c t o r s i n c l u d e "gap" a l o n e , gap m u l t i p l i e d by importance of those f o u r v a r i a b l e s . the f i r s t  Possible  "importance" a l o n e , a r e s u l t a n t v e c t o r o f  (impetus),  "leeway" a l o n e , and some combination  Three of those measures can be c a l c u l a t e d from  p o r t i o n o f the RNS; t h e f o u r t h , leeway, i s o b t a i n a b l e from the  second p o r t i o n . The  RNS was p i l o t  t e s t e d on a group of 49 p h y s i c a l and o c c u p a t i o n a l  t h e r a p i s t s working i n f i v e Vancouver h e a l t h - c a r e a g e n c i e s . administered  twice w i t h one week between t e s t s .  various r e l i a b i l i t y  The survey  was  Item-by-item data f o r  t e s t s ( t e s t - r e t e s t , h i g h e s t c o r r e l a t i o n w i t h any o t h e r  72 item, and squared  m u l t i p l e c o r r e l a t i o n s ) are presented  Cronbach's a l p h a measures of r e l i a b i l i t y c o n s i s t e n c y of the t h r e e s c a l e s .  i n Appendix D.  were used t o a s s e s s  Alpha v a l u e s were:  the i n t e r n a l  p r e s e n t l y t r u e - .82,  should be t r u e - .83, and importance - .81.  RECORDING OPINIONS SURVEY  The Recording  Opinions  Survey (ROS) i s designed  t o measure t h e  t h e r a p i s t s ' p e r c e p t i o n s of t h r e e t a s k - r e l a t e d f a c t o r s t h a t p o t e n t i a l l y might a c t as r e s t r a i n i n g f o r c e s i n a change s i t u a t i o n .  Those t h r e e f a c t o r s  are r e s o u r c e s , performance s t a n d a r d s ,  To develop  instrument,  a p o o l of statements was generated  p i s t s , problems noted educators  and / r e i n f o r c e r s .  i n the l i t e r a t u r e and d i s c u s s i o n s w i t h  e i g h t r e l a t i n g t o performance s t a n d a r d s ,  scale. ROS.  thera-  inservice  and s u p e r v i s o r s .  The ROS c o n s i s t s of 30 statements;  proper  from i n t e r v i e w s w i t h  this  recording.  eight r e l a t i n g to resources,  and 14 r e l a t i n g  to r e i n f o r c e r s f o r  F i g u r e s 12, 13 and 14 d i s p l a y the item s e t s f o r each  Items f o r each v a r i a b l e a r e randomly d i s t r i b u t e d throughout the T h e r a p i s t s r a t e each statement on a 5 - p o i n t , L i k e r t - t y p e s c a l e , r a n g i n g  from " s t r o n g l y d i s a g r e e " t o " s t r o n g l y  agree."  Choosing a method t o monitor t h e presence or absence of t a s k r e l 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 q u e s t i o n .  Should  monitoring  be done  by a r e p r e s e n t a t i v e of t h e o r g a n i z a t i o n , an o u t s i d e c o n s u l t a n t o r the persons i n v o l v e d i n the change process? by a manager or a c o n s u l t a n t . are the b e s t to  change.  source Leavitt  U s u a l l y , t h i s task i s c a r r i e d out  However, i t can be argued t h a t employees  of i n f o r m a t i o n as i t i s t h e i r behaviour (1972) m a i n t a i n s  t h e i r p e r c e p t i o n s of the world.  t h a t people  which i s expected  behave i n accordance w i t h  T h i s view i s c o n s i s t e n t w i t h the g e n e r a l  73 1.  On the whole, the p a t i e n t ' s c h a r t i s a v a i l a b l e when I go to w r i t e i n i t .  2.  T h e r a p i s t s a r e too busy t r e a t i n g p a t i e n t s t o be concerned w i t h d e t a i l e d r e c o r d i n g .  3.  The r e c o r d sheets used i n t h i s department a r e u n s u i t a b l e and inadequate.  4.  T h e r a p i s t s should recording.  5.  The r e c o r d i n g charts.  6.  Problem o r i e n t e d r e c o r d i n g the o l d method.  7.  T h e r a p i s t s i n t h i s department spend too much time r e c o r d i n g .  8.  W r i t t e n r e c o r d s a r e an unnecessary d u p l i c a t i o n of v e r b a l communication w i t h other members o f the p a t i e n t - c a r e team.  s e t a s i d e p a r t of each day f o r  sheets  a r e kept near the p a t i e n t s '  takes more time than  F i g u r e 12 Resources Items  theory  of behaviour espoused i n the present  study, t h a t i s , behaviour i s  a r e s u l t o f an i n t e r a c t i o n between a person and h i s environment. f o r the purposes of t h i s p r o j e c t , the employees' p e r c e p t i o n s of c h o i c e f o r m o n i t o r i n g The  t e s t e d on the same group o f t h e r a p i s t s c i t e d  Item-by-item s t a t i s t i c s f o r v a r i o u s r e l i a b i l i t y  ( t e s t - r e t e s t , highest  c o r r e l a t i o n w i t h any other  c o r r e l a t i o n s ) a r e presented resources  a r e the method  situational factors.  ROS was p i l o t  above (n = 49).  Thus  i n Appendix E.  item,  tests  and squared m u l t i p l e  Cronbach's a l p h a v a l u e s  were:  - .59, performance standards - .72, and r e i n f o r c e r s - .80.  74 1.  The standards f o r r e c o r d - k e e p i n g r e q u i r e d 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 ( f o r r e c o r d i n g ) readily available for reference.  3.  Regular a u d i t s should be done to monitor the r e c o r d - k e e p i n g of s t a f f i n t h i s department.  4.  The procedures f o r r e c o r d i n g are c l e a r l y i n the manual.  5.  The p o l i c i e s and procedures f o r r e c o r d i n g been c l e a r l y e x p l a i n e d .  have  6.  The standards f o r r e c o r d - k e e p i n g t h i s department are r e a l i s t i c .  by  7.  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 department r e q u i r e s t h a t the s u p e r v i s o r check each c h a r t .  8.  The e x p e c t a t i o n s defined.  is  stated  required  f o r r e c o r d i n g are  Figure  by  clearly  13  Performance Standards Items  75 1.  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 PT/OT p a t i e n t - c a r e r e c o r d should be used f o r peer review.  2.  A l l members of the p a t i e n t - c a r e team read a l l components o f t h e r e c o r d .  3.  D o c t o r s r e g u l a r l y read the t h e r a p i s t ' s e n t r i e s i n the patient-care record.  4.  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 only when they are read by a l l people c a r i n g f o r the p a t i e n t .  5.  Doctors r e g u l a r l y comment on the u s e f u l n e s s of the i n f o r m a t i o n w r i t t e n by the t h e r a p i s t .  6.  Record-keeping h a b i t s should be p a r t of the annual performance a p p r a i s a l of the s t a f f .  7.  Record-keeping has low p r i o r i t y w i t h hospital's administration.  8.  Nurses r e g u l a r l y read the t h e r a p i s t ' s e n t r i e s i n the p a t i e n t - c a r e record.  9.  Problem o r i e n t e d r e c o r d i n g w i l l improve t h e p r o f e s s i o n a l s t a t u s of t h e r a p i s t s .  should  this  10.  Nurses r e g u l a r l y comment on the u s e f u l n e s s of the i n f o r m a t i o n w r i t t e n by t h e r a p i s t s .  11.  Regular meetings should be h e l d t o d i s c u s s the problems o f changing to a new r e c o r d i n g system.  12.  D e t a i l e d records  13.  Problem o r i e n t e d r e c o r d i n g improves the r e l i a b i l i t y of the i n f o r m a t i o n i n the r e c o r d .  14.  The 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 the q u a l i t y of t h e i r r e c o r d keeping .  a r e e s s e n t i a l f o r peer review.  F i g u r e 14 Reinforcers  Items  Chapter  5  DATA ANALYSIS AND  The measured forces  change  over  that  26  ships  this  related  were:  to each an  examination  the r e c o r d .  and  retention  was  on  various  Specifically,  maintenance  of knowledge,  variables  An  standards,  the  of (3)  and  (6)  and  changes  major  second  RECORDING  well  s c o r e s were c a l c u l a t e d  and  Initially,  portion observed  i n recording  in this  As  analysed.  of  the  relation-  behaviour.  BEHAVIOUR  s t u d y were a c q u i s i t i o n  and  obtaining a score for  the  as  f o r each  of f i v e  problem  components  focus,  treatment  documentation.  analysis  items.  The  of the hypotheses  MAINTENANCE OF  of  the b a s e l i n e scores r e v e a l e d that  ( 4 8 . 6 % ) o f FRAS i t e m s w e r e p r e s e n t The  and  Those components were d a t a b a s e ,  f o l l o w - u p and  mentation  therapists  change.  presented  major dependent v a r i a b l e s  record, separate  POR.  of  (5) p e r f o r m a n c e  the data are  maintenance of r e c o r d i n g behaviour.  of  and  62  d a t a were c o l l e c t e d  v a r i a b l e were examined.  among i n d e p e n d e n t  plan,  of  (1) a c q u i s i t i o n  (4) r e s o u r c e s ,  chapter  deals with  The  of  time,  the process  (2) a c q u i s i t i o n  A C Q U I S I T I O N AND  total  practices  f o r proper r e c o r d i n g .  In  chapter  that  or hinder  to change,  reinforcers  During  investigated  behaviour,  motivation  data  weeks.  facilitate  six variables recording  i n record-keeping  RESULTS  i n the r e c o r d p r i o r  c o n t r i b u t o r s to t h i s Together,  those  two  to  approximately the  introduction  s c o r e w e r e d a t a b a s e and  subsets  accounted  half  f o r 92%  docuof  the  items  77 present  i n the t o t a l r e c o r d .  F i g u r e 15 p r e s e n t s  a comparison of  c o n t r i b u t i o n of each component at b a s e l i n e , one month and  the  f o u r months.  It  i s o b v i o u s from an examination of t h i s F i g u r e t h a t t h e r e were major d e f i c i t s i n t h r e e components of the r e c o r d , problem f o c u s , treatment  plan  and  After  f o l l o w - u p , when t h e r a p i s t s r e c o r d e d  the i n t r o d u c t i o n of POR  and  i n the c o n v e n t i o n a l manner.  the i n s e r v i c e e d u c a t i o n a l program which  accompanied i t , a l l p a r t s of the r e c o r d showed an improvement w i t h g r e a t e s t g a i n o c c u r r i n g i n problem f o c u s .  At t h i s p o i n t  the  (one month) 77%  of FRAS items were p r e s e n t .  Four months l a t e r , adherence to the new  format had  The  d e c l i n e d to 71%.  g r e a t e r p o r t i o n of t h i s l o s s was  items r e l a t i n g to problem f o c u s , treatment p l a n and Tables  9 and  10 present means, standard  t e s t s f o r t o t a l r e c o r d i n g b e h a v i o u r and and maintenance phases of t h i s study. all  components and  chance. new  recording  r e s u l t s , i t was  concluded  the t o t a l r e c o r d , the newly a c q u i r e d l o s s s c o r e of 5.5%  d e c l i n e was f o c u s items.  acquisition  9 shows, g a i n s o c c u r r e d  in  s i g n i f i c a n t l y greater  than  that t h e r a p i s t s acquired  the  behaviour.  Examination of maintenance data  The  significance  each component d u r i n g the  i n each i n s t a n c e the g a i n was  From those  among  follow-up.  d e v i a t i o n s and  As T a b l e  POR  due  was  (Table 10)  shows t h a t , i n terms of  l e v e l of r e c o r d i n g was  s i g n i f i c a n t at the  .002  level.  not m a i n t a i n e d . This  to s i g n i f i c a n t d e c r e a s e s i n treatment p l a n and  Small  m e n t a t i o n areas but  losses occurred those  those r e s u l t s , i t was  i n data base, f o l l o w - u p  l o s s e s were not  concluded  statistically  not maintained  and  problem f o c u s .  a l l t h e i r acquired  and  problem docu-  significant.  t h a t t h e r a p i s t s had m a i n t a i n e d  behaviour i n t h r e e components (data base, f o l l o w - u p had  and  overall  From  recording  documentation) but  l e v e l of r e c o r d i n g i n treatment  plan  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 D e v i a t i o n s and t - t e s t s f o r A c q u i s i t i o n of Recording Scores  Baseline Component  MPS  Data Base  Problem  1 month b  c  Mean  S.D.  Mean  S.D.  Difference  16  11.11  4.1  14.36  3.1  3.25  6.22  52  ,000  20  1.98  4.7  15.62  5.9  13.64  14.58  52  ,000  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  Total  92  44.72  9.58  70.47  13.1  25.75  16.19  52  ,000  Focus  Treatment  Plan  Record  Maximum p o s s i b l e  t-value  d.f.  score,  ^t-tests f o r correlated  means.  "A t - p r o b a b i l i t y o f .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.  t-prob  Table Means,  S t a n d a r d D e v i a t i o n s and t - t e s t s f o r Maintenance of Recording Scores  1 month Component  MPS  Mean  10  4 months  S.D.  Mean  S.D.  Difference  t-value  b  d.f.  t-prob  16  14.36  3.1  14.21  2.8  -  .15  .40  52  ,688  20  15.70  5.9  13.60  6.4  -2.09  2.52  52  .015  12  2.58  3.6  ,94  2.0  -1.64  4.80  52  .000  Follow-up  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  Total  92  70.68  13.17  65.72  11.8  -4.96  3.28  52  ,002  Data  Base  Problem  Focus  Treatment  Plan  Record  Maximum p o s s i b l e ^t-tests  score,  for correlated  means.  Q  A t-probability Non-significant.  o f .05 o r l e s s  represents  a change s i g n i f i c a n t l y  different  from  chance.  c  ACQUISITION AND  RETENTION OF KNOWLEDGE  An a n a l y s i s of responses  to the knowledge t e s t s showed t h a t b e f o r e  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 g e n e r a l r e c o r d i n g procedures  (42.5%) than s p e c i f i c  i s c l e a r from an examination months ( F i g u r e 16) of  i n f o r m a t i o n r e l a t i n g to POR  (27.5%).  of s c o r e s a t b a s e l i n e , one month and  It  f o u r :..  t h a t s u b s t a n t i a l g a i n s o c c u r r e d d u r i n g the i n i t i a l  phase  the study w i t h the g r e a t e r g a i n o c c u r r i n g i n the s p e c i f i c knowledge a r e a .  F i g u r e 16 a l s o demonstrates a s m a l l d e c l i n e i n g e n e r a l knowledge and  a very  s m a l l i n c r e a s e i n s p e c i f i c knowledge o c c u r r e d between the one-month and four-month p o s t i n s e r v i c e  follow-up.  T a b l e 11 p r e s e n t s means, standard d e v i a t i o n s and for  the t o t a l knowledge t e s t and  study. subset and  i t s two  significance  subsets d u r i n g both phases of  The maximum s c o r e f e a s i b l e f o r the t o t a l t e s t was c o n t r i b u t i n g 20 p o i n t s .  tests the  40, w i t h each  As T a b l e 11 r e v e a l s , the g a i n s i n g e n e r a l  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 h i g h l y s i g n i f i c a n t ,  w i t h 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 l e s s 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 . r e s u l t s , i t was  concluded  t h a t t h e r a p i s t s had  about r e c o r d i n g p r a c t i c e s and  a c q u i r e d and  From  these  r e t a i n e d knowledg  format.  MOTIVATION TO CHANGE  A n a l y s i s of responses  to items on the RNS  revealed that t h e r a p i s t s  were aware of d e f i c i e n c e s i n t h e i r e x i s t i n g r e c o r d i n g system and For example, they f e l t  that approximately  " i d e a l " r e c o r d were b e i n g met should be met. r e c o r d items.  50% of the c h a r a c t e r i s t i c s of  but they f e l t  almost  a l l the  an  characteristics  F i g u r e 17 p r e s e n t s a comparison of responses As  practices.  to the  t h i s F i g u r e shows, t h e r a p i s t s not o n l y p e r c e i v e d a  "ideal"  82  Specific Total General «/5  <D lOOi U)  O  c  <D u  80  k_  <D  a. to  60  o u to  40  3  20  UJ  o LU  O  W  -o  X  BASE |  lmth  INSERVICE  F i g u r e 16 A Comparison o f G e n e r a l , S p e c i f i c and T o t a l Knowledge Scores a t B a s e l i n e , One Month and Four Months  4 mths  T a b l e 11 Means, Standard D e v i a t i o n s and t - t e s t s f o r Knowledge A c q u i s i t i o n  Baseline  Acquisition MPS  Test  b  Mean  and R e t e n t i o n Scores  1 month  S.D.  Mean  S.D.  Difference  t-value  c  d.f  t-prob^  G e n e r a l 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  Total  40  13.93  7.4  30.97  5.8  17.03  19.81  58  .000  .44  1.42  51  .161  .17  .52  51  .606*  .27  .55  51  .585  test  1 month  Retention  4 months  3  G e n e r a l knowledge  20  14.04  3.6  13.60  3.5  S p e c i f i c knowledge  20  16.83  3.3  17.00  3.1  Total  40  30.87  5.6  30.60  5.3  test  S l i g h t d i f f e r e n c e s i n means, standard d e v i a t i o n s out d u r i n g the 4-month l i f e t i m e of the study. b  Maximum p o s s i b l e  *  -  means.  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 c e Non-significant.  *  and number of s u b j e c t s occur because o f subj ect drop-  score.  t-tests f o r correlated ^  -  from chance.  84  I j  | PRESENTLY TRUE | SHOULD BE TRUE IMPORTANT  1  ^  2  3  J j 37.1  3  4  36.1  1 7  NEVER  1  14  RARELY  I  21 SOMETIMES  1  28  1  1  35  42  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 " i d e a l " recording but they also f e l t the " i d e a l " c h a r a c t e r i s t i c s were important. Table 12 presents means and standard deviations f o r the raw scores and calculated values for variables r e f l e c t i n g 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. estimates was 0 to 100%. As Table 12 demonstrates,  The range for the  the present l e v e l of  f a c t u a l recording was estimated to be just less than 60%. the range of responses  It i s obvious from  (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 l e v e l was 88% and the responses ranged from 70% to 90%.  85 T a b l e 12 Means and Standard D e v i a t i o n s f o r M o t i v a t i o n to Change V a r i a b l e s  Range RNS P r o b e s  3  Mean  S.D.  Min.  true  23.39  5.52  Should be t r u e  37.11  Important  Max.  MPS  9  37  42  3.71  25  42  42  36.16  4.09  24  42  42  57.72  19.39  10  90  100  88.26  8.44  70  99  100  Gap  13.73  5.63  4  27  35  Impetus  39.00  4.84  26  49  55  (%)  30.54  20.48  10  99  100  Importance  36.16  4.09  24  42  42  Presently  Estimate  present  Estimate  expected %^  Variables  Leeway  %  b  e  'Recording Needs Survey 'Maximum p o s s i b l e  questions.  score.  'Estimate  of present  l e v e l of f a c t u a l recording.  Estimate  o f expected l e v e l o f f a c t u a l r e c o r d i n g .  'Variables d e r i v e d from RNS probes.  The  d i f f e r e n c e between the e s t i m a t e s  showed t h a t t h e r a p i s t s p e r c e i v e d  there  was a 30% d e f i c i e n c y i n departmental r e c o r d i n g p r a c t i c e s . Results  from the RNS demonstrated t h a t t h e r a p i s t s p e r c e i v e d  f o r changing t h e i r r e c o r d i n g p r a c t i c e s .  They estimated  a relatively  a need large  d e f i c i t e x i s t e d i n the o v e r a l l p r a c t i c e s o f t h e i r departments and, when  86 asked to examine the objectives of an " i d e a l " record, they f e l t there was substantial room for improvement. importance to those objectives.  Furthermore,  they attached considerable  From those r e s u l t s i t was concluded that a  motivational force to change, as measured by the RNS, was present i n the physical and occupational therapists i n this study. TASK-RELATED FACTORS I n i t i a l and subsequent resources, performance i n Figure 18. for  responses to task-related items about  standards and reinforcers are graphically represented  A summary of means, standard deviations and significance tests  i n i t i a l and subsequent  scores are presented i n Table 13.  Scores f o r  resources and standards subsets range from a minimum possible of 8 to a maximum possible of 40. Minimum and maximum scores f o r the reinforcers subset i s 14 and 70.  PERFORMANCE STANDARDS  RESOURCES  REINFORCERS  Strongly Disagree  I Disagree  Neutral  Agree  j 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 r e c o r d i n g  behaviour,  the s t a f f ' s a t t i t u d e s toward a l l t h r e e f a c t o r s tended t o be n e g a t i v e . terms of the r e s o u r c e s resources time and  subset,  were adequate.  t h i s response i n d i c a t e d the t h e r a p i s t s f e l t  This r e s u l t  i s somewhat unexpected as l a c k of  u n s u i t a b l e forms are c i t e d by  therapists i n general  a major r e a s o n f o r poor r e c o r d - k e e p i n g . standards, not  With r e s p e c t  i t appears t h a t t h e r a p i s t s f e l t  f o r c e r s s c a l e showed t h a t s t a f f f e l t  room f o r i n c r e a s i n g p o s i t i v e r e i n f o r c e m e n t  remained v i r t u a l l y  13,  rein-  p o s i t i v e r e i n f o r c e r s f o r proper  The mean v a l u e , which was  seen i n T a b l e  to performance  Responses to the  s i x p o i n t s below the " n e u t r a l "  p o i n t of the s c a l e , i n d i c a t e d that t h e r a p i s t s f e l t  As can be  elsewhere as  the e x i s t i n g standards were  c l e a r l y d e f i n e d , r e a l i s t i c or u n d e r s t a n d a b l e .  r e c o r d i n g were low.  In  t h e r e was  considerable  for their recording  the l e v e l s of r e s o u r c e s  s t a b l e throughout the study.  efforts.  and r e i n f o r c e r s  T h i s l a c k of change  i n d i c a t e d t h a t no major r e - o r g a n i z a t i o n of r e s o u r c e s  or i n c r e a s e s  r e i n f o r c e r s had  implementation of  There was,  occurred  during  the i n t r o d u c t i o n and  in  however, a s i g n i f i c a n t change i n performance s t a n d a r d s .  month a f t e r changes i n r e c o r d i n g were i n t r o d u c e d , departmental requirements f o r r e c o r d - k e e p i n g  staff felt  that  were more s h a r p l y  the  improve-  time.  RELATIONSHIPS AMONG THE  With r e s p e c t  One  focused.  An almost i d e n t i c a l score at the four-month p o i n t i n d i c a t e d t h i s ment d i d not decay w i t h  POR.  VARIABLES  to the c e n t r a l i s s u e 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 , r e g r e s s i o n e q u a t i o n s showed t h a t the major hypotheses were supported. of v a r i a n c e  A d d i t i o n a l e q u a t i o n s were s o l v e d to determine the'amount  i n r e c o r d i n g behaviour e x p l a i n e d  by the independent v a r i a b l e s  Table  13  Means, Standard D e v i a t i o n s and t - t e s t s for Task-related Variables  1 month  Baseline Variable  MPS  Resources  3  Mean  S.D.  Mean  S.D.  40  21.93  2.5  21.98  2.8  Reinforcers  70  35.25  4.2  36.30  Performance Standards  40  21.19  3.5  23.95  b  1 month  Difference  t-value  d.f.  t-prob^  .05  .13  56  .894*  4.7  1.05  2.04  56  .056*  3.0  2.75  7.05  56  .000'-  4 months  3  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 Standards  40  23.85  3.2  23.87  3.0  .02  .05  51  .962*  S l i g h t d i f f e r e n c e s i n means-, standard d e v i a t i o n s and number of s u b j e c t s occur because o f s u b j e c t dropout d u r i n g the 4-month l i f e t i m e o f the study. "Maximum p o s s i b l e t-tests  score,  f o r c o r r e l a t e d means.  t-probability Non-significant.  of . 0 5 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.  89 and  the r e l a t i v e c o n t r i b u t i o n of each independent  variance.  Those f i n d i n g s are presented  Acquisition  in this  v a r i a b l e to t h i s e x p l a i n e d section.  Hypothesis  The a c q u i s i t i o n h y p o t h e s i s proposed  that i n i t i a l  changes i n r e c o r d i n g  behaviour would be more c l o s e l y l i n k e d to m o t i v a t i o n to change, i n c r e a s e i n knowledge and  presence  of performance standards than to r e s o u r c e s and  f o r c e r s f o r proper r e c o r d i n g . complete r e c o r d and primary  subset  accounted  Data presented  i n T a b l e 14 show- t h a t i n the  i n a l l i t s components the v a r i a n c e accounted  ( m o t i v a t i o n , knowledge and  f o r by the secondary  subset  standards) was  f o r by  subset  to the f i r s t  v a r i a n c e accounted  for.  the  g r e a t e r than t h a t  ( r e s o u r c e s and r e i n f o r c e r s ) .  The  d a t a a l s o show t h a t i n the complete r e c o r d and f o u r components adding second  rein-  the  d i d not s i g n i f i c a n t l y i n c r e a s e the amount of  The  f o u r components where the a d d i t i o n a l v a r i a n c e  e x p l a i n e d by r e s o u r c e s and r e i n f o r c e r s was or  b e t t e r were treatment  In  the d a t a base component, t h e r e was  not s i g n i f i c a n t a t the  p l a n , problem f o c u s , f o l l o w - u p and  .05  level  documentation.  o n l y a m a r g i n a l d i f f e r e n c e between the 2  v a r i a n c e accounted  f o r by the primary  subset  (R  = .18)  and  the  secondary  2 subset  (R  =  component was  .17).  The a d d i t i o n of r e s o u r c e s and r e i n f o r c e r s i n t h i s  s i g n i f i c a n t a t the  .05 l e v e l .  c l u d e d t h a t i n the complete r e c o r d and t i o n , problem f o c u s , treatment behaviour linked  p l a n and  From these d a t a , i t was  con-  i n f o u r of i t s components, documentafollox^-up, the change i n r e c o r d i n g  t h a t o c c u r r e d d u r i n g the i n t r o d u c t i o n of POR  was  to changes i n knowledge, m o t i v a t i o n to change and  more c l o s e l y  changes i n the  c l a r i t y of performance standards than t o r e s o u r c e s and r e i n f o r c e r s f o r proper r e c o r d i n g .  Thus, the a c q u i s i t i o n h y p o t h e s i s was  confirmed.  more, w i t h the e x c e p t i o n of d a t a base, the r e l a t i o n s h i p proposed  Further-  i n the  a c q u i s i t i o n h y p o t h e s i s o c c u r r e d i n a l l components of r e c o r d i n g b e h a v i o u r .  Table  14  G e n e r a l 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  T o t a l v a r i a n c e e x p l a i n e d by a l l independent v a r i a b l e s  .27  .35  .32  .38  .27  .33  V a r i a n c e accounted f o r by Knowledge, M o t i v a t i o n and Standards  .23  .18  .20  .34  .15  .21  A d d i t i o n a l v a r i a n c e accounted f o r by Resources and Reinforcers  .04  .17  .11  .04  .11  .12 .  F  .58*  ratio a  An F r a t i o g r e a t e r  than 2.58  2.78  i s significant  1.83*  at the  .66*  .05 l e v e l w i t h 4 and 44  1.69*  degrees of  2.01*  freedom.  JL  subset  N o n - s i g n i f i c a n c e i n d i c a t e s support of the h y p o t h e s i s ; namely, that the a d d i t i o n of the second does not s i g n i f i c a n t l y i n c r e a s e the amount of v a r i a n c e e x p l a i n e d by the f i r s t subset. Note: Data f o r each r e g r e s s i o n e q u a t i o n i s presented  i n Appendix F.  91 Maintenance  Hypothesis  The second h y p o t h e s i s proposed behaviour would be more c l o s e l y l i n k e d performance  t h a t maintenance of r e c o r d i n g to r e s o u r c e s , r e i n f o r c e r s  and  standards than to l o s s o f knowledge and m o t i v a t i o n to change.  T a b l e 15 p r e s e n t s d a t a from r e g r e s s i o n e q u a t i o n s s o l v e d to i n v e s t i g a t e the maintenance h y p o t h e s i s . complete  I n s p e c t i o n of t h i s T a b l e shows t h a t i n the  r e c o r d and a l l f i v e components the v a r i a n c e accounted f o r by  primary subset  ( r e s o u r c e s , r e i n f o r c e r s and  i n c r e a s e d by the a d d i t i o n of the secondary  standards) i s not subset  the  significantly  (knowledge and m o t i v a t i o n ) .  C u r i o u s l y , i n the f o l l o w - u p 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 i n s t a n c e s , a d d i t i o n of m o t i v a t i o n  and knowledge to the v a r i a n c e a l r e a d y e x p l a i n e d by r e s o u r c e s , r e i n f o r c e r s and  standards d i d not r e a c h a s i g n i f i c a n c e l e v e l of .05 or b e t t e r . From those r e s u l t s , i t was  concluded t h a t the d e c l i n e i n r e c o r d i n g  behaviour d u r i n g the maintenance phase of changing behaviour was  more  c l o s e l y l i n k e d t o r e s o u r c e s , r e i n f o r c e r s f o r proper r e c o r d i n g and presence of performance to change.  the  standards than to l o s s of knowledge and m o t i v a t i o n  Thus, the maintenance h y p o t h e s i s was  the r e l a t i o n s h i p proposed  confirmed.  Furthermore,  i n the maintenance h y p o t h e s i s o c c u r r e d i n a l l  components of r e c o r d i n g b e h a v i o u r . P r o p o r t i o n of E x p l a i n e d V a r i a n c e Step-wise m u l t i p l e r e g r e s s i o n e q u a t i o n s were s o l v e d to determine  the  p r o p o r t i o n o f v a r i a n c e i n each component o f r e c o r d i n g performance e x p l a i n e d by the independent v a r i a b l e s . attempted  T a b l e 16 d i s p l a y s the independent  i n the a n a l y s i s of a c q u i s i t i o n and maintenance of  Summary s t a t i s t i c s independent  variables  performance.  showing l i n e a r dependence of r e c o r d i n g performance  v a r i a b l e s are presented i n T a b l e s 17  ( a c q u i s i t i o n ) and  18  on the  Table General  15  H i e r a r c h i c a l Test of the Maintenance  Hypothesis  Documentation  Data Base  Problem Focus  Treatment Plan  Follow-up  T o t a l v a r i a n c e e x p l a i n e d by a l l independent v a r i a b l e s  .38  .40  .34  .16  .12  .34  V a r i a n c e accounted f o r by Resources, R e i n f o r c e r s and Standards  .32  .31  .21  .14  .03  .23  A d d i t i o n a l v a r i a n c e accounted f o r by M o t i v a t i o n and Knowledge  .06  .09  .13  .02  .09  .11  .96*  1.16*  1.44*  .15*  .75*  F  ratio  SL  An F r a t i o  g r e a t e r than 2.31  is significant  at the  .05 l e v e l w i t h 6 and  Complete Record  1.14*  44 degrees of freedom.  * N o n - s i g n i f i c a n c e i n d i c a t e s support of the h y p o t h e s i s ; namely, that the a d d i t i o n of the second subset does not s i g n i f i c a n t l y i n c r e a s e the amount of v a r i a n c e e x p l a i n e d by the f i r s t subset. Note:  Data f o r each r e g r e s s i o n e q u a t i o n  i s presented  i n Appendix F.  93 T a b l e 16 V a r i a b l e s Attempted i n t h e A c q u i s i t i o n and Maintenance R e g r e s s i o n A n a l y s i s  Acquisition Phase  VARIABLES  Maintenance Phase  R e c o r d i n g Performance  B a s e l i n e - I month (residual)  Documentation Data base j Problem f o c u s Treatment p l a n Follow-up  1 month - 4 months (residual)  Knowledge B a s e l i n e - 1 month (residual)  General Specific  1 month - 4 months (residual)  M o t i v a t i o n t o Change  Baseline  Gap Important Leeway Impetus  Baseline  Performance Standards Baseline  Standards  1 month  B a s e l i n e - 1 month (gain)  Standards change  1 month - 4 months (gain)  Resources Baseline  Resources  1 month  B a s e l i n e - 1 month (gain)  Resources change  1 month - 4 months (gain)  Reinforcers Baseline  Reinforcers  1 month  B a s e l i n e - 1 month (gain)  R e i n f o r c e r s change  1 month - 4 months (gain)  94 (maintenance).  Two s e t s o f d a t a a r e d i s p l a y e d i n each t a b l e .  One s e t  d e a l s w i t h the p r o p o r t i o n of v a r i a n c e e x p l a i n e d by a l l v a r i a b l e s ; t h e second s e t , l a b e l l e d  "maximum," d e a l s w i t h e x p l a i n e d v a r i a n c e a t t h e p o i n t  of maximum p r e d i c t i v i t y o f t h e r e g r e s s i o n e q u a t i o n . I n s p e c t i o n of a c q u i s i t i o n d a t a f o r a l l v a r i a b l e s shows t h a t  each  component of r e c o r d i n g 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 s t r o n g e s t r e l a t i o n s h i p e x i s t s i n treatment  p l a n , where 38% o f i t s v a r i a n c e i s e x p l a i n e d .  The amount o f v a r i a n c e i n  other components i s 35% i n d a t a base, 32% i n problem f o c u s and 27% i n b o t h f o l l o w - u p and documentation. Data a s s o c i a t e d w i t h maximum p r e d i c t i v i t y i n i n i t i a l  change o f  performance show t h a t each component has a unique s e t of p r e d i c t o r s .  For  example, gap, s p e c i f i c knowledge and s t a n d a r d s have p r e d i c t i v e power i n a c q u i r i n g changes  i n treatment p l a n w h i l e leeway and r e s o u r c e s a r e  p r e d i c t i v e of changing r e c o r d i n g i n d a t a base.  Variables associated with  the remaining components of t h e r e c o r d a r e shown in T a b l e 17. I n s p e c t i o n o f maintenance  data f o r a l l v a r i a b l e s  (Table 18) shows  t h a t t h e change i n each component of r e c o r d i n g performance has a t l e a s t some degree o f l i n e a r dependence on t h e independent v a r i a b l e s .  The s t r o n g e s t  r e l a t i o n s h i p o c c u r s i n d a t a base where t h e j o i n t l y o p e r a t i n g v a r i a b l e s e x p l a i n 41% of t h e v a r i a t i o n .  The 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 i n  documentation and problem f o c u s i s 38% and 34% r e s p e c t i v e l y . v a r i a n c e i n treatment p l a n  Explained  (16%) and f o l l o w - u p (12%) i s c o n s i d e r a b l y lower.  Data a s s o c i a t e d w i t h maximum p r e d i c t i v i t y i n t h e d e c l i n e o f p e r f o r mance show t h a t each component has a unique s e t of p r e d i c t o r s . it  However,  i s obvious t h a t r e i n f o r c e r s and r e s o u r c e s a r e p o w e r f u l p r e d i c t o r s  because they appear, e i t h e r i n combination or s e p a r a t e l y , i n a l l components.  Table 17 Variance  i n I n c r e a s e i n Recording Components ( A c q u i s i t i o n Phase) Accounted f o r by 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  Multiple R a  b Max  Data Base  .59  .38  Problem Focus  .56  Treatment Plan  Component  All  R Square All  Standard Error  Max  A l l  Max  All  Max  ,35  .15  .84  .85  1.04  3.67  .19  .03  Leeway Resources  .48  .32  .23  .96  .91  1.27  3.01  .28  .03  S p e c i f i c knowledge Standards change Resources Reinforcers  ,62  .52  ,38  .27  .86  .83  1.68  5.06  ,12  .004  Gap S p e c i f i c knowledge Standards  Follow-up  ,52  .40  ,27  .16  97  .92  ,99  2.62  .47  .06  Standards Standards change Reinforcers  Documentation  .52  .33  ,27  .11  .85  .82  1.02  2.58  .45  .09  Gap Standards  Variance  explained  Variance  a t p o i n t of maximum p r e d i c t i v i t y of r e g r e s s i o n  All  Max  Variables i n Equation a t Maximum  by a l l v a r i a b l e s .  b  Note:  Data f o r each r e g r e s s i o n e q u a t i o n  i s presented  equation.  i n Appendix G.  Table 18 Variance  i n D e c l i n e i n R e c o r d i n g Components (Maintenance Phase) Accounted f o r by 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  Multiple R Component  All  a  M  b  Max  Standard Error  R Squa:re  F  All  Max  All  Max  All  P Max  All  Max  Variables i n Equation a t 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 R e i n f o r c e r s change General Knowledge Gap  Variance  explained  Variance  a t p o i n t o f maximum p r e d i c t i v i t y  Note:  by a l l v a r i a b l e s .  Data f o r each r e g r e s s i o n e q u a t i o n  of r e g r e s s i o n  i s presented  equation.  i n Appendix G.  97 By c o n t r a s t , g e n e r a l knowledge and (documentation). Table  gap  appear i n o n l y one  component  P r e d i c t i v e v a r i a b l e s f o r each component are shown i n  18.  R e l a t i v e C o n t r i b u t i o n of Independent V a r i a b l e s In a d d i t i o n to p r o v i d i n g an o v e r a l l p i c t u r e of the s t r e n g t h of r e l a t i o n s h i p between dependent and tions provide  the  independent v a r i a b l e s , r e g r e s s i o n s o l u -  d e t a i l e d i n f o r m a t i o n on the r e l a t i v e c o n t r i b u t i o n 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 ).  F i g u r e s 19 and  20 g r a p h i c a l l y d i s p l a y the  relative  c o n t r i b u t i o n of each set of independent v a r i a b l e s to each component of performance. Examination of those f i g u r e s shows t h a t the 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 d i f f e r s among components of  performance.  In the i n i t i a l  to change was  the main c o n t r i b u t o r to t h r e e components:  data base and  treatment p l a n  butor and  to problem focus and  change i n r e c o r d i n g  ( F i g u r e 19);  follow-up.  (acquisition),  standards was  Increases  motivation  documentation, the major  contri-  i n knowledge, both  general  s p e c i f i c , c o n t r i b u t e d a s u b s t a n t i a l p o r t i o n of e x p l a i n e d v a r i a n c e  o n l y two  components.  the e x c e p t i o n  They were problem f o c u s and  of data base, where r e s o u r c e s  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  treatment p l a n .  in  With  s u b s t a n t i a l l y contributed  to  were r e l a t i v e l y minor c o n t r i b u t o r s  to a l l components. Recording performance d e c l i n e d i n the maintenance phase and were the main c o n t r i b u t o r to t h i s d e c l i n e i n t h r e e components: problem f o c u s and  treatment p l a n .  component, and m o t i v a t i o n variance  to f o l l o w - u p  data  base,  R e i n f o r c e r s dominated the documentation  to change c o n t r i b u t e d a major p o r t i o n of  ( F i g u r e 20).  resources  explained  Changes i n knowledge c o n t r i b u t e d  nothing  Knowledge 3 %  owledge 3%  Motivation 14%  Motivation 14%  Standards 4 %  Standards 5% Resources 2%  esources 11%  inforcers 3%  einforcers 3% DOCUMENTATION C O M P O N E N T Explained Variance 2 7 %  DATA BASE COMPONENT Explained Variance 3 5 %  Knowledge 10%  Knowledge 8 % Motivation 5%  Motivation 13%  Standards 9% Resources  Standards 117a  6%  Resources 3% inforcers 1%  inforcers 4 % PROBLEM FOCUS COMPONENT Explained Variance 3 2 %  TREATMENT PLAN COMPONENT Explained Variance 3 8 %  Knowledge 1% Motivation 7%  Standards 12%  Reinforcers 7 % FOLLOW UP COMPONENT Explained Variance 2 7 %  Figure  19  C o n t r i b u t i o n o f M o t i v a t i o n , K n o w l e d g e and Task-related Variables to Increase i n POR F o r m a t  Reinforcers 2% Reinforcers 2 6 %  'Resources 1% Standards 1% ivation 5% Knowledge 5 %  Resources 2 2 %  Standards 8 % Motivation 6% Knowledge 3 %  DOCUMENTATION COMPONENT Explained Variance 38%  DATA BASE COMPONENT Explained Variance 41%  Reinforcers 6 %  ,Resources 15%  Reinforcers 5% Resources 7%  Standards 1% 'Motivation Knowledge  Standards 3% 'Motivation 1%  8%  4%  PROBLEM FOCUS COMPONENT Explained Variance 3 4 %  TREATMENT PLAN COMPONENT Explained Variance 16%  FOLLOW UP COMPONENT Explained Variance 12%  Figure  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 Task-related V a r i a b l e s t o Decrease i n POR F o r m a t  100 toward e x p l a i n e d v a r i a n c e i n treatment p l a n and f o l l o w - u p and o n l y minor amounts i n the o t h e r t h r e e components. Data r e l a t i n g to r e l a t i v e c o n t r i b u t i o n of v a r i a b l e s to e x p l a i n e d v a r i a n c e f u r t h e r support the hypotheses. e s s e n t i a l a s p e c t s of a c q u i r i n g a new  M o t i v a t i o n and standards are  behaviour but are f a r l e s s  than r e i n f o r c e r s and r e s o u r c e s i n i t s s u s t a i n e d  important  practice.  " B e s t " M o t i v a t i o n to Change V a r i a b l e One  of the s u b s i d a r y q u e s t i o n s addressed i n t h i s study concerns the  "best" motivation-to-change p r e d i c t o r . s e c t i o n s c l e a r l y demonstrate f o r c e i n a c q u i r i n g a new  Data p r e s e n t e d i n the p r e c e d i n g  t h a t m o t i v a t i o n to change i s an important  behaviour.  For example, the f o u r f o l d measure of  m o t i v a t i o n to change used i n t h i s study accounts f o r o n e - t h i r d of e x p l a i n e d v a r i a n c e i n t o t a l performance component r a n g i n g from 52%  a c q u i s i t i o n , w i t h c o n t r i b u t i o n s to each  (documentation)  to 16%  (problem f o c u s ) .  Its  impact on d e c l i n e of a newly a c q u i r e d behaviour i s c o n s i d e r a b l y weaker but it  still  accounts f o r 21% of t o t a l e x p l a i n e d v a r i a n c e .  One method of i d e n t i f y i n g the " b e s t " m o t i v a t i o n to change v a r i a b l e i s through examination of 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 or b e t a weights.  S i n c e b e t a weights are p a r t i a l r e g r e s s i o n c o e f f i c i e n t s they  may  be used as measures of the i n f l u e n c e of each independent v a r i a b l e upon performance w i t h adjustments made f o r a l l o t h e r independent (Nie et a l . ,  1975,  performance,  gap, leeway,  b e t a weights.  p. 322).  variables  R e g r e s s i o n equations u s i n g a c q u i s i t i o n of  importance and impetus y i e l d e d the a p p r o p r i a t e  Those data show t h a t a change i n impetus, a r e s u l t a n t v e c t o r  of gap and importance, would i n t r o d u c e the g r e a t e s t change i n performance. Furthermore, a change i n leeway,  the e s t i m a t e d d i f f e r e n c e between p r e s e n t  and expected r e c o r d i n g p r a c t i c e s , would i n t r o d u c e the l e a s t change i n  101 performance.  From those r e s u l t s , i t was  m o t i v a t i o n to change p r e d i c t o r was performance and  concluded  a combination  t h a t the  "best"  of a p e r c e i v e d gap  in  the importance a t t a c h e d to an " i d e a l " performance.  SUMMARY  The  i n t r o d u c t i o n and  measured over 6 1/2  months.  c o n t i n u e d use of a new V a r i o u s p e r s o n a l and  r e c o r d i n g format  was  organizationalvariables  were measured i n c o n j u n c t i o n w i t h measurements of r e c o r d i n g  behaviour.  Those v a r i a b l e s were m o t i v a t i o n to change, knowledge about r e c o r d i n g procedures  and  p r a c t i c e s , and  employee p e r c e p t i o n s r e l a t i n g to the  a v a i l a b l e f o r the t a s k , the c l a r i t y of performance standards of r e i n f o r c e r s f o r proper r e c o r d i n g . change, which was  month and  the  presence  With the e x c e p t i o n of m o t i v a t i o n to  measured once, a l l v a r i a b l e s were measured a t t h r e e  p o i n t s i n time: b a s e l i n e , one month and l i n e and  and  resources  f o u r months.  Changes between base-  one month r e p r e s e n t e d performance a c q u i s i t i o n ; changes between  one  f o u r months r e p r e s e n t e d performance maintenance. In the a c q u i s i t i o n phase, h i g h l y s i g n i f i c a n t changes o c c u r r e d i n  r e c o r d i n g behaviour  and knowledge.  performance standards reinforcers.  A small s i g n i f i c a n t  noted  in  and no change o c c u r r e d i n the l e v e l of r e s o u r c e s or  P r i o r to the i n t r o d u c t i o n of the new  employees demonstrated a m o t i v a t i o n to change. t h a t a c q u i s i t i o n of performance was  recording  Regression  format,  a n a l y s i s showed  s t r o n g l y i n f l u e n c e d by an i n c r e a s e i n  knowledge, a m o t i v a t i o n to change and Resources and  change was  the presence  of performance  standards.  r e i n f o r c e r s exerted c o n s i d e r a b l y l e s s i n f l u e n c e .  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 l o s s of r e c o r d i n g behaviour  occurred.  There was  f a c t o r s and knowledge d i d not d e c l i n e .  no change i n the t h r e e t a s k - r e l a t e d R e g r e s s i o n a n a l y s i s showed t h a t  102 maintenance and  of performance  performance  played  standards.  relatively  minor  was  strongly  influenced  by  resources,  L o s s o f k n o w l e d g e and m o t i v a t i o n  roles  i n the observed d e c l i n e  to  reinforcers change  i n performance.  Chapter 6  DISCUSSION AND CONCLUSIONS  The for  r e s u l t s presented  i n the p r e v i o u s chapter p r o v i d e some support  a s s e r t i n g t h a t an i n s e r v i c e e d u c a t i o n program h e l p s s t a f f  a new w o r k - r e l a t e d  to acquire  task but f u r t h e r a c t i o n s a r e r e q u i r e d t o h e l p  c o n t i n u e p r a c t i c i n g the new t a s k .  staff  S p e c i f i c a l l y , the f i n d i n g s show t h a t  p h y s i o t h e r a p i s t s and o c c u p a t i o n a l t h e r a p i s t s changed t h e i r r e c o r d i n g s t y l e to more c l o s e l y match the r e q u i r e d POR format when they p e r c e i v e d a need for  change, i n c r e a s e d t h e i r knowledge of POR and other g e n e r a l r e c o r d i n g  procedures defined.  and f e l t  the e x p e c t a t i o n s f o r r e c o r d - k e e p i n g were more c l e a r l y  Moreover, they a c h i e v e d  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 r e c o r d i n g were low and some i n s u f f i c i e n c i e s e x i s t e d i n the time and m a t e r i a l s a v a i l a b l e f o r t h i s t a s k .  Three months l a t e r ,  t h e r a p i s t s had not f o r g o t t e n how t o use POR nor d i d they f e e l t h e r e i n f o r c e r s , r e s o u r c e s or performance standards had a l t e r e d  i n any way, y e t  t h e i r use of POR d e c l i n e d . T h i s c h a p t e r p r e s e n t s a d i s c u s s i o n of those r e s u l t s under f o u r major headings:  changes i n r e c o r d - k e e p i n g  p r a c t i c e s , changes i n p e r s o n a l  a t t r i b u t e s , changes i n o r g a n i z a t i o n a l f a c t o r s , and a c q u i r i n g and maint a i n i n g performance change.  CHANGES IN RECORD-KEEPING PRACTICES  The  f i n d i n g s show t h a t PTs and OTs i n c r e a s e d t h e i r  r e c o r d i n g of POR items by a p p r o x i m a t e l y 103  overall  30% i n the a c q u i s i t i o n phase.  This  i n c r e a s e i s twice as l a r g e as that found by Hammett et a l . (1976) i n t h e i r study of p h y s i c i a n s and t h e i r use of POR.  However, i t should be noted  t h a t the b a s e l i n e s c o r e s f o r those p h y s i c i a n s (57%) was than the PT/OT b a s e l i n e s c o r e (49%) observed here. a t t a i n e d a somewhat s i m i l a r implementation  level  the Hammett study and 77% f o r the PTs and OTs the m a j o r i t y of r e p o r t s d e s c r i b i n g POR amount of implementation  considerably higher  In f a c t , b o t h  groups  (72% f o r p h y s i c i a n s i n  i n this study).  Unfortunately,  implementation do not s p e c i f y  the  so i t i s d i f f i c u l t t o determine whether the  amount observed here i s u s u a l or unusual.  Thus, i t i s t e n t a t i v e l y  c l u d e d t h a t the l e v e l of implementation a t t a i n e d by PTs and OTs  con-  i s within  an a c c e p t a b l e range. Implementation For  example, documentation  i n c r e a s e d by 69%. p l a n ) , 21% was  was  not u n i f o r m a c r o s s the components of the r e c o r d . items i n c r e a s e d by 5% w h i l e problem  Between those two  (data base) and 42%  extremes,  i n c r e a s e of 19%  ( f o l l o w - u p ) were r e g i s t e r e d .  s i g n i f i c a n t i n a l l components a t the .001  level.  f o c u s items (treatment  The i n c r e a s e  I n p a r t , the l a c k  of u n i f o r m i t y i s a f u n c t i o n of the number of items recorded b e f o r e  POR  was  o f f i c i a l l y adopted and the maximum number p o s s i b l e i n any one  For  example, t h e r a p i s t s were a l r e a d y r e c o r d i n g 94% of documentation  and  69% of d a t a base items b e f o r e POR  s m a l l amount of change was  was  component. items  introduced, therefore only a  p o s s i b l e i n those two  components.  The d a t a do not p r o v i d e a ready e x p l a n a t i o n f o r the wide v a r i a t i o n s observed among the remaining p a r t s of the r e c o r d . t h e r a p i s t s e x p e r i e n c e d most d i f f i c u l t y difficulty  w i t h problem  p l a n items might  f o c u s items.  I t would appear  that  w i t h treatment p l a n items and  least  P o s s i b l y the n a t u r e of the treatment  be r e s p o n s i b l e f o r some of those d i f f i c u l t i e s  items d e a l t w i t h the d u r a t i o n of the p l a n and  as  two  the expected response of the  105 patient.  T h e r a p i s t s may  be u n w i l l i n g or unable t o s t a t e how  long a  p a r t i c u l a r treatment p l a n w i l l be used and what response they expect a patient.  C e r t a i n l y t h i s type of commitment i s seldom  r e c o r d s elsewhere  from  seen i n PT/OT  i n Canada a l t h o u g h i t i s an accepted p a r t of  payment-for-  s e r v i c e c o n t r a c t s i n the U n i t e d S t a t e s . T h e r a p i s t s d i d not w h o l l y m a i n t a i n t h e i r i n i t i a l g a i n s i n format.  POR  R e s u l t s from the a u d i t done d u r i n g the f o u r t h month showed a  d e c l i n e of POR  items i n the complete  s i g n i f i c a n t a t the .002  level.  record.  Documentation  v i r t u a l l y a t the a c q u i r e d l e v e l , problem  and data base  not  remained  f o c u s and treatment p l a n showed  l o s s e s and the change i n f o l l o w - u p was  d i f f e r e n t from chance.  statistically  However, the observed d e c l i n e was  u n i f o r m a c r o s s the components.  significant  T h i s l o s s was  6%  not  significantly  Here a g a i n , l a c k of comparable d a t a from o t h e r  s t u d i e s makes i t i m p o s s i b l e t o determine whether t h i s amount of l o s s i s u s u a l or not but the r e s e a r c h e r ' s e x p e r i e n c e w i t h other programs suggests t h a t the d e c l i n e was One  of the major purposes  l e s s than  implementation  normal.  of t h i s study was  to examine the e f f e c t s  of v a r i o u s f o r c e s on the a c q u i s i t i o n and maintenance of POR. w i l l be more f u l l y d i s c u s s e d a f t e r changes i n p e r s o n a l and  Those r e s u l t s organizational  f a c t o r s have been examined.  CHANGES IN PERSONAL ATTRIBUTES  The p e r s o n a l a t t r i b u t e s monitored  i n t h i s study were knowledge of  r e c o r d i n g procedures and m o t i v a t i o n t o change.  B e f o r e d i s c u s s i n g .the  f i n d i n g s r e l a t e d t o each of those v a r i a b l e s , i t i s germane t o p o i n t t h a t m o t i v a t i o n t o change was attempt,  out  measured once, a t the b e g i n n i n g of the change  t h e r e f o r e i t i s not a "change" v a r i a b l e .  By c o n t r a s t , knowledge  106 was  measured t h r e e times, thus i t i s a "change" v a r i a b l e .  Increased Knowledge of R e c o r d i n g P h y s i c a l and o c c u p a t i o n a l t h e r a p i s t s had a b e t t e r u n d e r s t a n d i n g g e n e r a l r e c o r d i n g p o l i c i e s and procedures  (42%) p r i o r t o the  of the new  of POR  r e c o r d i n g system  definitions  (28%).  than they had  introduction  format, concepts  and  One month f o l l o w i n g the i n s e r v i c e program, t h e i r  knowledge surpassed t h e i r g e n e r a l r e c o r d i n g knowledge (84% to 71%). i n s e r v i c e program was so i t i s tempting  expected  t o h e l p the s t a f f a c q u i r e new  of  POR The  knowledge  t o accept those r e s u l t s as proof of i t s e f f i c a c y .  However, s e v e r a l a l t e r n a t i v e e x p l a n a t i o n s are p o s s i b l e and  those must be  c o n s i d e r e d b e f o r e r e a c h i n g such a c o n c l u s i o n . A c c o r d i n g t o Campbell extraneous v a r i a b l e s may, confound  and  S t a n l e y (1966), e i g h t c l a s s e s of  i f not c o n t r o l l e d  i n the e x p e r i m e n t a l d e s i g n ,  the e f f e c t of an e x p e r i m e n t a l treatment.  Those t h r e a t s to  i n t e r n a l v a l i d i t y a r e contemporary h i s t o r y , m a t u r a t i o n p r o c e s s e s , p r e t e s t i n g p r o c e d u r e s , measuring  instruments, s t a t i s t i c a l r e g r e s s i o n ,  d i f f e r e n t i a l s e l e c t i o n of s u b j e c t s , d i f f e r e n t i a l e x p e r i m e n t a l m o r t a l i t y and  selection-maturation interactions.  To c o n t r o l f o r some of those  extraneous v a r i a b l e s a n o n - e q u i v a l e n t c o n t r o l group was the s p e c i f i c purpose (independent  of answering  v a r i a b l e ) produce  the q u e s t i o n :  established for  D i d the i n s e r v i c e program  a change i n knowledge (dependent  variable)?  The n o n - e q u i v a l e n t c o n t r o l group c o n s i s t e d of 19 PTs and OTs were a t t e n d i n g a r e h a b i l i t a t i o n seminar  course.  They completed  who  the CRKI  t w i c e , w i t h a one week i n t e r v a l between t e s t s , and r e c e i v e d no  instruction  i n record-keeping p r a c t i c e s .  (CRKI)  G i v i n g both groups the same t e s t  i n s u r e d a g a i n s t m i s t a k i n g the e f f e c t s of p r e t e s t i n g and the main e f f e c t s of the i n s e r v i c e program.  instrumentation for  But, the c o n t r o l group took  the  107 t e s t at a d i f f e r e n t p e r i o d t o time so contemporary controlled of POR  for.  h i s t o r y was  not  totally  To determine whether a major event r e l a t i n g to r e c o r d i n g  o c c u r r e d d u r i n g the study a r e g u l a r check was made of p r o f e s s i o n a l  j o u r n a l s and o t h e r h o s p i t a l - w i d e i n s e r v i c e programs. so i t seems r e a s o n a b l e t o conclude t h a t contemporary s t a n t i a l l y confound  No events were noted h i s t o r y d i d not  the e x p e r i m e n t a l treatment.  M a t u r a t i o n p r o c e s s e s w i t h i n the group were c o n t r o l l e d f o r by the p r e t e s t and manoeuvre was  completed the t e s t  subsequent  expected  time of day was  p o s t t e s t s a t the same time of day.  t o h o l d any f a t i g u e f a c t o r c o n s t a n t .  not the same for each group.  i n the e a r l y evening.  However, the  The e x p e r i m e n t a l group  A l s o , the time gap was  p r e t e s t and p o s t t e s t ; the e x p e r i m e n t a l group had a one-week gap.  giving  This  the t e s t i n the e a r l y a f t e r n o o n whereas the c o n t r o l group  c o n t r o l group  sub-  took  not the same between  had a five-week gap and  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 m a t u r a t i o n p r o c e s s e s cannot be e n t i r e l y r u l e d t h e r e i s a s l i g h t p o s s i b i l i t y t h a t those e f f e c t s may  mask the r e a l  the  out;  treat-  ment e f f e c t s . As both groups remained  i n t a c t throughout  d i f f e r e n t i a l m o r t a l i t y d i d not o c c u r . was  the t e s t i n g  Similarly, s t a t i s t i c a l  period regression  not an i s s u e as s u b j e c t s were not s e l e c t e d on the b a s i s of extreme  scores. Isaac and Michael (1971) m a i n t a i n t h a t the main t h r e a t to validity  i n the n o n - e q u i v a l e n t c o n t r o l group  d e s i g n a r i s e s from  internal interaction  between such v a r i a b l e s as s e l e c t i o n and m a t u r a t i o n , s e l e c t i o n and or s e l e c t i o n and t e s t i n g . i s always  They argue t h a t without random s e l e c t i o n t h e r e  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  groups t h a t can contaminate  history,  the p o s t t e s t d a t a .  two  C e r t a i n l y , i t can be  argued  108 i n the present study t h a t the c o n t r o l group might have been more ready t o l e a r n because they were e n r o l l e d i n a U n i v e r s i t y c o u r s e . a c t i o n to p r e s e n t a s u b s t a n t i a l t h r e a t n e c e s s a r y t o show an i n c r e a s e not m a t e r i a l i z e ; the scores  For t h i s i n t e r -  to i n t e r n a l v a l i d i t y  i n c o n t r o l group p o s t t e s t  i t would be  scores.  This did  between the t e s t s remained v i r t u a l l y the same.  A f t e r examining the major s o u r c e s of c o n t a m i n a t i o n , i t i s concluded that  the i n s e r v i c e e d u c a t i o n program was m a i n l y r e s p o n s i b l e  observed i n c r e a s e  i n knowledge.  Thus, i t i s judged to be s u c c e s s f u l ,  i n s o f a r as i t helped t h e r a p i s t s g a i n a g r e a t e r of  f o r the  u n d e r s t a n d i n g of a l l a s p e c t s  recording.  Knowledge  Retention  The knowledge t e s t was r e p e a t e d f o u r 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 t h a t t h e r a p i s t s r e t a i n e d acquired  recording  knowledge.  a l l t h e i r newly  T h i s r e s u l t i s s i m i l a r to the f i n d i n g s of  other r e s e a r c h e r s  who have i n v e s t i g a t e d  t i o n a l programs.  For example, Deets and Blume (1977) found t h a t n u r s e s  retained  the long-term e f f e c t s of educa-  a s i g n i f i c a n t amount of newly a c q u i r e d  materials  t h r e e months a f t e r they had attended a c o n t i n u i n g Donegan e t a l . (1976) r e p o r t e d  f o r at l e a s t  e d u c a t i o n workshop.  s i m i l a r f i n d i n g s from f o u r programs f o r  a n e s t h e s i o l o g i s t s , and Jamieson (1972) found t h a t housewives i n the 24 to 39 age group r e t a i n e d newly a c q u i r e d  material  f o r at l e a s t four  months.  The f i n d i n g s of the present study add to the growing body of e m p i r i c a l r e l a t i n g to r a t e s of knowledge r e t e n t i o n among a d u l t s . lend  support to the n o t i o n  Furthermore, they  i n s e r v i c e e d u c a t o r s can expect  partici-  pants i n t h e i r programs to r e t a i n a v e r y h i g h p o r t i o n of newly  acquired  knowledge over s e v e r a l The h i g h  that  data  months.  l e v e l of knowledge r e t e n t i o n may have been due, i n p a r t ,  109 to t h e i n s t r u c t i o n a l t e c h n i q u e used throughout the i n s e r v i c e program. workshop format was used because i t i s i n accord p r i n c i p l e s of the a d u l t process,  learning process.  A  w i t h two f i r m l y e s t a b l i s h e d  First,  l e a r n i n g i s an a c t i v e  and t h e r e f o r e the most s u i t a b l e technique i s one t h a t encourages  a c t i v e p a r t i c i p a t i o n (Verner & Booth, 1964; H u t c h i n s o n , 1974; Knowles, 1970).  Second, r e t e n t i o n i s enhanced when a d u l t s a r e g i v e n  to immediately apply The  t h e newly l e a r n e d m a t e r i a l  the o p p o r t u n i t y  (Verner & Booth, 1964).  format used i n t h i s study met those c o n d i t i o n s ;  i t encouraged  p a r t i c i p a t i o n by emphasizing d i s c u s s i o n and keeping d i d a c t i c  active  presentations  at a minimal l e v e l , and i t made p r o v i s i o n f o r immediate a p p l i c a t i o n by i n c l u d i n g r e a l and simulated  problems f o r the s t a f f t o s o l v e .  thought t h a t those a c t i o n s would a s s i s t  I t was  the PTs and OTs t o g a i n and r e t a i n  a s u b s t a n t i a l amount of new knowledge. Motivation The  t o Change second p e r s o n a l  a t t r i b u t e expected t o be important i n d e t e r -  mining performance change was m o t i v a t i o n Motivation  t o change.  i s the end product of a s e r i e s of complex i n t e r a c t i o n s  among s e v e r a l v a r i a b l e s .  Depending on which m o t i v a t i o n a l  t h e o r i s t one  r e a d s , those v a r i a b l e s might i n c l u d e p h y s i o l o g i c a l and p s y c h o l o g i c a l 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 v a l u e expectation a belief  attached  t o a p a r t i c u l a r outcome, the  t h a t a p a r t i c u l a r a c t i o n w i l l l e a d t o a d e s i r e d outcome, and  that achieving  one g o a l w i l l l e a d t o another g o a l .  Faced w i t h  the obvious c o m p l e x i t y of measuring an i n d i v i d u a l ' s m o t i v a t i o n h i s s t y l e of r e c o r d i n g , m u l t i p l e measure. two  assumptions.  i t was decided  t o change  t o approach the concept through a  The development of t h i s f o u r - f o l d measure was based on First,  i t was assumed t h a t a p e r c e i v e d  deficit  between  110 a  present  tion  and  state acts  as  a motivational  i s c l o s e l y r e l a t e d to Leagans'  Golden's  (1973) c o n c e p t  surrounding to  expected  field.  a p a r t i c u l a r gap The  of  (1966) c o n c e p t  tension  The  second  or  perceived  between  the  that  acts  f o u r - f o l d measure of m o t i v a t i o n  as  to  deficiency:  l e e w a y and  gap.  g l o b a l view  of  deficit  i t measures  entire of  departmental recording  recording,  that  more s p e c i f i c ; to  compare  those be  two  highly  future  current  correlated.  The  In  correlations  overlap  may  of  essence, to  staff  them. both  of  The  content.  (r =  a gap  extent  simple  .60).  his attached  force. two  to which  basic  care.  the  i s much  S t a f f were  the  be  asked  argued  variables  that would  correlation coefficients  This  i t p r o f i t a b l e to  f i n d i n g suggests combine  the  a  requirement  Gap  It could case  and  leeway p r o v i d e s  a record.  I f t h i s were the of  Coffey  importance  t h e most  focused  were asked  leeway  This  (r =  on to  .17)  change d e a l s the  content  s t a t e how  staff  and  i m p o r t a n c e has  show  that  global  gap  with  of  does not  aspect imply  f o u r t h measure of m o t i v a t i o n ,  a  and  that  (r =  .28).  a  change, strong  impetus,  issue  each  is a  both  i t tends  desire  low  T h o s e low> with  that  of  "ideal"  i m p o r t a n c e has  minimal overlap  of  the  patient-care  important  f i n d i n g i s noteworthy because  often forgotten by  to  I t i s i n t e r e s t i n g to note  i n d i c a t e that  o b v i o u s but  the  assump-  deficit.  d e f i c i e n c y measures.  ledgement  find  of  and  a motivational  of p a t i e n t  "ideal"  measure of m o t i v a t i o n  correlations with  an  with  T h i s measure a l s o  o b j e c t i v e was  fulfilled  contents  Inspection  of  third  importance.  firm  the  measures overlapped.  aspects  record.  on  content  researchers  specific  system  the  Essentially,  i s , factual recording  i t focuses  a m o d e r a t e amount  as  need  change c o n t a i n s  measures of  perceived  of  This  i n d i v i d u a l and  a s s u m p t i o n was deficit  force.  to  con-  i s , acknowto reduce i t .  hypothetical  variable  c o n s t r u c t e d from  tion  of  impetus  with  the  was  two  based  importance  of  directly  on  the  the n o t i o n that  deficit  might  of  t e n s i o n between t h e i n d i v i d u a l and  it  might  is  some e v i d e n c e  be  show t h a t  the  an  acquisition  positive to  the  introduction  that of  the  forcers  presence  in this  staff  felt  the  proper  a key  experts  and  as  such,  Indeed,  of the b e t a  there  weights total  sufficiently  m o t i v a t i o n t o change  prior  FACTORS  organizational  f o r c e s was  expected  each  and  factor  forces  rein-  the r e l a t i o n s h i p s  i t i s necessary  i f their  to  The  s t a n d a r d s , r e s o u r c e s and  Before considering  change,  of  are  maintenance of r e c o r d i n g behaviour.  recording.  to e s t a b l i s h  p e r c e p t i o n s changed  among  how  the  throughout  POR.  departmental performance  role  o f POR.  guidelines  that The  in altering  (Mager & P i p e ,  w o r k e r s need  state  Guidelines for Recording  implementation play  possessed  ORGANIZATIONAL  performance  implementation  The for  and  about  Departmental  and,  a  c r e a t e the g r e a t e s t change i n  s t u d y were performance  f o r proper  forces  staff  of c e r t a i n  acquisition  those  indicate  of a m o t i v a t i o n to change. n o t i o n as a n a l y s i s  combined  POR.  CHANGES IN  examined  more a c c u r a t e l y  h i s surrounding f i e l d  would  construc-  a perceived d e f i c i t  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  to conclude  influence  The  POR.  results  The  this  i n c r e a s e i n impetus of  The  "best" indicator to support  measured v a r i a b l e s .  1971;  t o know what  the  f o r r e c o r d i n g contained the  s u p e r v i s o r s had  presence  of those  s t a n d a r d s was  recording behaviour N i s b e r g , 1976;  i s expected  of  established  because,  Rummler,  them.  as  1976)  standards  prior  to  expected  the to  performance point  out,  112 The  f i n d i n g s at  g u i d e l i n e s were not result a  i s hardly  baseline  clearly  auditing  system  first  level felt  month o f  throughout the  sharply  the  statistically requirements  recording  POR  next  departmental focused.  none o f  perceptions the  The  of  three  i s not  f o r record-keeping  It variable that  t o be lack  of  an of  a  rise  were not the  or  was  Two  existing  had  they  This  studied  established  had  an  At  standards  unchanged  the  end  of  to  one  at  the  probably  due  and  to  to  the  new month  they  small of  but  departmental  i n s e r v i c e program,  distribution staff  of  member.  a  procedures  to  read  their  copy of  the manual, i t i s  mean v a l u e s  f o r the  performance  OTs  each  during  were more  clarity the  that  first  m o n t h was  increased  changed  While  possibility. that  the  standards. of  any  s a t i s f a c t i o n warrants and  the  departments  remained  described,  i n wholehearted  part  four  performance  above the m i d - p o i n t  required  felt  for correct record-keeping  required  likely  i s noteworthy  integral  Reinforcers  change.  t o be  d i d not  staff  ability  a l l the  known w h e t h e r P T s  considered  the  perceived  where s t a n d a r d s were e x p l i c i t l y  it  the  change from b a s e l i n e The  OTs  r e a d i l y understandable.  months.  guidelines  and  practices.  p r o g r a m and  significant.  manual c o n t a i n i n g  or  PTs  p o l i c y manual nor  to monitor  Therapists' the  defined  s u r p r i s i n g as  d e t a i l e d record-keeping  show t h a t  of  the  scale.  This  agreement w i t h  the  As  standards  performance  worker's job  performance,  c l o s e r e x a m i n a t i o n by  suggests  clarity  this  future  standards  or  are  suitconsidered  apparent  researchers.  Resources  o r g a n i z a t i o n a l f a c t o r s were e x p e c t e d  T h o s e w e r e i n a d e q u a t e r e i n f o r c e r s and  proper  recording.  proper  recording  The  f i n d i n g s show t h a t  were low.  This  result  to  act  as  barriers  insufficient  therapists felt  comes a s  no  to  resources  for  reinforcers for  s u r p r i s e as  PTs  and  OTs  elsewhere r e p e a t e d l y  complain t h a t no-one ever reads t h e i r  "No-one" u s u a l l y r e f e r s to p h y s i c i a n s but  and  n u r s e s working on the same team  i t might a l s o i n c l u d e the department s u p e r v i s o r  h o s p i t a l management.  and  so i t seems l i k e l y  i n a p o s i t i o n to e i t h e r p r a i s e or c r i t i c i z e  members f o r t h e i r r e c o r d - k e e p i n g p r a c t i c e s on a r e g u l a r The  low  other members of  C e r t a i n l y , i n the h o s p i t a l s s t u d i e d , no mechanisms  e x i s t e d f o r r e g u l a r a u d i t i n g of PT/OT r e c o r d s s u p e r v i s o r s were not  records.  l e v e l of r e i n f o r c e r s p e r c e i v e d  to e x i s t at the  beginning This  of change i n d i c a t e s t h a t even when t h e r a p i s t s switched from one  The  encouragement from any  consequences of t h i s l a c k of r e i n f o r c e m e n t  staff  basis.  of the study p e r s i s t e d throughout the implementation of POR.  s t y l e to another they r e c e i v e d no  that  outside  w i l l be d i s c u s s e d  lack  recording source. in a  later  section. I t was  somewhat s u r p r i s i n g to f i n d t h a t the s t a f f p e r c e i v e d  such as time and m a t e r i a l s were adequate. a previous  The  r e s u l t was  study done by McGregor (1972) showed t h a t PTs  much of t h e i r time was  spent on r e c o r d i n g .  many l o c a t i o n s p r i o r t o the p r e s e n t  Also,  study r e v e a l e d  forms.  i s s u e of a v a i l a b i l i t y of r e s o u r c e s of r e s p o n s e s .  P h y s i c a l and  was  unexpected because and  felt  too in  t h a t t h e r a p i s t s were and  often frustrated  Perhaps the context examined e x p l a i n s  occupational  OTs  interviews with s t a f f  unhappy w i t h the amount of time needed f o r r e c o r d i n g w i t h p o o r l y designed r e c o r d i n g  resources  i n which  the  the d i s p a r i t y  t h e r a p i s t s i n t h i s study expressed  t h e i r f e e l i n g s w h i l e t r y i n g to improve t h e i r r e c o r d - k e e p i n g 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 .  c o u l d be argued t h a t t h e r a p i s t s i n v o l v e d  It  i n change might e x p e r i e n c e some  form of d i s s o n a n c e i f t h e i r a c t i o n s are at v a r i a n c e w i t h t h e i r b e l i e f s 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  so  surveyed groups  114 would p r o b a b l y not e x p e r i e n c e t h i s c o n f l i c t because  they were not  r e q u i r e d t o take a c t i o n . D u r i n g the implementation did  not change.  of POR, t h e r a p i s t s f e l t  the r e s o u r c e s  T h i s r e s u l t was not s u r p r i s i n g as no attempt was made t o  i n c r e a s e t h e time a v a i l a b l e f o r r e c o r d - k e e p i n g or t o change t h e r e c o r d i n g forms.  ACQUIRING AND MAINTAINING POR  To t h i s p o i n t , i t has been e s t a b l i s h e d t h a t t h e r a p i s t s  possessed  a m o t i v a t i o n t o change, gained and r e t a i n e d knowledge about r e c o r d i n g procedures and POR format, p e r c e i v e d an improvement, which p e r s i s t e d , i n the c l a r i t y of departmental requirements f o r r e c o r d i n g , f e l t were j u s t adequate,  and f e l t  resources  r e i n f o r c e r s were low and s t a b l e .  How d i d  those f a c t o r s i n f l u e n c e the a c q u i s i t i o n and maintenance of POR? The f i n d i n g s show t h a t the j o i n t combination of a m o t i v a t i o n t o change, i n c r e a s e d knowledge and improved  performance  standards (primary  subset) added s i g n i f i c a n t l y more v a r i a n c e t o a c q u i s i t i o n of POR  than  p e r c e i v e d l e v e l s of r e i n f o r c e r s and r e s o u r c e s (secondary s u b s e t ) .  This  i n d i c a t e s t h a t PTs and OTs implemented POR when they were m o t i v a t e d t o change, gained a d d i t i o n a l knowledge of r e c o r d i n g procedures and when they p e r c e i v e d an improvement i n t h e c l a r i t y o f departmental requirements f o r proper r e c o r d - k e e p i n g .  Implementation  was not s i g n i f i c a n t l y a f f e c t e d 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 j u s t adequate (as  p e r c e i v e d by the s t a f f ) .  resources  The p a t t e r n observed i n the complete r e c o r d  ( F i g u r e 21) a l s o o c c u r r e d i n each POR component  ( F i g u r e 19, p. 98) and,  w i t h t h e e x c e p t i o n of data base, t h e a d d i t i o n of t h e secondary  subset d i d  not 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 e x p l a i n e d by the primary subset.  115  Figure 21 D i s t r i b u t i o n of Explained Variance i n Acquisition Phase (Complete Record) A somewhat d i f f e r e n t picture emerged after an i n t e r v a l of three months.  The findings show that the newly acquired  recording  behaviour  had declined to some extent and the j o i n t contribution of resources, r e i n forcers and performance standards (the primary subset i n the maintenance phase) added s i g n i f i c a n t l y more variance  to the loss than motivation to  change and loss of knowledge (secondary  subset).  This indicates that decline i n POR was more c l o s e l y associated with persistent low l e v e l s of r e i n f o r c e r s , lack of change i n the available resources and lack of further improvement i n departmental requirements for proper record-keeping.  Problem oriented recording  loss was not  s i g n i f i c a n t l y affected by i n i t i a l l e v e l s of motivation to change and retained knowledge.  116 The pattern observed i n the complete record as may be seen i n Figure 22 occurred i n four components, the exception was follow-up where the pattern was reversed, as may be seen i n Figure 20, p. 99 . It i s useful to i d e n t i f y combinations of factors that help s t a f f acquire and subsequently lose new behaviour patterns, but i t i s more useful to know which factor i s the most potent.  Three l i n e s of evidence converge  to suggest that motivation to change i s the major factor influencing acquisition.  Motivation to change accounted for one-third of explained  change i n o v e r a l l POR implementation, and also contributed the most to change i n three POR components: plan.  data base, documentation and treatment  Furthermore, i n data base and documentation, motivation to change  accounted f o r almost twice as much change as increased knowledge and improved performance standards combined.  Figure 22 D i s t r i b u t i o n of Explained Variance i n Maintenance Phase (Complete Record)  117 M o t i v a t i o n to change played but, w i t h the e x c e p t i o n  of one  subsequent d e c l i n e of POR show t h a t two  f a c t o r s a r e p e r s i s t e n t low a v a i l a b l e resources. t h i r d s of e x p l a i n e d  l o s s of POR  Those  l a c k of change i n two-  i n the o v e r a l l r e c o r d w i t h each c o n t r i In those  problem f o c u s and  i n d i v i d u a l components where a treatment p l a n , the l e v e l of  the primary c o n t r i b u t o r to e x p l a i n e d  c o n t r i b u t o r i n one  was  (data base) and  not  change.  In two  s i g n i f i c a n t r e s o u r c e s was  r e i n f o r c e r s i n the o t h e r  c o n t r i b u t e d much to l o s s i n f o l l o w - u p  com-  the major  (documentation).  where m o t i v a t i o n  to change  the primary c o n t r i b u t o r . Before  of POR,  concluding  i t i s necessary  mance change t h a t was e x p l a i n e d by 33%  f i n d i n g s i n the maintenance phase  l e v e l s of r e i n f o r c e r s and  ponents where the l o s s of POR  was  a minor p a r t i n the  Together they account f o r s l i g h t l y more than  s i g n i f i c a n t l o s s occurred,  Neither  The  acquisition  the r e s p o n s i b i l i t y f o r l o s s of POR.  b u t i n g almost e q u a l l y to the l o s s .  r e s o u r c e s was  r o l e i n promoting  component, i t had  format.  f a c t o r s share  a key  and  34%  t h i s d i s c u s s i o n of a c q u i s i t i o n and  to s p e c u l a t e b r i e f l y on the v a r i a n c e  in perfor-  unaccounted f o r by the s e l e c t e d f o r c e s .  the f i v e s e l e c t e d f o r c e s i n the two r e s p e c t i v e l y ; thus, over 60%  accounted f o r by those  forces.  sources  Variance  phases of change  of observed change was  Obviously,  organizational-related forces f a c i l i t a t i n g In l o o k i n g f o r l i k e l y  maintenance  was  not  t h e r e were other p e r s o n a l and  h i n d e r i n g the change  and process.  of i n f l u e n c e , i t might be u s e f u l t o c o n s i d e r  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 and,  i n s e r v i c e program was  as such, i t was  designed  intended  to a c t as the u n f r e e z i n g  event  t o c r e a t e a major impact on b o t h a t t i t u d e s  and knowledge.  T h i s impact was  achieved  i n s e v e r a l ways.  For  the program was  g i v e n a h i g h p r o f i l e by h o l d i n g f i v e s e s s i o n s  example, on  118 consecutive  days i n s t e a d of the more u s u a l once-a-week s c h e d u l i n g ,  and  the  s e s s i o n s were h e l d i n a c o n f e r e n c e room r a t h e r than the PT/OT department. Those a c t i o n s were expected to h e l p attempt t o i n t r o d u c e mill  a new  r e c o r d i n g method and  not  the u s u a l  a  serious  run-of-the-  i n s e r v i c e program. Other a c t i o n s and  t h a t may  have helped  showing a v i d e o and  s t a f f r e a l i z e t h a t t h i s was  usefulness  discussing with  a c t i v i t i e s associated with  the i n s e r v i c e program  to induce p o s i t i v e a t t i t u d e s toward r e c o r d i n g  tape of Lawrence Weed e x p l a i n i n g the p h i l o s o p h y , of POR  (Weed p r e s e n t s  included  concepts  the m a t e r i a l i n a humorous f a s h i o n ) ;  the s t a f f the impact of b e t t e r c l i n i c a l d a t a on the  growth of both p r o f e s s i o n s ; and  allowing  share the l e a r n i n g experience.  This l a t t e r a c t i o n probably  s t a f f t o r e a l i z e they were doing  the m e d i c a l r e c o r d s  something new  and  future  librarian helped  to  the  important.  I f the s t a f f were ready to engage i n the change p r o c e s s ,  and  m o t i v a t i o n a l measurements i n d i c a t e d they were, i t seems reasonable  the  to  propose t h a t 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 i n c r e a s i n g t h e i r e x i s t i n g m o t i v a t i o n , aroused a sense of p r o f e s s i o n a l p r i d e and Taken t o g e t h e r ,  those a t t i t u d i n a l changes may  the v a r i a n c e unaccounted f o r by The w i t h other  induced  a f e e l i n g of  have challenge.  be r e s p o n s i b l e f o r some of  selected variables.  i m p l i c a t i o n s of t h i s o b s e r v a t i o n i s s u e s that have been i d e n t i f i e d  w i l l be more f u l l y e x p l o r e d  the program may  i n the next  for further research,  along  i n the course of t h i s d i s c u s s i o n ,  chapter.  Chapter 7  SUMMARY AND IMPLICATIONS  T h i s chapter draws t o g e t h e r the p r e v i o u s s i x c h a p t e r s through a summary of the presented m a t e r i a l . p r a c t i c e and f u r t h e r r e s e a r c h  Implications  with respect  t o theory,  complete t h e c h a p t e r .  SUMMARY  Formal r e s e a r c h  r e l a t i n g t o t h e impact of i n s e r v i c e e d u c a t i o n on  employee performance change i n h e a l t h - c a r e " i n s e r v i c e " remains a primary s t r a t e g y few  agencies i s scarce, y e t  f o r implementing change.  a v a i l a b l e s t u d i e s , i t appears t h a t e d u c a t i o n a l  contribute  From the  programs p r o b a b l y  t o s h o r t - t e r m 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 c o n s u l t a n t s  and change t h e o r i s t s suggest t h a t  educational  a c t i v i t i e s are u n l i k e l y t o produce permanent change because they a r e l i m i t e d to inducing attempt r e q u i r e s The  changes i n t h e employee, whereas a s u c c e s s f u l change  a l t e r a t i o n s i n both the person and h i s environment.  purpose of t h i s study was t o i n v e s t i g a t e 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 w o r k - r e l a t e d behaviour and concommitant changes i n s e l e c t e d p e r s o n a l  and o r g a n i z a t i o n a l f a c t o r s .  b e h a v i o u r was a new method of r e c o r d i n g Oriented (PTs)  Recording  patient-care,  The s p e c i f i c  c a l l e d "Problem  (POR)" and t h e p a r t i c i p a n t s were 62 p h y s i c a l  and o c c u p a t i o n a l  G r e a t e r Vancouver area.  therapists  (OTs)  The p e r s o n a l  119  located  therapists  i n four h o s p i t a l s i n the  and o r g a n i z a t i o n a l v a r i a b l e s  selected  120 f o r study were:  (1) m o t i v a t i o n t o change, changes i n (2) knowledge,  (3) performance s t a n d a r d s , recording.  (5) r e i n f o r c e r s f o r proper  The dependent v a r i a b l e , r e c o r d i n g performance, was  i n t o f i v e components: up and  (4) r e s o u r c e s , and  d a t a base, problem f o c u s , treatment  divided  plan, follow-  documentation. 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 among the dependent and  v a r i a b l e s were as f o l l o w s : closely linked  a c q u i s i t i o n of r e c o r d i n g behaviour  independent i s more  t o m o t i v a t i o n t o change, i n c r e a s e i n knowledge and  of performance standards  presence  than t o r e s o u r c e s and r e i n f o r c e r s f o r proper  r e c o r d i n g ; and maintenance of r e c o r d i n g i s more c l o s e l y l i n k e d t o the presence  of performance standards, r e s o u r c e s and r e i n f o r c e r s than t o l o s s  of knowledge and m o t i v a t i o n t o change. Two  r e s e a r c h hypotheses  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 behaviour accounted 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 would not 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 knowledge, m o t i v a t i o n t o change and presence of performance standards.  2.  The a d d i t i o n a l v a r i a n c e i n maintenance of r e c o r d i n g behaviour accounted f o r by r e t e n t i o n of knowledge and m o t i v a t i o n t o change would not 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 the presence 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 .  An a l p h a l e v e l e q u a l t o .05 was The  study d e s i g n was  were proposed  used  and  tested for significance.  to test f o r s i g n i f i c a n c e .  a modified time-series experimental design  w i t h measurements of a l l v a r i a b l e s except m o t i v a t i o n o c c u r r i n g t h r e e times: b e f o r e the i n t r o d u c t i o n of POR months l a t e r . Four independent Keeping  ( b a s e l i n e ) , one month l a t e r and a g a i n t h r e e  M o t i v a t i o n to change was instruments were developed  variables.  Inventory  measured a t b a s e l i n e o n l y . to measure the dependent  Knowledge was measured by the C l i n i c a l  (CRKI), a 13-item, s h o r t answer r e c a l l t e s t .  and  Record The  Recording  121 Needs Survey (RNS), a 7-item survey w i t h a 6 - p o i n t , L i k e r t - t y p e  rating  s c a l e , was used t o determine m o t i v a t i o n to change.  perceptions  of  Therapists'  performance s t a n d a r d s , r e i n f o r c e r s and r e s o u r c e s f o r proper r e c o r d i n g  were measured by the R e c o r d i n g O p i n i o n s Survey (ROS), a 20-item, a t t i t u d e survey w i t h a 5 - p o i n t , L i k e r t - t y p e s c a l e . measured by the Format Review A u d i t Sheet a 2-point s c a l e . to  the study.  The CRKI, RNS  The FRAS was  R e c o r d i n g performance  was  (FRAS), a 23-item c h e c k l i s t w i t h  and ROS were t e s t e d f o r r e l i a b i l i t y  prior  judged by u s e r s i n other c e n t r e s t o be a s t a b l e  instrument. POR  was  introduced  i n t o f o u r PT and two OT departments  i n s e r v i c e e d u c a t i o n program.  The program c o n s i s t e d of f i v e hours of  i n s t r u c t i o n spread over f i v e c o n s e c u t i v e working days. i n t e n s i v e program,  After  this  two 1-hour s e s s i o n s were h e l d ; the f i r s t a f t e r  i n t e r v a l of one month and the second t h r e e months l a t e r . those s e s s i o n s were n o n - i n s t r u c t i o n a l ; CRKI and ROS,  through an  and to c l a r i f y  an  Essentially,  they were used t o a d m i n i s t e r  the  any p r o c e d u r a l problems r a i s e d by the s t a f f .  Data on r e c o r d - k e e p i n g were c o l l e c t e d from 744 p a t i e n t - c a r e r e c o r d s . Four s e t s of p a t i e n t - c a r e notes (PT/OT s e c t i o n ) f o r each month p r e c e d i n g the  t h r e e measurement p o i n t s were s e l e c t e d randomly f o r each of 62  p i s t s and scored f o r the use of POR  thera-  format i n the complete r e c o r d and i n  each of the f o l l o w i n g f i v e s u b - d i v i s i o n s of the r e c o r d : f o c u s , treatment p l a n , f o l l o w - u p notes and  d a t a base, problem  documentation.  S e v e r a l types of d a t a a n a l y s i s were c a r r i e d out i n c l u d i n g  regression  r e s i d u a l s c o r e s f o r changes i n knowledge and r e c o r d i n g performance, g a i n s c o r e s f o r changes i n performance s t a n d a r d s , r e s o u r c e s and  reinforcers,  reliability  e s t i m a t e s f o r each subset of items on t h e RNS,  ROS  and t - t e s t s  ( c o r r e l a t e d means) f o r changes  i n knowledge and  and FRAS,  recording  122 performance during Multiple  i n the  p r o c e d u r e was The recording  of  to  after  an  test  and  amount o f  high  of  "ideal" and  they  least  they  retained  three  of  of  months,  retained  PTs  the  to  exist  f o r proper a  new  with  requirements low  levels  recording  statistically  behaviour.  of  the  associated  perceived  therapists lost  This  loss  r e i n f o r c e r s and  lack  requirements  than  to m o t i v a t i o n  to  knowledge.  between  therapists perceived  their  knowledge gained  i n the  than w i t h  levels  and  regression  acquired  i n department  recording  components  confirmed. OTs  resources  considerable  t o be  and  five  more c l o s e l y  f i n d i n g s were t h a t :  Reinforcers  improved  hierarchical  i n knowledge  departmental  attached  R e s o u r c e s were p e r c e i v e d requirements  general  p e r s i s t e n t low  and  a l l the  months.  of  improvement  newly a c q u i r e d  l i n k e d to  large deficit  record;  i n each  a c q u i s i t i o n was  three  the  levels  A  adequate l e v e l s  Other noteworthy relatively  performance  increases  phase.  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  b o t h h y p o t h e s e s w h i c h were  the  just  i n resources  c h a n g e and  to  the maintenance  f i n d i n g s were t h e s e :  and  interval  more c l o s e l y change  used  change, a p e r c e i v e d  r e i n f o r c e r s and  significant  of  used  significant  to  p h a s e and  independent v a r i a b l e s .  record-keeping  and,  was  in recording  behaviour  motivation for  acquisition  r e g r e s s i o n a n a l y s i s was  between changes changes  the  importance i n the  were p e r c e i v e d  just  current  acquisition  to  an  and  "ideal"  i n s e r v i c e program  as  a d e q u a t e and  records  a  low  throughout  remained  p h a s e and  so.  showed no  an record; for  the  at  study.  Departmental further  change.  IMPLICATIONS  This importance and  study  identified  i n e x p l a i n i n g why  subsequently  declined.  a  set  of  conditions  performance of  t h a t was  a work-related  Theoretical, practical  and  of  critical  task  research  increased implications  123 that  flow  from the  Theoretical  of  e d u c a t i o n as changing  basic  a means o f  c h a n g e and  concepts  The  model,  to  for  predicting  the  this  stabilized.  A  net  reducing  or  sets  forces.  A new  acting  on  the  consider  new  the  change  removing  forces  the  section.  behaviour.  i n the  One  to  According  new  when t h e  performance. (Lewin,  or  making  stabilizing  to  the  the  1947).  suitable that  force  field  field  adding  changes  s t a b l i z a t i o n phase throughout  a  force  strengthening  constant  the  broader  c h a n g e was  fall  by  a  change  i n the  or  of  change  change o c c u r s  i s achieved  i t focuses  supervisors  attempt  restraining forces,  remained  and  L e w i n i a n model of  by  inservice  program w i t h i n  Lewin's model of  they  on  change i s t h a t  educators  when a n e t and  reliance  work-setting.  a deliberate  the  Implicit  that  sole  inservice  i s achieved  balance  level.  an  in recording  behaviour  the  long-lasting  t a s k was  that  changes  target  about  identify for  performance l e v e l s r i s e  of  i n this concluding  changing  place  influence  showed  forces,  to  ignores  thus  that  findings  surrounding not  implementing  p e r s o n and  framework s e l e c t e d  model f o r  considered  reservations  t h i s s t u d y was  framework of  The  the  the  purposes of  additional  are  Implications  One  on  findings  is  driving  to  both  forces i s the  need  entire  change  process. In  the  present  s t u d y , k n o w l e d g e and  the  restraining  influence  and  performance  levels  force in  field.  any  levels was  not  of  Following  the  selected  declined.  This  achieved.  reinforcers  and  of  inadequate department  rose. those  This  implies  resources  implies  initial  d r i v i n g and  Throughout  m o t i v a t i o n were  a  c h a n g e s no  remained  r e q u i r e m e n t s was  change o c c u r r e d further  restraining forces  stable  the  a net  entire  rearrangement process  constant  and  strengthened,  two  change  and of  in  reduced the  occurred  performance the  force  restraining  t h e s e were  shown  field  forces,  124 to  be p r i n c i p a l l y r e s p o n s i b l e f o r performance d e c l i n e .  Both performance  outcomes were c o n s i s t e n t w i t h p r e d i c t i o n s d e r i v e d from Lewin's model, t h e r e f o r e , i t was understanding  concluded  t h a t t h i s model of change was  appropriate for  changes i n r e c o r d i n g performance.  The r e s u l t s l e f t  l i t t l e doubt t h a t changes i n p e r s o n a l a t t r i b u t e s  c o n t r i b u t e d 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 change i n the w o r k - s e t t i n g was decline.  m a i n l y r e s p o n s i b l e f o r i t s subsequent  Those f i n d i n g s emphasize the n e c e s s i t y f o r a c o n c e p t u a l  work to account  f o r the i n t e r a c t i o n between the performer  mance s e t t i n g .  I t i s argued here t h a t c o n v e n t i o n a l models of  e d u c a t i o n do not p r o v i d e such a framework; they a r e and not c o n t e x t - o r i e n t e d and,  as such,  meeting the l e a r n i n g needs of s t a f f . model accounts  for just  performance change. performer  and  frame-  the p e r f o r inservice  performer-oriented  they f o c u s on i d e n t i f y i n g  and  Thus, the t y p i c a l i n s e r v i c e  one p o r t i o n of the requirements  for  education  on-the-job  The RMPS model r e c o g n i z e s the need to i n t e g r a t e the  and h i s w o r k - s e t t i n g but i t l a c k s the c o n c e p t u a l c l a r i t y  L e w i n i a n model i n the a r e a of maintenance of r e s u l t s . study i n d i c a t e t h a t i n s e r v i c e e d u c a t i o n h e l p s s t a f f it  l a c k of  does not h e l p them t o r e f r e e z e .  The  of the  r e s u l t s of  this  to u n f r e e z e and move,  T h e r e f o r e , i t seems t h a t Lewin's model of  change i s more a p p r o p r i a t e f o r implementing l o n g - l a s t i n g changes i n workr e l a t e d behaviour  than an educator's  approach t o change.  P r a c t i c a l Implications Three p r a c t i c a l i m p l i c a t i o n s emerged from t h i s study t h a t may of  utility  to i n s e r v i c e educators and  implementing new for  s u p e r v i s o r s concerned  performance requirements.  The  be  with  f i r s t d e a l s w i t h the need  shared r e s p o n s i b i l i t y , the second f o c u s e s on the importance of a  s i t u a t i o n a l a n a l y s i s and  the t h i r d r e f e r s to the advantages of e v a l u a t i o n .  125 The  first  i d e a t o emerge from t h i s attempt to implement  term changes i n t o r e c o r d i n g supervisor  and  p r a c t i c e s i s that, i n a given  each has has  the s k i l l s  to h e l p  C o l l a b o r a t i o n i s e s s e n t i a l because  s t a f f become knowledgeable and  the power and  r e i n f o r c e r s , resources  and  the i n t r o d u c t i o n and  requirements.  The  implementation of POR  The  educator  e n t h u s i a s t i c and  p o s i t i o n to g i v e or w i t h h o l d  the  the  necessary  p a t t e r n of change observed i m p l i e d t h a t the  might have been more s u c c e s s f u l i f the educator and in  introducing  a unique c o n t r i b u t i o n to make t o the change p r o c e s s .  s u p e r v i s o r has  in  s i t u a t i o n , the  the educator must share the r e s p o n s i b i l i t y f o r  permanent change i n s t a f f performance.  long-  outcome  s u p e r v i s o r had  acted  unison. The  second i d e a of c o n s i d e r a b l e  importance t h a t emerged from  this  study i s that c o n s t r a i n t s are bound to e x i s t i n the work-place  therefore  a deliberate effort  change  should  program i s i n i t i a t e d .  be made to i d e n t i f y  E d u c a t o r s are v e r y  them b e f o r e  the  f a m i l i a r w i t h the importance of  d e t e r m i n i n g l e a r n i n g needs; the f i n d i n g s of t h i s study suggest t h a t s i t u a t i o n a l a n a l y s i s i s e q u a l l y important. s t r a i n t s to s u s t a i n e d and  use  of POR  might be  l e v e l s of r e i n f o r c e r s  time and m a t e r i a l s .  showed those c o n d i t i o n s e x i s t e d b e f o r e remained c o n s t a n t .  For example, the major con-  were p e r s i s t e n t low  l a c k of change i n such t h i n g s as  Post-hoc a n a l y s i s  the change program began and  Those d a t a suggest t h a t e d u c a t o r s and  they  supervisors  i n a b e t t e r p o s i t i o n t o manage change when they have  potential obstacles.  a  identified  J u s t as an assessment of l e a r n i n g needs h e l p s t t o  determine r e q u i r e d p e r s o n a l  changes so a s i t u a t i o n a l a n a l y s i s h e l p s  to  determine the n e c e s s a r y o r g a n i z a t i o n a l changes. A t h i r d i d e a emerged from the f i n d i n g s that c o u l d be utility  to supervisors:  the c r i t i c a l  of  considerable  importance of e v a l u a t i o n w i t h  respect  126  to planning  corrective actions.  Supervisors  t y p i c a l l y assume t h a t poor  performance can be remedied by f u r t h e r i n s e r v i c e e d u c a t i o n . instances present little is  t h i s assumption may be wrong.  study i m p l i e d  I n many  C e r t a i n l y , the f i n d i n g s i n the  that another i n s e r v i c e program would have done  t o h a l t the d e c l i n i n g p r a c t i c e of POR.  The important p o i n t  here  that the evidence t o support t h i s i m p l i c a t i o n came from t h e delayed  posttests.  Those t e s t s showed t h a t t h e s t a f f had not f o r g o t t e n any of  t h e i r acquired  knowledge.  v i s o r would have l a c k e d appropriate  Without those e v a l u a t i v e measures, t h e super-  information  corrective actions.  e s s e n t i a l f o r the p l a n n i n g of  Of c o u r s e , t h e importance of e v a l u a t i o n  i s not new; every program p l a n n i n g  manual and t e x t s t r e s s e s the need f o r  i t and most e d u c a t o r s , no doubt, s u b s c r i b e difficult  t o the concept.  t o e l i c i t much evidence of i t s p r a c t i c e .  I t i s , however,  I t i s argued here t h a t  s u p e r v i s o r s need e v a l u a t i v e m a t e r i a l and i t i s the e d u c a t o r ' s bility  responsi-  to provide i t .  Implications  f o r Further  Research  T h i s study posed and answered some q u e s t i o n s change i n h e a l t h - c a r e  agencies;  about performance  however, i t a l s o s t i m u l a t e d  a d d i t i o n a l i s s u e s that r e q u i r e f u r t h e r i n v e s t i g a t i o n . concerns the g e n e r a l i z a b i l i t y of the f i n d i n g s . are only  two of many groups of h e a l t h - c a r e  implement new r e c o r d i n g  systems.  a s e t of  One of those  issues  A f t e r a l l , PTs and OTs  p r a c t i t i o n e r s attempting to  D o c t o r s , n u r s e s and s o c i a l workers, t o  name a few, a r e e q u a l l y i n v o l v e d  i n recording  the c a r e  patients.  A d i r e c t o r of n u r s i n g  s e r v i c e s , f o r example, might be v e r y  interested  i n knowing whether s i m i l a r or a d d i t i o n a l f o r c e s i n f l u e n c e the  i n t r o d u c t i o n and implementation of a new r e c o r d i n g i n v e s t i g a t i o n i s needed t o c l a r i f y  this  issue.  they g i v e t o  system.  Further  127 An i s s u e of concern t o h o s p i t a l a d m i n i s t r a t o r s that was not addressed  i n t h i s study i s the c o s t i n v o l v e d  i n POR implementation  programs.  In terms of s t a f f time, the most obvious c o s t s occur d u r i n g t h e i n t r o d u c t o r y phase when weekly i n s e r v i c e time i s i n c r e a s e d from one hour t o f i v e hours.  Even though  the r e s u l t s of t h i s study suggest  that an  i n t e n s i v e i n s e r v i c e program e x e r t s a p o w e r f u l i n f l u e n c e on a c q u i s i t i o n o f POR format, other types of l e a r n i n g a c t i v i t i e s  should be i n v e s t i g a t e d .  However, c o s t s of d e l i v e r y cannot be s t u d i e d i n i s o l a t i o n . d i c t a t e s t h a t c o s t s of a c q u i s i t i o n r i s e when performance and an expensive program may prove t o be cheaper  Common sense  i s not m a i n t a i n e d  i n the long r u n .  There-  f o r e , l o n g i t u d i n a l i n v e s t i g a t i o n s a r e needed to examine the c o s t s of i n t r o d u c i n g and s u s t a i n i n g new r e c o r d - k e e p i n g  systems.  The t h i r d and perhaps most important i m p l i c a t i o n f o r f u r t h e r i n v e s t i g a t i o n concerns the degree of commitment of top e c h e l o n people t o change.  Maintenance  of performance  requires a l t e r a t i o n s i n the work-setting;  thus i t i n v o l v e s a member of the a d m i n i s t r a t i v e h i e r a r c h y , u s u a l l y r e p r e s e n t e d by the departmental s u p e r v i s o r , who must be prepared and committed to make the n e c e s s a r y o r g a n i z a t i o n - r e l a t e d changes.  I n the p r e s e n t study, the  v a r i a b l e " s u p e r v i s o r a t t i t u d e " was not s i n g l e d out f o r examination. s t u d i e s t h a t f o c u s on the degree  Further  of s u p e r v i s o r commitment t o performance  change would shed c o n s i d e r a b l e l i g h t on c r i t i c a l f a c t o r s t h a t maintenance of a newly a c q u i r e d b e h a v i o u r .  influence  BIBLIOGRAPHY  Abrahamson, S. Evaluation i n continuing medical education. Journal of the American M e d i c a l A s s o c i a t i o n , 1968, 206, 625-728. Bashook, P. G., Sandlow, L. J . , & Hammett, W. H. POMR s u c c e s s . 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H o s p i t a l A d m i n i s t r a t i o n , 1973, 65-77.  1964. Irish  18,  APPENDICES  133  APPENDIX A  Residual Regression  Score  A r e s i d u a l r e g r e s s i o n s c o r e 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 r e g r e s s i o n l i n e o f a l l s c o r e s . The  use of a r e s i d u a l s c o r e t o d e f i n e change i s s t a t i s t i c a l l y  more d e f e n s i b l e than a g a i n s c o r e f o r the f o l l o w i n g  reasons:  1.  I t provides subjects.  a s t a r t i n g p o i n t which i s common t o a l l  2.  I t i s independent o f and u n c o r r e l a t e d w i t h i n i t i a l status. Thus, when i t i s c o r r e l a t e d w i t h o u t s i d e v a r i a b l e s , c o r r e l a t i o n i s w i t h g a i n d e f i n e d as independent of i n i t i a l s t a t u s r a t h e r than a mixed f u n c t i o n , an unknown p a r t o f which i s i n i t i a l status.  3.  The r e s i d u a l g a i n s c o r e does n o t assume a zero p o i n t of measurement.  135  APPENDIX  B  Formula f o r T e s t i n g Hypotheses  ( i n c r e m e n t a l v a r i a n c e due to F  = variance  Where:  and X ^ ) / M  :  res  / ( N - k - 1)  X. and X_ a r e the secondary 4 5  subset:  M i s the number o f independent v a r i a b l e s i n the subset f o r which the s i g n i f i c a n c e t e s t i s b e i n g made; variance  res  i s the u n e x p l a i n e d v a r i a n c e ;  N i s the number of c a s e s ; and k i s the number of independent  (Nie e t a l . ,  1975, p. 339)  variables.  136  APPENDIX C FORMAT REVIEW AUDIT SHEET  Date of A u d i t ;  Base  Therapist:  Location:  Record  1 month  4 months  Items'  Documentation  PRESENT = Diagnosis Source o f r e f e r r a l Date o f r e f e r r a l P a t i e n t I . D. on f a c e sheet Patient  Data Base  I . D. on a l l c o n t i n u a t i o n sheets  All  e n t r i e s s i g n e d by t h e r a p i s t  All  e n t r i e s dated  All  entries  Medical  legible  history  Social history Physical Projected Problem  Focus  findings treatment  C o r r e c t problem  wording  A l l problems numbered Problem n o . / t i t l e f o r a l l treatment p l a n s Problem n o . / t i t l e f o r a l l p r o g r e s s notes Treatment Treatment  Plan  p l a n f o r each  Frequency o f treatment  problem specified  Duration of p l a n s p e c i f i e d Expected response o f p a t i e n t Follow-up  specified  SOAP format used i n one p r o g r e s s note SOAP format used i n a l l p r o g r e s s notes D i s c h a r g e summary  137  APPENDIX D Data r e l a t i n g  to p i l o t  t e s t of  RNS  Means,  standard  items  deviations  measuring  (figures  based  and  r e l i a b i l i t y  c h a r a c t e r i s t i c s on  p i l o t  of  testing  an  among  coefficients  " i d e a l " 49  subjects)  S.D.  Mean Code  C h a r a c t e r i s t i c  The of  PT/OT the  record  current  is  a  factual  state  of  the  j o u r n a l patient  PT/OT  record  communication of  the  acts  device  patient-care  Therapists i d e n t i f y  as  use  gaps  to  important  other  members  records  t h e i r  PT/OT  and  o b j e c t i v i t y  and  implementing  The  PT/OT  c l i n i c a l  record  provides  perspective  necessary  record studies  i n  planning  provides and  data  for  research  for  PT/OT  record  setting  provides  standards  of  information patient  care  PT/OT  the  quality  record of  provides  patient  an  care  index  of  correlatit  .97  .86  .75  .54  .49  .51  5.65  .55  .56  .56  .46  .60  .51  5.45  5.37  .74  .81  .57  .61  .54  .46  1.20  Presently  true  3.39  3.54  Should  true  5.37  5.21  4.90  4.85  1.06  be  be  .88  .45  .35  .45  .44  .77  .51  .61  .74  .55  .99  .53  .55  .74  .52  1.11  true  3.16  3.39  1.03  1.13  .69  .51  .56  .61  true  4.51  4.62  1.28  1.13  .68  .85  .85  .79  4.57  4.67  1.34  1.10  .65  .85  .85  .78  Presently  true  4.20  4.27  1.00  .99  .55  .55  .49  .60  Should  true  5.33  5.42  .83  .65  .48  .60  .63  .71  5.39  5.33  .84  .72  .48  .60  .71  .64  be  Presently  true  3.02  3.28  1.34  1.12  .55  .54  .58  .59  Should  true  5.08  5.02  1.01  1.06  .47  .53  .78  .63  4.78  4.62  1.16  1.25  .73  .53  .78  .55  1.33  be  Presently  true  3.88  3.69  1.32  .58  .63  .63  .72  Should  true  5.25  5.19  .84  .91  .56  .56  .76  .78  5.44  5.23  .74  .88  .60  .60  .76  .75  1.38  be  Important  The  Post  4.37  Important  The  Pre  5.67  Important  treatment  r  4.35  Important  The  multiple  true  Should  knowledge  Post  Squared  item  any  true  be  Presently  to  Pre  with  Highest  retest  Should  Important  team  PT/OT i n  an  Post  r  other  Test-  Presently  Important  The  Pre  for  record  Presently  true  3.48  3.71  1.17  .55  .63  .63  .60  Should  true  5.23  5.17  .80  1.06  .63  .79  .91  .82  5.32  5.08  .75  1.05  .78  .79  .91  .81  be  Important  APPENDIX E Data R e l a t i n g t o P i l o t T e s t of  1.  Performance s t a n d a r d  2.  Resources i t e m s .  3.  R e i n f o r c e r items.  items.  ROS  Means,  standard  deviations  and  (figures  r e l i a b i l i t y based  on  coefficients  p i l o t  testing  for among  items 49  S.D.  Mean Performance  The  standard  standards  department  The  for  are  i n s t r u c t i o n a l available  Regular  audits  The  the  p o l i c i e s  have ' The by  i n  been  The  the  and  for  this  Test-  Highest  retest  any  r  with  Squared  other  item  multiple  Pre  Post  c  Pre  Post  c o r r e l a t i o n  2.80  2.65  1.14  .95  .61  .46  .56  .48  is  3.52  3.40  1.45  1.05  .66  .64  .53  .46  the  3.73  3.65  .89  .80  .72  .39  .52  .59  .89  .82  .60  .64  .73  .62  a t t a i n  (for  be  recording)  done i n  to  this  recording  procedures  monitor  department  are  c l e a r l y '  3.17  recording  3.53  3.47  .84  .89  .69  .56  .61  .68  required  3.55  3.64  .89  .80  .74  .46  -.45  .52  2.27  2.33  1.07  .97  .49  .41  .52  .51  3.22  3.45  1.03  .87  .56  .56  .73  .73  3.56  for  explained record-keeping are  recording  supervisor  expectations  defined  by  standards  manual  department  Consistent that  for  required  Post  performance  reference  staff  c l e a r l y  standards the  for  of  procedures  stated  to  manual  should  record-keeping  Pre  record-keeping  d i f f i c u l t  r e a d i l y  The  items  measuring subjects)  for  r e a l i s t i c  i n  this  check  department  each  recording  requires  chart  are  c l e a r l y  Means,  standard  deviations  and  (figures  based  r e l i a b i l i t y on  p i l o t  coefficients  testing  among  for 49  Mean Resource  On  the  when  I  items  whole, go  to  Therapists be  record  the  Therapists  should  recording  The  recording  Problem than  is  a v a i l a b l e  4.00  3.88  resources  Pre  Post  Test-  Highest  retest  any  r  with  Squared  other  item  m u l t i p l e  r  Pre  Post  c o r r e l a t i o n  .77  .73  .71  .34  .31  .40  busy  t r e a t i n g  used  In  patients  to  2.59  2.56  1.02  1.03  .77  .44  .56  .54  are  2.87  2.69  1.18  1.08  .80  .41  .29  .50  3.98  4.00  .95  .84  .76  .28  .22  .34  3.86  3.76  .87  .88  .58  .31  .37  .38  1.03  .76  .45  .38  .48  recording  this  department  Inadequate  set  sheets  aside  are  part  kept  of  near  each  day  the  charts  oriented  the  o l d  Therapists time  chart  S.D.  Post  measuring  i t  d e t a i l e d  sheets and  for  i n  too  with  unsuitable  patients'  p a t i e n t ' s  write  are  concerned  The  Pre  items  subjects)  recording  takes  more  time  3.45  3.18  1.19  method  i n  this  department  spend  too  much  2.43  2.40  .84  .76  .63  -.44  -.49  .55  1.55  1.67  .50  .66  .49  .42  -.31  .34  recording  Written  records  of  verbal  of  the  are  an  communication  patient-care  unnecessary with  team  other  d u p l i c a t i o n members  Meana,  standard  deviations  and  r e l i a b i l i t y  (figures  based  coefficients on  p i l o t  for  items  testing  among  measuring 49  Mean Relnforcer  items  Information record  contained  should  be  A l l  members  a l l  components  Doctors in  the  records  by  a l l  Record-keeping annual  h o s p i t a l ' s  r e g u l a r l y  patient-care oriented  professional Nurses the  r e g u l a r l y  of  Detailed Problem of The  the  3.83  3.96  2.20  r  with  Squared  other  item  multiple  .97  .63  .61  .67  .49  1.00  1.08  .48  .52  .44  .54  2.18  1.10  1.01  .71  .73  .79  .67  2.96  3.12  1.27  1.18  .65  .46  .44  .41  2.16  2.12  .96  1.04  .72  .73  .79  .61  3.94  3.92  .75  .86  .64  .52  .56  .51  2.14  2.20  1.02  .96  .87  -.51  -.49  .58  entries  2.84  2.54  .99  .94  .79  .65  .78  .76  the  3.55  3.59  .98  .93  .64  .38  .45  .49  of  2.41  2.37  .96  .95  .79  .65  .78  .74  the  3.53  3.61  .94  .81  .39  .52  .41  .44  .89  c o r r e l a t i o n  review team  should  r e a l  entries  only  when  the  patient  the  the  they  usefulness  be  part  of  of  the  staff  low  are  of  therapist  should  read  p r i o r i t y  with  the  this  records  of  the  t h e r a p i s t ' s  recording of  should to  are  on by be a  the  the  that  quality  of  usefulness  held  essential  i n  Improve  therapists  new  recording  care  w i l l  therapists  comment  information  q u a l i t y  the  record  changing  oriented  p a r a l l e l s  on  by  w r i t t e n  meetings  problems  .71  any  Post  a p p r a i s a l  status  information  Regular  3.63  Post  Highest  retest  Pre  patient-care  Pre  Test-  administration  in  Problem  for  comment  has  3.83  recording  r  t h e r a p i s t ' s  valuable  w r i t t e n  Nurses the  the  c a r i n g  habits  Record-keeping  Post  proper  record  are  performance  S.D.  Pre  for  record  read  r e g u l a r l y  PT/OT  peer  patient-care  people  information  the  for  the  r e g u l a r l y  Doctors the  the of  patient-care  Detailed read  of  i n  used  reinforcers  subjects)  to  discuss  recording for  improves  peer the  system review  3.61  3.45  .96  .72  .61  .67  .60  r e l i a b i l i t y  3.69  3.80  1.08  .74  .44  .38  .45  .44  2.31  2.35  1.06  .95  .76  -.44  record therapists their  give  their  record-keeping  patients  .35  .49  APPENDIX F Regression data: a c q u i s i t i o n and maintenance hypotheses  IS  » * » * » « * » » * » *  • • » » * »» * * • *  DEPENDENT VARIABLE..  RESIDP1  ~  R E G R E S S I O N  1  0.45867 0.21038 0.03965 0.84844  RESIDGK4 RESI0SK4 NIMP NCHNG NSCHNG MTIMP TPRl TPRC1  RES IDGK4 RESI0SK4 NIMP NCHNG NtCHNG HTIMP TPRl TPRC1 I CONSTANT 1  8  ANALYSIS OF VARIANCE REGRESSION RESIDUAL  0.2 367790 -0.1795607 -0.4066062 -0.1149242 -0.9 454236E-02 0.4356699 0.7912815E-01 0.9731250E-01 -2.392366  BETA  VARIABLEISI ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE AOJUSTEO R SQUARE STANDARO ERROR • VARIABLE  0.57625 0.33206 0.08918 0.82627  0.17331 0.14872 0.33467 0.12407 0.00809 0.35062 0.04629 0.05791  2..  TRRCl TINFl TINFCl TRRl  DF 8. 37.  SUM OF SQUARES 7.09612 26.63429  F  VARIABLE  1. 867 1.458 1.476 0.858 1.366 1.544 2.922 2.824  TINFl TINFCl TRRl TRRCl  ANALVSIS OF VARIANCE REGRESSION RESIOUAL  RESIDGK4 0.2383606 RESIDSK4 -0.2693459 NIMP -0.6881043 NCHN6 -0.2066253 NtCHNG -0.1310931E-01 MTIMP 0.7241325 TPRl 0.7967712E-01 TPRCl 0.134 6623 TRRCl -0.6818585E-01 TINFl -0.4598062E-01 TINFCl 0.30158T4E-01 TRRl 0.2288751E-01 1 CONSTANT) -1.941188  BETA 0.21237 -0.29881 -3.24744 -1.34325 -0.31003 4.04456 0.31653 0.45916 -0.30699 -0.13676 0.10355 0.11187  MEAN SQUARE 0.88701 0.71985  0.17749 0.15295 0.35614 0.13010 0.00877 0.37599 0.05706 0.06566 0.04322 0.06250 0.05295 0.04338  F 1.23223  <  P 0.3082  • f  BETA IN  PARTIAL  TOLERANCE  -0.16069 0.14688 0.21659 -0.34362  -0.16795 0.15585 0.19184 -0.32432  0.86259 0.88897 0.61947 0.70341  DF 12. 33.  SUN OF SQUARES 11.20064 22.52976  MEAN SQUARE 0.93339 0.68272  VARIABLES NOT  STO ERROR B  1 l)  1.045 0.896 1.375 4.232  REINFORCERS CHANGE BASE TG 1MTH RESOURCES BASELINE RESOURCES CHANGE BASE TO 1MTH REINFORCERS BASELINE  VARIABLES IN THE EQUATION B  VARIABLE LIST REGRESSION LIST  VARIABLES NOT IN THE EQUATION  STD ERROR B  0.21096 -0.19920 -1.91894 -0.74711 -0.22359 2.43338 0.31435 0.33131  • *  GENERAL KNOWLEDGE CHANGE BASE TO 1MTH SPECIFIC KNOWLEDGE CHANGE BASE TO 1MTH IMPORTANCE GAP LEEWAY IMPETUS STANDARDS BASELINE STANDARDS CHANGE BASE TO 1MTH  .'•»••••-- VAHlABLtb IN IMt EQUATION  VARIABLE  • * * • » # » « « » »  COMPLETE RECORD IN ACQUISITION PHASE  VARIABLEISI ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE AOJUSTEO R SQUARE STANDARD ERROR  M U L T I P L E  F 1.803 3.101 3.733 2.522 2.236 3.709 1.950 4.219 2.489 0.541 0.3 24 0.278  VARIABLE  BETA IN  F 1.36716  P 0.2304  IN THE EQUATION  PARTIAL  TOLERANCE  F  ~  —  • • * » ** * * • * * » * • » » » » * >  DEPENDENT VARIABLE.. VARIABLE!SI  RESIDPL1  ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE ADJUSTED R SQUARE STANDARD "ERROR  » » » *  R E G R E S S I O N  MUL T I P L E  RESIDGK4 RESIDSK4 NIMP NCHNG NtCHNG KTINP TPR1 TPRCI  1  BETA  RES IDGK4 -0.2119090 RESIDSK4 0.54845 88 E- 01 NlMP 0.6134266 NCHNG 0.2 782380 -0.2102478E-02 NtCHNG WTIHP -0.6680432 TPR1 -0.6114T08E-01 TPRC1 -0.2 884668E-01 • CONSTANT) 1.477252  DF 8. 37.  SUM OF SQUARES 7.59102 25.06795  VARIABLEISl  ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE ADJUSTEO R SQUARE STANOARO ERROR  0.52015 0.2 7056 0.00531 0.84965  0.16814 0.14428 0.32468 0.12037 0.00785 0.34015 0.04491 0.05618  2  TRRC1 TINF1 TINFC1 TRR1  F  VARIABLE  1.588 0. 172 3.569 5.343 0. 072 .3.857 1.854 0.264  TINF1 TINFC1 TRR1 TRRC1  B  ANALYSIS OF VARIANCE REGRESSION RESIDUAL  RESIDGK4 -0.2200478 RESIDSK4 0.2 443471E-01 NINP 0.6067469 NCHNG T . 2 776940 NICHNG 0.1766901E-03 UTIMP -0.6772203 TPR1 -0.8451950E-01 TPRCI -0.3512628E-01 TRRC1 0.1064459 E-01 TINF1 -0.110 8636E-01 TINFC1 0.3329539E-01 TRR1 0.4879212E-01 1 CONSTANT! 1.027310  BETA -0.19925 0.02755 2.91007 1.83463 0.00425 -3.84408 -0.34123 -0.12154 0.04870 -0.03351 0.11618 0.24237  STO ERROR B 0.18251 0.15728 0.36621 0.13379 0.00901 0.38662 0.05867 0.06752 0.04444 0.06427 0.05445 0.04461  VARIABLE LIST REGRESSION LIST  1 2)  F 1.40053  P 0.2287  IN THE EQUATION —r-  BETA IN  PARTIAL  TOLERANCE  -0.0 5898 0.10170 0.18472 -0.05298  -0.06253 0.10945 0.16595 -0.05071  0.86259 0.88897 0.61947 0.70341  F 0.141 0.436 1.019 0.093  REINFORCERS CHANGE BASE TO 1MTH RESOURCES BASELINE RESOURCES CHANGE BASE TO 1MTH REINFORCERS BASELINE DF 12. 33.  SUM OF SQUARES " ' " 8.83624 23.82273  VARIABLES IN THE EQUATION VARIABLE  MEAN SQUARE 0.94888 0.67751  VARIABLES NOT  STD ERROR B  -0.19188 0.06747 2. 94211 1.83822 -0.05053 -3.79199 -0.2468 7 -0.09981  *  GENERAL KNOWLEDGE CHANGE BASE TO 1MTH SPECIFIC KNOWLEDGE CHANGE BASE TO 1NTH IMPORTANCE GAP LEEWAY IMPETUS STANDARDS BASELINE STANDARDS CHANGE BASE TO 1MTH  ANALYSIS OF VARIANCE REGRESSION RESIDUAL  0.48211 0.2 3243 0.06647 0.B2311  B  **••••••***  DOCUMENTATION IN ACQUISITION PHASE  VARIABLES IN THE EQUATION VARIABLE  *  MEAN SQUARE 0.73635 0.72190  VARIABLES NOT F 1.454 0.024 2.745 4.308 0.000 3.068 2.075 0. 271 0.057 0.030 0.374 1.196  VARIABLE  BETA IN  "  P 0.4539  IN THE EQUATION  PARTIAL  "  F 1.02002  TOLERANCE  F  •  *  •  •  *  •  DEPENDENT  *  »  »  »  •  »  VARIABLE..  VARIABLE!SI  ENTERED  *  *  »  *  *  •  RESIDPNI  *  *  *  OATA  ON S T E P NUMBER  *  •  BASE  1..  M U L T I P L E IN ACQUISITION  — r  1—  VARIABLE RESIOGK4 RESIDSK4  NIMP NCHNG NtCHNG WTIMP TPR1  TPRCI I CONSTANT 1 VARIABLEISI  VARIABLES B  0.18234 0.15646 0.35210 0.13053 0.00851  0.3882431 0.7539046E-01 0.1049935  2.09729 0.28967 0.34573  0.36888 0.04870 0.06093  E N T E R E D O N STEP  NUMBER  2..  V AK I A D L C J  B  0.1426238 -0.3192453 -0.6992270 NCHNG -0.2453066 NtCHNG -0.1443757E-01 UTIHP 0 . 7 3 7 27 3 3 tPRl 0.6944631E-01 TPRCI 0.1243256 TRRC1 -0.7574254E-01 - 0 . 1 2 9 3148 TINFl - 0 . 23763 16E-01 TINFC1 TRR1 -0.6979577E-03 (CONSTANT I 1.443295  —  Infc  C U U A I 1 U N  BETA 0.12290 -0.34254 -3.19159 -1.54235 -0.33023 3.98275 0.26683 0.40939 -0.32981 -0.37198 -0.07891 -0.00330  — — — — — —  STO ERROR  B  0.16145 0.15637 0.36409 0.13301 0.00896 0.38438 0.05833 0.06712 0.04419 "  *  *  »  •  •  *  •  *  »  VARIABLE REGRESSION  LIST LIST  1 3  TO 1HTH  OF  SQUARES 6.57838 29.48093  MEAN  SQUARE 0.82230 0.79678  — — — — — — —  VARIABLES  VARIABLE  BETA  TINFl TINFCl TRR1 TRRC1  IN  -0.31220 0.10848 0.09416 -0.31116  NOT  ,  F 1.03202  P 0.4301  I N T H E EQUATION PARTIAL  _ TOLERANCE  - 0. 32068 0.11312 0.08196 -0.28862  0.86259 0.88897 0.61947 0.70341  __£_4.126 0.467 0.243 3.271  REINFORCERS CHANGE B A S E TO 1MTH RESOURCES B A S E L I N E R E S O U R C E S CHANGE B A S E T O 1 M T H REINFORCERS BASELINE  TRRC1  A N A L Y S I S OF V A R I A N C E REGRESSION RESIOUAL  IN  SUM  1.296 3.033 1.075 1.160 0.540 1.108 2.397 2.970  TRR1  ""  BASE  F  TINFl TINFCl  0.58906 0.34699 0.10953 0.84472  CHANGE  DF 8. 37.  —  B  0.17889 -0.29237 -1.66635 -0.88402 -0.14309  MULTIPLE R R SQUARE A D J U S T E D R SQUARE STANOARO ERROR  RES IDGK4 RESIDSK4 N IMP  —  STD ERROR  -  VARIABLE  STANDAROS  0.2075937 -0.2724836 -0.3650699 -0.1406011 -0.6255917E-02  - 1 . 7 2 8736 V  *  IMPETUS STANDARDS B A S E L I N E  THE EQUATION BETA  •  TPRl  ANALYSIS OF VARIANCE REGRESSION RESIDUAL  IN  *  NCHNG NtCHNG TPRCI  0.42712 0.18243 0.00566 0.89263  *  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 S P E C I F I C KNOWLEDGE C H A N G E B A S E TO INT H IMPORTANCE GAP LEEWAY  RESI0GK4 RESIDSK4 NIMP  HTIMP  MULTIPLE R R SQUARE ADJUSTEO R SQUARE STANDARD ERROR  R E G R E S S I O N  PHASE  0.06390 0.05413 0.04435  DF 12. 33.  SUN  OF  SQUARES 12.51228 23.54703  MEAN  SQUARE 1.04269 0.71355  VARIABLES  —  F 0.618 4.168 3.688 3. 401 2.595 3.679 1.417 3.431 2.538 4.096 0 . 193 0.000  VARIABLE  BETA  IN  _  E. 1.4612 6  P 0 . 1888  NOT I N T H E EQUATION PARTIAL  TOLERANCE  f  s.  \ ?  » * » * « » * » * » » »  • • * * • •» * * * «  DEPENDENT VARIABLE..  RESI0PP1  VARIABLEISI ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE ADJUSTED R SQUARE STANDARD ERROR  MUL T I P L E  1  0.44963 0.20216 0.02966 0.97539  RESIDGK4 RESI0SK4 NIMP NCHNG NSCHNG MTIMP TPRl ~ T P R C l  ANALYSIS OF VARIANCE REGRESSION RESIOUAL  DF 8. 37.  RES IDGK4 RESIDSK4 NIMP NCHNG NSCHNG MTIMP TPRl TPRCl • CONSTANT! VARIABLEISI  BETA  0.2326114 -0.3055672 -0.2083535 -0.4 899345 E-01 -0.7401272E-02 0.2267474 0.4759315E-01 0.1444023 -1.847459  MULTIPLE R R SOU ARE' "H|l/Mnt ADJUSTED R SQUARE STANDARD ERROR  STD ERROR B  0.18121 -0.29640 -0. 85S76 -0.27848 -0.15304 1.10135 0.16532 0.42987  0. 19924 0.17097 0.38475 0.14263 0.00930 0.40308 0.05321 0.06658 — ...  ENTERED ON STEP NUMBER  11  K  F  —  -  VARIABLE  1.363 3. 194 0.293 0.118 0.633 0. 316 0.800 4.704  TRRCl TINFl TINFCl TRRl  TINFl TINFCl TRRl TRRCl  B  A 9 94 40m R ES IDfiK4 RESI0SK4 -0.4075002 NIMP -0.4770277 NCHNG —A -1 WinyiCf U * ft 3 3 O c O f NSCHNG -0.969 2771E-02 MTIMP 0.4955886 TPRl -"" f-Wl uH 7t~lI 7*l/,AAt, 0 0 jolrU 1 TPRCl 0.1 76236B TRRCl -0.5 576984E-01 TTNFTT —=0.4709845E-0I TINFCl 0.5432401E-01 TRRl 0.4038013E-01 fCONSTANT 1 — 1 f x j t a i a i i I4PI I V 1.60001S  BETA 0.17907 -0.39527 -1.96843 -0. 77205 -0. 20043 2.42026 A—1 - tfTTg 0. 14578 0.52463 -0.21954 -0. 1224 t r 0.16309 0.17257  MEAN SQUARE 1.11496 0.95139  —  VARIABLES NOT  F 1.17193  P 0. 3417  IN THE EQUATION  BETA IN  PARTIAL  TOLERANCE  -0.17356 0.19411 0.22292 -0.28109  -0.18047 0.20490 0.19643 -0.26393  0.86259 0.88897 0.61947 0.70341  DF 12. 33.  SUN OF SQUARES 13.93699 30.18393  MEAN SQUARE 1.16142 0.91466  0.20544 0.17704 0.41222 0.15059 0.01015 0.43519 0.06604 0.07600 0.05003 0.07235 0.06129 0.05022  1.26977  VARIABLES M O T l u T U C . * w \ &Mot.cd  STD ERROR B  1  F 1.212 1.578 1.445 2.696  !  VARIABLES IN THE EQUATION VARIABLE  1 4j  REINFORCERS CHANGE BASE TO 1MTH RESOURCES BASELINE ~" RESOURCES CHANGE BASE TO 1HTH REINFORCERS BASELINE  ANALYSIS OF VARIANCE KCUttlMUN RESIDUAL  ng-  0.06711 0.95638  VARIABLE LIST REGRESSION LIST  ..  2..  0.56203 l\  **  SUM OF SQUARES 8.91965 35 . 20 1 27  —  B  • *  GENERAL KNOWLEDGE CHANGE BASE TO 1MTH SPECIFIC KNOWLEDGE CHANGE BASE TO 1NTH IMPORTANCE GAP LEEHAY IMPETUS STANDARDS BASELINE STANDARDS CHANGE BASE TO 1HTH  ._ VARIABLES VARIABLE  * * » » * » * » * * »  R E G R E S S I O N  PROBLEM FOCUS IN ACQUISITION PHASE  F 1.252 5.298 1.339 0.814 0.913 1.297 0.404 5.378 1.243 '0.424 0.786 0.647  VARIABLE  BETA IN  nui  i n inc  PARTIAL  P 0.2815  EQUATION TOLERANCE  F  1  -p-  * • • • • • * * * • * • • * • * * * • • * * • DEPENDENT VARIABLE.. • VARIABLEISI  RES ID PCI  ENTERED ON STEP NUMBER  MULTIPLE ft R SQUARE ADJUSTED R SQUARE STANDARD ERROR  RESI0GK4 RESIDSK4 NIMP NCHNG NtCHNG "WTlMP TPRl TPRCl ICONSTANT)  -  I.  OTS8127  B  B  2.  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 TINFl ~OT4"049966E 0r TINFCl 0.703 S785E-01 TRRl -0.2375626E-01 (CONSTANT) -3. 386809 ;;  DF 8. 37.  SUM OF SQUARES 13.25578 25.9768 5  0.673 2.296 1.630 0.441 1.853 1.569 4.435 0.002  TRRCl TINFl TINFCl TRRl  IN THE EQUATION  0.14370 0.19688 -2.02871 -0.59052 -0.22210 2.51236 0.49073" 0.04771 -0.00007 0.11169" 0.22399 -0.10767  MEAN SQUARE 1.65697 0 . 70208  — VARIABLE TINFl TINFCl TRRl TRRCl  VARIABLES NOT  2.36010  P 0. 0367  IN THE EQUATION  BETA IN  PARTIAL  TOLERANCE  -0.03316 0.17862 -0.12716 0.05651  -0.0 3785 0.20697 -0.12300 0.05825  0.86259 0.88897 0.61947 0.70341  0.052J  1.6111  0.553 0.123  REINFORCERS CHANGE BASE TO IMTH RESOURCES BASELINE RESOURCES CHANGE BASE TO IMTH REINFORCERS BASELINE  ANALYSIS OF VARIANCE REGRESSION RESIDUAL  BET*  RESI0GK4 RES I0SK4 NIMP "NCHNG NSCHNG WTIMP "TPRl TPRCl TRRCl  VARIABLE L I S T REGRESSION LIST  -  VARIANCE  0.17116 0.14687 0.33052 0.12253 0.00799 0.34627 0.04571 0.05719  MULTIPLE R 0.61541 -R-SQUARE— 0737873 ADJUSTED R SQUARE 0.15281 STANDARD ERROR ' 0.85942  VARIABLE  • • • * • •  GENERAL KNOWLEDGE CHANGE BASE TO 1MTH SPECIFIC KNOWLEOGE CHANGE BASE TO IMTH IMPORTANCE GAP XEEWAV IMPETUS STANDARDS BASELINE STANOAROSCHANGEBASE TO IMTH  STD ERROR B  0.11597 0.22894 -1.84649 -0.49041 -0.23847 2.24649 0.35461 -0.00738  VARIABLEISI ENTERED ON STEP NUMBER  VARIABLES  ON  IN THE EQUATION BETA  0.1403752 0 . 2 22 5601 -0.4219617 -0.8135747E-01 -0.1087491E-01 0.4337741 0.9626757E-01 -0.2338914E-02 -2.214434  R E G R E S S  _  RESIDGK4 RESIDSK4 NIMP NCHNG "Ti'tCHN'6 HTIMP TPRl TPRCl  ANALVSTT~OF REGRESSION RESIDUAL  0.33788 0.19471 0.83790"  VARIABLES VARIABLE  M U L T I P L E  TRETSTMETfT Pt~AN I N AT^WsTTTdTTPl(ASE  DF 12. 33.  SUM OF SQUARES 14.85847 24.37416  —  MEAN SQUARE 1.23821 0.73861  1.67640  0.1181  VARIABLES NOT IN. THE EQUATION --  STO ERROR B  VARIABLE  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  BETA IN  PARTIAL  TOLERANCE  00  • W—:  » * » » * » * » * » « » « * * » » * • * * • MUL T I P L E R E G R E S S I O N -„ KtilUCil FOLLOW UP IN ACQUISITION PHASE  •  * * * * • * • « * »  •» ....^r... ucrcnucni r « l « t L C .  VARIABLE!SI ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE ADJUSTED R SQUARE J INHUMRU C H I U J K  0.39166 0.15340 -0.02965  VARIABLE  B  1..  RESIDGK4 RESIDSK4 NIMP NCHNG NtCHNG WTIMP TPRl TPRCI  RESIDGK4 RES IDSK4  UIM0""" "'"" NIPIP  NCHNG NtCHNG  UTTHP wit nr  TPRl TPRCI IUJNSTANTI  0.2244739E-01 -0.3663669E-01 " ' ' A0.2888814 4a<taAli 0.1379729 -0.653S875E-02 ,  ^H~"^J UA9>. * TT V O J f f  0.1067644 0.10395 80 -2.660146  _  F  0.51534 -v * c c -» 0.Z6557 -0.00149 0.96931  DCCirtf^lfA\ '  B  TRRCl TINFl TINFCl TRR1  A dCAalAlr—iST—  0.06777 RESIDSK4 -0.9274774E-01 -0.09197 NIMP -0.3459978E-O1 -0. 14596 NCHNG 0.? 5flOi.77P-711 ~ A I X A A C — •• v. £, 3uV*r f f c w X 0*14995 -0.30162 NXCHNG -0.1426844E-01 0.30019 HTIMP 0.6012761E-01 T•Ariw D t X—. : u . i i g w. ». Q.63336 TPRCI 0.1796887 0.54684 TRRCl -0.1070705 -0.43088 TINFl K. 7fllU.nOC.ni «-'iieA-»i— TINFCl 0.4339229E-02 0.01332 TRR1 -0.8565798E-01 -0.37424 i MuuirnfitMunvi i4 . —£. • X—' c.9- *it) f£ l  P 0.5755  •-  0.20822 0.17943 0.41779 0.15263 0.01028 0.44108 0.06694 0.07702 0.05070 0.07332"" 0.06212 0.05089  PARTIAL  0.00229 0.01680 -0.13997 -0.26203  0.00231 0.01722 -0.11973 -0.23885  c  TOL ERANCE  t  0.86259 0 . 8811*97 0.61947 0.70341  a.ooa 0.011 0.524 2.178  ,  OF 12. 33.  SUN OF SQUARES 11.21183 31.00551  MEAN SQUARE 0.93432 0.93956  —  STD ERROR B  BETA IN  REINFORCERS CHANGE BASE TO 1MTH RESOURCES BASELINE RESOURCES CHANGE BASE TO 1MTH REINFORCERS BASELINE  ANALYSIS OF VARIANCE KcbKESSION RESIDUAL  BETA  F 0.83803  "  TINFl TINFCl TRR1 TRRCl  VARIABLES IN THE EQUATION VARIABLE  MEAN SQUARE 0.80952 0.96598  VARIABLE  0.013 0.045 0.555 0.922 0. 487 0.581 3.965 2.401 ... .  «  1 6  -- VARIABLES NOT IN THE EQUATION  0.20077 0.17228 0.38769 0.14372 0.00937 0.40616 0.05362 0.06709 2..  SUM OF SQUARES 6.47613 35.74122  —  ST0 ERROR B  0.01788 -0.03633 1.21863 0.80174 -0.13825 -1.54587 0.37912 0.31637  VARIABLEISI ENTEREO ON STEP NUMBER  MULTIPLE R A I I A D C "1) C»UUAKc ADJUSTED R SQUARE STANOARO ERROR  OF 8. 37.  UtVOCW  BETA  VARIABLE LIST REGRESSION LIST  GENERAL KNOWLEDGE CHANGP RAtc TD I M T U SPECIFIC KNOWLEDGE CHANGE BASE TO INTH IMPORTANCE GAP LEEWAY IMPETUS STANOARDS BASELINE STANDARDS CHANGE BASE TO 1MTH  ANALYSIS OF VARIANCE REGRESSION RESIDUAL  i n inc EUUAIIUN  * »  F 0.167 0.267 0.007 0.029 1.925 0.019 7.101 5.'442 4.459 0. 077 0.005 2.833  VARIABLE  c 0.99442  VARIABLES NOT IN TMF • »-»« • nut. tr *I IVUI »n InC CIIUATIQN — BETA IN  PARTIAL  TOLERANCE  P 0.4748  ——— f  VO  :  _—.  *  »  *  *  *  DEPENDENT  *  •  »  »  •  *  *  *  VARIABLE..  *  *  *  »  •  RTSTDT*  VARIABLEISI ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE ADJUSTED R SQUARE STANDARO ERROR  *  *  »  »  *  COMPLETE  I..  0.48140 0.23175 0.11356" 0.74023  M U L T I P L E RECORD  TRRC2 T PR 2 TPRC2 TINF2 T T N FC 2 TRR2  R E G R E S S I O N  REINFORCERS CHANGE STANDARDS 1 M T H STANDARDS CHANGE 1 RESOURCES 1MTH RESOURCES CHANGE 1 REINFCRCERS 1MTH  ANALYSIS OF VARIANCE REGRESSION  OF 6. 39.  TTESIDOAX"  STD ERRORB~  BETA  TRRC2 -0.1S23232E-01 "TPR2 "~0T228649lE-0r TPRC2 -0.1877771E-01 TINF2 0. 51903 84E-01 TINFC2 0.6496012E-01 TRR2 0.5885273E-01 (CONSTANTI -3.813737  -0.09589 0.08664 -0.06991 0.18110 0. 18991 0.35070  VARIABLE (SI ENTERED ON STEP NUMBER  MULTIPLE R 0.57908 R SQUARE 0.33534 ADJUSTED R S Q U A R E — 0 . 0 9 3 6 4 STANDARD ERROR 0.74850  0.03467 0.05305 0.04599 0.04815 0.05986 0.03219  2..  RESI0GK3 RESIDSK3 NIMP NCHNG WTIMP NSCHNG  0. 277 0.186 0. 167 1. 162 1.178 3.342  SUM OF SQUARES 6.4462 5 21.36948  TRRC2  -0.86066 10E- 02 rPRz ""071/310847^01 TPRC2 0.6979419E-02 TINF2 0.458 62 85E-01 "TTNFCl— 0.86137676-01 TRR2 0.5261569E-01 RESIDGK3 0.2 081708 RESI0SK3 -0.7857571E-01 NIMP -0.4471942 -0.1925295 NCHNG WTIMP 0.4874138 NtCHNG 0.6681994E-02 (CONSTANTI -3. 634206  -0. 04526 0.04967 0.02599 0.16002 0.25183 0.31353 0.16042 -0.07199 -2.32407 -1.37827 2.99789 0.17402  P 0.0951  VARIABLES NOT IN THE EQUATION BETA IN  PARTIAL  TOLERANCE  RES IDGK3 RESICSK3 NIMP NCHNG WTIMP NtCHNG  0.14857 -6.06675 0.05287 -0.00156 0.05997 0.17488  0.16435 -0.06888 0.05852 -0.00171 0.0 6565 0.18226  0.94003 0.81812 0.94122 0.91610 0.92086 0.83449  1.055 0.181 0.131  o.oool 0.164 1.306  DF 12. 33.  SUM OF SQUARES 9.32760 16.48813  MEAN SQUARE 0.77730 0.56025  F 1.38743  P  Q« 2208  VARIABLES NOT IN THE EQUATION  ~STD~ERR0R~B~  0.03771 0.05568 0.05342 0.05170 0.06555 0.03946 0.20253 0.18278 0.35937 0.13089 0.38138 0.00852  F 1 .96077  GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS SPECIFIC KNOWLEDGE CHANGE 1 TO 4HTHS IMPORTANCE GAP I MPETUS ~~ — LEEWAY  ANALYSIS OF VARIANCE REGRESSION RESIOUAL  BETS  MEAN SQUARE 1.07437 0.54794  VARIABLE  VARIABLES IN THE EQUATION VARIABLE  1 1  TO 4NTHS  — -  VARIABLE LIST REGRESSION L I S T  1 TO 4NTHS " " ~ " "" TO 4MTHS  VARIABLES IN THE EQUATION VARIABLE  » • * * * » * » » *  I N TSATNTTNAME^PTTASE  VARIABLE  0.052 0.055 0.017 0. 787 1.727 1.778 1.056 0.185 1.548 2. 164 1.633 0.615  BETA IN  PARTIAL  TOLERANCE  O  M  DEPENDENT  VARIABLE..  VARIABLEISI  ENTERED  RES I O P L 2 ON STEP  MULTIPLE R R SQUARE R  STANDARD  ERROR  SQUARE  1..  I CONSTANT I  0 . 2 0 0 80 9 4 E - 0 1 0.7836112E-01 -5.318189  VARIABLEISI  ENTERED  STD  ADJUSTED  R  " 0 7 2 1 8 8 4 -0.17333 0.12138 0.04935 0.39251  NUMBER  2.  STANDARD  ERROR  0.61945 0.3 8371 0.15961 0.85742  SQUARE  VARIABLES VARIABLE TRRC2 ~TPR2 TPRC2 TINF2 TINFC2 TRR2 RES I0GK3 "RESIDSK3 NIMP NCHNG WTIMP NSCHNG I CONSTANT I  B  -0.1006983 0.35820 84 E-Ol -0.3448708E-01 0.4152705E-01 0.1588050E-01 0.1035006 0.3 887510 0.3914991E-01 0.1625521 0.27052 76E-01 -0.1764750 0.4037456E-03 -4.837404  IN THE  '  L  E  R  MAINTNENANCE  E  G  R  E  S  S  I  O  1  TPRC2 TINF2 TINFC2 TRR2  STANDARDS RESOURCES  1  TO  4HTHS  1  TO  4MTHS  CHANGE IMTH  RESOURCES CHANGE REINFORCERS IMTH  VARIANCE  N  DF 6.  SUN  TO  OF  »  *  »  •  »  •  B  *  •  »  VARIABLE  LIST  1  REGRESSION  LIST  2  SQUARES 1 1.90241  MEAN  SQUARE 1.98374  VARIABLE  F  . 81 701  2  0.70420  BETA  IN  NOT I N T H E E Q U A T I O N  P 0.0225  — :  PARTIAL  TOLERANCE  0.24147  JB.94003  0.03930 0.06014 0.05213 0.05458  0.575  NCHNG  0.06786  -0.138 89  0.088  WTIMP  0.03650  4.610  -0.13917  -0.15989  NSCHNG  0.92086  -0.08161  0.S97  -0.08925  0.83449  0.305  6.920 1.305 1. 1 2 9  RESI0GK3  0.20803  RESI0SK3 NIMP  0.04759  0.05153 -0.11231 -0.15916  - 0 . 0 9 6 76  IMPETUS LEEWAY DF 12.  RESIDUAL  337  SUN  OF  SQUARES  MEAN  SQUARE  15.10532  1.25878  24.26084  0.73518  VARIABLES  EftRW~fi"  VARIABLE 5.434  0.11410  .06378  0.315  -0.10793  .06120  0.318  0.12180  .05923  0.492  0.03903 0.51843 0. 25182 0703015 0.71012 0.16279  .07509  0.045 5.242 2.808 0.035 0.156 0.033  .04521 .23200 .20938 .41167 114994 43688 00976  0.81812 0.94122 0.91610  GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS SPECIFIC KNCWLEOGE CHANGE 1 T O 4MTHS IMPORTANCE GAP  ANALYSIS OF VARIANCE REGRESSION  .04320  0.00884  »  VARIABLES  -0.44516  -0.91240"  *  27.463 7 4  39.  RESIDGK3 RESI0SK3 NIMP NCHNG "STTNP  "STD  *  4MTHS  EQUATION  BETA  *  PHASE  REINFORCERS CHANGE STANDARDS IMTH  NSCHNG  MULTIPLE R R SQUARE  P  TRRC2 TPR2  ERROR  -0.45707  ON STEP  I  EQUATION  BETA"  0 . 6 8 7 044 I E - O F - 0 . 5 53 82 2 8 E - 0 1 0 . 4 13 85 3 0 E - 0 1  T  R E St DUAL  -  IN THE  -0.1033913  L  IN  ANALYSIS OF REGRESSION  g-  —  VARIABLE  TINFC2 TRR2  NUMBER  0.I9502 0.83917 VARIABLES  TRRC2 "TPR2 TPRC2 TINF2  DOCUMENTATION  0.54986 0.30235  ADJUSTED  U  0 . 163 0.002  BETA  IN  F I ' T l 221  NOT I N THE EQUATION PARTIAL  —  TOLERANCE  ^2.353. 0.101 0.486 0»988  * » « *» • * * * s  DEPENDENT VARIABLE..  RES IDPN2  VARIABLE  1  0.56074 0.31443 O.Z0896 0.71964  1/ AD  TRRC2 TPR2 TPRC2 T INF 2 TINFC2 TRR2  TRRC2 -O.2269812E-01 TPR2 0.65725 90E-01 TPRC2 0.3903O52E-O1 TINF2 0.1052284 TINFC2 0.4184266E-01 TRR2 0.3410128E-01 (CONSTANTI -5.094254  ANALYSIS OF VARIANCE REGRESSION RESIDUAL  OF 6. 39.  SUM OF SQUARES 9 . 26 3 21 20.19712  STD ERROR B  -0.11599 0.24200 0.14120 0.35677 0.11887 0.19745  0.63897 0.40828 0.19311 0.72681  0.03370 0.05157 0.04471 0.04681 0.05819 0.03130  F 0.454 1.624 0.762 5.054 0. 517 1. 187  -  B  — -  - -  MEAN SQUARE 1.54387 0.51787  F 2.98116  VARIABLE  BETA IN  PARTIAL  TOLERANCE  RES I0GK3 RESIDSK3 NIMP NCHNG WTIMP NSCHNG  0.13805 -0.09004 -0.11512 -0.10190 -0.12793 0.11142  0.16166 -0.09836 -0.13488 -0.11780 -0.14827 0.12293  0.94003 0.81812 0.94122 0.91610 0.92086 0.83449 '  2..  RESI0GK3 RESI0SK3 NIMP NCHNG WTIMP NSCHNG  ANALYSIS OF VARIANCE REGRESSION RESIDUAL  BEI A -0. 06881 0.18948 0.15445 0.31977 0.20969 0.33108 0.14944 -C.13001 -0.30789 -0.36643 0.25257 0.29113  1 3  <  ~  P 0.0171  —————— F 1.020 0.371 0.704 0.535 0.854 0.583 ~  GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS SPECIFIC KNGWLEOGE CHANGE 1 TO 4MTHS IMPORTANCE GAP IMPETUS LEEWAY DF 12. 33.  SUM OF SQUARES 12.02813 17.43220  VARIABLES IN THE EQUATION VARIABLE  VARIABLE LIST REGRESSION LIST  EQUATION BETA  VARIABLEISI ENTEREO ON STEP NUMBER  TRRC2 -0.1346543E-01 ——»•(. _—•jy514 |->«e' ji-56Ec—M 01 * l PKZ_______________0 62 TPRC2 0.426S308E-01 TINF2 0.9431734E-01 TINFCZ 0.7381417E-01 TRR2 0.5717873E-01 RES IDGK3 0.199S758 RESIDSK3 -0.1460514 NIMP -0.6097075E-01 NCHNG -0.5267700E-01 WTIMP 0.4226101E-01 NSCHNG 0.1150453E-01 I CONSTANT I -4. 440823  * *  REINFGRCERS CHANGE 1 T O 4 M T H S STANDAROS INTH STANDAROS CHANGE 1 TO 4MTHS RESOURCES 1MTH RESOURCES CHANGE 1 TO 4MTHS REINFGRCERS 1MTH  I A QJ C C  6  MULTIPLE R R SQUARE ADJUSTED R SQUARE STANDARD ERROR  » # * • * * » • * » *  REG R E S S I 0 N  OAT A BASE IN MAINTENANCE PHASE  VARIABLE! SI ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE ADJUSTEO R SQUARE STANDARD ERROR  MUL T I P L E  MEAN SQUARE 1.00234 0.52825  F 1.89749  P  —0.0721 ~.  -- VARIABLES NOT IN THE EQUATION  STD ERROR B 0.03662 0.05407 0.05187 0.05020 0.06 365 0.03832 0.19666 0.17749 0.34896 0.12710 0.37032 0.00827  F 0.135 0.906 0.677 3.529 1.345 2.227 1.030 0.677 0.031 0. 172 0.013 1.933  VARIABLE  BETA IN  PARTIAL  TOLERANCE  F  Ul  * * • » * * » » • * * » • * * * * • * • * • * DEPENDENT VARIABLE.. VARIABLE! SI  RES IDPP2  M U L T I P L E R E G R E S S I O N . PROBLEM FOCUS IN MAINTENANCE PHASE!  ENTERED ON STEP NUMBER  1..  0.45708 0.20892 0.08722 0.81775 VARIABLES IN  VARIABLE  ANALVSIS OF VARIANCE REGRESSION RfcTIBUAT"  I  B  OF 6; 397  THE EQUATION BETA  TRRC2 -0.4343331E-02 TPR2 ~0.1015504^01 TPRC2 -0.2 685926E-01 TINF2 0.430 8508E-0I TINFC2 0.1059702 TRR2 0.472 5198E-01 • CONSTANT! -2.913380  ' -  TRRC2 REINFORCERS CHANGE 1 TO 4NTHS TPR2~"STANDARDS IMTH' ~ TPRC2 STANDARDS CHANGE 1 TO 4HTHS TINF2 RESOURCES IMTH TINFC2 RESOURCES CHANGE 1 TO 4MTHS TRR2 REINFORCERS IMTH  •  MULTIPLE R R SQUARE ADJUSTED R SQUARE STANDARD ERROR  * » » * « • • » * » * * •  STO ERROR B  -0.02098 0.03535 -0.09186 0.13809 0.28457 0.25864  0.03830 0.05861 0.05080 0.05319 0.06613 0.03556  F 0.013 0.030 0. 280 0.656 2.568 1.765  VARIABLE L I S T REGRESSION LIST  1 4j ^  ~  SUM OF SQUARES 6.88762 26.07973  MEAN SQUARE 1.14794 0.66871  F 1.71664  ——————  VARIABLES NOT IN THE EQUATION  VAR IABLE  BETA IN  PARTIAL  RES IDGK3 RESIDSK3 NIMP NCHNG WTIMP NSCHNG  0.15693 -0.11590 0.16002 0.11660 0.19609 0.17409  0.17107 -0.11786 0.17454 0.12548 0.21156 0.17880  TOLERANCE 0.94003 0.81812 0.94122 0.91610 0.92086 0.83449 .  0.  — F lcl46 0.535 1.194 0.608 1.780 1.255  .— VARIABLEISI ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE ADJ USTED STANOARO ERROR  0.5 8183 0.33853  VAMIABLt TRRC2  U  RESI0GK3 RESIDSK3 NIMP NCHNG WTIMP NSCHNG  GENERAL KNOWLEDGE CHANGE 1 TO '»MTHS SPECIFIC KNOWLE OGE CH AN G E l 1 0 4MTHS IMPORTANCE GAP IMPETUS LEEWAY  ANALVSIS OF VARIANCE REGRESSION RESIDUAL  0.81291 VARIABLES IN  2  OF 12. 33.  SUM OF SQUARES 11. 16042 21.80694  THE EQUATION BETA  0.13533 34E-01 0.06538 ~--~y p_ A" D l#4eZ i ' U ' l 75e-02 lC'ill u.o 0.03044 TPRC2 -O.2147779E-02 -0.00735 TINF2 0.3 257965E-0I ' 0.10442 TINFC2 0.1250275 0.33575 TRR2 0.1756468E-01 0.09614 RES IDGK3 0.2460479 0.17416 A I ifci'itt'tt~ '• —Uti49M13 -0. 12591 NIMP -2.86710 -0.-6006032 NCHNG -1.48790 -0.2262727 • unr 0.6686648 3.77772 NSCHNG 0.16942 59E-03 0.00405 I CONSTANT1 -2.849606  SID  MEAN SQUARE 0.93003 0.66082  — ERROR B 0.04095 0.06047 0.05802 0.05615 0.07119 0.04286 0.21996 0. 19851 0.39029 0.14215 0.41419 0.00925  F 0.109 0.021 0.001 0.337 3.084 0. 168 1.251 0. 568 2.368 2.534 2.606 0.000  VARIABLE  "•'  VARIABLES NOT BETA IN  F 1.40740  P 0.?117  IN THE EQUATION  PARTIAL  TOLERANCE  F  » » » * * • » • • • * * » » » » » * * • » * « /  DEPENDENT VARIABLE..  RES~IDPC2  R E G R E S S I O N  1..  , 0.37*3* <• 0.14013 0.00784 0.64843  B—  ANALYSIS OF VARIANCE REGRESSION RESIDUAL  TRRC2  0.2516236E-01 -0.176 52 7 IE-01" -0.4005107E-01 TPRC2 -0.7676901E-02 TINF2 TINFC2 -0.50931 75E-01 TRR2 0.2100786E-01 I CONSTANTI -0.1975326  ~Twnr  VARIABLEISI  BETA  DF 6. ~397  SUN OF SQUARES 2.67228  ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE ADJUSTED ft SQUARE STANOARO ERROR  0.03037 0.04647 0.0402 8 0.04218 0.05243 0.02820  2,  RESIDGK3 RESI0SK3 NIMP NCHNG HTIMP NSCHNG  0.686 0. 144 0.9 89 0.033 0.944 0.555  "BETA  TRRC2 " TPR2 TPRC2 TINF2 TINFC2 TRR2 RESI0GK3 U.ES"Iff5IO~ NIMP NCHNG  0.2300041E-01  -=07202B502E-0r  -0.3642314E-01 -0.7 039374E-02 -0.5997427E-01 0.1943691E-01 -0.4 2203 96E-01 "OV5070796E-Or 0.7177293E-01 0. 21949 89E-01 wrtMp -0.6923914E-01 -0.33191 29E-02 NSCHNG I CONSTANTI -0.1827519  0. 14609 -0.09283 -0.16378 -0.02966 -0.21176 0.13988 -0.03928 0.05611 0.45049 0.18978 -0.51433 -0.10440  OF 12. 33.  BETA IN  RES IDGK3 RESI0SK3 NIMP NCHNG HTIMP NSCHNG  -0.06255 0.02030 0.01021 -0.07196 -0.0 25 53 -0.12013  PARTIAL  TOLERANCE  -0.06540 0.01980 0.01068 -0.07427 -0.02642 -0.11834  0.94003 0.81812 0.94122 0.91610 0.92086 0.83449  SUM OF SQUARES 3.00827 16.06179  MEAN SQUARE 0.25069 0.48672  VARIABLES NOT  STD ERTfflJTT 0.03515 0.05190 0.04979 0.04819 0.06110 0.03678 0.18877 0.17037 0.33496 0.12200 0.35547 0.00794  F 1.05928  P 0.4032  VARIABLES NOT IN THE EQUATION  VARIABLE  VARIABLES IN THE EQUATION  VARIABLE  1 5  0.163 0.015 0.004  _____  0.027 0.540  GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS SPECIFIC KNCWLEQGE CHANGE 1 TO 4MTHS IMPORTANCE GAP IMPETUS LEEWAY  ANALYSIS OF VARIANCE REGRESSION RESIDUAL  0.39718 0.15775 -0.148S2 0.69765  MEAN SQUARE 0.44538 0.42046  16.3977TT  —  STD ERROR B  0.15982 -0.08079 -0.18009 -0.03235 -0.17983 0.15119  VARIABLE LIST REGRESSION LIST  TRRC2 REINFGRCERS CHANGE 1 TO 4NTHS T P R 2 S T A N D A R D S IMTH TPRC2 STANDARDS CHANGE I TO 4MTHS TINF2 RESOURCES IMTH RESOURCES CHANGE 1 TO 4MTHS "TINFCT" TRR2 REINFORCERS IMTH  VARIABLES IN THE EQUATION VARIABLE  • * * * » • » • * • * * •  TREATMENT PLAN IN MAINTENANCE PHASE  VARIABLEISI ENTERED ON STEP NUMBER  MULTIPLE R R SQUARE ADJUSTED R SQUARE STANOARD ERROR  M U L T I P L E  VARIABLE 0.428 0.153 0.535 0.021 0.963 0.279 0.050 0.089 0. 046 0.032 0.038 0.175  BETA IN  F 0.51506  IN THE EQUATION  PARTIAL  —  TOLERANCE  P 0.8897  • * * • * • * * • * • • • • • • * • *  \ -  DEPENDENT  VARIABLE..  VARIABLEISI  MULTIPLE R SQUARE  RESIDPS2  ENTERED  ON STEP  Auiuiitu STANDARD  K SQUARE ERROR  -0.11519 0.92323  -  VARIABLES  : VARIABLE  NUMBER  VARIABLEISI  ENTERED  ON  STEP  •  UP  I..  M U L T I P L E I N MAINTENANCE  IN  THE  ADJUSTED STANDARD  R SQUARE ERROR  -0.19480 0.95562  _  VARIABLES  TRRC2 IKK* TPRC2 TINF2 TINFC2 TRR2 RESI0GK3  ' B f t " * ft iTkt^L  RESIDSK3 NIMP NCHNG WTIMP NSCHNG 1 CONSTANT)  H B  STD  NUMBER  -0.5438893E-02 O.Z2Z1810E-01 0.2584375E-01 0.3990051E-02 0.2695184E-01 0.9656427E-02 -0.4951166E-01 A  0 . 1• 0A"e>iV»"*i"«£T 59842 -0.5744860 - 0 . 2 320027 0.6191389 0.7519968E-02 -1.374299  0  VARIANCE  DF 6.  <  N  ...  1 TO  SUN O F  39.  F  B  324 617 735 005  0.07466 0.04015  RESIDGK3 RESIDSK3 NIMP NCHNG  0.002 0. 0. 0. 0. 0.  SQUARES 1.1523 1 33.24211  BETA  0.08732 -2.68493 -1.49359 3.42458 0.17612  STD  *  VARIABLE L I S T REGRESSION L I S T  MEAN  SQUARE 0.19205  096 006 006 105 298  F 0 . 22  1 b)  P 0.9661  532  0.85236  IN  NOT  I N THE  VAR I A B L E  BETA  PARTIAL  TOLERANCE  RES IDGK3 RES I0SK3 NIMP NCHNG WTIMP NSCHNG  0.00265 0.06346 0.04286 0.03640  0.00261 0.05839 0.04230 0.03543  0.06825 0.19567  0.06662 0.18181  0.94003 0.81812 0.94122 0.91610 0.92086 0.83449  —  G E N E R A L KNOWLEDGE C H A N G E 1 TO 4MTHS SPECIFIC KNOWLEDGE C H A N G E 1 TO 4MTHS IMPORTANCE GAP  F 0.000 0.130 0.068 0.048 0.169 1.299  — •  "TMPETUS LEEWAY  DF 12. 33.  SUM O F  SQUARES 4.25841 30.13601  EQUATION  -0.02572 0.07571" 0.08653 0.01252 0.07086 0.05176 -0.03431  *  4MTHS  VARIABLES  0.04 0.06 0.05 0.06  2..  * * * * * * * * * * *  PHASE  A N A L Y S I S OF V A R I A N C E REGRESSION RESIDUAL  THE  I  RESOURCES CHANGE REINFORCERS IMTH  ERROR  0.00995 0.06976 -0.01519 -0.01438 0.06348 0.11740  IN  S  EQUATION  0.35187 0.12381  IIIBIIBI g VAN!ABIE  S  TINFC2 TRR2  NSCHNG  R  E  4MTHS REINFORCERS CHANGE 1 T O STANDARDS IMTH S T A N D A R D S C H A N G E 1 TO 4 M T H S RESOURCES IMTH  WTTMP  MULTIPLE R SQUARE  R E G R  TRRC2 TPR2 TPRC2 TINF2  A N A L Y S I S OF REGRESSION  BETA  0.2103784E-02 0.204 7061E-01 -0.4S3T629E-02 - 0 . 4 581629E-02 0.2414324E-01 0.2 190771E-01 -1.182434  *  RESIDUAL  B  TRRC2 TPR2 TPRC2 TINF2 TINFC2 TRR2 (CONSTANT 1  *  FOLLOW  0.18304 0.03350  R  *  MEAN  SQUARE 0.35487 0.91321  F 0.38859  —  P 0 . ,9 35 n8 l1  VAR I A M F S M n T I M T H E E Q U A T I O N ERROR  B  0.04814 0.07109 0.06821 0.06601 0.08369 0.05038 0.25857 0.23336 0.45881 0.16711 0.48691 0.01088  F  VARIABLE  BETA  IN  PARTIAL  TOLERANCE  F  0.013 0.098 0.144 0.004 0.104 0.037 0.037 0 . 206 1. 5 6 8 1.927 1.617 0.478  Ul  APPENDIX G R e g r e s s i o n d a t a : summary t a b !  REGRESSION FILE  SUMMARY TABLES  TOTAL  03/15/80  (CREATION DATE = 06/22/78)  * * * * * * * * * * * * * * * * * * * * * * * DEPENDENT VARIABLE..  RETl~D~PT"  WITH NEW  PAGE  LABELS  H U L T  I  P L E  R E G R E S S I O N  * * * * * * * * * * * * *  COMPLETE RECORD IN ACQUISITION PHASE  VARIABLE L I S T REGRESSION L I S T  1 1  SUMMARY TABLE VARIABLE "TRIO  RE INFOftC E l i T ^ S l L T N l E TINFl RESOURCES BASELINE TPRCl STANOARDS CHANGE BASE TO IMTH R E S I D S K 4 — SPECIFIC"KNOWLEDGECHANGEBASETO IMTH RESI0GK4 GENERAL KNOWLEDGE CHANGE BASE TO IMTH TPRl STANCARDS BASELINE nrKRXT REINFORCERS CHANGE B A ^ E n r i r r M T f l TINFCl RESOURCES CHANGE BASE TO IMTH NCHNG GAP "NJJCHNG "LEEWAY" " ' " ' NIMP IMPORTANCE MTIMP IMPETUS {CONSTANT!  MULTIPLE R  R SQUARE  RSQ CHANGE  SIMPLE R  0.26247 0.33142 0.3777 5 0 . 40 537 0.43697 0.45244 0746193 0.4702 8 0.47989 0.50644 0.50694 0.57625  0.06889 0.10984 0.14270 0.16432 0.19095 0.20471 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 0.00868 0. 00778 0.00913 0.02619 0.00050 0.07508  0.2624 7 -0. 16047 0.13555 •0.02947 0.17865 0.13074 -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 -1.941188  BETA 0.11187 -0.13676 0.45916 -0.29881 0.21237 0.31653 -0.30699 0.10355 -1.34325 -0.31003 -3.24744 4.04456  REGRESSION  FILE *  *  SUMMARY  TOTAL *  *  *  DEPENDENT  *  *  03/15/80  TABLES  I CREATION OATE = 06/22/781 *  *  *  *  VARIABLE..  *  *  *  *  *  RES IDPTI  *  *  *  *  *  *  WITH NEW LABELS *  M  DOWMENTATTCTN  U  IN  L  T  I  P  L  E  ACQUISITION  R E G R E S S I O N  | i  VARIABLE NCHNG TPRl RESIDGK4 TINFCl WTIMP NIMP TRRl TPRCI TRRCl TINFl RESIDSK4 (CONSTANT 1  MULTIPLE R GAP STANDARDS BASELINE GENERAL KNOWLEDGE CHANGE 8ASE TO IMTH RESOURCES CHANGE BASE TO IMTH INPE TUS IMPORTANCE REINFORCERS BASELINE STANDARDS CHANGE BASE TO IMTH RE INFORCERS CHANGE BASE TO IMTH RESOURCES BASELINE SPECIFIC KNOWLEDGE CHANGE BASE TO IMTH  0.24563 0.32725 0.37174 0.39594 0.41513 0.48645 0.51409 0.51818 0.51903 0.51961 0. 52015  * * * * * * * * * * * * *  VARIABLE L I S T REGRESSION L I S T  1 2  PHASE  SUMMARY  i  PAGE  TABLE  R SQUARE  RSQ CHANGE  SIMPLE R  0.06036 0.10709 0.13819 0.15677 0.17233 0.23664 0.26428 0.26852 0.269 39 0.27000 0.2 7055  0.06036 0.04673 0.03110 0.01858 0.01556 0.06430 0. 0 2 765 0.00423 0.00087 0.00061 0.00055  0.24569 -0.22530 -0.17241 0.16 510 0.03099 -0.05849 -0.01523 0.10910 -0.10679 -0.03512 -0.02 730  B 0.2775322 -0.8450509E-01 -0. 2204216 0.3310614E-01 -0.6756498 0.605322 5 0.4854401E-01 -0.3529457E-01 0.1037015E-01 -0. 1137 503E-01 0.2476095E-01 1.040787  BETA 1.83356 -0.34118 -0.19958 0.11552 -3.83517 2.90324 0.24113 -0.12212 0.04745 -0.03438 0 .02792  I—' Ul CO  REGRESSION FILE *  *  SUMMARY  TOTAL *  *  *  *  (CREATION *  *  *  *  *  DEPENDENl VARIABLE..  *  *  06/22/781  DATE *  *  *  *  *  TJTETICrpNl  *  *  *  WITH  *  *  NEW  LABELS  u II i T r o i P M U L T I P L E  fATA BTSE~nr;ACQUISITION  R E G R E S S R E G R E S S  MULTIPLE  VARIABLE RESOURCES B A S E L I N E ' TINFl LEEWAY NSCHNG R E S O U R C E S CHANGE B A S E TO I M T H TINFCl -RESTDSX4— 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 REINFORCERS BASELINE TRRl S T A N D A R D S C H A N G E B A S E TO IMTH TPRCI TRRCT ~ ~ R E I N F O R C E R S C H A N G E B A S E TO I M T H STANOARDS BASELINE TPRl RESIDGK4  GENERAL  KNOWLEDGE  CHANGE  BASE  ~~~~ T M P O R T A N C E  ICONSTANTI  IMPETUS  GAP  '  TO  IMTH  I  O N IUN  *  *  *  *  *  *  *  *  *  *  *  *  *  VARIABLE REGRESSION  LIST LIST  1 3  PHASE  -  SUMMARY  ~NlNP~~ WTIMP NCHNG  PAGE  03/15/80  TABLES  R  R  TABLE  SQUARE  RSQ  CHANGE  SIMPLE  "OTO _"OTJO  0T08000  ^0T2T28 4  0. 4 4 3 8 9 0.46890 0.48779  0.14569 0.17729 0.19704 0.21987 0.23794  0.06569 0.03160 0.01975 0.02283 0.01807  "0750151 0.51497 0.52323 0.52343 0. 52885 0.58906  0.25151 0.26519 0.27377 0.27398 0.27969 0.34699  0.01358 0.01368 0.00858 0.00021 0.00570 0.06731  -0.21617 0.01924 -0.14863 0.1243 7 0.10788 -0.04200 0.11052 0.10875  TJT7ffZB4~ 0.38169 0.42106  B  R  -6.01074 -0.04992 -0.11998  -  0.1293148 0.1443 757E-01 0.2376316E-01 0.3192453 0.6979577E-03 0.1243256 -0.7574254E-01 0.6944631E-01 0. 1426 238 -0.6992 270 0.7372733 -0.2453066 1.443295  BETA -0.37198 -0.33023 -0.07891 -0.34254 -0.00330 0.40939 -0.32981 0.26683 0.1229(B„. -3.19159 3.98275 -1.S4235  03/15/80  REGRESSION SUMMARY TABLES FILE  TOTAL  1 CREATION DATE = 06/22/781  ***** * * * * * * * * * * * * * * * * * * DEPENDENT  V A R I A B L E . .  RESI0PP1  PAGE  7  WITH NEW LABELS M U L T I P L E  R E G R E S S I 0 N  * * * * * * * * * * * * *  PROBLEM FOCUS IN ACQUISITION PHA SE  VARIABLE L I S T REGRESSION L I S T  1 4 J  SUMMARY TABLE VARIABLE TPRCl TRRl RESIDSK4 TINFl RESIDGK4 TINFCl TRRCl TPRl NCHNG "~""N ACTING NIHP WTI MP (CONSTANT!  S T A N C A H O S CHANGE BASE TO IMTH REINFORCERS BASELINE SPECIFIC KNOWLEDGE CHANGE BASE TO IMTH RE S O URCE S BAS E L I N E " GENERAL KNCWLEOGE CHANGE B A S E TO IMTH RESOURCES CHANGE BASE TO IMTH REINFORCERS C H A N G E B A S E T O I M T H STANDARDS BASELINE GAP LEEWAY IMPORTANCE i IMPETUS  MULTIPLE R  R SQUARE  0.28424 0.35174 0.42905 0 . 47651 0.49506 0.51076 0.51545 0.52006 0.5252 0 0.53642 0.53758 0.56203  0.08079 0.12372 0.18408 0.22706 0.24508 0.260 88 0.26568 0.27046 0.275 83 0.287 75 0.28900 0.31588  RSQ CHANGE 0.08079 0.04293 0.06036 0.04298 0.01802 0.01580 0.00481 0.00478 0.00537 0.01191 0.00125 0.02688  SIMPLE R 0.28424 0.13910 -0.11478 -0.18857 0.11850 0.13413 0.01394 -0.07108 0.09309 -0.11997 0.03675 0.06608  B 0.1762 368 0.4038013E-01 -0.4075002 -0.4709845E-01 0.2298623 0.5432401E-01 -0.5576984E-01 0.4196836E-01 -0.1358 267 -0.9692771E-02 -0.4770277 0. 4955 886 -1.666818  BETA 0.52463 0.17257 -0.39527 -0.12248 0.17907 0.16309 -0.2195* 0.14578 -0.77205  -6.20043  -1.96843 2.42026  O  j  REGRESSION SUMMARY TABLES  '  FILE *  *  TOTAL *  *  *  DEPENDENT  *  *  03/15/80  *  *  *  VARIABLE. .  *  *  *  *  *  *  WITH NEW LABELS  06/22/781  I CREATION DATE *  RES IDPC1  *  *  *  *  *  PAGE  *  M U L T I P L E  Wi?A~TTtrNT~PLAN I N  R E G R E S S I O N  * * * * * * * * * * * * *  VARIABLE L I S T REGRESSION L I S T  1 5  ATTQTJTSITJWWAS-  SUMMARY TABLE MULTIPLE R  VARIABLE TPRl RESIDSK4 NCHNG —NSCHNG TINFCl RES IDGK4 TINFl TRRCl TRRl N  1  W  WTIMP TPRCI (CONSTANT)  STANDARDS BASELINE SPECIFIC KNOWLEDGE CHANGE BASE TO IMTH GAP XEEW AY RESOURCES CHANGE BASE TO IMTH GENERAL KNOWLEDGE CHANGE BASE TO IMTH RESOURCES BASELINE REINFORCERS CHANGE BASE TO IMTH REINFORCERS BASELINE IMPORTANCE IMPETUS STANDARDS CHANGE BASE TO IMTH  0.32958 0.44468 0.51542 0. 5455 8 0.56373 0.57267 0.57993 0.58853 0.59090 0.59136 0.61466 0.61541  R SQUARE  RSQ CHANGE  SIMPLE R  0.10862 0.19774 0.26566 0.29766 0.31779 0.32795 0.33632 0.34637 0.34917 0.34971 0.37781 0.37873  0.10862 0.08912 0.06792 0.03200 0.02013 0.01016 0.00836 0.01005 0.00280 0.00054 0.02810 0.00092  0.32958 0.28163 0.27181 0.03 876 0.07597 0.20084 -0.02815 0.08253 0.17749 0.09926 0.20406 -0.08884  B 0. 1332185 0.1913979 -0.9796 532E-01 -0.1012851E-01 0. 7035 785E-01 0. 1739373 0.4049966E-01 -0.1760 380E-04 -0.2375626E-01 -0.4636028 0.4851118 0.1511381E-01 -3.386 809  BETA 0.49073 0.19688 -0.59052 -0.2 2210 0.2 2399 0.14370 0.11169 -0.00007 -0,10767 -2.02 871 2.51236 0.04771  REGRESSION SUMMARY TABLES FILE  TOTAL  03/15/80  (CREATION OATE = 06/22/781  * * * * * * * * * * * * * * * * * * * * * * * DEPENDENT VARIABLE..  RESIDPS1  PAGE  WITH NEW LABELS M U L T  I P L E  R E G R E S S I O N  * * * * * * * * * * * * *  FOLLOW UP I N ACQUISlTToTTPHASE  VARIABLE L I S T REGRESSION L I S T  1 6J  SUMMARY TABLE VARIABLE  .  TPRl TPRCl TRRCl  _  NtCHNG NCHNG WTIMP RESIDSK4 RES IDGK4 ' — T I N FIT" (CONSTANT)  MULTIPLE R STANDARDS BASELINE STAN CARDS CHANGE BASE TO IMTH REINFORCERS CHANGE BASE TO IMTH REINFORCERS BASELINE LEEWAY GAP IMPETUS SPECIFIC KNOWLEDGE CHANGE BASE TO IMTH GENERAL KNOWLEDGE CHANGE BASE TO IMTH . RESOURCES BASELINE  0.18297 0.33943 0.39674 0.43670 0.44989 0.50107 0.50696 0.51074 0.51318 0.51510  R SQUARE  RSQ CHANGE  SIMPLE R  0.03348 0.11522 0.15741 0.19070 0.20240 0.25107 0.25701 0.26086 0.26336 0.26533  0.03348 0.08174 0.04219 0.03330 0.01170 0.04867 0.00594 0.00385 0.00250 0.00197  0.18297 0.12 578 -0.11013 0.03905 -0.08 702 0.09412 0.04743 0.02612 0.02941 -0.03703  B 0.1764047 0. 1774498 -0. 1056 200 -0.8521264E-01 -0.1422609E-01 0.3812211E-01 0. 2381206E-01 -0.8715064E-01 0. 8171376E-01 0.1825 759E-01 -2.559745  BETA 0.62641 0.54002 -0.42505 -0.3722? -0.30073 0.22152 0.11888 -0.08642 0.06508 0.04854  REGRESSION FILE  03/15/80  SUMMARY TABLES  TOTAL  (CREATION DATE = Ob/22/181  WITH NEW  ***** * * * * * * * * * * * * * * * * * * DEPENDENT VARIABLE..  RESIDP2  PAGE  12  LABELS  MU L T I P L E  RE  G R E S S I 0 N  * * * * * * * * * * * * *  COMPLETE RECORD IN MAINTENANCE PHASE  VARIABLE L I S T REGRESSION L I S T  1 1J  SUMMARY TABLE MULTIPLE R  VARIABLE TRRZ TI NFC2 RESIDGK3 TTNF7 RESIDSK3 NSCHNG NCHNG WTIMP NIMP TPR2 1 TRRC2 TPRC2 (CONSTANT)  REINFGRCERS IMTH RESOURCES CHANGE 1 TO 4MTHS GENERAL KNOWLEDGE CHANGE 1 TC 4MTHS RESOURCES IMTH SPECIFIC KNOWLEDGE CHANGE 1 TO 4MTHS LEEWAY GAP IMPETUS IMPORTANCE STANDARDS IMTH REINFORCERS CHANGE 1 TO 4MTHS STANDARDS CHANGE 1 TO 4MTHS  0.34294 0.44879 0.47085 0.49440 0.50561 0.51961 0.54188 0.54729 0.57626 0. 57807 0.57878 0.57908  R SQUARE 0.11760 0.20141 0.22170 0.24443 0.25564 0.26999 0.29363 0.29953 0.33208 0.33417 0.33499 0.33534  RSQ CHANGE 0. 11760 0.08380 0.02029 0.02273 0.01121 0.01435 0.02364 0.00590 0.03255 0.00209 0.00083 0.00034  SIMPLE R 0.34 294 0.32022 0.10 242 0.21472 -0.05247 -0.04201 -0.00 65 7 0.08617 0.07569 0.19176 0.03553 0.02041  B 0.5261569E-01 0.8613 767E-01 0.20 61708 0.4586 285E-01 -0.7857571E-01 0.6681994E-0 2 -0.1925 295 0.4874138 -0. 4471942 0. 1310847E-01 -0.8606610E-02 0.6979419E-02 -3.634206  BETA 0.31353 0.25183 0.16042 0.16002 -0.07199 0.17402 -1.37827 2.99789 -2.3 2407 0.04967 -0.04526 0.0 2599  Co  ;  REGRESSION SUMMARY TABLES  i  FILE  TOTAL  !  *****  03/15/80  (CREATION DATE = 06/22/781  WITH NEW  * * * * * * * * * * * * * * * * * *  DEPENDENT VARIABLE..  RES IDPL2  PAGE  13  LABELS  H U L T I P L E  R E G R E S S I 0 N  * * * * * * * * * * * * *  DOCUMENTATION IN MAINTNENANCE PHASE  VARIABLE L I S T REGRESSION L I S T  1 ?J -s.  SUMMARY TABLE VARIABLE TRRC2 TRR2 RESI0GK3 NCHNG TINF2 TPR2 TPRC2 RESIDSK3 TINFC2 WTIMP NIMP (CONSTANT1  MULTIPLE R REINFORCERS CHANGE 1 TO 4HTHS REINFORCERS IMTH GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS GAP RESOURCES IMTH STANDARDS IMTH STANDARDS CHANGE 1 TO 4MTHS SPECIFIC KNOWLEDGE CHANGE 1 TO 4MTHS RESOURCES CHANGE 1 TO 4MTHS IMPETUS IMPORTANCE  0.26512 0.50839 0.55251 0.5982 5 0.60813 0.61096 0.61441 0.61603 0.61663 0.61691 0.61942  R SQUARE  RSQ CHANGE  SIMPLE R  0.07029 0.25846 0.30527 0.35790 0.36982 0.37327 0.37750 0.37949 0.38023 0.38058 0.38368  0.07029 0. 18817 0.04681 0.05263 0.01192 0.00344 0.00423 0.00199 0.00074 0.00035 0.00310  -0 . 26512 0.25015 0.22278 -0.17957 0.06 546 0.2036 8 -0.10258 -0.01520 0.25715 -0.09904 -0.04348  B - 0 . 1005 980 0.1027386 0.3899 860 0.2554162E-01 0.4131524E-01 0.3573621E-01 -0.3403258E-01 0.3982017E-01 0.1511911E-01 -0.1698047 0.1563882 -4.807172  BETA -0.44472 0.51462 0.25262 0.15370 0.12118 0.11383 -0.10651 0.03067 0.03716 -0.87791 0.68319  -O  REGRESSION FILE  SUMMARY TABLES  TOTAL  03/15/80  (CREATION DATE = 06/22/78)  WITH NEW  * * * * * * * * » * * * * * * * * * * * * * * DEPENDENT  VARIABLE..  RESIDPN2  PAGE  14  LABELS  M U L T I P L E  R E G R E S S I O N  DATA BASE IN MAINTENANCE PHASE  * * * * * * * * * * * * *  -  VARIABLE L I S T REGRESSION L I S T  1 3  SUMMARY TABLE VARIABLE  "TTNFTJ2" TPR2 TINF2 RESTDSK3RESI0GK3 TRR2  STANDARDS IMTH RESOURCES IMTH "SPECIFIC"KNOWLEDGECHANGE1TO 4MTHS GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS REINFORCERS IMTH  NSCHNG NCHNG  LEEWAY GAP STANDARDS CHANGE 1 T O 4 M T H S " REINFORCERS CHANGE 1 TO 4MTHS IMPORTANCE  WTTHP  —  RESOURCES CHANGE 1 TO 4MTHS  TPftC2  TRRC2 NIMP  (CONSTANT)  IMPETUS  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  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 • RESIDPP2 PROBLEM FOCUS IN MAINTENANCE PHASE , DEPENDENT VARIABLE..  * * * * * * * * * * * * *  VARIABLE L I S T REGRESSION L I S T  1 4  SUMMARY TABLE MULTIPLE R  VARIABLE TINFCZ TRR2 WTIMP —TINF2 RESIDGK3 RESI0SK3 TPRC2 NtCHNG ' NCHNG NIMP ' TRRC2 TPR2  RESOURCES CHANGETHTO 4MTHS REINFORCERS IMTH IMPETUS "RESOURCESIMTH GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS SPECIFIC KNOWLEDGE CHANGE 1 TO 4MTHS STANDARDS CHANGE 1 TO 4MTHS LEEWAY GAP IMPORTANCE REINFORCERS CHANGE 1 TO 4MTHS STANDARDS IMTH  (CONSTANT)  0.36113 0.43095 0.46464 0.48570 0.50999 0.52335 0.52938 0.53371 0.53732 0.57964 0.58147 0.58183  R SQUARE 0.13042 0.18572 0.21589 0.23591 0.26009 0.27390 0.280 24 0.28484 0.28871 0.33598 0.33811 0.33853  RSQ CHANGE 0.13042 0.05530 0.03017 0.02002 0.02419 0.01380 0.00635 0.00460 0.00387 0.04727 0.00213 0.00042  SIMPLE R 0.36113 0.26783 0.19289 0.23171 0.11560 -0.07381 -0.01143 -0.03239 0.09648 0.15781 0.02357 0.12256  B 0. 1250275 0. 1756468E-01 0.66 86648 0.3257965E-01 0.2460479 -0.1496 215 -0.2147779E-02 0.1694259E-03 -0.2262727 -0. 6006 032 0. 1353334E-01 0.8746 275E-02 -2.849606  BETA 0.33575 0.09614 3.77772 0.10442 0.17416 -0.12591 -0.00735 0.00405 -1 .4 879.C -2.86 710 0.06538 0.03044  •I  ON' ON  <  •  03/15/80  REGRESSION SUMMARY TABLES FILE  TOTAL  (CREATION DATE * 06/22/781  ***** * * * * * * DEPENDENT VARIABLE..  WITH NEW  * * * * * * * * * * * * RESI0PC2  PAGE  N.  16  LABELS  M J L T I P L E  R E G R E S S I 0 N  * * * * * * * * * * * * *  TREATMENT PLAN I N MAINTENANCE PHASE  VARIABLE L I S T REGRESSION L I S T  1 5 J  SUMMARY TABLE VARIABLE TINFC 2  TRR2  TPRC2 TRRC2 NtCHNG TPR2 RESIDSK3 NIMP RESIDGK3  ~"~TIiNF2  MTIMP NCHNG IC0N5TANT)  MULTIPLE R RESOURCES CHANGE 1 TO 4NTHS REINFORCERS IMTH STANCAROS CHANGE 1 TO 4MTHS REINFORCERS C H A N G E 1 T O 4 M T H S LEEWAY STANOARDS IMTH SPECIFIC KNOWLEDGE CHANGE 1 TO 4MTHS IMPORTANCE GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS RESOURCES I M T H ~ IMPETUS GAP  0.25116  0.29916  0.34735 0.36989  0.38332  0.38770 0.39080 0.39332 0.39504 0.39588 0.39613 0.39718  R SQUARE  RSQ CHANGE  SIMPLE R  0.06308 0.08950 0.12065 0.136 82  0.06308 0.02641 0.03116  -0.25116  0.15031 0.15272 0.154 70 0.15606 0.15672 0.15692  0.00338  0.146 93  0.15775  0.01616  0.01011  0.00241 0.00198 0.00136 0.00066 0.00020 0.00083  0.13838  -0.17426 0.21 610 -0.07585 -0.07382 0.05 376 0.06326 -0.09569 -0.06664 0.03231 -0.05433  B -0.5997427E-01 0.1943691E-01 -0.3642314E-01 0. 230D041E-01 -0.3319129E-02 -0.2028502E-01 0.5070796E-01 0.7177293E-01 -0.4220396E-01 -0.7039374E-02 -0.6923914E-01 0.2194989E-01 -0.1827519  BETA -0.21176 0.13988 -0.16378 0.14609 -0.10440 -0.09283 0.05611 0.45049 -0.0392 8 -0.02966 -0.51433 0.18978  1  ON  \  REGRESSION FILE  03/15/80  SUMMARY TABLES  TOTAL  (CREATION DATE = 06/22/781  RESIDPS2  17  WITH NEW LABELS  * * * * * * * * * * * * * * * * * * * * * * * DEPENDENT VARIABLE.*  PAGE  M U L T I P L E  R E G R E S S I O N  * * * * * * * * * * * * *  FOLLOW UP IN MAINTENANCE PHASE  VARIABLE L I S T REGRESSION LIST  1 6  SUMMARY TABLE VARIABLE TRR2 NSCHNG TINFC2 NCHNG TPR2 WTIMP NIMP RESIDSK3 TPRC2 RESIDGK3 TRRC2 (CONSTANT 1  MULTIPLE R REINFORCERS IMTH LEEWAY RESOURCES CHANGE 1 TO 4MTHS GAP STANDARDS IMTH IMPETUS IMPORTANCE SPECIFIC KNOWLEDGE CHANGE 1 TO 4MTHS STANDARDS CHANGE 1 TO 4MTHS GENERAL KNOWLEDGE CHANGE 1 TO 4MTHS REINFORCERS CHANGE 1 TO 4MTHS  0.16292 0.22317 0.24612 0.27157 0.27572 0. 2790 7 0.33921 0.34397 0.35015 0.35136 0.35173  R SQUARE  RSQ CHANGE  SIMPLE R  0.02654 0.04981 0.06057 0.073 75 0.07602 0.07788 0.11506 0.11832 0.12261 0.12346 0.12371  0.02654 0.02326 0.01077 0.01318 0.00227 0.00186 0.03719 0.00325 0.00429 0.00085 0.00026  0.16292 0.11131 0.07426 0.04828 0.13848 0.08 891 0.06050 0.07906 0.05420 -0.00 888 0.06347  B 0.9348286E-02 0.7463105E-02 0. 2942610E-01 -0.2326 871 0.2U0493E-01 0.6212709 -0.5766 891 0. 1020015 0.2561242E-01 -0.4916640E-01 -0.4486310E-02 -1.242397  BETA 0.05010 0.17479 0.07736 -1.49800 0.07192 3.43638 -2.69523 0.08404 0,08575 -0.03407 -0.02122  CTN CO  

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